Columbia ®nibers(itp ' mtijcCitPofi^elugorfe OUcsc of l^tjpsiciansf anb ^urgcuns v^- ^- ?3r. ebUiin |!3. Cragin 1859-1918 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgicaldiseasesOOkeye THE SURGICAL DISEASES GENITO - URINARY ORGANS INCLUDING SYPHILIS BY K L. KEYES, A.M., M.D. PKOFESSOR OF GENITO-URINARY SURGERY, SYPHILOLOGY, AND DERMATOLOGY, IN BELLE%a-E HOS- PITAL MEDICAL COLLEGE ; CONSULTING SURGEON TO THE CHARITY, THE BELLEVUE, AND THE SKIN AND CANCER HOSPITALS ; CONSULTING SURGEON TO THE BUREAU OF OUT-DOOR RELIEF, BELLEVUE HOSPITAL ; SURGEON TO ST. ELIZABETH HOSPITAL, ETC. A REVISION OF VAN BUBEN AND REYES'S TEXT-BOOK UPON THE SAME SUBJECTS NEW YOEK D. APPLETON AND COMPANY 1889 Copyright, 1874, 1888, By D. APPLETON AND C03IPANY. PEEFAOE. Time and surgical advance have destroyed in great part the valne of the original treatise npon v^hich this revision is founded, making it an unsafe guide as a text-book upon certain subjects. The original book for which my dear old master and myself were mutually responsible was issued in 1874, and since that date until the present time has received no material alteration. The whole subject of litholapaxy has had its birth snice that date; supra- pubic cystotomy has been restored to a new life ; the surgery of the kidney has been constructed anew, and radical changes have been introduced into the surgery of the tunica vaginalis and that relating to the treatment of varicocele. Many minor advances have been made by the profession all along the line followed in this treatise. To bring the book up to date, therefore, it became necessary to recast it entirely, and the publishers have found it expedient to destroy the old stereotyped plates and to set up the entire book anew in type. There are comparatively few pages in which inter- polations of more or less importance have not been made. All the cases have been left out, to give place for new matter, and several of the chapters (on stone) have been di'opped entirely, being replaced by others. In this way it has been possible to add considerable new material without materially adding to the number of pages. The plan of the original book has been scrupulously adhered to, and its scope remains unaltered. I have missed the kindly counsel and the matm-e judgment of my friend and teacher, without which the original of this work would not have been written. His absence from this revision is to be deplored; but I feel jiistifled in making the revision because there appears to be a demand for it, and because all the text of the jy PREFACE. original work came from my pi'ii except Chaptei-s XIV, XV, XVI, and XVII — on stone. One of these chapters I have left un- changed, out of respect to my former pai-tner ; the othei-s have been rewritten. The book as it stands is an honest exhibit of my views upon all the subjects considered. E, L. Keyes. 1 Park Aveme. New Vokk. Fehruanj, ISSS. PREFACE TO THE ORIGINAL TREATISE. The steady growth of the science and art of surgery has in- volved a corresponding increase in bulk of the text-books in which its principles and practice are set forth — an increase already sug- gestive of either a limit in bulk soon to be reached, or the omission or slurring over of special subjects. In this alternative the prepara- tion of text-books on special subjects would seem to be the appro- priate remedy. The tendency of mankind to aggregate in large and constantly- increasing cities has led to a corresponding tendency to the growth of specialists in the different departments of medicine and surgery ; and the development in large cities of hospitals and schools, and opportunities for teaching, would seem to render them the natural repositories of accumulating experience and the sources of advanc- ing knowledge. It is from city practice and hospital experience, therefore, that the materials for the preparation of text-books on special subjects would be naturally sought, and from these sources the substance of the present work has been mainly derived. Its object is to present to the student and general practitioner a suc- cinct account of the nature and treatment of the diseases incident to the genito-urinary organs as they are encountered in private and hospital practice by those engaged in their daily and especial study. The literature of this department of surgery has been carefully studied with the purpose of reproducing every fact of practical value. It is hoped that the reader will recognize a conciseness in the grouping of these facts which will save him the necessity of reference to the numerous monographs and essays from which they have been collected. On account of the general character of the work as a text-book, it has been impossible to refer very largely to personal authority and experience, and this has been for the most part avoided except in reference to mooted points and exceptional or noteworthy phe- nomena. The extent of the subject-matter treated of, and the ne- cessit}' for compression, will be regarded, it is hoped, as a sufficient vi PREFACE TO THE ORIGIXAL TREATISE. apology for terbcness ami directness of expression or defect in style, while the circumstance of joint-authorshij) will exjilain any lack of uniforinity in manner throughont the work, of which the prepara- tion for the press has devolvetl mainly upon the junior author. The plan of the work is based upon an anatomical classiiication of the tissues and organs of which the diseases and deformities form the subjects of description. This necessitates some repetition and frequent reference to facts, cases^ or illustrations already given, or to be given, in connection witii other anatomical divisions of the geuito - urinary tract. These references are usually made thus: (Nephralgia), (Plate XX), (Case 45), the page not being specified, as the constant appearance of signs scattered through a page tends to confuse the reader. No difficulty need be experienced in turning to these references promptly, as the parenthetical word, case, or plate may be found at once credited to its proper page in the gen- eral index at the end of the book, or in the index to plates, or list of cases, at its commencement. The terms of measurement employed are uniformly English, with the exception of the centimetre and millimetre, which fre- quently occur in the text. These may be readily reduced to tlicir equivalent in inches by computation from the subjoined table.* The subject of syphilis is included, of necessity, in a treatise like the present. Opportunities for the observation and study of this disease on a large scale fall mainly to the share of the metropolitan hospital-surgeon and special practitioner. Although properly be- longing to the department of Principles of Surgery, there is no disease falling within the limits of this work concerning which clear and correct ideas as to nature and treatment will, at the present time, so seriously influence success in practice. Chapter YIII, Part If, on " Syphilitic Diseases of the Eye," has been kindly furnished, at the request of the authors, by Prof. II. D. iSToyes, M. D., whose authority on this subject is undisputed. They beg leave to thank Dr. Eoosa for aid, both ju'rsonally and through his excellent work " On Diseases of the Ear," in the prep- aration of Chapter IX, Part II, " On Syphilis of the Ear." Aclcnowledgments are also due to Dr. Partridge and Dr. Morri- son-Fiset, of the house-staff of the Charity Hospital, for kind assist- ance ; and to Dr. L. A. Stimsou for aid in many ways. * 1 centimetre = 4'433 lines, or "oO^YOS inch ; 1 millimetre = -443 line, or -03937 inch; or, roudilj, 1 millimetre equals half a line — about one twenty-fifth of an inch. New York, June, 1S74. OOETTENTS, PART I. DISEASES OF THE GENITO-URINARY ORGANS. CHAPTER I. DISEASES OF THE PENIS. PAGE Anatomy.— Anomalies ; Double Penis; Absence of Penis.— Fracture, Dislocation.— Cutaneous AfEections.— Tumors.— Cancer.— Amputation of Penis.— The Prepuce ; Circumcision.— Phi- mosis ; Remote Results of Phimosis.— Paraphimosis.— The Glans Penis ; Herpes Progeni- talis, Balanitis, and Posthitis, Vegetations, Epithelioma.— The Corpora Cavernosa ; Inflam- mation, Ossification, Calcification, Gummy Tumor, Circumscribed Chronic Inflammation . 1 CHAPTER II. DISEASES OF THE URETHRA. Anatomy.— Natural Curve of the Urethra.— Proper Curve for Instruments.- Catheterism ; Ob- stacles to Catheterism in the Healthy Urethra.— Deformities of the Urethra ; Imperforation, Atresia, Hypospadias, Hermaphrodism, Epispadias.— Urethral and Sexual Hygiene.— Injuries of the Urethra.— Urethral Fever.- Foreign Bodies.— Polypi 30 CHAPTER in. DISEASES OF THE URETHRA. Inflammation.— Causes.— Subdivisions : Gonorrhoea ; Bastard Gonorrhoea ; Urethritis.- Symp- toms.— Duration.— Course.— Gleet.— Complications of Urethral Inflammation.— Treatment ; Method of performing Injection ; Abortive Treatment.— Methodic Treatment of Increasing Stage, including Description of Wrappings ; of Stationary Stage, including Chordee ; of Decreasing Stage, including Copaibal Erythema.— Gleety Stage ; Treatment of Gleet.— The Endoscope.— Rare Sequelse of Gonorrhoea 54 CHAPTER IV. COMPLICATIONS OF GONOERHCEA. Folliculitis.— Inflammation of Lacuna Magna.— Cowperitis.-Peri-urethritis.— Adenitis.— Lym- phitis.— Gonorrhoeal Rheumatism ; Hydrarthrosis, inflammatory : affecting Sheaths of Ten- dons ; Bursas.— Diagnostic Table of Simple and Gonorrhoeal Rheumatism.— Gonorrhoeal Ophthalmia.— Gonorrhosal Conjunctivitis.— Diagnostic Table of Gonorrhoeal Conjunctivitis and Gonorrhoeal Ophthalmia 82 CHAPTER V. STRICTURE OF THE URETHRA. Definition.— Varieties ; Muscular, Organic— Organic Stricture.— Form.— Xumber.— Seat.— Tlie Lesion in Stricture.- Causes.— Time of Occurrence of Stricture.— Irritable and Resilient Stricture 98 viii CONTENTS. CHAPTER VI. STRICTURE OF THE I-RETIIRA. PAOR Instnimcnts and (heir I'sc— Filiform Bougies with Mananivrcs alone, and as Guides.— Bougies. —Bulbous Bougies.— Catheters.— Sounds.— Scale.— Advantages of Steel Instruments.— In- struments for Divulsion with Manoeuvres.— Instruments for Internal Urethrotomy with 3Ia- nanivres.— Perineal Urethrotomy with and without a Guide.- Rectal Puncture.— Supra-pubic Puncture. — Uieulafoy's Aspirator 109 CHAPTER Vn. STRICTURE OP THE URETURA. Diagnosis.— Use of Bulbous Bougie.— Symptoms of Stricture and its Results as affecting the Urethra, Bladder, Kidneys, Testicles, Rectum, Nerves, etc., including a Consideration of In- filtration, and the Harmlessness of Healthy Urine in contact with the Tissues.— Causes of Death from Stricture. — Recapitulation of Symptoms and Effects of Stricture .... 130 CHAPTER VIII. TRE.\TMEXT OF STRICTUKE OF TUE URETHRA. With Details for all Complications, and a Recapitulation 146 CHAPTER IX. DISEASES OF THE PROSTATE. Anatomy.— Function.— Deformities.— Injuries. — .\trophy.— Hypertrophy.- Bar at the Neck of the Bladder.— Symptoms and Results of Hypertrophy. — Course of Symptoms from commenc- ing Irritability up to Retention, Atony, Stone, Uraemia, Death IC9 CHAPTER X. DISEASES OF THE PROSTATE. Hypertrophy (continued).— Diagnosis ; Description of Instruments and Manoeuvres cmploj'cd in their Use.— Examination of Patient.— Methods of retaining Catheters in the Bladder. —Meth- ods of deciding upon the Character and E.\tent of Prostatic Deformity as affecting the Course of the Urethra. — Treatment.— Treatment of Complications.— Interna! Remedies in Prostatic Disease.— Natural Mode of Death due to Hypertrophied Prostate . . .184 CHAPTER XI. DISEASES OF TUE PROSTATE. Congestion.— Parenchymatous Prostatitis.— Terminations : in Resolution, Chronic Prostatitis, Abscess.— Treatment.— Gonorrhoea! Prostatitis.- Prostatic and Peri-prostatic Abscess.— Treatment of all Forms of Abscess.— Follicular Prostatitis.- Its Liability to be mistaken for Stone in the Bladder. — Treatment. — Tubercular Prostatitis. — Cancer of the Prostate. — Pros- tatic Concretions.— Prostatic Calculi.- Neuralgia of the Prostatic Urethra.— Syphilis of the Prostate 205 CHAPTER XII. DISEASES OF TUE BLADDER. Anatomy. — Anomalies and Deformities, Exstrophy. — Hernia of Bladdcr.—Hypertrophy.— Atro- phy.— Wounds.-Rupture of the Bladder.— Foreign Bodies.— Retention of Urine. -Inconti- nence : in Children, in Adults.— Tenesnius.-Chorea.-HKmaturia.-Neuralgia of the Vesi^ cal Neck.— Cause.- Symptoms.— Diagnosis.- Treatment 218 CHAPTER XIII. DISEASES OF THE BLADDER. Acute Cystitis.— Gonorrhoeal Cystitis.— Diagnostic Table of Cystitis of the Neck and Prosta- titis.- Pathological Lesions in Cystitis.— Treatment.— Chronic Catarrh of the Bladder.— Atony of the Bladder.— Paralysis, Heterologous Deposits, and Tumors in the Bladder- Walls 243 CHAPTER XIV. STONE IN THE BLADDER. Materials of which Calculi are formed.— Causes of Stone, internal and external.— Number.— Size.— Shape.— Weight.— Degree of Hardness.— Possible Consequences of Stone, including CONTENTS. jjj PAOE Symptoms, Pathology, and Modes of Death.— Symptoms considered in Relation to Dia^o- sis and Selection of Mode of Cure.— Sounding.— Circumstances prejudicial to a Choice of Lithotrity 2C3 CHAPTER XV. TKBATMENT OF STONE OTHEU THAN JtADICAL. The Preventive Treatment of Stone.— The Electrolytic Treatment of Stone.— The Solvent Treatment of Stone, General and Local.— The Palliative Treatment of Stone .... 280 CHAPTER XVI. LITHOLAPAXY. Modem Improved Lithotrity.— Cases suitable for this Operation.— Instruments? used, and their Method of Employment.— After-treatment.— Complications.— Litholapaxy in Women.- Relapse 290 CHAPTER XVII. LITHOTOMY. The Lateral Operation.- Cases suitable for it.— Instruments employed.— Operative Method.— After-treatment.— The Lateral Operation in Children.— The Median Operation.— Cases suit- able for it.— Operative Method.— Complications of Lithotomy.— Relapse after Lithotomy . 297 CHAPTER XVin. SUPRA-PUBIC LITHOTOMY. Cases Suitable for the Operation. — Operative Method.— After-treatment 312 CHAPTER XIX. DISEASES OF THE URETERS. Anatomy.— Anomalies.— Chronic Inflammation.— Dilatation.— Stricture.— Wounds . . .310 CHAPTER XX. DISEASES OF THE KIDNEY. Anatomy.— Anomalies.— Floating Kidney.— Nephrorraphy.— Injuries.— Suppression of Urine.— Nephralgia.— Phosphatic Urine.— Oxaluria.— Gravel and Kidney-Stone.— Nephritic Colic— Nephro-lithotomy.— Pyelitis, Pyelonephritis, and Perinephritic Abscess.— Pyelitis. Patho- logical Lesions.— Causes.— Calculous Pyelitis.— Perinephritic Abscess,— Treatment of Pyeli- tis. —Hydronephrosis.— Kidney-Cysts.— Hydatids.— Tubercle.— Cancer.— Other Tumors of the Kidney.— Nephrotomy.— Nephrectomy.— Syphilis of the Kidney 317 CHAPTER XXI. DISEASES OF THE SCROTUM. Anatomy.— Injuries.— (Edema.— Emphysema.— Eczema.— Intertrigo.— Pityriasis.— Eczema Mar- ginatum.— Pruritus Genitalium.— Pediculi Pubis.— Phlegmonous Erysipelas.— Elephantiasis. —Tumors and Cancer of Scrotum.— Epithelioma 3,53 CHAPTER XXn. DISEASES OF THE TESTICLE. Anatomy. — Anomalies. — Cryptorchidism. — Luxation. — Hypertrophy. — Atrophy. — Injuries. — Hsema tocele.— Hematocele of the Cord.— Free Bodies in the Tunica Vaginalis . . .362 CHAPTER XXin. DISEASES OF THE TESTICLE. Hydrocele, acute, chronic— Diagnostic Table of Chronic Hydrocele with Incarcerated Hernia.- Palliative Treatment.— Radical Treatment.— Congenital Hydrocele.— Diagnostic Table of Congenital Hydrocele and Hernial Tumor.— True and Spurious Hydrocele of Hernial Sac- Encysted Hj-drocele of Testis.— Spermatocele.-Spermatic Congestion.— Origin of Sperma- tocele—Hydrocele of Cord, diffuse, encysted 374 X CONTENTS. CHAPTER XXIV. DISEASES or THE TESTICLE. PAOE Inflammation.— Orchitis.— C.iuscs.- Symptoms.— Pathologlciil Changes.— Prognosis. — Treat- ment.— Epididymiiis.-Frequency and Date of Appearance in Gouorrha'a.— Causes.— Symp- toms.— Sterility as a Kesnit of Epididymitis.— Diagnostic Table of Orchitis and Epididy- mitis.— Treatment of Epididymitis 388 CHAPTER XXV. DISEASES OF TUE TESTICLE. Psendo-tubcrcnlar Epididymitis.— Tubercular Testis.— Symptoms.— Pathology.— Treatment Sypliilitic Epididymitis.— Syphilitic Orchitis ; Interstitial ; Gnmniy.— Cancer.— Sarcoma.— Diagnostic Table of Syphilitic Testis, Tubercular Testis, Cancer, Sarcoma, including Diag- nostic Features of Different Fungi.— Castration.— Dermoid Cyst.— Irritable Testis.— Neu- ralgia Testis 406 CHAPTER XXVI. MALADIES INVOLVING TUE GENITAL FUKCTION. Impotence.— True Impotence, its Causes and Treatment.— False Impotence, its Causes and Treatment. — Sterility.— Masturbation.— Pollution, Nocturnal and Diurnal. — Spermatorrhoea. —Erotomania.— Satyriasis.-Priapism.— Aspermatism 427 CHAPTER XXVII. DISEASES OF THE CORD. Anatomy.— Spasm of Cremaster. — Varicocele, mild, severe 449 CHAPTER XXVIII. DISEASES OP THE VAS DEFEUENS AND SEMINAL VESICLES. Anatomy.— Inflammation, acute and chronic 455 PART II. CHANCROID AND SYPHILIS. CHAPTER I. CUANCROID. Definition.— Transmissibility to Animals.— Cause of Chancroid.- Indefinite Inoculability.— Rela- tive Frequency.— Methods of Conta£;ion.— Explanation of Apparent Long Period of Incu- bation. — Situation of Chancroid.— Symi)toins.— Course.— Character of Scar.— Variation of Chancroid from Tj-pe, in Initial Form, in Shape, in Number, in Size, in Duration, in Pain, in Condition of Base, in Course (Relapse).— Complication by Vegetations, by Syphilitic Chancre, by Inflammation, by Gangrene and Gangrenous Phagedena, by PuJtaceous Pha- gedena, by Bubo, by Lymphangitis.— Diagnosis of Chancroid.— Prognosis .... 400 CHAPTER n. CHANCROID. Prophylactic Treatment.— Local Treatment of Chancroid.— Local Treatment of Phagedena.— General Treatment of Chancroid. — Bubo ; simple; virulent. — Treatment of Bubo. — Lymphangitis ; simi)le ; virulent ; syphilitic. — Treatment of Lymphangitis .... 479 CHAPTER III. sypuiLis. Nature.- Unity and Duality. — Length of Time required for Absorption of Virus.- Analogy with Vaccine Virus. — Second Attacks of True Syphilis. — Transmissibility to Animals.- CONTENTS. XI PACK Incubation of Syphilitic Chancre.— Induration, parchment-like, split-jx^a, diffuse— Ulcer- ation.— Secretion.— Pain. — Nature of Scar.— Auto- and Iletero-rnoculution.— Vaccinal Syph- ilis. —Multiple Inoculation. — Fluids capable of transmitting SypliiliH by Inoculation.— Methods of Transmission of Syphilis. — Duration of Chancre.— Number.— Size.— Situation. — Form.— Symptoms of Urethral Chancre. — Course of Chancre. —Complications. — "Mixed Chancre." — Transformation mto Mucous Patch. — Phagedena and Gangrene. — Treat- ment of Chancre.— Syphilitic Bubo.— Lymphangitis 402 CHAPTER IV. SYPHILIS. Diagnostic Table of Syphilitic Chancre, Chancroid, Herpes, and Ulcerated Abrasion.— Of Syphi- litic Bubo and the Bubo of Chancroid.— Of Svphilitic Lymphangitis, and the Lymphangitis of Chancroid.— General Syphilis.— Secondary, Tertiary, Malignant, Irregular, and Inter- mediary Syphilides. —Prognosis of Syphilis. — Duration. —Influence of Gout and Scrofula upon the Course of Syphilis.— The Ten General Characteristics of Syphilides.— Concomitant Symptoms of Secondary Syphilis. — Secondary Incubation, Syphilitic Fever, Alopecia, Indolent Glandular Engorgement, Sore Throat, Analgesia 526 CHAPTER V. GENERAL TREATMENT OF SYPHILIS. Hygienic, Tonic, Specific Treatment. — Syphilization. — Treatment of Early Syphilis. —Bad Effects of Mercury.— Methods of administering Mercury.— Treatment of Late Syphilis.— Mixed Treatment.— Treatment by the Iodides.— Methods of administering Iodine in Syphi- lis.— Quantity of Iodide which may be required.— Duration of General Treatment . . . 5.50 CHAPTER VI. SITIIILIS OF SKIN AND MUCOUS MEMBRANES, Syphilides, Secondary and Tertiary.— The Secondary Syphilides.— Concomitant Symptoms on Mucous Membranes 5S3 CHAPTER VII. SYPHILIS OF SKIN AND MUCOUS MEMBRANES. The Tertiary Syphilides.— Concomitant Symptoms on Mucoits Membranes COO CHAPTER Vin. SYPHILIS OF THE EYE- The Lachrymal Apparatus. — The Eyelids : Chancre, Mucous Patches, Gummy Tumors, Ptosis. — The Conjunctiva.— The Sclera.— The Cornea.— The Iris ; Mydriasis ; Iritis, Varieties and Complications, acquired and hereditary. — Prognosis. — Treatment. — Vitreous Humor, Hya- litis. — Crystalline Lens, Cataract. — Cyclitis. — Choroiditis, exudative and atrophic. — ^Retini- tis. — Neuritis Optica. — Paralysis of Muscles.— Periostitis 609 CHAPTER IX. SYPHILIS OF THE EAR. Syphilis as affecting the External, Middle, and Internal Ear 631 CHAPTER X. STPHILIS OF SPECIAL TISSUES AND ORGANS. Syphilis of the Nails.— Dactylitis.— Syphilis of Tendons, Sheaths of Tendons, and Aponeuro- ses.— Syphilis of Muscle.— Syphilis of Joints.— Sj-philis of Bone.— Syphilis of Cartilage — Syphilis of Lymphatic Glands.— Syphilis of the Mammary Gland 633 CHAPTER XI. VISCERAL STPHILIS. Syphilis of the Vascular System.- Syphilis of the Respiratory System.— Syphilis of the Di- gestive System, including the Tongue and the Great Abdominal Glands.— Syphilis of the Peritonaeum, Thyroid, and Tliymus.— Syphilis of the Geuito-Urinary System . . . .647 xii CONTENTS. CHAPTER XII. STrnrLi9 of the nervous system. paqb The Lesions : Symptoms, Prognosis, Treatment.— Genoral Cliaraeteristics of Nervous Symp- toms in nil Cases.— Syphilis of x\u- Hrain.— Syphilis' of the Cord.— Syphilis of Special Nerves . . " COS CHAPTER XIII. INHEUITED SYPHILIS. Inheritance from either Parent, the other remaining sound.— Abortion due to Syphilis.— Date of Appearance of Symptoms.— Symptoms.— Visceral Syphilis.— The Syphilitic Countenance- Treatment of Inherited Syphilis C79 LIST OF ILLUSTEATIOI^S. FIGUnE PAGE 1. Transverse section of penis (flaccid) 2 2. Transverse section of penis (erect) 2 3. Forceps for circumcision 12 4. Method of reducing paraphimosis 18 5. Method of reducing paraphimosis 19 6. Method of reducing paraphimosis 19 7. Diagram of the urethra 31 8. Lacuna magna 32 9. Vertical section through glans and fossa navicularis 32 10. Transverse section of spongy urethra 32 1 1. Transverse section of prostatic urethra 32 12. Proper curve for conical urethral instruments {o, b) 34 13. Faulty curve («, 6) 34 14. Proper curve 34 15. Passing the sound, first position 35 16. Passing the sound, second position 36 17. Passing the sound, third position 36 18. Passing the sound, fourth position 37 19. Conical-pointed, hard-rubber syringe 65 20. Conical-pointed glass tip for syringe 66 21. Keif'er's hard-rubber syringe nozzle 67 22. Soft-rubber universal injector 67 23. Rubber-capped glass pipette 69 24. Syringe for deep urethral injections 78 25. Linear stricture of the urethra 102 26. Annular stricture of the urethra 102 27. Soft catheter for introduction on two-foot guide 110 28. Soft catheter, with screw-tipped guide 110 29. Tips of whalebone guides 110 30. Banks's whalebone bougies Ill 31. False passages in the urethra Ill 32. Olivary bougies, properly made {A) 112 32. Olivary bougies, improperly made {B) 112 33. Head of bulbous bougie 113 34. Otis's urethrometer 113 35. Silver catheter - 114 36. Bumstead's catheter, with whalebone guide 114 37. Conicity of steel sounds 115 38. Conical tunneled sound = , 115 39. American and French scales 116 40. Thompson's rapid dilator 118 xiv LIST OF ILLUSTRATIONS. FIGUUE PAGE 41. Civialo's uretlivotonie 120 42. lliiisonncuve's uictbrotonu', Buinstiad's modification 121 43. Maisonneuve's urethrotome, Voillemior's moditicatiou 121 44. Otis's dilating urethrotome 122 45. Blunt grooved staff for perineal section 123 46. Blunt grooved staff for perineal section, with guide 1 28 47. Goulcy's cathcter-staif 123 48. Dieulafoy's small aspirator 127 4y. Soft-rubber tube to be worn in suprapubic puncture 129 50. Silver tube to be worn in suprapubic puncture 131 51. Pocket at inferior commissure of the meatus 132 52. Dilatation of urethra behind stricture 133 53. False passage 155 54. Hvpertrophy of the prostate, with false passage ' 173 55. Hypertrophy of upper portion of prostate 174 56. Posterior median hypertrophy 176 57. Posterior median hypertrophy 177 58. Healthy prostate 177 69. Sacculated bladder 179 60. Long-curved silver catheters 185 61. Thompson's curve for soft catheter 187 62. Mcrcier's catheter coudec (A) 188 82. Mercier's catheter bi-eoudee (B) 188 63. Soft-rubber catheter 188 64. Otis's stylet 189 65. Keyes's stylet 189 66. Squire's vertebrated catheter 190 67. Gross's spiral catheter.. 190 68. Mercier's false-passage catheter 190 69. Thompson's stone-searcher 191 70. Posterior median prostatic hypertrophy 192 71. Harrison's bulbous bougies 193 72. Rubber bag for vesical injection 197 73. Fountain syringe, with two-way stop-cock 197 74. Rubber urinal 199 75. Urinal for exstrophy of the bladder 224 76. Thompson's searcher 277 77. Mercier's sonde coudce 277 78. Bigelow's lithotrite 291 79. Jaws of Bigelow's lithotrite (open) 291 80. Jaws of Bigelow's lithotrite (closed) 291 81. Wheel of Bigelow's lithotrite 292 82. ReHquet pattern of lithotrite jaws 292 83. Bigelow's wash-bottle 293 84. Keyes's straight tube for washing bladder 29 1 85. Keyes's curved tube for washing bladder 294 86. Staff for lateral lithotomy 299 87. Scalpel for lithotomy 299 88. Blizard's knife (English pattern. A) 299 88. Blizard'.s knife (American pattern, B) 299 89. Blunt gorget 299 90. Scoop 299 91. Lithotomy forceps, straight, with crossed handles 300 LIST OF ILLUSTIIATIONS. XV FIGURE j,^„j. 92. Lithotomy forceps, curved, with crossed handles 300 93. Metallic tube, with obturator 300 94. Ilevcrse-flow tube, with globular head 300 95. Shirted cannula 30i 96. Keith's tenaculum ;jC,] 97. Pritchard's anklets and wristlets ;if)l 98. Bony outlet of the pelvis 302 99. Diagrammatic outlet of the pelvis 303 100. Markoe's median lithotomy staff 309 101. Little's median lithotomy staff. 309 102. Little's director 399 103. Petersen's rectal colpeurynter ,013 104. Cancer of the kidney in a child 349 105. Pediculi pubis 359 106. Section of haematocele 371 107. Section of hydrocele 377 108. Simple hydrocele with hernia 378 109. Congenital hydrocele with congenital hernia 383 110. Cupped sound 444 111. Modification of Reverdin's varicocele-needle 4.54 112. Fumigator 5gg 113. Berg's case of syphilitic dactylitis 635 114. McCready's case of syphilitic dactyhtis 636 PART I. DISEASES OE THE GENITO-URIMRY OEGAXS. CHAPTEE I. DISEASES OF THE PERIS. Anatomy. — Anomalies ; Double Penis ; Absence of Penis.— Fracture, Dislocation.— Cutaneons Af- fections.— Tumors.— Cancer.— Amputation of Penis. — The Prepuce ; Circumcision. — Phimosis ; Remote Results of Phimosis. — Paraphimosis. — The Glans Penis ; Herpes Progenitalis, Balanitis, and Posthitis, Vegetations, Epithelioma. — The Corpora Cavernosa ; Inflammation, Ossification, Calcification, Gummy Tumor, Circumscribed Chronic Inflammation. The penis is a genital organ. Its urinary function is purely sec- ondary. It is conformed anatomically to subserve the genital function. In the adult it measures, when at rest, from the root of the scrotum to the meatus urinarius, from two and a half to four inches ; when erect, from five to seven inches. It consists essentially of three seg- ments — the two corpora cavernosa, lying together like the barrels of a gun, and the corpus spongiosum — like the ramrod — beneath them, the whole surrounded by integument. The Corpora Caveristosa arise on either side from the tuberosi- ties and ascending rami of the ischium. They come together under the symphysis pubis, and continue side by side, forming the main bulk of the penis. They terminate anteriorly in a conical extremity, over which the glans jDcnis (the terminal expansion of the corpus spongiosum) fits like a cap. There is no vascular communication be- tween the tissue of the corpora cavernosa and that of the glans penis, nor with that of any part of the corpus spongiosum. Each corpus cavernosum is surrounded by its own fibrous sheath — tunica albuginea — which, together, are so dense and strong that they will support the weight of the cadaver without giving way.* The * Cruveilhier, "Traite d'Anatomie descriptive," Paris, 1S65, vol. ii, part i, p. 386. 1 DISEASES OF THE PENIS. sheath is, however, plentifully su}i})liod with clastic fibers, which allow it to accommodate itself to the variable size of the organ. The parti- tion between the corpora cavernosa is perforated by numerous aper- tures, to insure thorough and symmetrical erection. The tissue projier of the corpora cavernosa is known as spongy, or erectile. Erection takes place when thcarooh-e of this tissue become distended with blood, as shown in Fig. 2. TuE Corpus Spoxgiosum URExnR.E is also comiioscd of erectile tissue. It surrounds all that portion of the urethra lying in front of the triangular ligament, anteriorly forming the cap over the conical ex- trenfity of the united cor2)ora cavernosa — known as glans penis — posteriorly terminating in the bulb, which lies just in front of the triangular ligament in the angle of the converging crura i)enis. The Glans Pexis is covered by a semi-mucous membrane endowed with peculiar sensibility, especially around the raised posterior border — the corona glandis. The epithelium covering the glans is line ; the papillae minute (Home) ; the sebaceous glands (of Ty- son) large and numerous, and most jalentiful about the fra^ium. These glands secrete the white, badly-smelling material which collects, in uncleanly persons, behind the corona. The func- tion of the glans penis is to furnish a soft-skinned expansion for the distri- bution of the terminal filaments of the nerves of sexual sensibility. One important function of the cor- pus spongiosum is acquired through its bulb — namely, that of assisting in the expulsion of the last drops of urine or semen from the urethra. The prostate, levator ani, and deej) urethral muscles — especially the compressor iTrethrai — contract upon the fluid remaining in the canal after micturition, in that spasmodic etfort called by the French the "coup de piston." This forces the last few drops beyond the bulb of the urethra. Now the middle fibers of the accelerator urinoe — those which surround the bulb and adjacent portions of the corpus caverno- sum — contract and forcibly drive the blood, which was contained in the areolae of the bulb, forward along the corpus spongiosum, forcibly distending that body, and thus bringing the walls of the urethra more closely into contact in a progressive wave. This helps to explain, as 1 1 t;V*^^%v.i:r \\&v~!v w^^^^^^ Figs. 1, 2 (Cruveilhier). Transverse Section of Penis.— Fig. 1. Flaccid. Fig. 2. In erection. 1,2. Dor- sal vein and artery. 3. Erectile ti.ssiie. 4. Tunica albuginea. 5. Integument. C. Tunica albugmea of corpus spongi- osum. 7. Erectile tissue. 8. Urethra. BUCK'S FASCIA. 3 shown by A. Gucrin,* why the last few drops of urine do not escape promptly, but dribble away in cases of organic stricture of any severity ; for, with such a stricture, the areola) of the erectile tissue become more or less obliterated at the constricted point, and Ein obstacle is formed to the free passage of the wave of blood forward along the corpus spongiosum. The three erectile bodies which have been briefly described arc sur- rounded by the sheath proper of the penis — a membrane important in its pathological relations, and sometimes known as Buck's fascia, from the distinguished surgeon who first accurately described it. f This fascia may be said to arise from the linea alba and symphysis pubis by a tri- angular bundle of fibers known as the suspensory ligament of the penis. The fibers spread out upon the corpora cavernosa, extend over the conical head of these two bodies, and are at this point firmly attached to the under surface of the glans penis, which may be removed entire with the fascia. The sheath, after encircling the corpora cavernosa, splits into two layers, to embrace and form a sheath for the corpus spongiosum. The fascia is attached behind along the rami of the pubes, and is identical with the deep layer of the superficial fascia of the peri- nasum, curving under the transverse muscles, and finally losing itself in the anterior layer of the triangular ligament. The cavity of this fascia is bounded anteriorly by the under surface of the glans penis, and pos- teriorly by the triangular ligament. Its boundaries have a practical bearing upon the burrowing of infiltrated urine. Urine may escape out of the urethra, and yet be prevented by this fascia from passing the limits above described for an indefinite time, unless Eichet J is correct in stating that, at the root of the penis above, the fascia can not be distinguished from that covering the pubes — that it is here loose in character — and that urine may escape at this jDoiut out of the sheath into the areolar tissue of the abdominal wall. The lymphatics and veins of the penis run along the dorsum of the member, and receive in their course branches from the corpus spongio- sum, which encircle the penis between the folds of Buck's fascia. The lymphatics lead mainly to glands lying along and above Poupart's liga- ment on either side. The arteries come from the internal pudics. The connective tissue which attaches the integument of the penis to the fascia is very loose and elastic, and, like that of the eyelids, does not contain fat. The skin of the penis, except that it tends to become pigmented af- ter puberty, does not differ essentially from ordinary integument. Over the glans penis it folds back upon itself, forming a non-adherent sheath for the glans (the prepuce), evidently intended to preserve the delicate sensibility of this portion of the member. * "Des Retrecissemcnts du Canal de I'Uretre." Mem. de la Soc. de Chir., vol. iv, 1857. f " Trans. Am. Med. Ass.," vol. i, p. 367. X "Traite d'Anatomie Medico-Chirurgicale," Paris, 1873. 4 DISEASES OF THE PENIS. The Prepuce is composed of two layers, a cutaneous (external), and a more delicate semi-mucous (internal). The point of junctiou of these two is called the orifice of the prepuce. Between these layers is a very loose aaid elastic connective tissue, without fat, which allows the two surfaces to be entirely sciiarated from each other, and the pre- puce effaced, by drawing back the integument of the penis until the glans is entirely uncovered. The mucous layer of the prepuce is sup- plied with the glands of Tyson. It is much less clastic than the cutane- ous layer. The prepuce is attached to the lower angle of the meatus urinarius, or orifice of the urethra, by a triangular fold of mucous membrane called the frajuum preputii — analogous to the fra?uum lingua?. ANOMALIES OF THE PENIS. Deformities of the penis are constituted by abnormalities in some of its constituent parts. The most common examples will be men- tioned in connection with these parts. As anomalies of the penis, two conditions demand especial notice — double jjenis and absence of the penis. Anomalies in size occur, as when the penis is nine or ten inches long when at rest, or only a couple of inches long when erect ; but these variations are very uncommon. Double Penis is excessively rare. It is analogous to double uterus and vagina in the female, but by no means so common. Undoubtedly it is not so uncommon as the records of surgery would seem to imj^ly, for the existence of this deformity is naturally accompanied by an ex- cessive sensitiveness on the part of the patient which leads him to shun observation and comment ; and, as the defect is not necessarily accom- panied by any symptoms affecting the general health injuriously, the patient does not voluntarily subject himself to the inspection of a phy- sician, and thus keejis himself out of the books. Case I, reported by the authors, exemplifies this fact, and chance alone allows it to be placed on record. A case of this anomaly is reported by Mr. Ernest Ilart* (with sev- eral plates of the imticnt in different positions), in the person of a well- formed, healthy man, the victim of a monstrosity by foetal inclusion. Between his thighs there gi-ew a third thigh, terminating in a leg and double foot, all small and deformed. In front of this thigh there was a shrunken, empty scrotum, bordered on either side by a well-devel- oped scrotum, each containing one testicle. The joenis was double, each organ being well formed and perfectly developed. They were both in proper j^osition, each measuring four and a half inches when pendent, being larger than normal. The left was the larger in cir- cumference, and appeared to have become so by being used in j^refcr- ence to the other. Both became erect at the same time under excite- * London "Lancet," January, 1866, p. 71. ACCIDENTS TO THE PENIS. 5 ment. The urine or the semen, as the case mif(ht be, was discharged simultaneously by both organs. In the first edition of this treatise was published a typical personal case of double penis in a man of forty-two, who presented no malformation except the possession of two well-formed virile members, one of which was imperforate, its urethra opening at tlie peno-scrotal angle, A case of double penis is reported by Alan P. Smith.* The patient had a stone in one of his bladders, was^ut and cured. He could pass water from either bladder at will. Paetial Development of the Penis. — The penis is sometimes defective in some of its parts, which leads to a more or less pronounced twisting of the organ. This deformity is generally accompanied by other defects (hypospadias). Absence of the Penis. — A case of congenital absence of the penis has been observed by Nelaton.f The scrotum was well developed, and contained testicles. The child urinated through the rectum. Another similar case has been reported by Goschler. J Eevolat * has still an- other. Bouteillier || reports an infant seemingly without penis. Un- der the skin above the scrotum a movable body was felt. This was liberated by incision and proved to be a rudimentary penis. ACCIDENTS TO THE PENIS AS A WHOLE. Contusions. — The escape of blood under the skin in superficial contusions of the penis is often excessive, on account of the laxity of the connective tissue and the large size of the superficial veins. Deeper contusions give rise to localized swelling from circumscribed effusion of blood. This swelling fluctuates, increases in size on erec- tion, and deforms the penis more or less, causing it sometimes to devi- ate from its natural direction. OiDening into such a collection of fluid is not to be thought of, as it might give rise to suppurative inflamma- tion. If the contusion be severe enough, inflammation of the corpora cavernosa results, ending in suppuration or gangrene. Severe con- tusions involving the urethra may lead to infiltration of urine and loss of substance, with urethral fistula. The penis is sometimes introduced by a patient into a ring. The penis swells, the patient is ashamed to seek relief, and serious inflam- matory mischief — even gangrene, urinary fistula — may ensue. This ac- cident is rather a classical one. G-uillot in such a case, where the ring was of gold, conceived the happy idea of dissolving it in a bath of mer- cury. Demarquay narrates many curious instances of similar charac- * " Trans. Med. and Chir. Faculty of Maryland," April, 1878. f "Gaz. des Hop.," January 28, 1854. J " Vierteljahrschrift fur practische Heilkunde," Prag, part iii, 185*7. * " Journal de Sedillot," tome xxvii, p. 3Y0 ; and Demarquay, " Maladies Cliirurgical du Penis," Paris, 1877, p. 538. II " Union m^dicale de la Seine inferieure," xl, 1875, p. 27; and Demarquay, op. cif., p. 539. C DISEASES OF THE PENIS. tor where tlic surgeon has been eallod to get the penis out of some very extraordinary positions. Treatment of contusion consists in combating inflammation, em- ploying cokl,- cYai)orating, astringent lotions ; later, perliai)s, com- pression, and in giving the absorbents time to remove the effusion. AVouxDS. — The penis is liable to be -wounded by accident or design. In the latter case insanity, or the melancholy depression often attend- ing the loss of self-respect produced by masturbation, is usually at fault, and induces the patient to mutilate himself ; or the injury may be inflicted by a woman, jealousy being the motive. Superficial cuts are unimportant ; but woiinds extending within the sheaths of the corpora cavernosa may give rise to troublesome, possibly fatal haemorrhage, while the cicatrices left after healing may distort the penis and render erection imperfect and painful. In a case of traumatic aneurism of the penis following a cut by a knife, Malgaigne * had to tie the dorsal artery. Treatment. — Clean the wound. If a large artery is spirting, tie it, but let the oozing points alone. Join the edges as accurately as pos- sible with points of fine suture not introduced deeper than through the fibrous sheath. Employ moderate pressure in dressing. Erections, which are sure to occur since the local inflammation induces an influx of blood, always retard healing. Even in cases seemingly desperate, where the penis has been almost wholly severed from the body, an attempt should be made to save it. A remarkable success in a case of this sort, where the whole penis was severed, except a portion of one corpus cavernosum, is related by Ar- taud.f It is not probable in such a recovery that the erectile power is- restored. (For injuries involving the urethra, refer to diseases of that canal.) FEACTUBK OF THE PENIS. When the fibrous sheaths of the corpora cavernosa are ruptured by sudden forcible flexion of the erect penis, a sort of fracture of the member is produced, with extensive extravasation of blood — sometimes amounting to traumatic aneurism. Pain, generally present as a symp- tom, is sometimes replaced by a sensation of heat, distention, and weight. Tlie late Valentine Mott J reported two interesting cases of this accident, where the only treatment employed was rest and cold locally. Both cases recovered with a useful organ and no deformity. n. A. Veazie * reports a case of complete fracture of the penis during intercourse. Demarquay has cited many others. •-•• " Revue Mcdieo-Chir. do Paris," July, 1850, p. 52. f "Bull, de la Soc. de Chir.," vol. vii, p. 451. X '•Transactions of the New York Academy of Medicine," vol. i, part i, 1851, p. 99. * "New Orleans Medical and Surgical Journal," 1881. DISLOCATION OF THE PENIS. 7 Treatment. — A silver or stout woven catheter, strong enough to resist lateral comj)ression, is first passed into the bladder to insure the patulousness of the urethra when the degree of swelling threatens closure. Upon this the penis may be compressed with adhesive straps and cold applied. A risk to the patient in this condition is that ex- cessive tension from internal hasmorrhage may arrest circulation and produce gangrene — a very rare accident — or damage miglit come from urinary infiltration when the urethra is involved, as in Dittel's case. In the latter contingency, prompt and free incision is indispensable ; with threatened gangrene, antiseptic incision would be justifiable, the bleeding-point being controlled by ligature or cautery. When the swelling is not excessive, an evaporating lotion is all that is required, and in from three to eight weeks the patient is usually well. After recovery an indurated spot may remain to mark permanently the site of the injury, making erection perhaps imperfect or painful, and interfering with sexual intercourse. PRACTUBE OF THE CORPUS SPONGIOSUM. The corpus spongiosum alone may be fractured. This is generally occasioned by ''breaking the chordee" in gonorrha3a by violently straightening the organ during erection. The inflamed tissue gives way, yielding urethral haemorrhage as an immediate and traumatic stricture a remote result. The healthy corpus spongiosum may be fractured during erection. Dittel* gives such a case. The authors have seen another, f DISLOCATION OF THE PENTS. In violent contusions involving the jDenis, particularly when the integument is dragged upon, as, for instance, when the clothes are caught and torn away upon a revolving wheel, the whole penis may be shot out of its investing cutaneous sheath and lodged in the scrotum, perinffium, groin, or under the integument of the abdomen, according to the direction of the force. In such cases the semi-mucous mem- brane of the prepuce gives way either at the preputial orifice or just behind the corona. A number of instances of this curious luxation have been recorded. The penis is usually not discovered until reten- tion of urine or the passage of urine by some opening at a distance from the preputial orifice directs attention to the contused genitals, when the penis is found to be only a sheath of integument containing clotted blood. Sometimes it has been difficult to find the penis at all ; but an intelligent search will always reveal it, and then the surgeon's obvious duty is to replace it in its sheath, incising the integument about the root of the sheath as far as may be necessary to attain the desired result. * " Wien. med. Blatter," 1885, No. 2. f "Van Buren and Keyes," first ed., p. 7.. 8 DISEASES OF THE PENIS. In dislocation tlie urethra is often ruptured low down, and, after the organ has been replaced in its sheath, external perineal section without a guide nuiy bo called for, an operation particularly suitable in view of the traumatic stricture which is inevitable. In this wa}' the continuity of the canal is restored. In one case in an infant of six years, Xelaton * reduced a dislocated penis through the preputial oritice by means of Coo2)er's aneurism needle, assisting its hook-action by external manipulation. CUTANEOUS AFFECTIONS OF THE PENIS. ilany ordinary cutaneous aflfections also involve the integument of the penis. Venereal ulcers are very common here. Elephantiasis usually invades the scrotum primarily. In phlegmonous erysipelas early and very extensive parallel incisions in the long axis of the organ may be necessary to prevent gangrene of the skin and extensive denu- dation of the penis. LYMPHATIC AFFECTIONS OF THE PENIS. Inflammatory lymjihangitis may complicate a Yariety of lesions. The venereal varieties will be described in their projDer i^lacc. Simple inflammatory lymphangitis behaves like a mild erysipelas and needs no description. It may occur spontaneously, but most often complicates gonorrhoea or chancroid. It yields to local cooling and astringent lo- tions. Occasionally it goes on to a gelatiniform oedema quite dense and hard, a sort of false elephantiasis, affecting chiefl}^ the prepuce, and this condition again is sometimes complicated by little solid promi- nences, which are fistula communicating with the lymphatic plexus. Sometimes they discharge sero-pus. They may be cured by excision. The lymi^hatic vessels of the penis are sometimes found dilated as a result of no obvious cause. I have seen quite a number of these cases, the dilated vessel being thin-walled, translucent, and varying in size up to a half-inch in di- ameter. I have seen the dilated vessel encircle the i)enis behind the corona, and at other times have noted its track for a short distance lat- erally along the penis, and I have noted it as an oval cystic pouch hanging from the end of the prepuce. I have never attempted to cure a case, as there were no symptoms. Demarquay f has an interesting section upon this subject. Ilugier J gives an example where there were several dilated trunks which yielded pure lymph on puncture. Bean in such a case passed a seton, left it in a few minutes, and accomj)lished a cure by adhesive inflammation. A case reported by Friedrich is quoted by Busey,*' where, after chan- * "Gaz. des H&p.," 18.50, p. 341. f Op. cU., p. 306. X " Bull, dc la Soc. de Chir.," 1851-'') 2, p. 592. * " Congenital Occlusion and Dilatation of Lymph Channels," New York, 1878, p. 175. TUMORS OF TUB TENIS. 9 croid, the inguinal glands inflamed and the penis became turgesccnt. A dull-white, whoy-likc vessel appeared around the base of the corona glandis, receiving a number of other anastomotic vessels, and termi- nating in a median large trunk on the dorsum penis. Peri -glandular suppuration occurred in the groins, the abscesses were opened, and with the healing of the latter the enlarged lymphatic trunks gradu- ally disappeared. TUMORS OF THE PENIS. Fatty, fibrous, cystic, erectile, melanotic, and other tumors are occasionally, but very rarely, found on the i^enis. Their removal is a question of Judgment involving a recognition of the function of the penis as an intromittent organ, and the possible loss of this function from the formation of cicatrix. Cancee of the penis, except epithelioma, described under diseases of the glans penis, is exceedingly rare. The medullary variety is some- times seen, especially in boys, following injury of the part. It grows rapidly in a lobular form, unequally in the corpora cavernosa. It in- volves the glans, and sprouts out under the prepuce. The veins of the penis become larger and tortuous. The distention of the common fibrous sheath of the penis, by the rapid growth of the new formation within it, may compress the urethra, and make retention of urine im- minent, calling for external perineal urethrotomy to relieve the blad- der, as occurred in a case of a boy under the charge of Dr. Weir,* at St. Luke's Hospital, in this city. The pain of this form of cancer is severe. Some of the bulging prominences along the penis are very soft, and give a fallacious impression of fluctuation, which is very marked. Local heat is increased, and, as the disease may develop not long after injury to the part, the question of suppuration of the corpora cavernosa may present itself to the young surgeon. The inguinal glands soon become involved, the patient emaciates rapidly and dies. Prognosis is the worst, and amputation, the only resource, is not to be thought of, unless the growth be very recent, and involve only the fore part of the member. Eelapse would even in such cases be almost inevitable. Cutaneous horns of large size have been found upon the penis growing from the glans or the integument. Brinton, of Philadelphia, has described a curious case, referring in his article to all previously recorded instances of the affection, f Consult also Demarquay. J AMPUTATION OF THE PENIS. In amputating the penis, as much of the organ should be spared as possible. If it is divided too near the root, it will retract behind the * " American Journal of the Medical Sciences," April, 1876, p. 407. f " Medical News," Philadelphia, August, 18S7. % Op. cit., p. 326. 10 DISEASES OF TUE PEXIS. sympli3'sis, unless care be taken to prevent it, and render it diflScult to control haemorrhage. Therefore, where the section must be low, a stout ligature may be passed behind the proposed limit of operation, through some part of the sheath of the penis, as a preliminary step, before cutting into the corpora cavernosa, or the root of the penis may be transfixed by two long acujnincture needles passed at right angles. When amputation is made low down, the urethra should be dissected loose toward the bulb, and brought out into the perineum behind the scrotum to guard against soiling the clothes during urina- tion. Only under rare conditions is partial amputation of the penis al- lowable. It may sutUce where cancer is confined to the glans penis, but generally the whole organ has to be sacrificed if any amputation is performed. For partial amputation, the skin should be incised at a point somewhat lower than it is desired to divide the body of the penis, as the latter shrinks after section. The corpora cavernosa should be severed with one stroke of the knife. The haemorrhage is free, and many spirting points will require ligature. The arteries are liable to retract into the tissue of the corpora cavernosa, and the for- ceps must be slender-pointed and grasp well to seize them. Some- times they can not be pulled out. Pressure and cold will arrest ooz- ing, but some persulphate of iron should be at hand to be used if necessary. If there is tissue enough, the urethra should be divided about half an inch in front of the point of j)roposed section as the first step of the operation after dividing the skin. When all bleeding has been quieted, the urethra is slit into two equal lateral flaps, and these are united by many points of fine suture to the skin, over the corpus spongiosum, on either side. In case there is not enough tissue to spare, the expedient of Mr. Teale* may be resorted to, which consists in slitting the under surface of the uretlira after amputation, to the extent of about two thirds of an inch, and uniting the mucous mem- brane to the skin on each side of the slit by suture. If the urethra is not especially attended to, stricture of a very serious character is sure to follow cicatrization. If the precaution has been omitted at the time of operating, and stricture has resulted, it may be dealt with subsequently by Teale's method. Galvano-cautery may be employed in amputation of the penis, or the ecraseur of Chassaignac, or Maisonneuve's modification with a stout wire, and the urethra treated by Teale's method. After the ecraseur, however, sharp bleeding will sometimes come on in a few hours. As a rule, each of these latter methods is comparatively blood- less, but after any operation there may be recurrent hremorrhage shortly, accompanied by a tendency to erection. Properly applied pressure will arrest it. An excellent historical chapter upon ampu- * " ilcdical Times and Gazette," vol. xix, p. 354. THE rREPUCE. 11 tation of the penis is given by Louis Jullicn* in ]iis '^Tlicsis." Cu- badc has contributed f some points. When it is desired to remove the entire penis, including the bulb of the urethra, the method first used by Delpcche (1832), then by Lallemand, Roux, and Bouisson, is a good one, namely, as a first step in the operation, to split the raphe, inclosing one testicle in each half. Then Cabade's process may be employed, making a houtonniere in the membranous urethra^ incising the integument above and around the root of the penis, and taking ofl: each crus penis separately with the ecraseur passed through the boutonnure between the crura penis. Of course, if the bulb and a portion of the urethra can be spared for trans- plantation in the perinseum, so much the better. In such case a por- tion of the sides of the scrotum may be united above the orifice of the transplanted urethra in such a way as to form nymphse in front (as Howe has called them), which during urination direct the stream downward and backward. Howe first did this ; later. Fowler J of Brooklyn. Instead of using the ecraseur upon the crura sejoarately, it is more surgical, but more difficult on account of hasmorrhage, after sjDlitting the scrotum and separating the urethra, to dissect out each crus penis separately, and remove it entire from its insertion along the ischial and pubic rami. With forcipressure forcejos this manoeuvre is perfectly practicable, and the amputation of the penis thus becomes complete. The inguinal glands, if implicated, should be removed. THE PEEPXTCE. Defoemities. — Practically, the deformities of the foreskin (phimo- sis and atresia of the orifice excepted) are unimportant. The prepuce is sometimes bifid, enlarged into a pouch, redundant, projecting half an inch or more beyond the apex of the glans, or only rudimentary from arrest of develojiment. Between the two latter limits it may be of any length, covering more or less of the glans. When the prepuce is deficient, the epithelium of the uncovered glans penis becomes hard and tough, more nearly resembling ordinary cuticle. Under these circumstances the sensibility of the part is diminished, but, at the same time, it is rendered less liable to become excoriated or to take on inflammation. Hence, absence of the prepuce is not to be re- gretted, and the operation for its restoral, postheoplasty, need not be touched upon. Dieffenbach performed it once on account of neu- ralgia of the glans penis. Excessive length of the prei)uce may demand operative interfer- ence. Moderate length alone, however, can hardly be said to consti- tute a defect, and may be left unmolested unless complicated by induration, thickening, or a contracted preputial orifice (phimosis), * Paris, 1873. f " Bull, de la Soc. de Chir.," tome iv, 187S, p. 500. X "Annals of Anatomy and Surgery," September, 1881, p. 102. 12 DISEASES OF THE PENIS. or, unless it becomes troublesome, by getting constantly inllamccl, or occasions and keeps uj) balanitis. Great length of the prepuce is some- times the result of constant traction, as in children with stone. CIRCUMCISION. In this operation the orilice of the prejiuce, with more or less of its mucous and cutaneous layers, is cut away. According to Hebrew chronologists, circumcision was instituted as a religious rite by Abra- ham in the year of the world 2059 — nineteen hundred and forty-one years before Christ. Several Eastern nations still practice it as a hygienic measure. The chosen people preserve the custom as a re- ligious ceremony, performing it on the eighth day. Few operations in surgery have received more modifications than this simple one of ablation of the prepuce. The indication is to re- move the orilice of the prepuce and all redundant tissue, and to insure looseness of what is left. This may be accomplished as follows : If phimosis exists, first insert a well-oiled probe into the preputial cul-de-sac, and with it sweep the entire surface of the glans to detect adhesions and break them up, if they are not too firm. Then mark oflf with an aniline pencil the limits of the integument which it is proposed to remove. This line should follow the curve of the corona glaudis at a short distance in front of it, while the member is lying at rest. !Evow seize the redundant ^Dre- puce laterally on both sides, and draw it forward until the circumcision forcej^s can be locked in such a manner upon the redundant integument that the aniline line shall lie just in front of the closed blades, taking care not to include the tip of the glans in the grasp of the forceps. To do this the forceps must not be applied transversely to the long axis of the ]ienis, but obliquely, and sometimes it is necessary to roll the integument a little forward and not to catch the preputial orifice as a point of traction in order to get the aniline line outside of the forceps. With scissors curved on the flat, the outlying portion of prepuce may now be cut away. This method of operating removes two dangers. The aniline line insures a removal of exactly that portion of integument which it is desired to take away, and the possibility of cutting away a band of integument of in- definite dimensions is averted. Moreover, a loose oval orifice is insured for the new prepuce, and the narrow, circular, con- stricting band of cicatrix, sometimes left by the old operation to re- new the deformity after healing, becomes impossible.* Furthermore, * I have more than once been called upon to relieve by operation a phimosis resulting from a former operation (Keyes). circumcision. CIIICUMCISION. 13 by so placing the forceps, the frcnum and its artery arc generally spared. Fenestration of the forceps is not desirable, because the mu- cous membrane has to be cut away, and sutures should not be placed until this has been done. After the forceps has been removed, the inner layer of the prepuce is to be slit down to the corona upon the dorsum of the glans, and the entire mucous membrane to be trimmed away on either side up to the frenum, leaving only enough tissue to serve to hold the sutures. The redundant tissue about the frenum is appropriately trimmed, bleeding points attended to by pressure or torsion, and, if necessary, to insure thorough looseness of the raw border of the integument, a liberating incision is made directly down the dorsum of the penis, for a quarter of an inch or more. It may be necessary to dissect away old adhesions between the mu- cous layer of the prepuce and the glans penis, but they will generally tear. Ligatures are rarely necessary. When required, fine catgut may be used, but it is better, rather than to use ligatures, to catch bleeding points in the grasp of the final horse-hair sutures, so that the same traction which unites the wound may also constrict the bleeding point. The wound may be washed with a mild bichloride solution, but such disinfection does not seem to be necessary ; primary union seems always to occur. In the infant no suture is required. The parts coapt naturally, and healing is accomplished usually in about forty-eight hours. In the adult healing is greatly facilitated by numerous sutures to keep the cut edges in apposition, for the operation usually produces a tendency to erection, and erection disturbs the relation of the j)arts. Erection does not, however, interfere with healing in the least, if the oval line of incision is very loose. No tension is brought upon the stitches by any amount of erection, and I do not consider it of any im- portance, or to be guarded against in any way. In my hands, rather coarse horse-hair has proved the best material with which to suture the cut edges. The first suture should be ap- plied at the raphe, and then all the others are certain to fall naturally in place. As many as twenty-five sutures may be applied when the wound is long. Each one should take in the least possible portion of integument on the one side and of mucous membrane on the other. The first knot is to be drawn very tightly to cut into the tissues, the second loosely, to avoid severing the first. The ends of the suture are to be cut off about an inch long. This prevents the wound from rolling in during the swelling of the first two days, and there are no short, sharp little points left to prick the tissues during the displace- ment caused by swelling. The member is now washed, dried, and may be inserted into a large roll made by tying up a towel with a string, and lashing this thick jDer- forated disk by cords passed about the thighs and body. Against this 14 DISEASES OF TBE TEXIS. thickened, perforated disk the penis rests on the inside. It is kept from contact with the patient or the bed-clothing, and in the partially erect joostnre most suitable to prevent oedema. It is not my custom to apply any description of dressing whatsoever, or any wrappings, to the penis. In a child that wears a napkin I still use the perforated piece of lineu folded over the penis and well greased — simply to prevent adhesion of the wound to the diaper. No further attention surgically is required. The horse-hair su- tures spontaneously cut their way out without suppuration, and come away in the scab. On the third day, as the swelling subsides, the long ends of the horse-hair sutures may be trimmed down close to the scab, to prevent their being pulled upon during the motions of the patient. Eest in bed, although not essential, is desirable, if prompt union is expected. Union by first intention may be counted upon, and the patient may go about practically well on the fourth to the eighth day, according to his healing capacity. An opiate for sleep and a laxative are the only medicines usually required. The diet need not be modi- fied. It is better to perform this operation with the aid of ether. I have succeeded moderately well by injecting twenty drops of a four- per-cent solution of the hydrochlorate of cocaine between the layers of the foreskin a few minutes before commencing the operation, but the effect is not all that could be desired. When from previous disease, specific cause, or otherwise, union by first intention is not obtained, the granulating wound is to be treated on ordinary surgical principles, with stimulating applications in lotion or ointment. The other Operations for overcoming tightness require but slight mention. A very common and sufficiently good operation, where the prepuce is tight but not redundant, consists in making one incision along the dorsum of the prepuce, including both layers, from the orifice to the base of the corona, and uniting the two layers of pre- puce on either side. It is better to trim off the corners. Several par- tial incisions at different points have been advocated. Lister approves this method. Another method consists in nicking the mucous membrane at the orifice, pulling the prepuce back, until the orifice again becomes tight, and then nicking again, and so on, until the mucous layer is sufficiently loose to glide easily over the corona. Again, where the prepuce can be retracted when the penis is not erect, the mucous membrane alone has been divided upon a director, the prepuce being pulled back and the cut made along th6 dorsum of the penis, from just behind the corona to the junction of mucous membrane with skin. The longitu- dinal incision is to be united transversely. Both these operations will yield imperfect results unless the skin be very loose and the entire strict- ure situated in the mucous membrane, which is not always the case. MORBID CONDITIONS OF TILE TREPUCE. 15 The frceniim maybe too short and require division — readily ofTocted with a sharp-pointed bistoury, the artery being twisted or tied, Compressed sponge (Montcggia) and laminaria digituta have been used to distend a tight preputial orifice, but the cases Avliere this treat- ment yields anything more than temporary relief must be few. Forcible dilatation * has been employed by Nelaton, Cruise,f of Dub- lin, and others, -and favorable reports rendered. A two- or three- bladed forceps, made expressly for the purpose, is inserted, closed, into a tight preputial orifice, the desired amount of dilatation being first decided upon, and then, by suddenly separating the blades of the Instrument, dilatation (perhaps more properly divulsion) is effected. The prepuce is now retracted and held behind the corona for from twenty-four to forty-eight hours, water-dressing only being employed. This treatment might be useful in some cases, but the application of circumcision is universal. The elastic ligature has had some ad- vocates (Hue, of Eouen).J MORBID CONDITIONS OF THE PREPUCE. Phimosis ((^t/^ow, / Mncl) exists where the orifice of the prepuce is so small that the glans penis can not be uncovered. The orifice of the prepuce may be congenitally absent (atresia prejoutii). Phimosis is congenital or acquired, simple or inflammatory, or complicated by other diseases or by adhesions. With very young children, phimosis is so common that it may be considered normal. The foreskin of a child is developed out of all proportion to the rest of the penis, taking the member after jjuberty as a standard of comparison. This long prepuce is often a source of anxiety to young mothers, who fear that the condition may remain permanent. They may be assured that it will right itself as the child grows. Whenever the prepuce can be retracted sufl&ciently to allow the glans to be seen, there need be no anxiety about the future ; the preputial orifice will enlarge sufficiently before or at puberty. This anxiety is similar to that of mothers about short frse- num linguae. A positive indication for operation, in the case of a child, does exist, however, where the preputial orifice is smaller than that of the urethra. This condition is known to exist when the prepuce " balloons" during micturition, for the urine flows into its cavity more rapidly than it can escape from its orifice. In these cases the retention of a drop or two of urine in the cavity of the prepuce, after each act of urination, must, sooner or later, lead to inflammation of one or both of the mucous sur- faces, and may give rise to severe suppurative inflammation, the growth * Known as Nekton's operation, " Gaz. dcs Hop.," 31, 1S68. t " Dublin Quarterl}'," xlviii, p. 482. X " Bull, de la Soc. de Chir.," tome iv, 1878, p. 682. 16 DISEASES OF THE PEXIS. of vegetations, adhesions of the prepuce to the ghms, formation of pre- putial stone, or incrustation of ghms. Wlien the prepuce is too tight in the aOult, an operation may be called for as a prophylactic against future disease, although phimosis, strictly speaking, does not exist. Here the collection of smegma, or an attack of herpes, may give rise to an inflammation Avhich will ne- cessitate an operation under unfavorable circumstances. Again, if an individual with tight prepuce gets chancre, chancroid, or gonorrha3a, serious inflammatory complications are liable to arise. Phimosis may be brought about secondarily through induration and inelasticity of the skin, caused by frequent attacks of preputial inflammation. AVheu such inflammation is prolonged in the chronic state, the meshes of the connective tissue, at first distended with serum, become secondarily thickened and hypertrophied, sometimes to an ex- tent almost worthy of the name of elephantiasis. The serum is ab- sorbed and its place supplied by a hyperplasia of connective tissue, leaving a thick, long, indurated, inelastic iirepuce, interfering not only with sexual intercourse, but sometimes even with urination. Another common cause of acquired phimosis is the cicatrization of multiple chancroid around the orifice of the prepuce. Bourgadc* al- ludes to diabetes as a cause of phimosis (four cases). Verneuil has seen two, and speaks of a surgeon who lost two cases on which he operated. Demarqnay f quotes a case, reported by Marx, where a passionate and jealous woman made her lover wear a gold padlock (sometimes two) with which she secured the preputial orifice, keeping the key herself. The victim of her charms carried his padlocks, which were replaced from time to time through new punctures, during four or five years, until such a degree of irritation had been set up that Petroz and Dui^uytren, when consulted, diagnosticated cancer, and removed the prepuce. No relapse of the " cancer "' is recorded. Inflammatory Phimosis is a transient condition. It may leave true phimosis behind, as above detailed, but usually does not. Any variety of phimosis may be complicated by inflammation. It is better not to circumcise when the prepuce is inflamed, if it can be avoided, as the process of repair would be retarded, and an ugly cicatrix may result. If the inflammation is caused by chancroid, this rule should be particularly observed when jiossible, for the edges of the wound become inoculated in spite of every precaution. Where inflammation is slight, but cedema excessive, phimosis ensues (lymphitis). Here position and pressure with collodion, and perhaps puncture on each side of the frajnum, are indicated, or light cooling lotions. Treatment of Injlammalory PJdmosis. — Keep the patient in bed, and elevate the penis over the hypogastrium. Evaporating lotions may be used locally, containing a little spirit or a (gr. x-xx) solution * " Le Progr6s Med.," September 2, 1876. f Op- «<•. P- 392. MORBID CONDITIONS OF THE PIIEPUCE. 17 of tannin, frequently wasliing out the cavity of the prepuce by means of a syringe with a Hat nozzle, with some mildly-stimulating lotion, such as dilute lead- water or carbolic acid (gr. ij to the ? j), or Labar- raque's solution ( 3 ss. to the 3 j). Eemote Results oe Phimosis. — Besides predisposing to local in- flammatory disorders^ leading to imperfect development of the glans penis, and acting as an obstacle to sexual intercourse, phimosis may occasion a variety of morbid conditions by reflex action. L'Allemand enumerates it among the causes of spermatorrhoea. It may occasion frequent desire to urinate (irritability of the bladder), finally cystitis ; but its disturbing influence in a reflex way upon the rest of the organ- ism I believe has been very much overrated. Dr. Sayre, of New York, has published several cases of relaxation of the muscles of the back with curvature of the spine in children, caused by phimosis with adhesions, the local irritation being so great as to keep the little patient in a condition of almost constant priapism. Prolapsus ani not unfrequently accomj)anies phimosis in children when the prepuce becomes inflamed, and symptoms resembling those of stone in the bladder are not uncommon from the same cause. Paraphimosis (Trapa, outside ; ^t/^ow, / bind) exists where the pre- puce gets behind the corona glandis and can not be replaced. Causes. — An unnaturally tight preputial orifice is a predisposing cause to paraphimosis. It sometimes hapisens that young boys, who retract the prepuce, perhaps for the first time, find themselves unable to replace it. Instances are reported where rings of metal have been forced upon the penis, retracting the prepuce. The glans penis now becoming a little turgid, the patient is unable to remove the ring. Shame deters him from seeking relief at once, and the ring is only found during an operation, after days or weeks of suffering, buried deep in the swollen, oedematous, perhaps gangrenous penis. Inflammatory paraphimosis may depend upon balanitis, gonorrhoea, herpes, chancroid, chancre, etc. The prepuce, already a little in- flamed, is retracted, to see or dress some ulceration concealed in its cul-de-sac, or is, perhaps, held back by bandage for convenience of dressing, or, if short, becoming inflamed and oedematous, it may roll itself back. It soon inflames further, oedema increases, and reduction becomes impossible. Symptoms. — In paraphimosis the glans penis is swollen and livid. If the patient is seen at once, there may be no inflammation, either of the prepuce or the glans ; but, in many cases — in all eventually, if un- relieved — both are inflamed to a greater or less extent, the glans per- haps being gangrenous from arrest of circulation. Behind the corona, most marked below, rises a tense, shining, oedematous belt of the mu- cous layer of the prepuce, the connective tissue of which is filled with serum. Behind this there is a deep sulcus or furrow, most marked 2 18 DISEASES OF THE TEXIS. above, often the seat of superficial ulceration. Here lies the stricture : behind it there rises another aKJcmatous fold, usually smaller than the one in front. If the stricture of the prepuce is tight enougli to arrest the circula- tion, it may linally cause the destruction by gangrene of all tissues lying in front of it. 2'reatmint. — The first point to decide in a case of paraphimosis is in regard to strangulation. If it exist, delay is inadmissible ; if not, temporizing exiiedieats may be resorted to, to reduce inflammation, before appealing to forcible reduction or operation. The test is simple. In strangulation the glans penis is turgid, swollen, blue-black, cold, de- void of sensibility, and perhaps shows already points of commencing gangrene. If there be no strangulation, the glans may be normal, or, if swollen, is red — at least not black — warm, and by compression the blood may be driven out of it ; sensibility is also preserved. A para- phimosed glans penis may be inflamed, but still not strangulated. Paeaphimosis with Strangulation. — In these cases ether should always be administered. Often under the relaxation of anaesthesia reduction is accomplished with comparative ease. Ice should be first used locally to produce shrinkage, and a few small jiunctures may be made to let out serum from the ridge in front of the stricture, if the swelling be excessive. The following are the best methods of reduc- tion : Seize the penis behind the strictured prepuce in the fork of the index and mid- dle fingers of both hands, one placed on either side. This gives more even pressure forward than when one hand only is used. Now make pressure with the thumbs on both sides, in such a direction as to compress the glans laterally, rather than from before backward, and at the same time pull the strictured portion of the prepuce forward, the idea being to make the glans as small as possible by compression, and rather to pull the stricture over the glans than to push the glans through the stricture. The latter attempt is liable to do more harm than good, by flattening out the glans over the stricture, and rendering redaction less possible than before. The corona and a little of the mucous layer of the pre- puce beyond should be slightly oiled, and an attempt may be made to insinuate the edge of the thumb-nail under the stricture to assist in lifting it over the corona. In some cases it is preferable to encircle the penis with one hand, using the other for manipulation. Finally, Mercier's method might be tried. The surgeon stands on the patient's right, places the index Fig. 4. MORBID COiXDITIONS OF THE PREPUCE. 19 and middle fingers of his right hand longitudinally along the lower sur- face of the penis, and the pulp of his thumb on the dorsum of the glans penis and the oodematous ridge in front of the point of stricture. By firm pressure crowding down the swollen mucous layer of the pre- puce, he endeavors to insinuate the end of the thumb-nail under the stricture. If he succeeds in this, grasping the penis and the two fin- gers of the right hand beneath in a circular manner with the left hand, he draws the strictured point up over the thumb-nail. Bardinet's* method — inserting the rounded end of a hair-pin under the stricture on each side, and with these making lateral pressure upon the glans while the prepuce is worked forward — is simple and often effective. If a prolonged, careful attempt . Fio.^mmps). at reduction fails, the strictured point must be divided. To accom- plish this subcutaneously, a tenotomy-knife is introduced flatwise along the sheath of the penis under the stricture, and is made to cut outward, until all tension is re- lieved. Instead of this, a simple incision may be made through the skin down to the sheath of the penis. Inflammatory con- solidation of tissue may make it necessary to divide the stricture at several points. After reduction, the treat- ment consists in position, rest, and cleanliness, syi'inging the preputial cavity with warm water hold- ing a small amount of disinfectant, or mild astringent, in solution. If any contagious ulcer has been the cause of paraphimosis, the surgeon should carefully examine his fingers for cracks or fissures before commencing manipulation. So much handling is required that infection is very apt to occur unless the epidermis of the hands is sound. In Paraphimosis without Stra]S"gulatiox, if the case is recent, reduction must be effected or inflammation will surely set in and com- plicate the situation. Eeduction may be accomjilished as detailed above, or by the method successfully employed in the Children's Hos- *"L'Union Medicale," ISIS, p. 900. Fig. 6. 20 DISEASES OF THE TEXTS. pital at Pcstb.* Here the penis, j)rei)uce, and glans arc togctlier subjected to strong continued i)rcssure. Several narrow strips of adhesive jilaster are applied longitudinally from the middle of the penis, over the apex of the glaus, to the middle of the penis oppo- site the starting-point. The meatus urinarius is left uncovered. In this way the organ is surroiinded and compressed by longitudinal strips. Over these, commencing just behind the orifice of the urethra, a nar- row strip of plaster is wound spirally, using pretty firm pressure, until the penis is covered by its circular bandage iip to the middle. The application is not painful. In twenty-four hours reduction may be accomplished ; a thin rubber bandage is more simple in its apjilica- tion, and more pi-omptly effective. In old or anannic patients, having gonorrhoea or an ulcer about the head of the penis, accompanied by lymphangitis, and where the i)rcpuce is short, a large amount of serum may collect in the prepuce, roll it back, and render paraphimosis imminent. The best treatment here is a little rest, with elevation of the penis and a])plication of a twenty-grain solution of tannin, followed by free use of collodion as soon as the patient rises. Unlike the scrotum, the prepuce bears collodion well. In the majority of cases, when complicating chancroid, herpetic, or other ulceration, paraphimosis is purely the result of inflammation and oedema, and there is no strangulation. Here the main inflammatory condition mxist be treated, aided by position, pressure, puncture, evai:)o- ratiug and astringent lotions. These will usually be sufficient, but in severe cases a shar]) watch should be kept up for any evidences of com- mencing strangulation. Should it occur, the point of stricture must be straightway relieved. (For other diseases of the prepuce, posthitis, herpes, Ycgetations, cancer, etc., refer to diseases of glans penis.) DISEASES OP THE GLANS PENIS. Herpes Progexitalis. — This affection consists in the development of clusters of vesicles upon reddened patches on the mucous covering of the glans or on either layer of the prepuce — occasionally on other ])ortions of the neighboring skin — attended by a slight sensation of heat and tingling. When occurring on the cuticular layer, herpes runs its course as it does elsewhere on the body ; but, when vesicles de- velop "within the preputial orifice, the eruption is modified. Under these circumstances the epithelium of the vesicles gets soaked off, little exulcerations result, more or less general inflammation is apt to arise from retention of the secretions, and balanitis, with posthitis, vegeta- tions, and inflammatory phimosis, may be the ultimate result. In broken-down constitutions the ulcerations perhaps become deep and angry, diagnosis with chancroid difficult, while the glands in one or both groins may inflame and suppurate. These extreme results are rare. ♦Schmidt's " Jabrbuclier," and Bumstead on " Venereal," p. 122, 1870. DISEASES OF THE GLANS PENIS. 21 . When the affection has once occurred, it shows a marked tendency to return. There is often a periodicity about the attacks. Tight pre- puce and contact of irritating discharges act as predisposing causes. Diagnosis. — Vesicles, usually in groups, always precede the ulcera- tions, while the latter are irregular in shape, superficial, and very rarely complicated by suppurating bubo. The pus is not auto-inoculable. Attention to these points will generally render diagnosis with chancroid easy ; where grave doubts exist, auto-inoculation is the proper test. Treatment is the same as for balanitis. In relapsing cases a long course of iron and arsenic internally often effects a permanent cure. Balanitis {fSdXavo's, a gland) is an inflammation of the surface of the glans penis. Posthitis (ttoo-Ot], the prepuce) is an inflammation of the prepuce, chiefly affecting its internal surface. Neither can exist for any length of time without becoming more or less complicated by the other. For practical purposes they must be considered together. Causes. — Persons of irritable skin and gouty habit are predisposed to this disorder. A long and tight prepuce is always a predisposing cause. The exciting causes are mechanical irritation or uncleanliness from retention of smegma preputii (a white, curdy substance composed of epithelial cells in fatty degeneration and sebaceous matter), or from prolonged contact with gonorrhoeal, leucorrhoeal, menstrual, or other irritating fluids. Symptoms. — The membrane at first becomes reddened, then mottled and moist ; next the epithelium comes off in patches, leaving irregular excoriations, which soon ulcerate and discharge a purulent fluid of greater or less consistence. These ulcerations are not preceded by vesicles. There is a burning soreness with itching at the end of the penis, usually scalding on urination. The whole substance of the pre- puce may inflame, become intensely reddened around the orifice, and infiltrated with serum, producing inflammatory phimosis, especially if the prepuce is naturally long or tight. The ulcerations rarely become deep, and the inguinal glands do not often suppurate. They frequently become somewhat large and tender. In chronic balanitis with phimosis, the mucous surface of the prepuce is found upon exposure to be covered with granular prominences. Warty growths are not infrequent. K. W. Taylor^ has described a peculiar ringed affection of the pre- puce and glans — narrow rings of reddened mucous membrane covered by a thin layer of eijithelial scales. The inclosed area is normal, the rings vary from one-fourth to one-half inch in diameter. Sometimes there are segments of circles. The affection is sometimes painful or itching. The rings remain stationary for a time. Sometimes they come out in successive crops. They get well withoiit scar, slowly, under the use of arsenic internally. They should not be confounded with lichen planus of the glans penis. * "Archives of Medicine," vol. xii, No. 3, December, 1834. 22 DISEASES OF THE PENIS. Diagnosis. — Balanitis may be confoimdcd with herpes, ehaueroicl, chancre, or gonorrluoa. x\t the ulcerative stage it can not be distin- guished from balanitis supervening upon herpes. In the early stage its vesicular origin distingnishes it. Chancre is usually single and in- durated. In chancroid the ulcerations are deeper and the pus auto- inoculable, yet both of these specific ulcers may be com})licated by balanitis. Balanitis has been described under the name of external gonorrhoBa. It may be mistaken for actual gonorrhoea, if there is phimosis, under which circumstance it is very a])t to complicate the main mahuly. AVhen the meatus urinarius can be seen, however, a little care will easily decide whether the pus comes from the urethra or not. Treatment. — If the prepuce can be retracted, simple balanitis may be speedily relieved. Cleanliness is of the first importance, but soap should not be used. Warm water with the disinfectant, if needed, will remove all the discharges. After washing, the parts should be dried by gently touching them with a soft cloth, and dusted with a mixture of finely powdered calomel and calcined magnesia, or with calomel alone. If the ulcerations are deep, iodoform is preferable. A piece of lint or old linen, cut so as to be just large enough to cover the surface of the glans, is now to be moistened in one of the follow- ing lotions : Or, Or, Or, 5 Vin. aroiual., 3 ij- 1 ss. Aquae, | j. 5 Pulv. opii, 3 j- Dissolve in six ounces of boiling water, and add Liq. plumbi subacetat., 3 j- Filter and cool. IJ Aluminis exust., gr. v-x. Aquie, 3 j. Simple dilute lead-water, or a gr. ij-iv solution of sulphate of zinc. The linen so moistened is laid around the glans, leaving the apex and meatus uncovered ; and, finally, the prepuce is pulled forward to its natural position. In this way friction between the inflamed sur- faces is avoided, all the discharges are absorbed, and a mildly stimu- lating fluid is kept in constant contact with the ulcerated or abraded surfaces. The dressing should be repeated twice to four times daily, according to the discharge. iVfter recovery a dry piece of linen should be kept between the glans and preijuce for some weeks, re- newed twice daily. If the prepuce can not be retracted, its cul-de-sac should be thor- oughly washed out with tepid water, by means of a syringe with a flat nozzle, if possible, every two or three hours, according to the rapidity DISEASES OF THE GLANS PENIS. 23 of the formation of the pus ; iind, each time after the cavity has been cleaned, a mild solution of carbolic acid, or enough of any of the lotions above mentioned, to distend the prepuce, should be gently thrown in, retained a moment, and then allowed to escape. If the prepuce is much inflamed, rest, position, and evaporating lotions locally, should be used in addition to the other measures. If the inflammation runs so high that sloughing of the prepuce seems im- minent, it is better to take off the tension by slitting up the dorsum. If chancroid be present, however, the surgeon must remember that inoculation of his wound is inevitable. The diagnosis of chancroid can be made by auto-inoculation of the pus. If this gives a positive result, it sometimes becomes a matter of the nicest judgment to decide whether to operate or not. In cases of grave doubt, it is best to ojier- ate in order to expose the sore, whose ravages (perhaps of the glans penis) are going on in darkness uncontrolled. A large chancroid ex- posed is better than a smaller one concealed. In chronic and inveterate cases of balanitis, or where insignificant causes produce constant relapse, circumcision affords a certain cure. All the unhealthy, thickened, inner layer of the prepuce should be removed. Where this is seriously objected to, which is rarely the case when there is much suffering, relapses may be rendered less frequent by the observance of the strictest cleanliness, and the use of a filtered solution of tannin and acetate of lead, or of tannic acid in glycerin, 3 J to I j ; or of alcohol, one part to two of water, kept up for a long time, followed by long use of a piece of dry linen to separate the m.u- cous surfaces. Adhesions after balanitis are uncommon after the age of early childhood. Vegetatio^sts upon the penis are commonly denominated venereal loarts. This title, however, is not exact, since there is no necessary connection between them and any venereal disease as a cause. They are nothing more nor less than papillary overgrowths, often highly vascular, and composed in large excess of epithelium. They may be prominent and pedunculated, or flat, and growing from a considera- able surface. They are nearly always multi23le. They are caused by the contact of irritating fluids with a membrane of naturally delicate texture, or simply by lack of cleanliness. The most favorable condi- tion for their production consequently exists in gonorrhoea, balanitis, or when mucous patches occupy the cavity of the prepuce. Their favorite seat is just behind the corona glandis, but they are also en- countered anywhere within the cavity of the prepuce — at its orifice, upon its cutaneous surface — or even within the urethra. They are found also upon the scrotum, and frequently around the anus. They are, when numerous, bathed in a fetid, puriform secretion, and may get large enough within the prepuce to cause phimosis. They occur 24 DISEASES OF THE PEXIS. upon young childron, and are found in tlioir greatest luxuriance with- in and around the vulva of pregnant women attected with irritating discharges — discharges by no means of necessity venereal in any sense. There is a contagious element about them. Treatment. — The observance of cleanliness alone often causes vege- tations to shrink up and disappear. In any case this is the first essen- tial to the success of any course. In case vegetations are complicated by balanitis, treatment of the latter will often at the same time triumph over the warts. If they persist, however, or constitute the main dis- ease, all the pedunculated growths should be carefully removed with curved scissors, and the surface from which they grow cauterized with nitric acid or any other escharotic. The flat growths are best disposed of by the ap])lication of nitric acid, at intervals, until the base from which they spring has been destroyed. If the warts are dry, they may be covered sejjarately with collodion containing corrosive sublimate, in the proportion of 3 j to 33. This is allowed to dry on, and, when it separates, all or the greater part of the wart comes with it. The application may be repeated if necessary. Where the number of vege- tations is too great to allow of their treatment seriatim, attention to the general health, cleanliness, and local dusting with calomel is the proper course. This plan, so efficacious in treating condylomata and mucous patches about the anus, is particularly applicable where the vegetations are surrounded by an excess of moisture. Epithelioma Penis. — The epithelial variety of cancer is that form which usually attacks the glaus penis and the prepuce. It commences more frequently upon the former — generally after middle life. Symptoms. — Epithelioma usually first appears as a small, flat, warty, or simply excoriated surface, of which the base is perhaps from the first slightly indurated, especially when the disease commences at the meatus. The surface of this insignificant induration becomes ex- coriated, bleeds a little, and is the seat of a slight darting or burning pam. A dark-colored scab now forms if the spot is exposed to the air, but this is picked off or falls off, disclosing an ulcerated surface beneath. In this way the disease advances by ulceration backward, involving everything in its course. The discharge is thin, sanious, fetid ; the ulcer deep, irregular, unhealthy ; the edges hard, sinuous, livid, everted. Its course, at first slow, becomes later more rapid, pur- suing the usual march of epithelial cancer in other localities. In some cases the wart-growth becomes exuberant before ulceration occurs. As the disease advances the patient fails in strength. The inguinal glands on both sides become involved and may ulcerate. Now, if the strength hold out, the disease will spread from the root of the penis over the abdomen, groins, thighs, and perinreum, and involve the anus. The scrotum may ulcerate awa)% leaving the testicles hanging out, and in this horrid condition the sufferer dies, worn out, or perhaps sudden- DISEASES OF THE CORPORA CAVERNOSA. 25 ]y from hgemorrhago, some large vessel in tlic perinaeum being opened by the advancing ulceration. The diagnosis of epithelioma of the penis is often difficult in tJio early stages. All warty growths, especially if they are not much ele- vated and occur upon individuals past middle life, whose habits seem to be cleanly, and above all if there is even a shade of hardness around the base of the growth, all such excrescences should be regarded with suspicion, and their progress carefully watched. When ulceration com- mences, doubt may be laid aside, and then temporizing is of no avail. Active measures should be resorted to at once, unless the age of the patient or some other condition contraindicates an operation. Prognosis and Treatment. — Vigorous measures before the inguinal glands become involved afford the only chance of cure, and even then prognosis must be guarded, for relapse locally or in the glands is very common. Extensive local scraping and cauterization, if applied very early, may cure a superficial case ; but deep ulceration imperatively de- mands amputation at a point by so much the farther back as the ulcera- tion is extensive. It is mistaken kindness to spare tissue in such cases. If the inguinal glands are involved, they also should be thoroughly re- moved at the same sitting ; but even such removal affords little hope of permanent cure. In old cases of extensive disease, the bladder should be permanently drained above the pubes or through the peri- naeum for the patient's comfort, and anodynes used freely. DISEASES OF THE COEPOEA CAVERNOSA. Injuries of corpora cavernosa and cancer have been already de- scribed. Inflammation of the substance of the corpora cavernosa is very rare, except as the result of contusion, when it may run high, become excessively painful, and terminate in suppuration or gangrene. Spon- taneous inflammation occurs, very exceptionally, during the course of acute dyscrasial disease — typhus, small-pox, etc. It may complicate severe urethritis. It is always a dangerous affection, tending to termi- nate in gangrene. Treatment. — Beyond sustaining strength, but little can be done. Evaporating lotions may he used locally. If pus forms, it should be evacuated early, using care to distinguish between pus and effused blood. Ossification of the Penis is excessively rare. J. von Lenhossek * found what he helieves to be the first case observed, in an autopsy upoi a patient of forty-two, dead of typhus. There were dorsal and ventral bones, with channels for the vessels and the urethra. The point of origin seemed to be the septum of the corpora cavernosa. Haversian canals and true bone corpuscles were found. Demarquay f figures a specimen representing a large bone in the center of the penis reaching * Virchow's " Archiv.," Ix, April, 1874, p. 1. f Op. cit, 354. 26 DISEASES OF THE TEXIS. from the glans half way back, taken from the Vienna Pathological Museum, s})eoimen 2,3-i2. Wm. II. Porter* reports a case of true osteoma of the penis. Calcification of the Pexis. — Ossification was the term formerly ajiplied to this affection until the niicroscoiie demonstrated the absence of bone corpuscles in the earthy mass. Calcification consists in a depo- sition of plates of calcareous matter in the corpora cavernosa, one or both, particularly in the fibrous sheath. The condition is analo- gous to atheroma of arteries. Mild chronic inflammation, followed by fatty degeneration, precedes the calcareous deposit. The disease usu- ally comes on insidiously, and discloses itself by the fact that erection is imperfect and painful. The penis bends during erection, the calca- reous jiatch occupying the center of the concavity of the curve, since the sheath loses its elasticity at this point, and whatever of the erectile tissue is involved is, of course, indistensible. Tlie causes of calcification of the penis are unknown, f Injury has no ]30wer to produce it. It occurs after middle life, when all calcifi- cations are most common. Prognosis. — The calcification may cease after more or less of each corpus cavernosum has suffered, or it may involve the whole organ pretty generall}'. The hard plates and masses of calcareous matter can be distinctly felt on manipulation. Sexual intercourse is liable, finally, to be seriously interfered with, if not jireveuted altogether. Under these circumstances the patient is often driven to thoughts of suicide, urged on by that morbid depression which always, in the male, accom- panies a consciousness of sexual iucajiacity, be that incapacity fancied or real. Treatment. — Medicine holds out no hope to the sufferer. If the disease has come to a stand-still and the deposit is superficial and small, it may be removed with the knife — an oj^eration which has been performed with success by Eegnoli and by MacClellan.J Chroxic Circumscribed Inflammation of the erectile tissue of the corpora cavernosa. This very rare malady was described in the first edition of this treatise upon a foundation of five typical cases which I had seen with Dr. Van Buren, and which were there detailed. Since that time I have seen about a dozen new cases, but I have learned no new feature of the disease. I have seen only one case become entire- ly well. But I have encountered a number of cases, scattered through the literature of the day, and shall note the opinions of others on this peculiar malady while I adhere to the original description of its 2)hysi- cal characters and course, as given in the first edition. The affection comes on insidiously, without apparent cause, al- * "New York Medical Record," September 2, 1882, p. 270. \ Cretification of products of inflammation is not here referred to. X Velpeau, " Xouveaiix Elements de Medccine Operatoire," Paris, 1839, vol. iv, p. 33G. DISEASES OF THE CORPORA CAVERNOSA. 27 though the patient sometimes ascribes it to local injury. He first dis- covers that something is wrong by noticing a slight pain in the penis at a certain point when the organ is erect. On examination he detects a hard, flattened mass, with sharj)ly-defined margins, occupying tljo substance of one or both corpora cavernosa near the surface, and feel- ing like cartilage — elastic, springy ; not with a bony feel like a calca- reous plate. The corpus spongiosum never ^participates in the disease. The penis bends during erection at the affected point, and along the edge of the hardness a little pain is experienced. This indurated mass, which is of varying size and usually irregularly oval in shape, with often a projecting line of hardness toward the root of the ^lenis, may remain stationary for an indefinite period, gradually decreasing at last without moving, or progress slowly backward or forward, sometimes retaining its size and shape by disappearing anteriorly as it advances toward the root of the penis, or vice versa, sometimes growing larger by remaining stationary at one end while it enlarges at the other, or by growing laterally. A slight tenderness is sometimes felt along the line of advancing induration, and moderate uneasiness is usually pro- duced by pressing the induration between the fingers, the same feeling as that experienced during erection. The seat of election is the dor- sum of the penis forward, the patch spreading equally around each corpus cavernosum, and being usually more blunt forward than pos- teriorly. Sometimes a single patch is found laterally in one corpus cavernosum, not reaching the dorsum, and there being no companion on the other side. The disease occurs after middle life. The patients are usually healthy, and certainly are not uniformly subject to any diathetic disease, although more patients are noticed as having had gout or rheumatism than any other malady. Gronorrhoea, syphilis, stricture, bear no possible etiological relation to this malady, and treat- ment by mercury and iodide of potassium is absolutely negative. The integument of the penis is in no way involved. The malady appears to be a chronic thickening of the sheath and a portion of the under- lying erectile tissue of the corpus cavernosum, which thickening aj)- pears to obliterate the meshes of the erectile tissue and prevent their distention with blood during erection of the rest of the organ.* This malady appears to have been observed and described by De Lapeyronie,f but first accurately depicted by Kirby,J who gave some * Syphilitic gummata of the corpora cavernosa have physical characters similar to those above detailed, except that the syphilitic node is more deep (sometimes) and often less sharply defined than the malady above considered, and the node breaks down or in- creases in all directions — or perhaps resolves — but it does not increase on one side while it gets well on the other. Furthermore, gummy tumor is dissipated by treatment. Ricord has given a description of these gummata in the corpus cavernosum. Zeissl believes that they almost always occur in the posterior third of the organ. f " Mem. de I'Acad. de Chir.," 1*743, tome i, p. 423. X "Dublin Medical Press," 1849, vol. xxii, p. 210. 28 DISEASES OF THE TEN'IS. cases, and came to the conclii.sion that gout was the efTicient cause. Actou, in his '' Koprocluctive Organs," refers vaguely to two cases of imperfect erection as "strange anomalies." Possibly these two cases were examples of the malady under consideration. II. J. Johnson* reports four cases as " chronic inllammation of the corpora cavernosa."' Galligo f describes these indurations as special tumors of the jienis, in 1852. Demar(piay \ refers to this malady as having been described under tiie names induration of the erectile tissue of the penis, nodes, ganglions of tiie corpora cavernosa, plastic induration, by many au- thors — Boyer, Patissier, Lcrminier, Vidal (De Cassis), Eicord, and others. Cruveilhier * believes the affection to be a fibrous transforma- tion of the erectile tissues of the penis, but doubtless some of the authors above named have confused the results of fracture and trau- matisms, gummata, tumors, and calcifications with the malady now under consideration. Gross, in his "Surgery" (1859), mentions an indurated tumor of the pectiniform septum, removed by operation, which may have been some analogous condition. Marchal (De Calvi) || gives a case occurring in a diabetic subject. Prescott Hewett ^ reports two cases in 1866, calling the malady a spontaneous blocking of the corpus cavernosum, and ascribing it to gout as a cause. J. Mason Warren,^ in 18G7, gives three cases of apparently typical examples of this malady under the name of indurated tumor of the penis. He notes one case where the induration completely disappeared. Charles G. Smith, of Fall River,! reported a case in 1874, and in tlie same year Howard Marsh,! of St. Bartholomew's, brought out three cases. Eldridge % gives a case in 1876. I have not attempted to put into print a dozen or more cases which I have encountered since the first edition of this treatise appeared, most of which were seen as private patients in my office, and a few presented at the Xew York Dermato- logical Society by several of its members. Hodgen,** of St. Louis, re- ported three cases in 1876 as "reflex induration of the jienis." He thought that the influence of cold had a causal relation to his cases. Cameron (Mcdico-Chirurgical Society of Glasgow, October 8, 1879) read an essay on gouty tumors of the penis, reproducing Kirby's ideas as to the cause of these formations. Sir James Paget advocates the * London " Lancet", November, 1851, p. 481. f "Gaz. Medicale," 1852, p. 440 (reference from " Gaz. Med. Italiana Toscana "). X Op. ciL, p. 344. * " Anatomie Pathologi(iuc," tome iii, p. 594. II "Les Accidents Diabetifiues," 1864, p. 401. ^ "St. Bartholomew's Hospital Reports," 18(56, vol. ii, p. 82, et scq. () "Surgical Observations with Cases," Boston, 18G7, p. 245. I "New York Medical Journal," June, 1874, p. OOC. I " New York Medical Journal," Sept., 1874, p. 269. I "New York Medical Journal," 1876, p. 260. ** " Transactions of the Medical Association of the State of Missouri," 1876, p. 28. DISEASES OF THE COlirORA CAVEKNOHA. 29 same etiology. Finally, Verncuil,* in 1883, reports four cascH, in whicli glycosuria coincided in three. He believes tlie condition to be non- inflammatory, and analogous to the contractions of the palmar and plantar aponeurosis which are encountered among gouty subjects. lie thinks the cause is gouty, and is interested in tiie fact that three out of four were also diabetic. Trelut, in the same meeting of the surgi- cal society, reported that he had seen two cases, Monod one, and Le Fort three, none diabetic. I do not know that the urine was tested for sugar in the earlier cases seen by Dr. Van Buren and myself. None of the later cases examined were diabetic, or any of them, so far as I know. Some of the cases had the gouty diathesis, but this can not be affirmed of all of them. Tuffier,f in an exhaustive article, while omitting a number of cases of which I have record, has collated thirty-five cases, in which no diathesis is noted in nine, fifteen were gouty, and eleven diabetic. The malady being far more common in advanced life than at any other time, he searched patiently among twenty-five hundred old men at Bicetre and at Ivry without finding a single specimen of which to study the pathological anatomy after cut- ting it out, and mentions Cruveilhier and Eicord as having been equally unsuccessful in trying to find a case for dissection ; but, after his arti- cle was finished, one of these nodosities was cut out by Verneuil, Oc- tober 25, 1884, and Leloir reported that in its pathological histology it was composed of a tissue analogous to that of keloids — embryonic cells m clusters tending to fibrous transformation, few vessels, with fibrous planes resembling cicatricial tissue. Prognosis. — The prognosis is negatively good in that the malady never ulcerates or degenerates into anything malignant, may get spon- taneously better, even possibly well, or may, and sometimes does, progress backward until it gets so low down toward the root of the penis that it no longer interferes seriously with upright erection. I have seen more than one patient who, at one time being debarred from sexual intercourse, has by a shifting of the position of the induration again become capable. In one case I believe this was due to an im- provement in the condition of the induration without any change in its position — a change coming on spontaneously. Treatment. — An effective treatment of this singular malady is yet to be discovered. Thus far only time has seemed to help it, while blisters, oleate of mercury, tincture of iodine externally, with mercury, the iodides of potassium, and sodium, and local electrolysis, have uni- formly failed. Perhaps alkaline or anti-gouty remedies may hare something more to offer in the future than the ineffective means now in use. * " Bull, de la Soc. de Chir.," 1883, tome viii, p. 826. f "Ann. des Mai. des Org. Genito-Uriuaires," July and August, 1885. 30 DISEASES OF THE URETHRA. CHAPTER II. DISEASES OF TUB URETHRA. Anatomy.— Natural Curve of the iTcthra.— Propor Curve for Instruments.— Catheterism; Obstaclee to Catheterii-ni in the llealtliy Urethra.— Deformities of the Urethra ; Imperforation, Atresia, Hypospadias, Ilorniaphroilisni, Epispadias. — Urethral and Sexual llygiene. — Injuries of the Urethra.— I'rethral Fever. — Foreign Bodies. — Polyi)i. TuE urctlira is alwa3-s a shut canal througliout its whole course, except ■when distended by some foreign substance. Commencing at the neck of the bladder, it tunnels the u])per part of the prostate, perforates the triangular ligament, and terminates at the end of the penis. Its size varies greatly, and, like the penis and testicles, it re- mains comparatively very small until after puberty. Its length has been estimated at all points between five and fourteen (Pitha) inches. The length varies with the condition of erection or flaccidity of the organ. Its mucous membrane, according to Robin and Cadiat,* is manifest- ly richer in elastic fibers than any mucous membrane of the body. It may be lengthened by disease (enlarged prostate). In round num- bers, the length of the urethra of a well-proportioned adult is eight inches, six lying in front of the triangular ligament (spongy portion), a little less than one inch between this and the apex of the prostate (muscular or membranous portion), a little more than one inch sur- rounded by the prostate (prostatic portion). The sjiongy portion is surrounded throughout by the erectile corpus spongiosum, terminating below in the bulb. Here the canal pierces the triangular ligament — that firm, fibrous fascia, stretching across the space bounded by the ischio-pubic rami — and, becoming membranous, is covered (besides the muscular fibers of organic life) by voluntary muscular tissue which entirely surrounds it. This muscle has had special names given to different portions of it by Guthrie, iliiller, and Wilson. In this muscular group, described as one muscle by Cruveil- hier (transverso-urethral), is often the seat of spasmodic stricture ; and it is here that muscular contraction may oppose the passage of an instrument into the bladder for several minutes, even when there is no evidence of urethral disease. These are the muscles which consti- tute the voluntary " cut-ofP," over which every healthy individual has full control. To allow the urine to pass, these are voluntarily relaxed, with the vesical sphincter, and then the detrusor expels the urine by its tonic tendency to contraction, over which the individual has no * " Structure intime dc la muqueuse et des glandes urcthrales," "Journ. dc I'Anat. ct dc la Physiologic," September, 1874, p. 514. THE UIIETIIRA. 31 control. If a catheter be introduced, so us to do away with any effect of the ''cut-off" muscles, no voluntary effort of the individual can arrest the stream of urine, nor indeed cause it to flow with greater force unless the abdominal muscles or diaphragm be called into action. This "cut-off" then controls urination in health: relaxed, the urine flows; voluntarily contracted during any part of the act, the stream is cut off as sharply as if by a knife. Some erectile tissue and a good deal of unstripcd muscle are found around this as well as around all other joortions of the virethra, but the function of the cut-off muscle must be kept clearly in view, on account of its bearing upon catheterism and sj)asmodic stricture. The membranous urethra is, of all parts, the most positively fixed. There is no marking on the mucous lining of the canal to indicate any division between it and the spongy portion. The separation into parts is arbitrary. The prostatic urethra bores the prostate, sometimes barely covered by that organ above, sometimes surrounded by a con- siderable thickness of the same. Unstriped muscle, of which the prostate is mainly composed, sur- rounds the urethra from one end to the other, and enters largely into the erectile structures of the penis as well. The diameter of the normal urethra varies even more than its length — it has been estimated at from two to six lines, A fair average is not larger than three tenths of an inch — about No. 27, French scale. But, whatever its size, the urethra is not a tube of uniform caliber from end to end. It has naturally three points of j^hysiological narrowing — one at the meatus ; the second commencing about one inch back, and being most pronounced somewhere in the third inch, some- times at three and a half inches ; the third point of narrowing being the point of entrance into the triangular ligament. The meatus is normally the narrowest point. The two points of enlargement are the fossa navicularis (so called from its supposed resemblance to a boat), v;hich is situated just inside the meatus, and T ' the bulbous urethra, Fig. 7 {Tiiompson). OCCUPVing' a position '^' ^' ^^'^ '^ represent the prostatic, membranons, and spongy >■ J ^ t portions. immediately in front of the triangular ligament. Of the two, the latter is the larger. The urethra enlarges again in the prostate (prostatic sinus). Fig. 7, from Thompson, shows these points in diagram. In the fossa navicularis lies the valvule or lacuna magna (Fig. 8), a little mucous flap on the roof of the urethra about half an inch from 32 DISEASES OF THE URETHRA. the meatus, shut ting in a fossa about two lines deep. In this yalvule the points of small instruments arc liable to become engaged. There are other blind j)ouches or lacuna^ of variable size scattered along the urethra, chielly on its roof, and known as the sinuses of Morgagui. They run ))arallcl with the urethra for perhaps half an inch, and ter- minate in a cul-de-sac. Cruveilhier found one an inch long. The openings of these sinuses all look toward the meatus, and are often large enough to receive the points of filiform instru- ments, a fact to be remembered in manipulatiu:^ Avith fine bougies (sec Fig. 31). Another lacuna in the urethra, which may catch the point of a fine instrument, is the sinus iiocularis (Guthrie) or utriculus of the prostate, a deep little depres- sion running down in front of and underneath the veru montanum. The mucous glands of the urethra are small clusters of minute fol- licles, very abundant, opening either on the free surface of the mem- brane or into the sinuses of Morgagni. Fig. 8 (CnieeUhie)-). Fio. (Crureithier). Vertical section tlirough glans and fossa naviculari?. Fig. 10 {Cruveilhier). Transverse section of penis. Cowper's glands are small, round, lobular bodies about the size of cherry-stones, lying just behind the bulb of the urethra in tlie trans- verso-urethral muscle. Their ducts are sometimes very long, but average a full inch, and open into the floor of the ure- thra. Their fiuid is supposed to aid in di- luting the sperm. The urethra has about the same amount of sensitiveness in health as the conjunctiva. In the membranous urethra, however, sensibility is exaggerated. The color of the membrane is a pale pink. In a state of rest its walls lie in contact, obliterating the cavity of the canal, so that a cross-section presents a slit instead of an opening (Figs. 0, 10, and 11). Fig. 11 (Cruveilhier). Transverse section of center of prostate. IJ. EJaculatory ducts. Sp, Sinus pocularis. CURVE OF THE URETHRA. 33 CuKVE OF THE Ueetiira. — In connection with tlie anatomy of the urethra, it is advisable to give some details of explorations, and of catheterism and the use of instruments in the normal canal. The lowest point of the urethra is just in front of the triangular ligament, where it lies about one inch beneath the symphysis pubis. From this to the meatus the canal takes any position according to the direction given the penis ; toward the neck of the bladder, however, the urethra is said to have a fixed curve. This is not strictly true, for straight instruments may enter the bladder — a proceeding sometimes difficult, often painful, never absolutely indispensable, if indeed neces- sary. At rest, however, the urethra has a curve which, in the mem- branous portion, is fixed, and runs on an average at a distance of from two fifths to three quarters of an inch from the symphysis pubis. It varies slightly with individuals and in the same individual at differ- ent periods of life, being shorter and sharper in the child, longer in the old man. A distended bladder or enlarged j^rostate lengthens the curve. The proper average curve, as recognized since Sir Charles Bell, and insisted on by Sir Henry Thompson, the one which will mathemati- cally accord with the greatest number of urethras, is that of a circle three and one-quarter inches in diameter ; and the proper length of arc of such a circle, to represent the subpubic curve, is that subtended by a chord two and three-quarter inches long.* An instrument made with a short curve of this description will readily find its way through the normal urethra into the bladder without the employment of any force. It is very desirable that instruments intended for habitual use should be so constructed,! inasmuch as many of the difiiculties of catheterism arc due to a defective curve in the instrument employed. The defect most frequently encountered is a too great straightness of the last half-inch — a deviation of the curve at its most important point. In an instrument properly made (Fig. 12) it will be found that a tangent to the axis of the curve at its extremity will intersect the projected axis of the shaft at a little less than a right angle {n h h). If the curve comprised only a quarter of the circle, the tangent would meet the projected shaft at a right angle (m g h) ; but instru- ments made of this length and a little longer, as they are usually found, invariably have the last part of the curve tilted off into a faulty direction, as shown in the plate (Fig. 12), making the angle between a tangent to the axis of the curve at this point and the pro- * " In the winter of 1852-53, assisted by the late Dr. Isaacs, I made a series of care- ful experiments upon sections of frozen subjects, as well as by injecting the urethra with numerous substances, afterward carefully cutting out the casts. I found the average curve to be identical with the one given above." — Van Buren. f An instrument destined for habitual use by the patient is sometimes made half an inch short in the curve, on account of the greater ease of introduction of such an instru- ment through the pendulous urethra. 3 34 DISEASES OF THE URETHRA. jected axis of the shaft obtuse {I j h), and falling within the right angle. Fig. 13. a and h represent faulty curves — still occasionally encountered on instruments. Fig. 14 shows the correct curve. It is better to prolong the curve around the circle, and even slightly decrease that of the terminal quarter of an inch, as instruments so made are less liable to be defective, and the point is, for all practical pur- poses, still at right angles to the shaft, and one and three-quarter inch from it. A knowledge of this relative position and direc- >/Z ITd Fio. 12.— Instruments as ordinarily made, with faulty curve, (9a, 0(/ fB6niqn6). Correctly-curved conical instrument, Ob. Length of natural curve of urethra, / A. Length of chord of curve of sound, h 0,2xg inches. tion of the point is of great importance in difficult catheterism. A moderately short curve is as good as a long one, provided it is accu- FiG. 13.— Faulty curves. rate ; indeed better, for, when the instrument is made with the full length of curve, three tenths of the circle, that portion subtended by a chord of two and three-quarter inches, its point is so far from the shaft that it is sure to " wabble " when the point encounters an obstruction. This ob- jection is all the more api^licable to the Benique instrument (Fig. 12, (/ h o), on account of its having a Fig. i4.-Proper cune. postcrior as wcll as an anterior curve. CATIIETEPJSM. 35 This "wabbling" is not of serious importance in the healthy canal, but it is very distracting to the surgeon when a tight stricture is to be entered. Here the short conical point, at right angles to the shaft and one and three-quarter inch from it, is vastly superior on account of steadiness, and is equally certain to follow the urethral curve accu- rately. Exploration of the Urethra — Catheterism. — The introduc- tion of a sound, staff, or catheter into the bladder is generally spoken of as " catheterism." The use of the staff or sound is sometimes denomi- nated ''sounding." The manoeuver in either case is the same. There being given a canal of certain dimensions and curvature, and an instru- ment to fit it, the problem is to introduce the latter into the former. Nothing is easier, although to perform the operation perfectly is less simple than would at first appear. No amount of instruction, no vol- umes of directions, can teach the student how to pass the sound. He must learn by doing it, first upon the dead, then upon the living body. Some suggestions may, however, be given. Always make the patient lie down on his back, with his head on a pillow, his legs slightly separated, his body relaxed, his fears quieted, and himself as comfortable as possible. Both hands should be practiced in introducing the sound, and the surgeon should keep his elbow sup- ported during most of the operation, in order that his hand may be more steady. If the right hand is used, the surgeon places himself at the patient's left, and vice versa. To explore the canal, a simple, blunt, steel instru- ment, of medium size, is se- lected, and properly -warmed. The penis is gently encircled by the fingers and thumb of one hand, the instrument held lightly with the points of three fingers and the thumb of the other. The shaft of the in- strument is held over the fold of the groin, its handle nearly in contact with the skin, from which latter (the integument, first of the groin and then of the abdomen) it is not to be moved away until the point of the instrument is about to enter the fixed portion of the urethra (membranous). The instrument, at first held along the groin, with its point high and handle low (Fig. 15), is entered at the meatus, and the penis is molded up over it. It is not pushed into the urethra, but the urethra is made to swallow the Fig. 15. 36 DISEASES OF THE URETHRA. Fig. 16. instrument, as it were. When the curve, and perhaps an inch of the shaft, has disappeared within the meatus, the handle of the instru- ment is swept around over the surface of the helly, so as to lie exactly over the linea alba, i)aral- lel with it, and still close to the integument (Fig. IG). The whole shaft of the instrument is now to be gently pressed toward the feet, being still kept close to and parallel with the surface of the belly (the penis, meanwhile, being lightly grasped be- hind the corona glandis, and held steady). The point of the instrument should be followed Avith the little linger of the hand which manages the penis, and, when it gets fairly past the peno-scrotal angle, the whole scrotum, with the testicles and penis, should be largely seized with the hand and pressed up against the pubis, with slight upward traction. The point may now be felt to settle down and adapt itself to the sub-pubic curve, whence on, the weight of the instrument, properly directed, should carry it into the bladder. As soon as the curve lies well against the sym- physis, the scrotum, tes- ticles, and penis should be dropped ; the hand which held them takes the instru- ment, simply steadies it in the median line, and gradually carries the shaft away from the abdomen (Fig. 17), making the han- dle describe the arc of a circle, and depressing the shaft between the thighs until it lies nearly in the same plane with them. No pushing movement should be imparted to the instrument during this time. The handle is simply made to describe the arc of a circle, and the point in a healthy urethra can not go astray. While the instrument is being depressed between the thighs, the free hand is employed in pressing down upon the mons veneris and root of the penis (Fig. 18), to stretch the suspensory liga- FiG. 17. CATHETERISM. 37 Fig. 18. ment — a point of importaTicc to the easy introduction of an instru- ment, and one which supplies to the short curve all the advantages claimed for the longer Benique curve. When the instrument is in the bladder, its point may be moved freely from side to side by partly rotating the handle. The instrument should be withdrawn with the same slowness and care with which it was introduced. No traction is needed. The motions used in intro- duction are simply re- versed. The handle of the instrument is lightly caught, and without traction made to describe the arc of a circle until it touches the abdomen over the linea alba. It is then carried around to the groin, and, by a tilting motion, unhooked from the urethra, ending exactly where it commenced along the groin, the handle low, the point high. The first principle of instrumentation in the urethra is to avoid the use of force. Even in a healthy subject, sometimes, the beak of the instrument will become arrested by contraction of the unstriped mus- cle surrounding the canal. A little patient waiting will overcome this, and the instrument glides on. The arrest of a sound from mus- cular contraction usually occurs at the entrance of the membranous urethra from spasm of the '* cut-off" muscle (spasmodic stricture). The practiced touch rarely fails to detect at the handle of the instru- ment the slight contractions of the muscular fibers around its point, and in this way diagnosis with organic stricture is easy. Gently hold- ing the instrument in place for a few minutes, with slight forward pressure, will tire out the muscles, and, if the obstruction is muscular, the sound will shortly pass. At this same point any instrument is liable to be arrested mechani- cally in a healthy urethra by the triangular ligament. Here, it will be remembered, the urethra is narrower than anywhere else within the orifice, and just in front of this point exists, naturally, the greatest width of urethra. Now, if the canal be flabby, or the instrument not large enough to distend it (a small sound is more liable to catch here than a large one), the point may become arrested along the floor by the triangular ligament, or along the roof (more rarelv) in the little fossa lying above the edge of the subpubic ligament. The instrument is known to be arrested by the bulging out of its curve in the perina- 38 DISEASES OF THE URETHRA. um as the shaft is being depressed between tlie thighs and the rebound of the handle when liberated. The obstacle is overcome by gently nianaHiveriug the point of the instrument by partial withdrawal and re- introduction or by slight depression of the beak, then lifting it over the obstacle with a finger in the perinfeum, at the same time pulling up the point of the instrument to make it sweep the roof of the canal. This will generally render the introduction of a finger into the rectum unnecessary. The dangerous *' tour de mAitre " * might be gently tried, but no force should ever be used in any manipulations at this point, as a false passage is easily made here and under these very circumstances. The depression of the handle of the instrument alone is capable of ex- erting enormous power. The sound represents a lever of the first order, and the surgeon has the long arm. With a little patience a suitable instrument will always pass into the bladder unless there is stricture. When the point has traversed the membranous urethra, it must continue on freely if the prostate is normal. The so-called spasm of the neck of the bladder does not ex- ist as an obstruction to the passage of instruments. Instruments small enough to engage in the sinuses of Morgagni are not used in the healthy canal. Instrumentation m morbid conditions will be detailed in connection with the different diseases requiring it. A silver catheter is introduced in the same manner as the sound. In using soft instruments without a stylet the penis is slightly pulled upon, so as to efface any circular folds, and the instrument is pushed straight onward into the bladder. If it gets arrested, partial with- drawal and rotation during the next forward movement will cause it to pass. No instrument should enter the urethra unless it is smooth, pol- ished, and well oiled. Warmed oil, thrown into the canal with a syringe, greatly facilitates the passage of instruments. The sensation exiierienced by the healthy urethra is that of hot points pricking the canal along the part being traversed by the foreign body. As the instrument enters the membranous urethra, a desire to urinate begins to be felt, which increases as the prostate and neck of the bladder become distended by the instrument, so that the patient sometimes believes that urine is flowing away, in spite of the sur- geon's assertions and his own observation to the contrary. Nausea, and even syncope, may occur as the instrument distends the prostate, especially on the first introduction in sensitive young peojile. Occa- sionally distention of the prostatic sinus produces a partial venereal orgasm. * The tour dc mditre consists in introducing a sound with the shaft between the legs until the point is arrested at the bulb. Then the handle is rapidly made to describe a , semicircle until it reaches a vertical position, when it is at once depressed between the thighs. It is brilliant, effective, but dangerous. DEFORMITIES OF THE URETHRA. 09 If the patient faints, the instrument should be withdrawn at once and the legs elevated, while the head is hung over the edge of the lounge upon which he has been lying. The facility with which this may be done, if necessary, is one of the reasons for placing the patient on his back. DEFORMITIES OF THE URETHRA. The urethra is subject to arrest and error of development, but is not often seriously deformed. Among curiosities of deformity may be mentioned the abnormal position of the meatus on the side of the glans penis ; the termination of the ejaculatory ducts in a separate canal, running along the dorsum of the penis and opening behind the glans * (gonorrhcea of this canal has been noted) ; termination of the urethra in the groin, f Perkowsky J found in a well-formed penis, besides the healthy urethra, a second canal opening at the base of the glans and affected with gonorrhoea. He split this subcutaneous canal to the symphysis, where, he says, it terminated in a blind pouch. Luxardo * describes a gonorrhoeal patient who had three openings at the end of the penis. One gave exit only to semen. The two lower ones ap- peared to communicate, and both had gonorrhoea. E. B. Ward | re- ports three brothers, each of whom had a triple opening to the ure- thra, but he does not state whether they communicated or that one was not a seminal duct. Chopart ^ reports of a patient of seventeen that he had never passed water by his penis, but had a constant watery diarrhoea. His ureters opened into his rectum ; but he doubtless had a penis, for he is stated never to have urinated "par la verge." When the penis is absent the bladder is usually also lacking in these cases, and the ureters discharge into the rectum. No case of double urethra is known, except with double penis. Valvules pointing backward (Guyon) occasionally exist congenitally in the urethra, and partially prevent the outward flow of urine. They are found about the veru montanum, or near the bladder. Congenital stricture has been ob- served by Nelaton,^ by James Syme, and by many others. J Con- genital urethral dilatations of great size have been observed in a few cases, attended by atrophy of the corpus spongiosum at the dilated point. Their relief is effected by cutting away the redundant tissue, accurately coapting the edges of the wound, and treating as for longi- tudinal incision of the urethra. All the foregoing anomalies are exceedingly rare. There are other * Cruveilhier, op. cii., p. 420. f Haller, quoted by Pitha, op. cit. X " Centrlbltt. f. Chir.," No. 50, 1883, p. 816. * "L'Union Medicale " (an Italian reference), Xo. 54, 1883, p. 663. II "New York Medical Record," September 1, 1383, p. 251. ^ " Maladies des Voies urinaires," 1830, p. 325. ^ Phillips, " Traite des Maladies des Voies urinaires," p. 2*71. ^ " British Medical Journal," p. 1, 1862. 40 DISEASES OF THE URETHRA. deformities, however, which are more common, namely — impcrfora- tion, atresia, hypospadias, and epispadias. Impekfouation axd Atresia. — The meatus alone may be imper- forate (or sti'ictured), or any portion of the canal may be obstructed by a membranous partition, or replaced by a fibrous cord : in these cases the urachus sometimes continues open for the escape of urine. Joseph Englisch * has furnished a contribution to this subject. If the meatus alone is occluded, an opening is made at the point where it ought to be, and the healing of the Avound prevented by daily use of bougies. If a diaphragm exists farther down, it may be punc- tured with a fine trocar. The same instrument may be used where there is atresia, the point being pushed along the course which the urethra naturally follows. If the atresia involves a portion of the pendulous urethra only, success may be hoped for. The bleeding is not great, and may be arrested by cold and pressure. When, how- ever, the whole urethra is replaced by a fibrous cord, the prognosis is very bad. A direct opening from the perinoeum into the bladder would be the most judicious surgical proceeding in these cases, the urethra being attended to afterward. Without a previous opening in the perineum, a fine trocar, a blunt tenotomy-knife, or a silver probe may be used, to cut and break down the connective tissue occupying the position where the urethra ought to be, and this maybe continued on from the meatus into the region of the neck of the bladder. Sometimes immediate success crowns this desperate course, while again the attempt has been abandoned, and after a number of hours urine has found its way out through the artificial opening. Interesting cases have been collated by Guyon f and Demarquay. Such openings necessarily tend to recontract, and must be constantly kept dilated. Hypospadias axd Epispadias are the most common congenital deformities of the urethra. According to Baron, J epispadias occurs once for one hundred and fifty cases of hypospadias, but Marchal did not find a single case of epispadias in examining sixty thousand con- scripts. Rennes * states that a military surgeon found ten cases of hypospadias among three thousand conscripts. Hypospadias descends sometimes by inheritance. Hypospadias (utto, heneath ; (nrd^w, I divide). — This deformity consists in an arrest of development of a portion of the lower wall of the urethra, its lateral halves failing to unite in the median line. Ko- bclt II gives a representation of the injected separate halves of the cor- *"Ueber angeborene Vcrschliessungen," etc., "Arch. f. Kindcrheilkuntle," Bd. ii, 1S81, pp. 85 and 291. f " Des Vices dc Conformation do I'Urethre chez rilomme ot dcs Moyens d'y rem6- dier." Th5se, Paris, 1863, and Demarquay, op. dt., p. 581. \ Quoted by Dolbeau, "De 1' Epispadias," etc., Paris, 1801, p. 11. * " Obs. med. sur (luelques Maladies rares," etc., "Arcli. G6n. de M6d.," 1831, Ixxvii, p. 1. I " De I'appareil du sens genital," etc., 1851, pi. 1, fig. 2, and p. 96. DEFORMITIES OF THE URETHRA. 41 pus spongiosum in a case of hypospadias. The embryo at two months has hypospadias normally. The scrotum has not yet united, and, if natural evolution ceases here, the last degree of hypospadias results with bifid scrotum. Hypospadias may occur at any jooint in front of the membranous urethra, but does not involve the latter or the pro- static portion of the canal ; consequently, no matter how extensive hypospadias may be, the patient has control over the escape of urine. "When hypospadias is scrotal, the penis is usually very imperfectly devel- oped, imperforate, and looks like a large clitoris. The bifid scrotum passes very well for a vulva, and in this way some of the so-called hermaphrodites are formed, the true sex perhaps only being discovered after adult age has been reached. The monstrosity known as her- maphrodite does exist, but is excessively rare. To constitute a true hermaphrodite, there must be penis and testicle, uterus and ovary.* Hypospadias, anterior to the peno-scrotal angle, is more common than the scrotal variety, and most frequent of all is hypospadias con- fined to the glans penis or its immediate vicinity. That part of the urethra lying between a hypospadial opening and the meatus is usually absent or impervious, but maybe patulous for a short distance in front of the opening in the floor of the urethra, or even up to the meatus. Hypospadias, as commonly encountered in practice, consists of an absence of the fraenum preputii, and a flaring open of the meatus in- feriorly, or an inferior opening in the canal within a few lines of the natural meatus, the position of which is usually marked more or less perfectly in its usual site. The glans penis may be bifid. The ure- thral orifice in hypospadias is small, as a rule. The only disturbances caused by hypospadias are functional. The patient may not be able to pass water without wetting himself, as in scrotal hypospadias, and if the opening is too low in the canal he may be impotent, from inability to throw the semen against the uter- ine orifice. Simple hypospadias rarely calls for surgical interference, and opera- tions which have been performed for its relief are not over-encourag- ing in their results — that is, in regard to restoring large portions of the canal — but rapid advances are now being made in this direction (Duplay).t Hypospadias of the glans penis is unimportant ; many patients pos- sess it without being aware of the fact. It may be necessary to enlarge the opening in case of stricture of the urethra, in order to introduce instruments of sufficient size to accomplish thorough dilatation. * Concei'ning hermaphrodism, may be consulted, with advantage, the extensive work of Isidore Geoffroy Saint-Hilaire, " Des Hermaphrodismes : Hist. gen. et prat, des Anoma- lies de I'Organisation," etc., 1836, vol. ii ; and art. " Hermaphrodism," " Nouveau Diet, de M6d. et de Chir. pratiques," 1873, vol. xvii, p. 488. \ " Arch. Gen.," May and June, 18'74. 42 DISEASES OF THE URETHRA. Comph'cafion,^. — One complication of serious importance may occur with hypospadias, wliich always demands operation. It is where the corpus spongiosum and urethra are too short, so that, although the meatus urethrae may be found at or near the apex of the glans, still the short urethra acts like the string of a bow, and keeps the penis curved at all times, particularly during erection. The patient is some- times retromingent. The penis may be straightened in these cases by cutting through and dissecting up the fibrous string which represents the urethra, and letting the meatus find its own position at the peno- scrotal angle. Then the fibrous septum of the corpora cavernosa must be cut, and deep transverse sections made in the sheath of the penis beneath the corpora cavernosa. In one case I have seen a por- tion of the integument of the penis slipped in to cover the raw area with admirable result. I have succeeded in this way in restoring thorough erection, and I know one patient in this condition who mar- ried, to his satisfaction. But to make a new urethra is a more diffi- cult matter ; to make a good urethra not possible. It may serve as a urinary canal, but as a projector of semen I believe that a tube with- out retractile walls would be useless. To straighten a penis, Bouisson* first advised division of the sep- tum of the corpora cavernosa with a tenotome. Physick,f of Phila- delphia, removed a V-shaped piece of corpora cavernosa behind the glans, and Pancoast and Gross have follo^ved his example. T. Auger J first operated successfully for this condition, building an entire new urethra at the same time, but Duplay's * method is a better one. Epispadias (eVl, above ; a-n-a'Cui, I separate) is a fissure of the supe- rior wall of the urethra with ectopia of the canal (Guyon). It is very rare. The urethral opening may be upon the glans, or anywhere along the top of the penis, as far back as its root. When the membranous and prostatic urethra are involved, there is also exstrophy of the blad- der. The orifice of the urethra in ei^ispadias is large. Sometimes a finger may be passed through it into the bladder, that part of the urethra lying in front of the opening being an open gutter. Inconti- nence of urine is frequently observed when the opening is far back, especially if the pubic bones are separated. There may be complete epispadias without exstrophy of the blad- der. Dolbeau | has published an autopsy of this condition, with plate. The penis is short and thick in epispadias, or small and more or less * "De rilypospadias," etc. ("Tribut i la cliirurfrie "), Paris, 18G1, vol. ii, p. -187. f " A Century of American Medicine," 1876, pp. 188. X "Hypospadias p6no-scrotal," Paris, 1875, pp. 15. * "De I'Hypospadias p6no-scrotal," etc., " Archiv. Gen.," May and June, 1874, and i')id., March, 1880, p. 257. II " De I'Epispadias, ou P^issiire ur6thrale superieure, et de son Traitement," p. 46, Plate UI. Paris, 1801. URETHRAL AND SEXUAL IIYGIEXE. 43 deviated. The pubic bones are usually, but not necessarily, separated in complete and sometimes in incomplete epispadias. There may be hernia of the bladder, without positive exstrophy.* Epispadias is an arrest of development in the upper wall of the urethra, but it is still a matter of hypothesis how the urethra gets above the united corpora cavernosa ; for, even when the genital buds, which are to form the corpora cavernosa, are still separate at the fortieth day of fetal life, the urethra is beneath them. The fact, however, remains, as proved by Dolbeau's dissection, that the ure- thra gets above the corpora cavernosa, and fails to unite in its upper wall, the corpora cavernosa effecting their faulty union none the less. With exstrophy of the bladder, where the lower part of the abdominal wall is absent, and the pubic bones do not come together, it is easier to understand how the roof of the urethra may be wanting throughout. Treatment. — Mature surgical judgment can not promise a cure from operative procedure in epispadias. The adaptation of a proper urinal is the best treatment, either the model, advised for esstroj)hy (Fig. 75), or the rubber urinal (Fig. 74). Operations which have been undertaken very often fail, erections and contact of urine, with small- ness of the flaps, being the chief causes. The operations which have been most -successful in covering over the canal are those of J^elaton and the modification by Dolbeau. They consist in freshening the edges of the flattened urethral furrow, and bringing down over it a quadrilateral flap of integument, which is adjusted, epithelium inward. The hairs of the flap must be removed by electrolysis. The raw sur- face of this flap is in its turn covered by sliding flaps (epithelium out- ward) from the sides of the penis ; or by dissecting up a flap from the scrotum, leaving it attached on both sides and, running the penis under it, so as to bring the raw surfaces of both flaps into contact, separating the scrotal flap after firm union has been effected. Both of these operations have been successful in roofing in the canal, but the incontinence of urine has not been overcome, f URETHRAL AND SEXUAL HYGIENE. Before passing to the morbid conditions of the urethra, its hygiene in health and disease demands consideration. That the urethra may be in a healthful state, able to get well if diseased, and then to remain well, two points must be observed. They comprise fully the hygiene of the canal. They are : (1) That the urine be non-irritating in character. (2) That sexual excitability be quieted. * " Joum. de Med., Chir. et Pharm.," p. 14, 1S41. f For minute details of the operation, see Nelaton, " Traite de Pathologic exteme," and Dolbeau. These cit. and Dolbeau, "Archiv. Gen.,*' March, ISSO, p. 257. 44 DISEASES OF THE rRETIIRA. (1) Urine, to be non-irritating, miist be normal, faintly acid or neutral, free from sharp crvstals, and not too concentrated. Hence measures tending to bring the fluid to this state are hygienic. These measures include general hygiene of the skin, stomach, muscles, lungs, etc., but also in many cases (especially where the subject is of gouty habit) certain dietetic precautions. The latter consist in the avoid- ance of all alcoholic fluids, especially sweet fermented wines and malt liquors. New ale is particularly harmful. All of these substances tend to create sharp crystals of uric acid in the urine, as well as to concentrate and acidify it. From this cause alone inflammation of the urethra may spring. Lemon-juice is also somewhat irritating to the urethra, as are, to a mild degree, all the condiments, salt, pepper, mus- tard, and, it is said, asparagus. In inflamed states of the canal, gen- eral hygiene prescribes rest. (2) The quieting of sexual excitability is an object not less im- portant, but by far more difficult to accomplish. No part of the body can be in perfect health unless its function is being regularly and satis- factorily performed. This is seen in stomach, brain, muscle, excretory duct. For example, when all the urine escapes from the urethra, through a large fistula in the perinaeum, the fore part of the canal contracts and becomes hyperaesthetic. The urethra, however, only performs the function of a sexual canal at longer or shorter intervals. If there were no erotic fancies, the ure- thra would never be called upon to participate in the sexual function, and the latter would have no influence over its health or disease. In the eunuch the hygiene of the urethra undoubtedly does not include the sexual problem. If, then, the individual be absolutely pure in thought, word, and deed ; if he never has or has had an erotic fancy, direct or remote, then his urethra would be a urinary canal, and its hj'giene would be simple. But absolute purity is not a common attribute of man, as anyone who has the honesty to accept facts must allow, and the rule that every male adult has more or less strong sexual longings and necessities must be admitted. Hence is establishod the rule, borne out daily and hourly by an intelligent study of the parts concerned, both in health and dis- ease, that the urethra is not in the best conditions for health unless the sexual needs are attended to. There is no possible means of acccftn- plishing this result except marriage. Fornication is always irregular, unnatural, often excessive, and therefore is harmful and worse than nothing, looked at from a merely worldly point of view. Masturbation is degrading, and bears upon the whole well-being of the individual by ruining his morale. Nature's safetj'-valve, involuntary ejaculation during sleep, is inefficient. Marriage alone allows healthy, natural, unstimulated sexual relations, and alone accomplishes the first neces- sity of urethral hygiene — namely, sexual quietude. Hence the value INJURIES OF THE URETHRA. 45 of marriage as a curative agent in morbid conditions of the urethra, especially if there be any nervous element in the case — an element which is almost invariably present in some degree. In all conditions of acute inflammation, sexual intercourse must be, of course, absolutely interdicted. Excessive indulgence is bad at •any time, but worst of all is stimulation without relief. This state is, unhappily, a common one among the unmarried men of large cities. Such individuals, looking at suggestive pictures, reading ex- citing books, taking part in impure conversation, become ripe sub- jects for nervous disease of an obscure sort, not only of the urethra but of the whole body. In fact, this undue stimulation, without appropriate relief, is far more often the cause of hypochondria, melancholy, and functional perversion, than is the masturbation to which the public generally ascribe it. Nor can such an individual, by any plan of fornication, escape the evil consequences to which stimulated but ungratified desire exposes him. Marriage with a pure woman may right him — rarely anything short of this. Hence, when such a case presents itself where marriage is impossible, or if the patient be already unhappily married, there is but one course left to advise, and that is absolute continence and an effort at purity of thought, with a strict avoidance of all possible tempta- tions to erotic thought or act, whether entering through the mind, the eye, or the ear — whether actual or implied, direct or remote. Could such a patient imitate the heroic example of St. Augustin — a record of which that honest father of the Church has left behind — he could control the hygiene of his urethra, and doubtless save him- self much distress in life. INJURIES OF THE URETHRA. Injuries of the urethra, of seemingly an unimportant nature, often entail serious consequences. From the position of the canal, and particularly from the fact that it runs along the middle line of the perinseum, it is more exposed to injury than any other por- tion of the genito-urinary apparatus. Contusion" of the pendulous urethra is rare. If severe, it is followed by effusion of blood, haemorrhage, inflammation, abscess, slough, and finally traumatic stricture — often by fistula, with loss of substance. Contusion of the deep urethra, on the other hand, is quite common. The sub-pubic ligament lies directly beneath the symphysis pubis, filling up the angle made by the junction of the two bones. This ligament is nearly as hard as bone, while its lower edge is thin and sharp. In all falls upon the perineum, the urethra lies between this sharp edge and the body upon which the indi- vidual falls. The injury to the urethra is in proportion to the 46 DISEASES OF THE URETHRA. force of the blow upon the perina?um. The caual may be entirely cut across, or more or less crushed transversely. Injury by violence to the ])orin;vuin involves to a greater or less extent the membra- nous uretlini and the bulb which partly overlies it. The immediate results are swelling, more or less escape of blood fi-om the injured bulb into the surrounding tissues, often haemorrhage from the ure- thral orifice ; dilKculty in emptying the bladder, perhaps amounting to absolute retention ; possible infiltration of urine ; perineal abscess and listula ; and finally traumatic stricture of the most obstinate character. Injury to the perinasum is not uncommon at any age from falling astride a fence, while walking on it, a wheel, while mounting a coach, etc. In boys a kick in the perinasum is often sufficient to damage the canal permanently, without apparently occa- sioning any immediate injury. Treatment. — If the patient can pass water and there is no infiltra- tion of urine, no attempt should be made to introduce an instrument into the bladder immediately after contusion of the urethra, for fear of making a false passage at the injured point of the canal. All means, local and general, must be used to keep down inflammation. If, however, there is retention, either immediate, or secondary from inflammation, and warm baths, local fomentations, and opiates do not relieve it, an attempt should be made to pass a soft, French olivary catheter very gently into the bladder. Failing in this, a long filiform whalebone bougie may be tried ; and, if this pass, a soft catheter, open at both ends (Fig. 26), may be made to enter the bladder pushed along upon it as a guide, or any tunneled instrument, soft or solid, guided in the same manner. If the bladder cannot be readily reached, perineal section should be at once resorted to, as this remedies the retention, and is the best treatment for the traumatic stricture which will inevitably follow. If a soft instrument can be introduced easily, it should be with- drawn after the bladder has been relieved, and reintroduced when necessary. If much difficulty is experienced in passing the catheter the first time, it should be tied in and left for a day or two, unless it causes the patient too much irritation, and then be withdrawn, cleaned, and reintroduced at intervals. As soon as the inflammation following the injury subsides, the passage of conical steel sounds must be commenced, increasing in size until the largest instrument is reached which the meatus will admit, and this must then be intro- duced by the patient himself weekly for a time, and then at appro- priate intervals for an indefinite period, to prevent recontraction of the traumatic stricture. If infiltration of urine has taken place, large, free, dependent in- cisions must be made in the scrotum and perinaeum, to let out the urine and prevent sloughing ; the scrotum must be elevated, and qui- INJURIES OF THE URETIIIIA. 47 nine and iron promptly commenced and followed up, to combat fur- ther complications. In this or any other condition of serious compli- cation or difficulty, the soundest surgery demands the performance of perineal section at once, inasmuch as this course not only provides for a free issue of urine (infiltrated or not), but puts the urethra under immediate control, and includes the proper means of avoiding trau- matic stricture. WOUHDS INFLICTED ON THE URETHRA FROM WITHOUT. — In children severe wounds in the perineal urethra may result from the breaking of the earthen vessel upon which they sit to empty the bowels and bladder. These may be followed by infiltration of urine with sloughing. Any part of the urethra is liable at any time of life to ordinary cutting injuries, inflicted by accident or design. Fracture of the pelvis, gunshot-wounds, etc., may damage the urethra very seriously. In a general way it may be stated that wounds of the ure- thra heal more readily in the perinseum than elsewhere (as illustrated by the median operation for stone), and are not apt, in this region, to be followed by fistula, unless there is some obstacle to the free escape of urine in front of the injury (stricture). Transverse wounds of any portion of the canal are followed by stricture (Eeybard).* Longitud- inal wounds, correctly coapted, are not. Wounds of the scrotum, extending into the urethra, are more liable than others to be followed by infiltration of urine, on account of the looseness of the connective tissue of the part. Treatment of External Wounds. — Wounds involving the perineal urethra, if the canal be healthy (cuts made for stone), and the incision nearly longitudinal, may be left to granulate without interference. If, however, the wound is transverse, it should be dilated systemat- ically while healing, as after perineal section for stricture. Where the pendulous urethra is wounded, the following course should be pursued : Unite the edges of the wound, at once and very accurately, with the finest silk suture. Draw off the urine from four to six times in the twenty-four hours. The catheter should be small, so as to dis- turb the process of repair as little as possible, and it should be em- ployed often enough to keep the bladder from becoming distended. Should the bladder .till, a little urine is apt to be forced along the ure- thra outside the catheter when the latter is introduced, and the ob- ject of using the instrument — to keep the wound from the contact of urine — to be frustrated. When the surgeon can not see his patient often enough to empty the bladder regularly, a catheter of pure caoutchouc, of medium size, should be first introduced into the bladder, the wound united over it, and the instrument tied in, corked, to be opened every few hours. It should be retained until healing is complete. The rubber is better * "Traite pratique sur les Retrecissements de I'llrethre," Paris, 1S53, p. 67. 48 DISEASES OF THE URETHRA. than any harder material. Very extensive transverse injuries to the urethra may be remedied. In one rcmiirkable case* tlie whole ure- thra and four liftlis of the penis were cut transversely through and yet satisfactorily repaired. Wounds inflicted upon the Urethra from within are mainly such as are made by the surgeon in careless or rough manipulation (false passage), by divulsion of stricture, by internal urethrotomy, by lithotomy carelessly performed — especially in children where the ure- thra is cut or torn transversely — by the passage or rough extraction of stone fragments, the introduction of foreign bodies by the patient, etc. When such wounds occur, the urine comes in contact with the raw surface, and '' urethral fever " is the common but not inevitable con- sequence. The more altered and decomposed the urine, the more liable is the patient to suffer. URETHRAL OR URINARY FEVER. This peculiar malady is better known in its symptoms than as to its cause. Its study has received serious attention from able hands, f but whether it is neurotic or due to urinary absorption is not yet clearly decided. The affection may assume any one of four distinct types : 1. There may be a sharp chill, of longer or shorter duration, com- ing on anywhere within the first twenty-four hours (occasionally later), after manipulations upon the urethra or bladder, attended by an eleva- tion of the temperature, and followed by fever (with perhaps delirium) and by sweat. After this there is no further trouble, or there may follow a number of days of general febrile excitement, malaise, inap- peteuce, loss of strength, etc., and slow recovery, or other paroxysms of chill and fever, with more or less complete intermissions, may en- sue. This is the most common form. 2. There may be only a few slight rigors without much marked fever or any sweating — these passing off and leaving the patient as well as before. * "Bull, de la Soc. de Cliir.," tome vii, p. 550, and tome viii, p. 26, d seq. f Girard, " Resorption urineuse et Ur6mie dans les Maladies dcs Voles urinaires," Paris, 1873. Malherbe, " De la Fifevrc dans les Maladies des Voies urinaires," Those, Paris, 1872. Banks, " Certain rapidly Fatal Cases of Urethral Fever after Catheterism," " Edin- burgh Medical Journal," 1871, p. 1074. Englisch, " Wien. med. Presse," No. 9, 1874. Gosselin and A. Robin, " L'Urine ammoniacal et la Fievre urineuse," Paris, 1874. Clark, Sir A., Discussion on. "Lancet," vol. ii, 1883, and "Edin. Med. Jour.," April and May, 1874. Morris, H., a most suggestive chapter on " Urinary Fever in Surgical Diseases of the Kidney," American reprint. Lea Brothers & Co., pp. 398-434. Harrison, "On Toxic Urine in Relation to Certain Surgical Operations on the Urinary Organs," " Edin. Med. Jour.," July, 1886, p. 251. URETHRAL OR URINARY FEVER. 49 3. There may be a distinct violent chill coming on rapifJly, but of variable duration, attended by intense j)rostration, alarm, anxiety, and excitement at first, accompanied by violent vomiting, profuse diarrhoea, coldness, and lividity of the surface, almost total suppression of urine, all the evidences of uraemia, and a rapidly fatal issue. 4. There may be slight chill and fever, followed by the (usually rapid) development of septicasmic symptoms and death, or, more slowly, by true pyasmia and death, the autopsy revealing abscesses in the prostate, kidney, liver, lungs, suppuration in the joints (knee, shoulder), fluid in the pleura, pericardium, etc. All cases can be arranged under these heads. The first two are by far the most common, and fortunately the least disastrous. That all these disorders should depend upon the simple absorption of urine through an abraded surface is in the highest degree improb- able. Other forces are at work, and these are probably shock and reflex action, suspending the function of the kidneys, often already diseased. The condition of the urine also has much to do with the origin of urethral fever. It produces no effect in contact with a wounded surface, when it is normal, being sometimes used (in France) as a dressing to fresh wounds.* When in ammoniacal fermentation, it is undoubtedly capable, if absorbed, of occasioning septicaemic and pysemic phenomena, and, unfortunately, in bladder and urethral dis- ease, the urine is very often more or less decomposed. The mystery about urethral fever is, that it does not occur more constantly, when the conditions are the same. The majority of patients escape, whether the urine is ammoniacal or not, whether the wound or the violence be great or small. The same patient may have a chill one day and escape it after an exactly similar operation on the next. The simple gentle passage of a small, soft bougie may give rise to it, while violent divulsion or urethrotomy, performed a day or two after- ward, may produce no such result, and again after divulsion, which has been negative, the passage of a steel sound may produce a chill, Nor is it instrumentation alone which is the exciting cause, since pa- tients, upon whom no instrument has ever been used, have well-marked exacerbations of chill and fever in connection with urethral and blad- der disease, and these patients cease to have chills (which they usually call " dumb ague ") after the use of instruments in their urethra has dilated the stricture. Other patients have no chill until dilatation has reached a certain limit, after which every effort to pass an instrument of a larger size is liable to be followed by urethral fever. The extent of the injury done is no index of the amount of fever that will follow. The gentle passage of a smooth sound may cause speedy death, while * Dr. Partridge, at my suggestioD, injected sixty-minim doses of healthy urine into the subcutaneous tissue of the arm of many patients at the Charity Hospital, in lSv3, never exciting suppuration. — Keyes. (See, also, note under Extra yasation of Urise.) 4 50 DISEASES OF THE URETHRA. extousive wounds and lacerations of the canal are often absolutely in- nocuous, and that, too, where the urine is strongly alkaline, even ammoniacal. Gosselin, while patriotically adhering to the " absorption urineuse " theory, inclines to a belief that the absorption of the bacteria of decomposing urine may have something to do with the deadly result, as well as the absorption of carbonate of ammonia, to which he ascribes a large share of inlluence. The position of the injury inflicted by the instrument is of impor- tance. At and near the meatus even serious injuries very rarely give rise to chill, though decom2)osed urine pass freely over the raw surface. The danger increases in proportion to the depth at which the injury is inflicted. Nor does a wound seem to be necessary at all, since cases are on record where death, following rajiidly u])on the introduction of a smooth instrument, has failed to reveal on autopsy any lesion of the canal. Here shock and reflex action (Banks) arresting kidney secre- tion would seem to be the immediate cause of death. The chill may come on before the instrument used has been withdrawn from the urethra, but usually it does not follow for some hours, and generally not until after urine has flowed through the canal. In the rapidly fatal cases, old and often advanced kidney disease, or at least intense kidney hyperaemia, is found on autopsy ; but in some cases these organs have been j^ronounced normal. Morris believes the kidney to be always pathologically the cause of the symptoms of urethral fever, the lesions varying from congestion through interstitial nephritis to abscess. He strongly advocates the nervous reflex theory in all cases. Even in these latter there has usually been suppression of urine ; but simple suppression of urine does not often kill in one or two days, and, to solve the problem in these cases, we are forced to fall back upon the effects of shock. Treatment. — The treatment of urethral fever is mainly prophylac- tic. The object is to avoid chill ; for, after the latter has occurred, but little can be done to modify the paroxysm. I do not know any remedy that can avert chill in all cases, but I place more reliance upon a combination of pilocarj)ine and morphine than on anything else. I have seen more than one case where chill necessarily followed ordinary urethral instrumentation, and have averted the chill witii the same instrumentation by the subcutaneous use of from a fifth to a tenth of a grain of muriate or nitrate of pilocarpine given subcutaneously with five or ten minims of Magendie's solution just before or after the operation. I have also often seen this means fail, and therefore only suggest it, not as a cure, but as the best treatment I know. The very best prophylactic treatment, perhaps, is a jirolonged milk- diet and the use of benzoic acid in five- to fifteen-grain doses in cap- sule, or of larger doses of the bcnzoatc of soda, Avhich is better borne in all cases where the urine is ammoniacal — especially if it is also URETHRAL OR URINARY FEVER. 51 slightly putrid. But when the urine is normal these precautions arc unnecessary. Quinine is generally given both before and during urethral fever — but I find myself each year attaching less and less importance to it either as prophylactic or curative in urethral fever. Still, it can do no harm, and I do not wish to condemn it from an impression, which may be faulty. Quiet and rest in bed for some hours — perhaps a day or more — before an operation have a good influence, and a Avarm bath just before an operation, I believe, is not without advantage. I have ceased to believe that anassthesia at an operation materially lessens the chance of chill, nor do I believe that the local use of a solution of the hydrochlorate of cocaine has any good effect in this direction. I am also beginning to have more faith in the efiBcacy of tying in a cathe- ter — a large, soft, rubber one — after urethral operations which involve portions deeper than the anterior fold of the triangular ligament. In front of this point I think it unnecessary, because what urethral fever comes from operations on the anterior urethra is usually slight. After perineal section and tying in a tube, and after lithotomy operations in the perinasum, urethral fever is the exception. If the attack is a rapidly pernicious one, morphine, hot-air baths and stimulants, cups to the loins — and a bad prognosis — constitute the treatment. If surgical kidney or pyeemia are ushered in by chill, they must be treated generally on their symptoms ; but a milk-diet, per- haps a little quinine, and mild, sometimes heavy stimulation, consti- tute our most hopeful weapons of attack in these serious conditions. The suggestions of Gouley * and Long f as to the prophylactic value of the tincture of the chloride of iron and of two-minim doses of Fleming's tincture of aconite I can not indorse by any personally fa- vorable experience. The peculiarities of this fever are well known. The profession is familiar with Thompson's case, J where a man with old, tight stricture died on the third day after the passage of an instrument, luliich liad heen used upon Mm very many times before. Vomiting with severe chill came on in an hour — immediate suppression and death followed. Autopsy failed to reveal any lesion of the urethra caused by the instru- ment. The kidneys were intensely congested and soft. Among Velpeau's* cases — which have become classical — no kid- ney lesions were found in several patients who died in this sudden manner ; and hardly a year goes by that the medical journals do not furnish reports of further victims to urethral fever, some without, but the majority with, kidney disease. * "Diseases of the Urinary Organs," 1S73. f "Liverpool Med.-Chir. Jour.," January, 1858. :j: " Stricture of the Urethra," third edition, London, p. 94. * "Le9ons orales d. Clin. Chir.," etc., Paris, 1841, p. 326. 52 DISEASES OF THE TRETIIRA. I have had a number of cases wlicre the passage of any instrument effecting even very moderate dihitation icifhout brimjing Hood would be followed by cliill, and yet divulsion, tearing the urethra, and opening the fixsucs freely, did not occasion the customary chill and fever. In short, there are so many exceptions that a rule can not be safely for- mulated ; but, in a general way, it may be said that the greater the violence, the deeper in the urethra that the violence is a])plied (but I must except cases of perineal external incision), the more ])utrid and ammoniacal the urine, and the more damaged (in a surgical, pyelitic way) the kidneys, the greater the liability to urethral fever, and, if it comes, the more likely is it to be grave. FOREIGN BODIES IN THE URETHRA. The most varied substances are found in the urethra,* introduced by the patient under the influence of that perverted and depraved sexual instinct which affects the male of all ages who gives up his mind to impure thoughts and whose sexual necessities are not met. Seeds, stones, beads, beans, peas, nails, pins, needles, hair-pins, slate-pencils, portions of glass, wax, cork, and a host of other sub- stances, are thus introduced into the meatus, and, slipping beyond the reach of the fingers, are not unfrequently swallowed by the urethra. Broken catheters and bougies, esi^ecially in cases of stricture, and in- struments left a demeure, if not well fastened, may slip past the me- atus and travel toward the bladder. Fragments of stone after crush- ing, or small stones, may also become arrested in the ui-ethra and demand the surgeon's aid. Then, again, stone may form in the pros- tate, or in the urethra behind a stricture, or ui^on a nucleus — some small foreign body introduced from without ; foreign bodies from dermoid cysts, or passing through fistula in the rectum, may reach the urethra and become arrested there. Long bodies always tend to travel toward the bladder, especially if they are sharp at one end (pins), as such bodies are always introduced blunt-end foremost. Stones and rounded bodies lie in the naturally wider parts of the canal (fossa na- vicularis, bulbous urethra), or become arrested by stricture. If foreign bodies are not removed, one of three consequences fol- lows : 1. They travel on into the bladder and form a nucleus for stone there ; or, 2. Stone forms around them in the urethra ; or, 3. They cause the urethra to inflame, bring on retention of urine, and finally become encysted or ulcerate their way out, leaving behind fistula and ultimately stricture. Treatment. — If the body be long and soft (catheter, piece of wood), it may be transfixed with a stout needle through the floor of * Consult Poulct on "Foreign Bodies." Translation. William Wood & Co., New York, 1880, p 110. FOREIGN BODIES IN THE UiiETIIRA. 53 the urethra and the canal pushed back over it, like a glove over a fin- ger, as far as possible, when it may be transfixed again, and ho urged forward until it reaches the meatus ; otherwise, the long urethral foi'- ceps, the alligator forceps, the ingenious scoop of Leroy d'Etiolle for small round bodies, or the urethral lithotrite may be used. I have employed* for this purpose successfully the ordinary Thompson stricture divulsor, opening it after passing the foreign body, and, on closing the instrument, finding the latter between the blades. In manipulating with any ordinary forceps, if the finger on the outside can detect the foreign body and can get behind it, nothing should divert the surgeon from keeping up pressure at that point to j)revent his instrument from pushing the offending substance still deeper into the canal. If the foreign body lies behind a stricture, the latter must be cut, divulsed, or rapidly dilated (continuous dilatation), to allow the pass- age of a suitable instrument for extraction. Pins and needles usually necessitate an opening of the urethra from the outside. Such an opening should never be made through the scrotum, for fear of infiltration. It is preferable to cut through the perinseum, even if the foreign body has to be pushed back in order to be caught. The urethra may be opened by cutting upon the for- eign body, or upon the end of a staff in the urethra pushed up to it. The after-treatment of wounds so made is the same as for incised wounds of the urethra. The incisions should invariably be longitudi- nal. Dieffenbach removed a pin very adroitly from the membranous urethra, by introducing a finger into the rectum, pushing upon its head until the point had been caused to penetrate the skin, and then seizing and forcibly extracting it. I extracted one with Thompson's divulsor. Polyin and Warts. — Polypi are occasionally found in the urethra, several of them at a time, or, more often, one alone. They are usu- ally attached to the floor of the canal, habitually in the anterior part of the urethra. They are generally soft, gelatiniform, but sometimes fibro-cellular, of greater firmness. At an autopsy, Thompson f found one five-eighths of an inch long, attached to the summit of the veru montanum, a very rare situation. Urethral polypi are usually small, but sometimes large enough to obstruct the free outflow of urine and occa- sion some muco-purulent discharge. When pedunculated, they may be removed (if detected in the anterior urethra) by being snared with a wire loop ; when deeply seated, they must be torn away with forceps. Demarquay % has collected some interesting cases. Ordinary venereal warts sometimes grow within the urethral orifice, and are difficult to dispose of, particularly if deeply seated in the canal. I have seen * "New York Medical Record," March 6 and May 1, 1SY5. f London "Lancet," March 15, 1856, p 288. % Op. cit, p. 333. 54 DISEASES OF THE URETHRA. tbeni tlu-ough the eudoscope several inches doAvn the urethra. They yield an annoying, thin, purulent discharge. Their treatnaent is cau- terization through tiie endoscopic tube,* bismuth injections, and in- ternally the, tincture of thuja occidcntalis u]) to one-drachm doses. "Warts near the meatus may be cut or scraped away, and the base from ■which thcv jrrow cauterized. CHAPTER III. DISEASES OF THE URETHRA. Inflammation.— Causes. — Subdivisions : Gonorrhcra ; Bastard Gonorrhnea ; Urethritis. — Sj-mptoms. — Duration.— Course.— Gleet.— Complications of Urethral Inflammation. — Treatment ; Method of performing Injection ; Abortive Treatment.— ^Methodic Treatment of Increasing Stage, in- cluding Description of Wrappings ; of Stationary Stage, including Chordee ; of Decreasing Stage, including Copaibal Erythema. — Gleety Stage ; Treatment of Gleet.— The Endoscope. — Rare Sequelae of Gonorrhoea. Gonorrhoea — Urethritis. — Of all the diseases encountered in genito-urinary surgery, urethral inflammation is the most common. Furthermore, although a strictly local affection, and exerting no poi- sonous action upon the blood, it is the most yenereal of all venereal diseases, since it is tlie commonest malady acquired during the copu- lative act. A most respectable antiquity is given to the disease by the fifteenth chajiter of Leviticus, and, although it is contended that the discharge known to the Jewish lawgiver was a simple urethritis, and that gonorrhoea (a specific infection) did not appear until later (ac- cording to Astruc,f in the year 1545-'46), yet the disease was evi- dently a running from the urethra, and discussions about its simple or specific nature belong to theoretical and not to practical text-books. We have to start from the clinical facts that all inflammations of the urethra are characterized by the discharge of pus, or muco-pus, from the meatus, and that the best guide for treatment is the amount of the inflammation, and the quantity and quality of the discharge J — an inflammation of given intensity requiring a given treatment, whether it has sprung from specific contagion or from chemical or mechanical irritation. This point makes it necessary to study both maladies, clinically, under the same head. That there are two maladies, one virulent and one simple, is and always has been certain ; the difficulty has been to distinguish between them, for their symptoms are nearly identical. Modern science is endeavoring to solve the problem, and * Belfield, " Diseases of the Urinary and Male Sexual Organs," New York, 1884, p. 69. f "De Morbis Venereis," Paris, 1736. X " Dry gonorrhcra " is an impossibility. The morbid state formerly known by that name is neuralgia of the urethra. URETIIKAL INFLAMMATION— CAUSES. 55 the gonococcus of Neisser* is constantly arrogating to itself now claims as the active virulent cause of true specific gonorrhoea. The term gonorrhoea is ctymologically inaccurate, indicating, as it does, a flow of semen (yovos) ; but usage has secured to it a precise signification even among the laity (almost to the exclusion of the old Saxon term dap), and any alteration would lead to confusion. Ure- thritis signifies simply inflammation of the urethra, consequently gon- ovrlacBa is urethritis, but the converse does not hold good ; and, al- though without the microscope it is impossible, in a condition of high urethral inflammation, to pronounce upon its origin with certainty, yet it is better for practical purposes to retain the two terms, calling that gonorrhoea which has been derived unmistakably from an indi- vidual of the other sex with a gonorrhoea, and reserving the term ure- thritis for all inflammatory urethral discharges having another origin, and for all cases of doubt. This latter precaution is of the utmost importance to the student and young practitioner. It is better that a hundred of the guilty should escape than that one innocent person should be accused. Experience proves beyond a doubt that a high condition of urethral inflammation attended by an abundant dis- charge, and presenting absolutely no diagnostic features to differen- tiate it from a gonorrhoea unless the microscope solves the doubt — that such a urethral inflammation may be acquired by a healthy young lover from his equally healthy mistress, by a young husband from his wife, or may be produced by applying a chemical irritant to the urethra. These cases are doubtless rare, but are of undoubted authenticity, and it becomes the surgeon's duty to hesitate long before asserting the infidelity of a man or woman, and thus, perhaps, accus- ing the innocent and destroying the harmony of a family. It is proper to state that a healthy man may get a urethritis from a woman who has none (may give himself the gonorrhoea, as Ricord puts it) far more easily than a woman can get a discharge from a healthy man, unless, of course, great mechanical violence be used, as in rape. Causes of Urethral IxFLAiiMATiox. — Gonorrhoea is a notori- ously contagious disease, and it may be acquired, from any person having it, by the mere contact of the discharge with the mucous membrane of the urethra, f It is not necessary that the surface * "Cntrlbltt. f. Med.," No. 28, ISTO, p. 497. I The only mucous (or other, as far as known) membranes of the body capable of tak- ing on inflammation from the contact of gonorrhoea! pus are the urethral, vesical, by ex- tension (gonon-hoeal cystitis), the vaginal (the uterine and tubal by extension), the con- junctival, and the rectal. Buccal, aural, nasal, and umbilical gonorrhoea have been men- tioned, but authors are of accord that the cases cited are not conclusively proved. Gon- orrhoea of the rectum has undoubtedly been observed in several instances ; one case by Tardieu (" Etudes medico-legales sur les Attentats k la Pudeur," p. 180) in a prostitute who had practiced sodomy ; and three cases by Allingham (" Diseases of the Rectum," London, ISYl, p. 23'7), all in prostitutes, "who all confessed the manner in which they 56 DISEASES OF TUE URETHRA. slioiild be abraded. Simple contact is euougli without any sexual act, as has been abundantly proved by the experiments of B. Bell, Baumes, Eodet, and others.* Tl»e discussion upon even tiie existence of a virulent gonorrliOBa has been active of late years. Ricord did not believe strictly in it, thinking that one could give himself a gonorrhoea. Bumstead decided against it, the German school declared the inflammation to possess no virus sid generis, and matters were rapidly reaching a position that would make the assumption of any ditfercnce between gonorrhoea and urethritis untenable f when Neisser's announcement appeared claiming that he had discovered the essential causative clement of gonorrhoea to be a peculiar vegetable parasite which he likened to sarciua and christened gojiococciis. This announcement naturally challenged con- troversy, and there has been no stint of investigation. J Pure cultures of the vegetable organism have been difficult to obtain, and much con- fusion in the long discussion to which this question has given rise is due to the fact that there is another coccus,, much like the gonococcus, which may be found normally in the urethra (urethrococcus) ; and indeed a similar black set of spots may be found in the normal secre- tions of other membranes (mouth) and even in the pus of an acute abscess. The difference, however, appears to be this, that while a single coccus is only a black minute dot, and this dot is about the same in appearance and under staining whether the coccus be a gonococcus, got so affected." Gosselin also saw a case, " Retrecissements syphilitiqucs du rectum," "Arch. Gen. de Med.," 1854, vol. ii, p. 066. R. Winslow reports an epidemic of rectal gonorrhoea arising from sodomy in a juvenile asylum near Baltimore, " Medical News," August 14, 1886. Rollet reports a case, "Diet. Encyc. des Sci. Med.," art. "Rectum." The subject has been investigated by Boniere, "Arch. Gen. de Med.," April, 1874; Re- quin, " Elements de Path. Med.," tome i, p. Y29. Tliiry has a case, " Presse Med. Beige," No. 34, 1882, p. 201. * Rollet, "Traits des Maladies ven6riennes," Paris, 1864, pp. 211, el scg. •)• See an excellent paper by Morrow, " New York Medical Journal," September, 1881, p. 263. X Among the able articles may be instanced : A. Neisser, " Ueber eine der Gonorrhea eigenthiimliche Mikrococcusform," " Cntrlbltt. f. d. medicin. Wissenschaften," No. 28, IS'ZQ. A. Bokai, " Ueber das Contagium der acuten Blennorrhoea," " AUgem. med. Centralzeitung," No. 74, 1880. A. Neisser, " Die Mikrococcen der Gonorrhoea," " Deutsche med. Wochenschrift," 1882, p. 279. M. Bockhart, " Beitrag zur Actiologie und Patho- logic des Ilamrohrcn-Trippers," " Vicrtcljahrschrift f. Derm. u. Syph.," 1883, p. 3. E. Welander, " Quelques recherches sur les microbes pathogenes de la Blennorrhagie," " Gaz. Med.," 1884, p. 267, and " Nord. med. Arkiv.," Bd. xvi, No. 2. Ernst Bumm, "Der Mikroorganismus der gonorrhoischen Schleimhaut-Erkrankungcn," Wiesbaden, 1885. An- toinc Magnin and George M. Sternberg, " Bacteria," New York, William Wood & Co., 1884. Bockhart, " Monatsschrift f. pract. Dermatologie," 1886, No. 4. These arc among the best of the earlier contributions to the subject. Many others have appeared and are still appearing. George E. Brewer has very ably summarized the subject in an article, " The Modem Treatment of Urethritis," in the " Journal of Cutaneous and Genito-Uri- nary Diseases," May, 1887, p. 170. URETHRAL INFLAMMATION— CAUSES. 57 a urethrococcns, or a coccus i'ouiul with any indifToront pus, yot the true gonococci, as Neisscr has sliowii, are pociiliar in their develop- ment, and arrange themselves always in multiples of two and in lines tending to be parallel, showing their growth by segmentation. Thus a scattered set of dots means nothing, but dots arranged in couples, in fours, and in parallel sets mean the specific gonococcus. Theoreti- cally this distinction seems easy to make, but practically it is sometimes quite difficult to decide whether the clusters of minute dots in a given field of pus are arranged at random in a clump or paired off, yet a little careful study usually decides the point, and the more one exam- ines the little dots the more clear seems to be the difference. An- other distinction seems to be that the true gonococci are found inside the pus-cells — other cocci only outside. Recently Max Bockhart * has described two cocci found in non- virulent urethritis as special varieties. The gonococcus of Neisser is uniformly found in the pus and in the conjunctival tissues in gonor- rhceal ophthalmia. The specific organism has also been found in the pus taken from a knee-joint in a case of gonorrhoeal arthropathy (Hall).f Westermark J has also found it in the pus of a pyosal^Dinx. The little black dots which constitute the gonococcus lie within the pus-cells as well as upon them and in the fluid surrounding them. Single points have no value. To be distinctive, the gonococcus must be arranged in the specific grouping in pairs and fours and in linear groupings. To prepare a specimen of pus for examination, a good method is to place a little pus on a cover-glass, cover this with another cover-glass, and after pressing the two together slide them apart. This leaves each covered on one side with a thin, uniform film of pus. The cover-glass is now to be passed a few times rapidly through the flame of a spirit-lamp, the purulent film being upward. This causes the thin film to adhere to the glass. Next, the dried film is covered with a very strong watery solution of methyl violet. This is to be after a couple of minutes poured off, and the purulent film gently irrigated with water to wash away the excess of coloring matter. The cover- glass is now to be mounted with glycerin. The nuclei of the cells are seen darkly tinged in purple, the outlines of the cells and their granular contents are faintly tinted, while the groups of cocci are quite manifest as clusters of minute black dots arranged as already indicated above. A magnifying power of about five hundred diameters is ample for a ready appreciation of the gonococcus. The more virulent the case and the thicker the pus, the more abundant and characteristic are the groups of gonococci. The plant persists to the end of the conta- gious stage of the disease. * " Monatsschrift f . prakt. Dermatol.," April, 1886. •)• " New York Medical Record," March 20, 18S6, p. 335. X Referred to iu " New York Medical Record," July 31, 1886, p. 138. 58 DISEASES OF THE URETHRA. Theoretically, then, the gonococcus is a most valuable means of diagnosing virnlence in a given urethral discharge ; and practically so, as well, in a small minority of cases. I have frequently examined urethral discharges, and intensely purulent ones at that, and, failing to find the gonococcus, have pronounced the source of alleged contagion to be non-virulent, and the patient to possess a discharge which he could not communicate to another, and have not yet been proved to be Avrong. On the other hand, I have found abundant gonococci possessing all their typical qualities in patients who were married and practicing sexual intercourse without communicating disease to their wives. I have found typical gonococci in the little shreds of pus Avhich are washed out of the urethra by the urine in some cases for months after all discharge has ceased, and I have seen such patients marry and their wives escape unharmed. Yet I have never examined a thick, purulent discharge, -which I believed for other reasons to be virulent, without finding it loaded with gonococci, and my belief is that this organism is the contagious element in the discharge. But I believe also that the practical application of this test leaves something to be desired, for, while all contagious discharges unmistakably contain typical gono- cocci, there are certainly some cases in which the organism exists and yet where intercourse is practiced without spreading the contagion. A discharge not containing gonococci is certainly not contagious, and this fact is one of great practical importance and a xcrj reliable one. A discharge containing gonococci, however, is not necessarily conta- gious iri a virulent way. But, clinically, a purulent discharge from the urethra is a given malady, and that its cause is sometimes virulent (gonococcus) and sometimes simijle does not materially alter the question of its clinical management, nor interfere with the clinical study of the question of urethral purulent discharges as a whole, for, unfortunately, the dis- covery that gonorrhoea is of vegetable origin does not at once furnish us with a means of always being able to abort the disease. Parasiti- cides are well enough theoretically, but, practically, gonorrhoea is still difficult to abort, but, apparently, not so much so as it was before Xeisser made his brilliant discovery. Attempts have been made to differentiate the true from false gon- ococci by staining and again decolorizing the micro-organisms. Roux * devised such a method, and in this country Charles W. Allen f comments upon it and thinks well of it. I have tested the method and find that it does not give me satisfactory results, and I believe that a reliable method of positively differentiating true from false gonococci is yet to be found. * "Le Concours Medical," November 13, 1886. f "Practical Observations on the Gonococcus," "Journal of Cutaneous and Genito- urinary Diseases," March, 1887, p. 81. URETURAL INFLAMMATION— CAUSES. 59 Besides the gonococcus, then, as a cause for uretliral inflammation, we have other agencies acting from within and from witliout, capable of producing similar if not identical clinical symptoms. A priori there is no reason why the influence of cold should not produce a catarrhal discharge from the mucous membrane of the ure- thra, just as well as from that of the other mucous expansions ; but clinical experience teaches that this is the rarest of all causes, if, in- deed, it exist at all for the healthy canal. An irritating substance acting locally seems to be essential to urethral inflammation. The only exceptions to this rule are those cases where prostration or excess- ive fatigue has given rise to a discharge in broken-down constitutions of the strumous or gouty order, where prolonged ungratified venereal excitement has been followed by actual inflammation of the canal, as in the case reported by Latour, and alluded to in most text-books,* or where some inflammatory trouble, usually affecting other parts, has accidentally appeared in the urethra. Some author has reported a case of ordinary herpes of the urethra with discharge alternating with herpes of the thigh. Bassereau and Bumstead speak of cases of muco- purulent urethral flow coming on with the first appearance, or with a relapse of secondary syphilitic eruptions, the cause of which was the development of mucous patches upon the urethral mucous membrane. Ricord f details a case of tubercular deposit within the urethra at- tended by urethral discharge. A patient under the author's care with tertiary syphilis has had a muco-purulent discharge on several occa- sions, depending upon the development of a tubercular eruption in the urethra, growing sufficiently to occasion obstruction to the free escape of urine, and supplying a decided discharge ; symptoms always relieved, and the caliber of the urethra restored, by the internal exhi- bition of iodide of potassium. Syphilitic tubercles around the orifice of the urethra are not very uncommon. Mechanical Violence — sufficiently intense or prolonged — will always produce urethritis ; but in these cases the inflammation is usu- ally developed in proportion to the extent and character of the injury, and tends to get well rapidly. To this class of causes belong the rough use of instruments in the urethra, instruments left a demeure (tied in), violence inflicted by foreign bodies introduced from with- out or passing from the bladder (stone fragments). The abundant formation of large crystals of uric acid in the urine acts also mechan- ically by scratching, but usually is insufficient to cause urethritis in a perfectly healthy subject. As a rule, urethritis from mechanical violence commences at once, and tends to get well speedily, if the cause does not continue to act. Chemical Violence. — Irritants acting chemically are potent for evil. Under this head come strongly concentrated acid urine ; the * Rollet, op. cit., p. 236. \ " Bull, de I'Acad.," Tol. xv, p. 565. 60 DISEASES OF THE UKETIIRA. action of certain substances ingested — cantliarides ; strongly acid or alkaline injections ; rancid or acrid iluids or secretions — leucorrluoal disci uirges, lochia% and the menstrual How. Of these chemical irritants the last group mentioned deserves spe- cial notice. As a rule alone they are unable to cause urethritis ; something else must intensify their action in order to make them ctfective, and that something is eitiier prolonged and excessive sexual excitement and indulgence, a weakened condition induced by fatigue and excitement, an impaired state of urethra coinciding with stricture or left behind by previous attacks of intlammation, or individual idio- syncrasy, or coincidence of some other cause, as irritating urine. If this were not the case, married men would be much more afflicted than they are, for few women (especially in large cities) are free from more or less Icucorrho^a, and young married couples are very apt to disregard the beginning and the end of the menstrual flow. Viewing the subject from this stand-point, it becomes easy to account for the fact that one man may live with impunity with a woman having a leucorrhoeal flow, while another who attempts to share her favors (under stronger venereal excitement) immediately acquires a dis- charge. The " acclimatation " of Eicord is accounted for in the same way ; that is, where a man in his earlier and more amorous approaches acquires a urethritis from a woman with leucorrhoea, but afterward lives with her unharmed, although her discharge may continue una- bated. Finally, in this way is explained Eicord's celebrated "receipt for getting a gonorrlicea" {" recette j^our attra^Jcr Ja chcmde-jnsse"), which consists in taking a young, amorous, pale, blonde girl (prefer- ably with a leucorrhoea), dining with her, drinking white wine, cham- pagne, coffee, and liquor in abundance, dancing with her vigorousl}'-, performing the sexual act as frequently as possible during the night, taking a prolonged warm bath in the morning — and a " j^recaution- ary" injection. Such a course would undoubtedly be effective, espe- cially if the individual testing the "receipt" were lymphatic, with a large meatus and a tight prepuce, or had a slight hypospadias ; and especially if his urethra contained patches of congestion or slight stricture left behind by old attacks of inflammation. Before passing to the symptoms of inflammation of the urethra, it is well to take a short, comprehensive view of the three most common forms of urethral flow at their commencement as they come under the surgeon's notice. They are given below in the inverse order of their severity, and may be styled urethritis, bastard gonorrhoea, and gonor- rhoea : TJeethritis. — Cases like the following are not very uncommon. The patient, often a lymphatic young man, perhaps not long married, virgin of all antecedent venereal disease, finds, on the first, second, or third day after having indulged in sexual intercourse, probably to ex- URETURAL INFLAMMATION— SYMPTOJLS. f)l cess (possibly also after unwonted j^otations, and with a partner having a leucorrhosa), a slight, uneasy sensation at the meatus, a littie smarting, and a pearly drop — or possibly the lips of the urethra glued together — in the morning. Here the prognosis is usually good. The inflamma- tion will probably not run high or last long, and the microscope will not be able to detect any specific gonococci. A diagnosis of urethritis may be made with certainty here, but, nevertheless, the discharge may become profuse, the inflammation run high and continue many weeks, and the disease thus become indistinguishable from gonorrha3a. Such an attack may be acquired from any irritating discharge, aided by idio- syncrasy, acid urine, excessive excitement, etc. Bastaed Gonorehcea. — A patient comes with a little oozing from the meatus, perhaps with no itching sensation, nor any smarting on urination ; but he says that he has had '' the disease" on several occa- sions previously, and he is terrified at this sign of a new attack, which he believes inevitable. He states that (perhaps after copious libations of ale, beer, or champagne) he sinned with a suspicious party, and that while examining himself on the following morning — or after forty- eight hours — he discovered, to his horror, the little opaline drop at the meatus, and he comes at once to seek relief. This is by far the most common story. Such a patient has a damaged urethra, a jiatch of chronic congestion with or without thickening of the urethral walls, or perhaps a positive stricture, of which he knows nothing, has been left behind by his previous attacks, and. he has irritated this surface and given himself a discharge, when the woman was, in all probability, sound, or had, at best, only a certain amount of leucorrhoea. This is not true gonorrhoea : it is bastard. A little alkali internally, rest, and a mild injection, followed by the gentle hnd judicious use of the steel sound, will usually soon quiet the patient's fears and overcome the threatened evil. In such cases always examine for stricture later on. GoNOEEHGEA. — True gonorrhoea requires no idiosyncrasy, no ale or champagne, no excess, no weakened condition of the urethra for its development, but simply intercourse with a female having a gouor- rhoeal discharge. Here, after a period of perfect rest lasting from three to eight days, as a rule, the urethral disturbance commences, and runs the given course of virulent, specific gonorrhoea. Symptoms of Inflammatioist of the Ueethea. — The period of incubation or hatching — that period which elapses between the suspi- cious contact and the first appearance of discharge — varies from a few hours (rarely less than twenty-four) to fourteen days (rarely more than eight). The first symptom in true gonorrhoea is usually noticed on the fifth to the seventh day. It may be stated as a rule, to which there are, however, numerous exceptions, that the shorter the period of in- cubation the milder will be the succeeding attack ; but this rule does not hold after the seventh day. A tickling, teasing, itchy irritation 62 DISEASES OF TUE URETURA. is first felt at the orifice of the urethra. Tlie lips of the meatus are found adherout, or a slight, bluish, sticky discharge is seen be- tween them. A slight stinging is felt on urination. The lips of the meatus now- swell a little and become reddened. The quantity of dis- charge increases, and it becomes opaline. Greater pain is felt in pass- ing water. The meatus feels hot and sore. After the lifth day from its first appearance the discharge becomes much more copious. It gets thick and purulent, and soon acquires a greenish color from slight admixture with blood, which latter may ap- pear in little streaks. If, during erection, the mucous membrane be- comes cracked, ha?morrhage may be considerable. Pain is now felt all along the pendulous portion of the urethra, and the canal is sensitive to pressure. Irradiating pains may be complained of in the groins, testicles, perinanim, cord, and back. Involuntary seminal discharges at night are sometimes brought on by the local irritation, and such ejaculations may be exceedingly painful. The urethral mucous mem- brane becomes thickened by the inflammation, and the stream of urine is consequently small, forked, or dribbling. Eetentiou may come on, possibly from spasmodic muscular contraction, or by extension of the inflammation backward, causing sudden congestion of the prostate (Thompson) — a condition recognized by rectal examination. But re- tention Avitli gonorrhoea is, of all complications, the most rare, unless the patient continues to drink hard, or has already a rather tight stricture before he acquires the disease. As the inflammation advances, the prejrace may become oedematous (lymphitis), occasioning phimosis or parajDhimosis ; or, if the prepuce be naturally tight, the inflammation may extend into the balano-prepu- tial cavity and light up balanitis. Erections, also, at this time become painful, threatening chordee. This indicates that the inflammation has extended beyond the free surface of the mucous membrane, and has included the delicate meshes of the erectile tissue of the corpus spongiosum. As a rule, the higher the grade of urethral inflamma- tion, the greater liability is there to chordee. In actual chordee more or less of the areolar structure of the corpus spongiosum has become obliterated by the efEusion of plastic lymph, while other portions lose their distensibility. This condition may implicate a longer or shorter distance along the urethra, sometimes nearly the whole pendulous portion. The corpus spongiosum consequently does not allow com- plete distention of its areolas, and hence the urethra is comparatively too short for the erect corpora cavernosa, and bends the penis down- ward like a bow during erection, the urethra being the chord to the bow. If the corpora cavernosa should become inflamed and the cor- pus spongiosum escape, the arching would be in the opposite direc- tion. This sometimes, but very rarelv, takes place. A sort of spuri- ous chordee, upward or lateral, may be caused by inflammation of the URETHRAL INFLAMMATION— SYMPTOMS. 63 lymphatics along the dorsum or side of the penis. In chordcc, great pain is felt from the stretching of the inflamed erectile tissue. This pain is measurably relieved hy bending the penis so as to increase the bow, and in this way to slacken the string ; and it passes off entirely as erection disappears. Chordee is most frequent during the night and toward morning. It may render sleep impossible. The point of great- est curvature is situated anywhere along the pendulous urethra, most frequently near the glans — gland arque (Ricord). The pernicious practice of " breaking the chordee," which consists in roughly straight- ening the penis when erect, gives rise to a haemorrhage which may become excessive and be the starting-point of organic stricture. After the disease has continued at its height for from one to three weeks under favorable circumstances, the pain on urination, which had traveled down to the root of the penis, ceases, the discharge be- comes more watery, chordee infrequent. The discharge diminishes down to a drop in the morning, the meatus again sticks together, and finally even this ceases, and the patient is well. During all this local inflammatory disturbance there is little if any constitutional sympathy. There may be some feverishness for a time, or, in nervous individuals, a real or fancied feeling of prostration during the continuance of the discharge. The DuRATio]!«r oe Go]sroRRH(EA is variable. A well-managed case lasts from three to six weeks, as a rule ; but the discharge may con- tinue for months or even years. A first gonorrhoea is the most se- vere ; but it is also the most certain to get perfectly well if carefully managed. Course of Gokorrhcea. — The urethral inflammation commences at the meatus and travels slowly backward. According to Desor- meaux,* on the eighth day of the discharge, the anterior half of the urethra has become invaded, its surface is congested, without polish, and covered with little bare spots, like those seen in balanitis, where the epithelium has exfoliated. There is no ulceration. When the discharge is older, the lesions are identical, but deeper seated. The disease tends to limit itself and to become localized at the bulb, in the fossa navicular! s, or at some intermediate point, where there may have been much chordee; At these points of localization, the surface is of a vinous red, the polish of healthy epithelium is absent, and there are perhaps a few granulations. The submucous tissue thickens, impair- ing the vascularization of the part, and this process may go on to the formation of organic stricture. Where the disease runs this course, instead of getting well, we have gleet. Gleet. — In gleet, whether due to forming stricture or not (the former condition is vastly more common), a certain amount of sticky, * " De I'Endoscope et de ses Applications au Diagnostic et au Traiteaient des Affec- tions de rUrethre et de la Vessie," Paris, 1S65. 64 DISEASES OF THE URETHRA. bluish fluid — often only a drop at the meatus in the morning — con- tinues to be secreted after gonorrhoea — from altered patches of the urethra — or coming from the stretched and congested membrane be- hind a stricture. Gleet, then, is a s3'mptora of two structural lesions, and signifies that there are patches of congestion in the canal, covered or not by granulations, or that stricture exists, and that the discharge comes from behind it. Granulations, analogous to those seen in granular lids, may be observed, when present, through a urethral tube, as may the little vegetations, or polypoid growths, which sometimes spring from altered patches of urethral membrane. Idiopatliic gleet may come on in individuals of a strumous or gouty diathesis, the immedi- ate cause being a broken-down constitution or acid urine. Prostatic congestion and enlargement are also liable to be attended by a slight gleet, as are also mucous patches in the urethra, etc. Of these varie- ties, the strumous urethritis, like other manifestations of the diathe- sis, is usually found in early life, while gouty gleet belongs more par- ticularly to middle age. An explosion of gout may come on in this way, a distinctly purulent urethritis of some severity appearing sud- denly in a gouty individual, after chilling of the legs or excess at table, especially in regard to drink. When an individual with a gleet is found to be gout}', whether his discharge be idiopathic or not, it is particularly advisable to enforce urethral hygiene and general dietetics. Gleet tends to last iudetinitely, but is often so very slight as to be ignored. An individual so aifected is a ripe subject for bastard gonorrhoea. The simple congested patches, without sensible thicken- ing or granulations, which furnish the gleety discharge after an ordi- nary gonorrhoea, are kept from getting well by alcohol, malt liquors, sexual excess, fatigue, violent exercise, anaemia, gouty or strumous habit, etc. If one of these causes for the continuance of a discharge do not exist, it will usually get well of itself, or certainly with the help of some mild injection, or after a few introductions of the sound. Gleet is contagious when purulent — the more copious and creamy the discharge the greater its infecting power, but only if it contains gonococci. COMPLICATIO^rS OF URETHRAL IlfFLAMMATIOX. — Of the COmphca- tions of gonorrhoea, some have already been described : balanitis, in- flammatory phimosis, chordee, jaossible retention, and ha3morrhage. Others will receive attention when considering the organs they affect — epididymitis, orchitis, inflammation of seminal vesicles, gonorrhoeal cystitis, catarrhal i)rostatitis, prostatic congestion, prostatic and peri- prostatic abscess. The others will be dealt with after the section on treatment — folliculitis, cowperitis, suppurating peri-urethritis, lym- l^hangitis, and adenitis — all being extensions of inflammation from the URETnRAL INFLAMMATION— TREATMENT. 05 urethral mucous membrane ; finally will bo considered gonorrho;al rheumatism, gonorrhceal ophthalmia, and gonorrhoeal conjunctivitis. Treatment of Urethral Inflammation. — There are two methods of treating inflammation of the urethra : 1. The abortive — which seeks to strangle it at once. 2. The methodic — a treatment based upon the intensity and stage of the inflammation. Injection of the urethra is a proceeding so often resorted to, both early and late, in inflammation of the canal, that the subject of treat- ment may be well introduced by a few words upon a proper method of performing this surgical manoeuvre. First, as to a choice of instrument. The nozzle of the syringe must be short, for fear of scratching and irritating the already inflamed membrane, and must expand suddenly, so as to be adaptable to orifices of all sizes. Any syringe more or less like the one shown in Fig. 19 is capable of enabling an injection to be made without wetting the patient or scratching the inside of his inflamed urethra. Such a syringe should hold between three and four drachms, not that the whole of this quantity must be introduced at each injection, but because that amount may be necessary to properly distend the urethra in many instances. To inject elegantly, the patient encircles his penis behind the corona with the thumb and first finger of his left hand, uncovering the glans penis in part or wholly. In the right hand he holds the syringe be- tween his thumb and last three fingers, placing the to]3 of his index-finger within the ring. He now inserts the blunt nozzle into the flaring meatus, and, pulling the penis forward with his left hand, he pushes the blunt nozzle well into the gaping urethra, and at the same time slowly causes the piston to descend. He continues this manoeuvre until a positive feeling of distention in the deep urethra warns him that the urethra will hold no more. Then, tightening the encircling grasp of the left hand, he removes the syringe and holds some convenient vessel in front of the penis, Now relaxing the press- ure upon the urethra, the injected fluid spurts out without soiling clothing or hands. It is always well to pass urine immediately before using an injection, that the canal may be thus freed from pus. Abortive Treatment. — The idea of aborting gonorrhoea by the internal use of balsams has been abandoned. The old idea of abortive treatment was to irritate the urethra, substituting a simple for a poi- sonous inflammation. The modern idea is by hot irrigation to soothe the membrane and wash out the poison, or by antiseptic or autipara- 5 Fig. 19. 66 DISEASES OF THE URETHRA. sitic drugs to destroy the gouococcus. Nitrate of silver and chloride of zinc, formerly in great rejnite, are no longer relied npon, and this is fortunate, for they often did harm, and rarely, if ever, any good in true gonorrhani, the only one of the class of maladies we are con- sidering really worth a serious effort at producing its abortion. Iodo- form has been tested and abandoned, and the present favorites are jiro- longed irrigation and varying strengths of the bichloride of mercury. If the abortive treatment is to be tried as such, it should be used within the first twenty-four hours of the commencement of an attack. The bichloride of mercury in solution has been used at varying strengths up to one in one thousand — nearly half a grain to the oimce. This, however, is not capable in my hands of aborting gonorrhoea. Even a sixteenth of a grain in the ounce often produces severe pain, and greatly increases the grade of the inflammation in a fresh, young case of true gonorrhoea. I have never, with the bichloride of mercury, been able to entirely arrest a true gonorrhoea at once or to kill the gonococcus — using it weak or strong, at long or short intervals. The irrigation method has had some ardent advocates. There are two ways of using it — one deep, the other superficial. By the deep method a small, soft catheter is gently inserted uj) to the hole in the tri- angular ligament, and a pint or more of very hot water is run through the urethra one or more times a day. Sometimes a strong astringent injection, as of tannin, is used once a day after the injection. This method I believe to be dangerous in some cases. It will abort urethri- tis and bastard gonorrhoea, but in my hands it has always failed to modify a virulent attack in any way except to aggravate it, and I have treated a number of cases in which cystitis, prostatic congestion — even abscess — epididymitis, etc., had been directly caused by this abortive method of deep urethral irrigation early in an attack at the hands of other surgeons. I think this method often useful in old cases or late in an attack — not in the beginning. Dr. Holbrook Curtis and Dr. Brewer think highly of it in the early stages, and have advo- cated it in the journals. The method by anterior irrigation is more rational, since the virulence of the malady confines itself at first to the anterior segment of the urethra. This method combines irrigation with a very mild antiseptic action. Its introduction in New York is largely due to Dr. Halstead and the Roosevelt Dispensary. The method is simply to put a quart of tepid or hot water, at a strength Fig. 20. of half a gram of bichloride of mercury in twenty-two ounces (about 1 in 20,000), into a fountain syringe, the rubber tube of which is armed with a nozzle of glass shaped like Fig. 20. This blunt nozzle is simply crowded into the urethra, and then the fluid is allowed to flow. Soon the canal is distended, after which URETHRAL INFLAMMATION— TREATMENT. G7 the whole quart of fluid is allowed to run through the anterior ure- thra by slightly letting up the pressure on the orifice so that the water shall trickle out slowly alongside of the glass noz- zle. L. F. Keifcr* has devised a hard-rubber nozzle for irrigation (Fig. 21). The nozzle is kept crowded into the meatus, the fluid runs in through one arm and out at the other, the ure- thra being kept ballooned out, and a constant irrigation being kept up by regulating the amount of outflow with the finger over the orifice of out- flow in the arm of exit. This irrigation is re- peated three times a day, and the malady, if treated within twenty-four hours of the beginning of the attack, may be sometimes aborted, it is said. This is true for urethritis ; if the gonorrhoea is virulent, it can nearly always be moderated in violence and sometimes cured in the second week — at the earliest. This is my present view ; others claim better results. Instead of the fountain syringe, I now generally get the patient to use for himself a little red soft-rubber irrigator called the universal in- jector (Fig. 22). I direct the patient to dissolve one fifth of a grain of bichloride of mercury in eight ounces of water (or to make the solution even much weaker if this strength causes pain), and to practice irrigation of his urethra with it in the manner described above about three times a day. A speedy diminution in the discharge often follows, but not invariably. I rely upon it, in the beginning of all acute attacks, with growing confidence. This treatment, even if it fails, has yet the enormous advantage that it can not j)ossibly do harm, and that stricture can not be caused by it, a statement which could not be made of the old abortive treatment by strong injections of the nitrate of silver. Methodic Teeatment oe Ueetheal Inflammatio^t. — This is the rational treatment for all forms of urethral discharge, whatever their nature, based upon the quantity and quality of the discharge and the grade of the inflammatory action. The hygienic part of the treatment is of the utmost importance. If it be disregarded, the best-directed efforts may fail to arrest the discharge. Many cases of simple urethritis and bastard gonorrhoea require little else than the hygienic treatment. The hygiene of gon- orrhoea is as follows : Fig. 22. " Medical Record," April 9, 1887. 68 DISEASES OF THE URETHRA. Absolute continence until at least ten days after the entire cessa- tion of discharge, and avoidance of anything liable to induce sexual excitement — company of a mistress, exciting books, thoughts, etc. No alcoholic stimulants of any sort, particularly no sweet fermented wine (champagne), and, above all, no malt liquor, should be drunk during the treatment. Physical repose is desirable. Increasinij Stafjv. — There is no objection to trying the abortive treatment by anterior mild bichloride irrigation in any case seen early enough. "Where it does not cure, it does no harm, and nothing of any greater value can •well be done at this time. An alkaline medi- cine is tiie only internal one required. The bicarbonate of soda is often used, but the citrate of potash, being mildly diuretic, usually acts better. It may be given in simple watery solution or variously flavored, at a dose of gr. x — xx, to be taken in water, preferably during the second hour after each meal. Enough to make and hold the urine alkaline is all that is required, and such a dose should be maintained through the entire treatment, whatever other medicine may be used. If the ardor urinee is very gi'cat, and the alkali alone does not control it, from one to five minims of the fluid extract of hyoscy- amus may be added to each dose of alkali. Sirup of cinnamon masks the taste of this drug reasonably well. Occasionally twenty-grain doses of the bromide of potassium will moderate the ardor urincB, and act as an alkali better than the citrate with hyoscyamus. It is hardly projier to use opiates for the simple burning on urination. If the bicarbonate of soda or potash be used as an alkali, a convenient form of adminis- tration is in the shape of the compressed jDellets novr so much in fashion. Among the balsamic preparations, the oil of sandal-wood and the balsam of copaiba help to moderate the ardor urinae in the first stage of gonorrhoea, and positively moderate the discharge in bastard gonor- rhoea and urethritis — while the cubeb preparations are of less value in my opinion. These balsams are of great value in the treatment of catarrhal troubles of the urethra, but to be of service they must be digested comfortably. If sandal-wood oil gives a man such a pain over his kidneys that he can neither exercise nor sleep, and if copaiba so upsets his stomach that he is constantly nauseated and declines food — such a patient is not suitable for the administration of either of these drugs, and it is folly to push them. But, if he digests either of them reasonably well, either of them will help him materially, in all of the acute and many of the sub-acute and chronic forms of urethral discharge. Both these substances are to be found in capsules, lU x in each. The dose to commence with is one after each meal, and in- crease up to two or three at a dose, if the patient's stomach bears the medicine kindly ; otherwise, it is better not to push the drug. Sandal- wood oil may be taken dropped upon a lump of sugar. The less fas- URETHRAL INFLAMMATION— TREATMENT. (39 tidious may take all the requisite medicine at a dose in combination, as in the following formula : ;^ PotassEe citratis, 3 ij-vj. Bals. copaibjB, 3 iij-vj. Extr. £1. hyoscyami, . .- 3 ss-ij. Syr. acaciic, § jss. AqupQ menth. pip., q. 8. ad § iij. M. S. Shake. Tcaspoonful in water. This is easier to digest than the old " Lafayette mixture," and the citrate of potash is aj)parently better than the niter and liquor potas- S9e of that compound. This mixture may be largely modified by substituting sandal- wood oil for copaiba, leaving out the hyoscyamus when not required, putting in bicarbonate of soda for the citrate of potash if the diuretic effect is not desired, and substituting winter- green water for the mint water, or even adding liquorice, according to taste. When a combination is found that suits the patient's palate and stomach moderately well, it may be persisted in during all the acuter stages of the malady, moderating the dosage of the various in- gredients as required. Another aid to easy micturition is Milton's plan of immersing the penis in hot water before and during the act. Fournier advises a similar use of very cold water. Hot water I think better than cold in the acute stages. Its use just before re- tiring has some power in preventing erection and chordee at night. The lorappings about the penis should be light. A susj)ensory bandage with penis-bag attached is a suitable ap- paratus, some absorbent cotton being put into the bottom of the penis-bag. A simple wrap when the discharge is free is two thicknesses of ordinary water-closet paper. In this the penis is wrapped, the free end of the resulting roll being twisted or gummed. This retains itself. If the discharge is light and the prepuce long, a piece of lint or absorbent cotton spread over the meatus and glans, and retained on either side by the prepuce, makes the best dressing to pro- tect the clothes. Or, if the preiouce is short, it may be re- tracted, and the glans passed through a hole just sufficient to receive it, cut in the center of a large piece of muslin. The muslin is drawn behind the corona. Finally, by pull- ing forward the short prepuce, the dressing is completed. When injections are used in the increasing stage, they should be very mild ones, that is, when the irrigation plan is not attempted. I have derived great advantage from using fig- as. a four-per-cent solution of the hydrochlorate of cocaine, and causing the patient to inject from ten to fifteen minims of it several times a day — sometimes before each urinary act, since it greatly re- duces the ardor urinse. A dropper with a long-drawn point, nicely 70 DISEASES OF THE URETHRA. rounded, aud a rubber cap is tlie most convenieut iustriimcnt for in- sertion (Fig. 23). The solution must be thrown in gently and retained by com})ressing the meatus fur several minutes. In this way the con- gestion of the acute stage is diminished, the discharge reduced, the pain on urination mitigated greatly, and chordee sometimes much modified. In tiie matter of injections much depends ujion Avhat the disease is which is being treated — as to the value of early injections or other- wise. In very acute cases the cocaine is all that can be used. In lesser stages of inflammation some aid may be exijected from the use of simple dilute lead- water, or. Or, IJ Liq. pliimbi subacetatis dil., 3 j. Mori)lii;r acotatis, gr. j. M. Zinci sulphocarbolat., gr. j-ij. Aqua\ 3 j. M. Or, in less acute forms, aud especially when the malady is simple urethritis, 5 Ziuci sulph., gr. j-iij. Aquae, 3 j. M. Or, Or, Zincj sulph., gr. j-iij. Li(i. plumbi subacetatis dil., 3 j. M. S. Shake before using. I^ Alumiuis exust., gr. x. AquED, ' §j. M. Or, if more astringeucy is required, 5 Acid, tannic, gr. v-x. AqucG, §j. M. The bichloride of mercury does not give as good results in my hands as an ordinary injection (I do not now refer to irrigation) in the early as in the late stages of urethral inflammation, yet sometimes very mild solutions do good even early in an attack ; such as, 5 Hydrarg. chlorid. corros., gr. ss. AqUcB, 3 xij-xxv. M. A suitable injection may be used two or three times a day. It is better to dilute with water any injection that it is proposed to use the first time it is employed, and to increase the strength if it is well borne and does not produce the desired effect upon the discharge. These simple means will cure many cases of urethritis or bastard gon- orrhoea after some days. Should the discharge be diminished but not cured, the strength of the injections may be increased in the second week, or the treatment for gleet instituted and stricture sought for. If on the other hand the inflammatory symptoms and discharge in- URETHRAL INFLAMMATION— TREATMENT. fl crease in the second week, then the malady is in all probal>ility viru- lent gonorrhoea, and the case passes on rapidly to the second stage. SxATioisrARY Stage. — In this stage all the inflammatory symptoms have reached a certain high grade, where they tend to remain, for from one to three weeks, with very little change from day to day. The treatment of the first stage, without any injections, must be kept up. Rest, as nearly absolute as possible, must be enjoined upon the patient. Prolonged and frequent warm baths are beneficial in this stage. The sandal-wood oil or copaiba, which has been until now kept up at a moderate rate, must be steadily.but gradually increased, according to the tolerance of the stomach, until the full dose is reached. The approach of nausea, copaibal erythema, or diarrhoea, indicates that the patient is saturated with the remedy, if it be copaiba ; perhaps pain in the back, if it be sandal-wood oil. Patients can rarely take more than thirty minims at a dose. The maximum dose must be maintained for a week. If at the end of that time a positive effect is not produced, the drug in use should be changed, or, possibly, combined with some preparation of cubebs. Should retention come on, and it is one of the rarest com- plications, a finger in the rectum will usually make out a swollen, hot, tense prostate, as large as an egg, which throbs against the end of the finger, and is very sensitive to pressure. Under these circum- stances, fifteen or twenty leeches may be applied to the perinaeum ; that many, or none. They are rarely, if ever, absolutely necessary. The patient must be kept warm in bed, with hot fomentations, or a light poultice or water-bag, over the hypogastrium and perinseum ; or he may take a hot sitting-bath for a few minutes at a time every half- hour. The water must be above 100° Fahr., and the bath of short duration. The patient should be plied with mucilaginous drinks (flaxseed-tea, etc.), and get the equivalent of about one grain of ojDium every hour until the urine flows, which it invariably will do unless rather a tight organic stricture existed before the gonorrhoeal attack. In any case of great urgency a small, about ISTo. 14 French scale, soft olivary catheter, without a stylet, may be very gently introduced, or, indeed, failing this, the aspirator employed ; or Cazeuave's expe- dient of ice in the rectum might be tried. The most difficult part of the treatment of the stationary stage is to soothe the painful erections and keep off chordee. This can only be effected measurably. ISTo anaphrodisiac has yet been discovered. Camphor, belladonna, conium, bromide of potassium, ergot — not one of these possesses the virtues attributed to it. The best course is for the patient to keep his urine dilute and alkaline, avoid lascivious thoughts, and resort to prolonged immersions of the penis in very hot water before retiring. He should sleep, lightly covered, on his side rather than on his back, on a hard bed, after a small evening meal, in 72 DISEASES OF THE URETHRA. a cool room ; and, if necessary, use as medicines large doses of lupulin or opium in pill or suppository, preferably the former. Lujjuliu rubbed up into gr. iv pills, or taken in powder with sugar, is of un- doubted service, simply because it promotes profound sleep. But the dose must be large. Less than gr. xx is useless, and from 3 ss to 3 j may be given on retiring. No constijiation or other bad symptom follows. Bromide of potassium, in doses of from tliirty to sixty grains at night in water, repeated once, if necessary, will control chordce in some cases. The cocaine urethral injections seem also to have some value, but in some cases nothing short of opium or morpliine, pref- erably in su]ipository, can be trusted to subdue the symptom. When a patient wakes with chordee, the penis should be jslunged into the coldest water which is at hand, or, what is better, if it is win- ter, laid along a piece of iron (axe-head, railing), or otlier metal, which lias been exposed to the cold. The bladder should be emptied as promptly as possible. The patient must be strongly cautioned against breaking the chordee. If this is done, the immediate effect is relief of pain, but the inevitable ultimate consequence is traumatic stricture. Decreasing Stage. — The slightest falling off in the amount of discharge, or in the pain, or other inflammatory symptom, ushers in this stage. Chordee, however, may persist long after it has been reached. The time of its advent depends considerably upon the suc- cess of previous medication. Advantage must be taken of this tend- ency of the discharge to decrease. Hygiene and alkali should be kept up, and the balsam or oil of sandal-wood pushed. The stomach has already become accustomed to its presence, and will usually allow the dose to be increased. If the discharge diminishes rapidly, the remedy should be held at full dose, but not increased. Earely more than three or four capsules at a dose (gtt. xxx to xl) will be needed, or indeed tolerated. It is exceedingly desirable not to disgust the stomach with the copaiba, as this necessitates its discontinuance. If copaiba is well borne and properly administered, it is the most effi- cient of the anti-gonorrhoeal internal remedies. Each of the drugs — copaiba, sandal-wood oil, cubebs, oil of turpen- tine — imparts an odor to the urine peculiar to itself. Besides its dis- agreeable action on the stomach, large doses of copaiba (in certain in- dividuals even small doses) give rise, in some cases, to a peculiar ex- anthema resembling roseola. CoPAiBAL Erythema. — This eruption consists in the appearance upon the whole body of small red blotches, closely aggregated, slightly elevated, causing a tingling, hot, itcliy sensation. The eruption is unimportant, and subsides in a few days if the remedy be discontin- ued. It is sometimes mistaken by young practitioners for a syphilitic roseola. The rapidity of its appearance, the hot, inflammatory char- acter of the patches, the itching and tingling of which the patients URETHRAL INFLAMMATIOX— TREATMENT. 73 complain, are sufficient to make the diagnosis. The pain and itching are soothed by a warm bath. In these cases the urine always smells strongly of copaiba. Wlien such a rash comes on the urethral dis- charge ceases, but it will reappear as the eruption fades. Conse- quently it is not wise to discontinue treatment. It is simply neces- sary to change the drug. Urticaria, or "hives," may also be excited by the ingestion of copaiba, and certain obscure nervous phenomena have also been referred to its use, such as headache and giddiness. Severe pain in the lumbar regions is excited in some individuals by the use of sandal-wood oil in excess. Thus far nothing has been said about cuhebs. The different prep- arations of this remedy are more stimulating than copaiba or sandal- wood, and are consequently better adapted to combat the subacute and distinctly retiring forms of inflammation than the advancing or stationary. They are very aj)plicable to the latter jDortion of the stage of decline, and to the gleety stage. As a rule they are well borne by the stomach, often increasing the appetite, and allaying dys- peptic symptoms. Occasionally the stomach rebels even against cubebs. Of the powder, the dose is from one to two drachms in sweetened gum-water. The fluid extract, in drachm-doses, is efficacious and not unpalatable ; but the most efficient preparation is the oleo-resin. This may be administered in capsules containing gtt. x. The dose is from one to three capsules. By changing from one to the other of these three remedies, in sluggish cases, the effect of each seems to be increased. The compound prescriptions and pastes, containing both co- paiba and cubebs and other substances in varying quantities, often are found clinically to act better than any one of the substances alone — but there is no one thing that acts equally "well in all cases. The pre- scription already given when speaking of the advancing stage is some- times very advantageously modified by adding to it a little fluid ex- tract or even oil of cubebs. If the bursting of the capsules in the stomach tends to nauseate, the pilulge copaibse, TJ. S., may be used. These dissolve slowly, and are sometimes less offensive. Some oleo-resin of cubebs may, if necessary, be included in their composition. Turpentine and other so-caUed anti-blenorrhagic medicines are unreliable in comparison with the three already mentioned, but, like cantharides, are of some use toward the end of an attack. To recapitulate, balsam of copaiba is the best preparation, and is applicable to all stages of the disease, but some individuals can not tolerate it, and in some it produces derangement of the stomach, skin, and nervous system, unless used with prudence and skill. More attention is necessary for its successful administration than is usually bestowed upon it. Steadily carried up to the full dose in the stationary stage, with close attention to the gastric capacities of 74 DISEASES OF THE URETHRA. the patient, it is capable of being highly efficient. "Within one week after saturation has been reached, the full effect of tlie remedy is at- tained. If at the end of this time the stomach can bear no more, and the discharge is unmodified, tiie oleo-resin of cubebs should be com- bined with, or substituted for, the copaiba. The above statements only apply to manageable cases where urethral hygiene has been main- tained. Protracted employment of full doses of copaiba is damaging to the stomach, and rarely of service in curing the disease if the first effect have failed. Oil of yelloio sandaJ-ioood is a most excellent remedy ; in some cases certainly doing better than copaiba. It is not objected to, as a rule, by the stomach, but may produce severe pain in the loins. It is applicable to all stages of the, disease. The maximum curative ef- fect is usually noticed during the week after the full dose of the rem- edy has been attained. Oleo-resin of cubehs is usually well borne by the stomach. It may produce slight diarrhoea (as, indeed, may copaiba or sandal-wood). It is fitted for treating subacute and chronic cases, or for use in com- bination with either of the other so-called specifics. It sometimes produces symptoms of vesical irritability, particularly if used freely. These three remedies may be alternated, commencing with sandal- wood and ending with cubebs. The last one in use when the dis- charge has ceased should be continued for at least ten days — one cap- sule less being taken daily until the remedy is gradually dropped. These remedies have been found ineffective when given by the rectum. Their action is a local one. They undergo a change in passing through the kidney, and are excreted with the urine. It is the contact of this urine with the inflamed surface of the urethra which produces the benefit;* consequently they are useless in the female unless the urethra is affected. Injections are of great service in the stage of decline. Any of the formulae of page 70 may be used, commencing with the milder and passing on to the stronger solutions. The two injections from which I have derived the greatest advantage in the declining stage are the following : And 5 Hydrarg. cblorid. corros., gr. ss. Aqutc, § xij-iv. M. IJ Zinci permanganat., gr. ss-ij. Aquie, gj. M. Some cases can not use bichloride solutions at all on account of the pain caused. * As has been proved in cases of large fistula in the floor of the urethra where the urine could be turned off, the part behind the opening getting well first — the anterior part of the urethra being subserjuently cured by being injected with the patient's urine, freshly passed and full of modified copaiba. TREATMENT OF GLEET. 75 Gleety )Stage. — A gleet is a mucoid discharge from tlie uretlira. All urethral discharges become gleety before they cease, and sucli a gleet, following upon an uncomplicated gonorrha-a, tends to get well by the simple observance of the hygiene of the urethra. This rule, however, has many exceptions. In undertaking the treatment of a gleety discharge, its cause must be studiously sought out and treat- ment applied accordingly. Sometimes the patient requires treatment more than the urethra — as in idiopathic gleet from strumous or gouty tendency. In such cases the observance of hygiene, as affecting the urethra, with alkali, cod-liver oil, quinine, and iron, constitutes the outline of treatment. Of the tonic preparations, the tincture of the sesquichloride of iron holds the first rank, on account of its astringent properties. Excess of treatment is not infrequently the cause of pro- longation of gleet, the patient, either with or without a physician's advice, trying blindly one injection after another, and all sorts of in- ternal medication, importuning his friends for their " infallible " pre- scriptions, and worrying his urethra with endless interference, search- ing for a specific which he can not find, notwithstanding the countless number which are confided to him by sympathizing companions. In such a case the best medication is to reassure the patient and instruct him in everything relative to urethral hygiene, leaving the canal entirely alone for a week, simply watching to see what the discharge really amounts to. Everything earthly has an end, even a gleet, as Thiry has sagely remarked, and no treatment will sometimes succeed where over-treat- ment has only served to keep up the evil. Such cases are found chiefly in unmarried young men, who are kept in a constant morbid state of excitement about their genitals by ungratified sexual desire, or its irregular or excessive indulgence. In these cases the "dis- charge " may be invisible except to the patient, a slight gluing of the meatus in the morning being the only tangible evidence that some- thing is wrong. Here the mind is often more diseased than the body, and marriage is the proper remedy. A regular, moderate exercise of the sexual organs tends surely to keep down congestion and to allow that rest which is most important in efi:ecting a cure. Yet care must be exercised in advising marriage, if the discharge be at all purulent and contains gonococci. No such pus can be pronounced free from contagious properties, although, practically, in my experience it has sometimes turned out to be so. In all cases of prolonged purulent gleet, a lesion in the urethra (stricture, granulations) should be sought for and treated. If not found, and if no gonococci are present, mar- riage is proper, and not only not harmful but even beneficial in its effect upon the discharge. The most common of all causes for continued gleet is stricture already present or forming. Special causes of gleet require special 76 DISEASES OF THE URETHRA. means of treatment, ami will be mentioned under their respective heads. They are : lacunul inllammation, chronic co\vi)eritis, inlhim- mation of the seminal vesicles, hYpertroi)hy of the prostate, conges- tion, catarrhal inflammation, tubercular or other prostatic disorder (abscess, etc.), fistula with internal opening, peri-urcthral abscess, diathetic idiosyncrasies, mucous patches in the urethra, etc. Next to stricture, an altered congested patch of urethral membrane, with or without thickening or granulations, is the most common lesion keep- ing up a gleety discharge. The treatment of gleet dependent upon tliis cause, or existing without urethral or other appreciable lesions, finds its proper place in this section. Treatment. — Where no lesion is discovered, the following treat- ment is advisable : The urine must be kejit mildly alkaline, without oppressing the stomach, hygienic conditions as affecting the urethra must be carefully observed, the provocation of sexual excitement in- terdicted. There is no objection to ordinary sexual intercourse if the patient be married and living with his wife ; all extra excitement, however, during the act, and all provocation of the sexual appetite, are to be avoided. The use of copaiba or oil of sandal-wood, which- ever may have been found serviceable in the stage of decline of gonor- rha?a, may be continued, or substituted by tiie oleo-resin of cubebs in moderation. Tincture of iron, quinine, and a little claret, may be ordered, if tlie patient is anaemic or run down, and especially if the urine is alkaline, or contains phosiihates in excess. A stimulating or astringent injection should be employed. Any of the formulae already given will answer, but it may be necessary gradually to increase their strength. There is little use of a multiplicity of injections, and of running from one to another in trying to find a specific virtue. It will be hard to prevent the patient from doing this of his own motion, but his own dignity should prevent the surgeon from encouraging the patient in his folly. The fewer the number of injections a surgeon employs the more good will he be able to cfPect with them. He will learn how to handle them to more advantage, and will understand their power for good or evil. Nearly all known drugs have been at different times vaunted in injection for urethral discharge, but only a few hold their place. Besides the injections already given, several others have proved serviceable in the gleety stage : the chloride of zinc (gr. j in the 3 j), sulphate of copper (gr. j in the 3 j), and vary- ing strengths of alum, tannin, and sulphate of zinc in combination, either strong solutions used occasionally, or weak ones often. Bumstead praises the persulphate of iron, 3 ss to 3 vj. Finally, alcohol is often efficient. Perhaps the best way of using this stimu- lant, which, like tannin, is indicated where discharge seems to be kept up by an atonic state of the urethral membrane, is according to Ricord's formula, namely — to commence with two parts of rose-water TREATMENT OF GLEET. 77 to one of red wine, and to continue increasing the latter until pure wine can be used, unless the discharge cease meanwhile. Glycerin may be combined with any of the above formulai, as may also mor- phine, although the latter is rarely of much service. The substances just mentioned h.ave been proved by long and gen- eral experience to be best adapted to the treatment of urethral inflam- mation. Three points must be remembered m regard to injections : 1. That the old false idea about burning out the disease is absurd, and that the aim must not be to use an injection as strong as can be borne,* but, on the contrary, to use as weak a one as will do any good. 2. That, when a gleety discharge ceases under the employment of a given injection, the latter should be continued for at least ten days longer, and given up gradually. 3. That in certain cases the discharge becomes reduced to a mini- mum, but will not wholly cease. In these cases the injections are probably maintaining a condition of hypersecretion of urethral mucus, and their discontinuance will cause the discharge to cease. In a general way, it may be said of injections that they are among our best weapons for fighting gleety discharges, if used correctly, of a proper strength, and at the right time. Like all good things, they may be abused. Any injection strong enough to bring blood may be the starting-point of stricture. Any injection, thrown too deeply into the canal, may light up epididymitis or cystitis of the vesical neck. No injection should cause actual jDain. A sense of smarting and warmth, lasting a few minutes, is not objec- tionable. Carefully performed deep urethral injections may be used with advantage when the surface from which the discharge comes is situated in the membranous urethra or thereabouts. To inject projoerlv, I believe that a very small amount of fluid should be used, not more than three minims, and that it should be deposited accurately upon the inflamed area. After long using with little success various sjringes furnished with lateral minute perforations, I have come to depend exclusively upon a syringe with one small perforation at its terminal end (Fig. 24). Having located the granulating area with a bulb or otherwise, the tip of this syringe is to be carried down to the proper depth, and there a deposit of three minims to be placed. I rely for deep urethral injection almost entirely upon solutions of nitrate of silver of a strength of gr. j to grs. xx — occasionally even grs. xlviij to the ounce — according to effect, repeating the application not oftener * William M. Mastin reports a case of tubular sloughing of the entire length of the ure- thra " involving the mucous and sub-mucous tissues," caused, he believes, by using a sat- urated solution, in water, of the sulphate of zinc and acetate of lead four times a day for urethritis. — "Ann. of Anatomy and Surgery," ISSl, p. 274. 78 DISEASES OF THE URETHRA. than three times a week, and at lengthening intervals as the strength of the solntion is increased. If this method is snitable, each injec- tion produces a more or less ]ironounccd el?ect n])on tlio discharge ; if improvement is not manifest after two or three injections, it is useless ^ ^■\aViU*t>.H*,« M»t&CO. Fig. -Zi. to continue the course. Occasionally a fifty-per-ccnt solution in water of the glycerole of tannin will arrest a deep urethral discharge after the nitrate of silver fails. 1 have experimented with many other sub- stances only to discard them. The deep urethral syringe has almost entirely disphiced in my practice the use of the various medicated soluble bougies and the cupped sound with tan no-glycerin paste. Another kind of injection, called isolating, higlily praised by Caby,* is still occasionally resorted to. It consists in throwing in bismuth, or calamine, or chalk, suspended in a sticky fluid, or as soluble suppositories — the object being to coat over the walls of the urethra with one of these insoluble powders. They sometimes act efEcctivcly, bat often cause a good deal of discomfort from the collec- tion of little hard lumps of bismuth and mucus along the canal. The following is a good type of this style of injection, combined with a mild stimulant : R Zinci sulph., gr. j-ij. Bismuth subnitratis, Pulv. acacite, iia 3 j- Aqua?, 3 iv. M. Shake thoroughly before using. Milton is loud in praise of blistering the penis externally, com- bined with mild astringent injection ; but this treatment is altogether too severe for general adoption. Electricit}", both the continued and the induced currents, internally and externally applied, has been vaunted for the cure of gleet. In my hands it has proved of no value. Gleet, unconnected with serious urethral lesions, gets well under treatment by injection. If the discharge remains gleety a fortnight or more, even if there be no urethral lesion of importance, a well-oiled, conical, smoothly-polished sound, as large as the meatus will com- fortably admit, should be passed into the bladder, with the utmost gentleness and slowness, and withdrawn at once with the same delib- eration and care. This simple operation, repeated every third or * "Nouveau Mode de Traitcmcnt de divers Affections g^nitaux chez I'llomme ct chez la Femme par rEmploie de Sous-nitrate de Bismuth." Thtse, Paris, 1858. TREATMENT OF GLEET. Y9 fourth day, will rarely fail to cure the discharge. The sensibility of the canal becomes blunted by contact with the instrument, its irrita- bility overcome by tlie slight distention to which it is subjected, while the tonic effect of the cold metal is also probably a factor in produc- ing the good effect. A steel instrument is much better than a soft bougie. There is no object in leaving the instrument longer in the canal than it takes to pass it slowly into the bladder and as slowly withdraw it. The instrument must fill without stretching the meatus. The meatus may be congenitally small, and this alone may keep up a discharge. In such a case a little poach can be felt with a bent probe, formed behind the lower commissure of the meatus.' Such a condition may be promptly relieved by incising the meatus. This sim- ple oj)eration occasionally cures a gleet of long standing. Finally, in regard to instruments, the greatest care and gentleness should be employed. Used too often or clumsily, they do harm by in- creasing the grade of inflammation, or joossibly bringing on an attack of epididymitis. In the cases under consideration, no instrument should be reintroduced until all irritation and teirfporary increase of discharge, produced by its previous use, have subsided for twenty-four hours. Where patches of urethral congestion keep up a discharge, they may be detected by passing a full-sized bulbous bougie into the bladder. When the head of the instrument reaches the altered spot, the patient will complain of slight pain, which will disappear as the bulbous head of the instrument passes on to the healthy urethra beyond. Any little thickening in the walls of the canal is recognized at the same time. Furthermore, if a patient with one of these patches makes water into a glass vessel, and the fluid be held up to the light, one or more thready filaments may be seen gradually sinking through the urine. If one of these be caught and placed under the microscope, it will be found to consist of pus-corpuscles adhering together ; in other words, it is a soft scab, and indicates that a portion of urethra is not covered by healthy epithelium, but is abraded (not ulcerated), and covered by soft, round leucocytes. These shreds are always found in cases of forming stricture, in every stage of the complaint. When these signs of urethral lesion exist, the gentle use of the steel sound becomes the first requisite of treatment. The balsams may be discontinued, and injections become of secondary importance. Ure- thral hygiene (p. 43), and the gentle, persevering use of a full-sized conical steel sound, will often effect a cure. In some cases the '^cold- sound" (Winternitz *), a closed silver tube like a catheter, with a par- tition running down centrally within, nearly up to the tip, so that water injected into one of the compartments, after circulating through the instrument, runs out from the other compartment, is worth a trial. I use iced water for about five minutes, and reajsply about every second * " Berl. klin. Wochenschrift," July 9th, IS?*?. 80 DISEASES OF THE URETHRA. day. In some cases of urethral neuralgia and of pollution also, this instrument yields good results. The endoscope is of some service in treating obstinate cases, but its aid is very rarely required. Thompson's remark about its usefulness is a fair criticism : ** If a man has a good and tolerably practiced hand, with a fair share of intelligence, I do not think he will gain a great deal by the endoscope ; and, if he has not, I think it Avill be of no use at all." Yet the altered spots of urethral membrane can be very clearly seen through the endoscope, granulations can be detected where they exist, and local applications of considerable strength made, which could not be applied with safety by any other means. The expensive and complicated instruments of Desormcaux, Cruise, and modifica- tions of the same, are but little if at all better than a simple straight urethral tube of black, hard rubber furnished with an obturator. The silver tube known as Klotz's endoscope answers well. All the illumi- nation required for these tubes may be obtained by reflection from a concave mirror strapped to the forehead. For examining the deep urethra, however, direct sunlight or a strong artificial light is neces- sary for illumination. To make a thorough inspection, the tube should be introduced well into the membranous urethra, the obturator withdrawn, the oil and mucus wiped away from the membrane presenting at the bottom of the tube, and then, tlic illumination being brought to bear, each successive portion of membrane may be inspected as the tube is withdrawn. The healthy mucous membrane has a pale-pink color, and contrasts strongly with congested spots, which are of a vinous red without polish. Such spots can be plainly seen as they come across the end of the tube, and any granulations upon them are readily recognized by the practiced eye. The topical remedy for granulations suggested by Desormeaux, and which can be very accurately ai^plied through the tube by means of a little cotton twisted upon a long probe, is a solution of nitrate of sil- ver of from 3 ij to the 3 j up to the saturated solution. The latter should be only used in the case of large granulations, and then is to be very sparingly applied. Iodine, sulphate of copper, tannin, car- bolic acid, etc., used as local applications, give fair results. The ad- vantages of treating by the endoscope are, that the spot to which an application has been made may be inspected from week to week, and the effect of treatment critically observed. This topical treatment is to be repeated at first twice a week, then weekly for several months. W. T. Belfield,* of Chicago, has an excellent chapter on endoscopy. He is the exponent in this country of the views of Josef Griinfeld, of Vienna, whose work f and instrument he extols. The electric cys- * "Diseases of the Urinary and Male Sexual Organs," New York, 18S4, p. 69. t "Die Endoskopie dcr Harnrolire und Blase," one of the volumes of Billroth and Liickc's " Deutsche Chirurgic." SEQUELS OF GONORRUffiA. gl toscope of JSTitzc, made by Ilartwig, of Berlin, is an analogous in.stru- mcnt for inspecting the bladder. It has a visual field, it is claimed, of considerable size. Leiter, of Vienna, makes also an admirable endo- scoi)e and cystoscope illuminated by an electrical lamp. SEQUELS OF GONOERHCEA. Certain unusual sequelae of gonorrhoea may be mentioned here be- fore entering into a detail of its complications. After discharge has absolutely ceased, the patient is usually as well as he was before ; but there are exceptions. Among the most frequent of these is pain on passing water, ranging from an itching up to an absolute burning ; and this neurosis may last from a few months up to many years. The pain may be confined to erections and ejaculations, the latter depending upon some disturbance at the prostatic sinus. There may be urethral j^ains independent of erection or urination, sometimes se- vere in character — perhaps paroxysmal — and known as urethral neu- ralgia.* These different kinds of pains disappear, as a rule, in a few weeks or months. No treatment, except the observance of urethral hy- giene, seems to be of much service. If they persist, t.here is probably some lesion of the canal, even although there be no discharge. Where there is no lesion, a resumption of the physiological exercise of the organ tends greatly to reduce the abnormal sensibility of the urethra. The judicious use of steel sounds at intervals, and the local employ- ment of electricity, seem to hasten a cure. Where the trouble per- sists, a careful search should be made for stricture or deep urethral congestion. A condition of irritability of the neck of the bladder is sometimes left behind by gonorrhoea, attended by frequent desire to urinate, and sometimes a spasmodic action of the detrusor during micturition (neu- ralgia of the vesical neck). The urethra sometimes remains inelastic, causing a little dribbling. Both of the above sequelas are overcome by hygiene and the steel sound. Castelnan f mentions a singular condition of prostatic and urethral anaesthesia — the patient having no orgasm, and being unconscious of the passage of semen — left behind by gonorrhoea, and coinciding with an inflammatory engorgement of the urethra. The normal sensation returned after several months. Various other unimportant functional troubles have been men- tioned as sequels of gonorrhoea. * The disease formerly known as " dry gonorrhcea " is simply urethral neuralgia, com- ing on alone without any antecedent gonorrhcsa — the canal not being inflamed, nor the malady, in any sense, a gonorrhoea. f " Observation de Blennorrhagie suivie de Douleurs et d' Abolition de la Sensation agreable pendant le Coit," " Ann. des Mai. de la Peau et de la Syph.," lS43-'44, tome i, pp. 148-151. 6 82 COMPLICATIONS OF GOXORRUlEA, CHAPTEE IV. COMPLICATIONS OF QONOEKHCEA. Folliculitis.— Inflammation of Lncnna Magna.— Cowperitis. — Peri-uretliiit is.— Adenitis.— Lymphnn- gitis.— Cionorrhaal Uheumatism ; Hydrarthrosis, Inflammatory, aflVcting Sheaths of Tendons ; Bursic- Diagnostic Table of Simple and Gonorrhoea! Uheumatism.— Cionorrluval Ophtliaimia. — Gonorrhieal Conjunctivitis. —Diagnostic Tabic of Gouorrha-al Conjunctivitis and Gonorrha-al Ophthalmia. FoLLiccLiTis. — During the acute stage of gonorrhoea, sometimes there ajipear along tlie urethra, especially in the region of the fossa navicularis, one or more small, round tumors, slightly sensitive to pressure, varying from the size of the head of a large pin to that of a pea. These tumors are cysts by occlusion of the mouths of the lacuna? of Morgagni. Inflammation seals the orifice of the follicle, and the lacuna is converted into a cyst containing pus. As the latter contin- ues to be produced, the cyst enlarges. The pain accompanying it is insignificant, and the little lump is detected by accident. It feels like a hard ball movilig under tlie skin and attached by a pedicle. This pedicle is the obliterated neck and orifice of the follicle. The little tumor tends to remain stationary for some time, and then suddenly to enlarge, soften, involve the integument, open externally (very rarely into the urethra), and, after discharging, remain fistulous for a long time ; not, however, communicating with the urethra. These tumors have been compared by Ch. Hardy,* who has described them very ac- curately, to wens of the scalp. The best treatment consists in incising the skin and enucleating the cyst entirely, or excising a considerable portion of its wall, allowing the wound to heal by granulation. Another form of lacunal inflammation is where the lacuna magna in the roof of the urethra continues inflamed, pcrha])s after all tlie lining membrane of the urethra has returned to its normal condition. The mouth of this lacuna is too large to become obliterated, and the result is a gleety discharge, which tends to run on indefinitely. This condition maybe relieved by introducing a fine director along the roof of the urethra until it is caught in the lacuna, and slitting open the pouch as recommended by Phillips, f CowPERiTis. — Inflammation in and around Cowper's glands is rare. It seems to occur only in connection with urethral inflamma- tion. GublerJ has written exhaustively on the subject. Cowperitis * "Mumoirc sur les Abces blennorrlia.':^iqucs," Paris, 1864. f "Maladies dcs Voies urinaircs," Pari.-^, 1860. X "Des Glandcs de Mory (Tulf:;airement Glandes de Cowper), et de leurs Maladies chez I'Uomme." Th5se, Paris, 1749. COWrERITIS— PERI-URETIIRITLS. 83 rarely comes on before the tliird or fourth week of gonorrho3a. Sex- ual intercourse, catheterism, and other irritations, have seemed to provoke it, but it may arise simply from extension of inflammation without appreciable immediate exciting cause. Only one gland is usually alTcctcd — by preference the left. Both may be (rarely) in- volved. The connective tissue around the gland is always largely im- plicated in the inflammation, making the disease mainly a peri-cow- peritis. The symptoms are, painful tension of the perinreum in the region of the bulb, increased by sitting, by pressure, by the friction of the pantaloons, slight swelling, with no change in color of the skin. On palpation, a small, deep, ovoid or pyriform tumor is felt, the larger end toward the anus, the small end confounded with the bulb. It is about the size of a bean, on one side of the raphe, between the trans- verse muscle and the bulb. Soon the surrounding tissue becomes in- volved, and the tumor is completely masked. After this the phenom- ena are identical with those of perineal abscess. The inflammation often includes the scrotum. It is limited posteriorly by the transverse muscle of the perinaeum, and usually crosses the raphe, but remains always more prominent upon the side where the inflammation began. Constitutional sympathy depends upon the height of the inflam- mation. The abscess usually breaks externally. Its cavity is found to be partitioned, the compartments seeming to represent the lobules of the gland primarily affected. If the abscess open internally, uri- nary infiltration and fistula are to be feared. Hence the value of an early incision. Simple cowperitis may undergo resolution. It is supposed that these glands are more or less inflamed in those cases of gleet accompa- nied by painful tension at the bulbous region. When peri-glandular inflammation ensues, suppuration seems inevitable. Gubler cites a syphilitic gummy tumor of the perineum, which occupied the exact position of Cowper's gland. Treatment. — Early in the disease, absolute rest, fifteen or twenty leeches over and around the painful spot, warm baths, a laxative, and an alkaline diuretic, constitute the treatment. If, m spite of these measui'es, suppuration comes on, it should be aided by poultices, and an early incision resorted to. The rule is, not to wait for positive fluctuation, which is difficult to detect through the hardened, inflamed peringeum. Pus has usually formed m one week. If it be not reached by the incision, no harm is done. The tissues will become disgorged, and whatever matter may subsequently form will find its way out through the incisions already made, which should be deep and thor- ough. If retention comes on, or is threatened, immediate external incision is imperative. Peri-Ukethritis terminating in abscess. Chordee is a peri-ure- 84 COMPLICATIONS OF GONORRHOEA. thritis, but lias little or no toiulcney to sujipnrnto, and jiassos otT during subsidence of tbe general inlhunnuilion. Suppurative ])cri- urethritis is rarely idiopatbic. Its classical causes are gonorrba}a, or iufiltratiou- in connection with stricture. During gonorrbooa, suppu- rative inflammation may attack any portion of tbe sjiongy tissue around tbe uretbra, but tbere are two jioints of election, tbe fossa na- vicularis and tbe bulb. Anteriorly, peri-urctbral abscess usually de- velops on one side of tbe fra?num. It may commence centrally, bulge on botli sides, and in tins way be bi-lobed. At tbe bulb, tbe abscess begins centrally as a rule. Here tbe affection is far more serious. The whole perina^um becomes involved, the inflammation perhaps ex- tending back to and around tbe anus. The root of tbe penis and the scrotum may also be included. Constitutional symptoms, usually ab- sent with abscess at the fossa navicularis, are invariably present with abscess of tbe bulb, their intensity being proportionate to the grade of tbe inflammation. When a large extent of spongy tissue, anywhere along tbe urethra, fulls into suppuration, constitutional sympathy is marked. These abscesses are only slightly jiainful at lirst, but they soon enlarge and become tender, being surrounded by a boggy asdema. Tiiey do not furnish the shot-like feel of the little cystic tumors of folliculitis. Treatment. — An early deep incision is imperative, long before pus can be made out. If this is neglected anteriorly, traumatic hypospa- dias may result, while in abscess of the bulb tbe most serious conse- quences may ensue. The remarks made in relation to abscess attend- ing peri-cowperitis apjily with still more force bere ; ulceration into the uretbra, retention, inflltration, burrowing of matter, with all their disastrous consequences, are to be feared if abscess of the perinjeum breaks internally. None of these serious results are, however, inevi- table. Should tbe abscess open into the urethra, the surgeon's duty is to watch, and only to interfere externally with the knife when ure- thral fever, pain, renewed swelling, and local tenderness, with ten- dency to the formation of other purulent collections near by, warn him that urine escapes from the canal, is burrowing, and requires an external outlet at once. In such a case, if tbere be no prominent point to incise (and any opening must be deep), it is better to perform external perineal urethrotomy, including, if possible, all fistulous tracts in the incision. The fistula may require subsequent attention. Abscesses (probably peri-prostatic), complicating gonorrhoea, occasion- ally occur behind the triangular ligament. These are liable to cause retention, may discbarge into the urethra, or may be opened from the rectum after careful ex2:)loration. Among the rarer complications of gonorrhoea resulting fatally, maybe mentioned pyelitis, of which Murchison* I'cports two cases, * "Trans. Clin. Soc," London, 1876, p. 25. ADENITIS— LYMPHANGITIS. S5 and peritonitis starting from abscess of the seminal vesicles or their ducts, or from peri-prostatic inflammation and sub-peritoneal abscess in the iliac fossa, the abdominal wall, or lumbar region. Hunter first alluded to ]3eritonitis as being due to gonorrhoja, and a number of cases — some of them terminating fatally — have been recorded. Fau- con * has an excellent article on the subject. Hill and Cooper f quote some of these fatal complications. Agncw I relates a personal case. Adenitis. — Inguinal adenitis of very mild type may complicate gonorrhoea. Suppuration is very exceptional. In the strumous, indo- lent adenopathy may persist after the urethral discharge has ceased. Should pus form, it is not auto-inoculable. Treatment — if any is called for — is rest and tincture of aconite and belladonna locally. Gonorrhoeal epididymitis and cystitis will be considered later. Lymphangitis. — More or less lymphangitis is a common compli- cation where urethral inflammation runs high. Several different forms are found. They have been well described by Fournier.* Where the lymphatic vessel alone is involved, no pain is felt, nor does any external appearance attract the patient's attention. The finger, however, detects indurated cords under the skin, a dorsal trunk being usually the most prominent. The feel of these cords is exactly simi- lar to that of the same vessels in the lymphangitis of infecting chancre (Fournier). If there be peri-lymphangitis, reddened streaks are seen upon the sides or back of the penis, and the corded lymphatics are felt hard, knotty, painful on pressure, often several of them matted together. They may be isolated by the fingers from the subjacent parts. There are painful tension of the inguinal glands and oedema of the prepuce. The treatment is rest, emollient dressings (warm lead-water cov- ered with oil-silk, poultice), warm baths, perhaps a few leeches in the groin. Occasionally abscesses form along the course of the hard cords. These should be opened early, as the pus is liable to burrow, and may denude a considerable extent of the penis. Another form of lijmphangitis is that where the superficial lym- phatics (not the trunks, although both may suffer together) become inflamed (erysipelatous lymphangitis). Here a superficial redness, evenly spread out, involves the skin, which is swollen and very sensi- tive to the touch. This affection is often limited to the prepuce, Avhich becomes cedematous and liable to phimosis. If the whole penis is attacked, fever runs high and the local distress is intense. Treatment is the same as for lymphangitis of the trunks. Eesolu- tion is the rule. Matter may form, however, and denude the penis. * "De la peritonite et du phlegmon sous peritoneal d'origine blennorrhagique," "Ar- chiv. Gen.," ISVY, October, p. 385, and November, p. 549. f Second edition, p. 542. % "Surgery," vol. ii, p. 468. * "Nouv. Diet, de Med. et de Chir. prat.," p. 185. 86 COMPLICATIONS OF GONORRU(EA. This may be preveuted by early incisions. Tlie indication for the knife is a porky, doughy, brawny condition of the iutogumcnt, like that felt in phlegmonous erysipelas. A hard ceihma of the preimce may be left behind by these different forms of lymphangitis, especially in the neighborhood of the frrenum, sometimes causing phimosis. Lymphangitis may leave the lymphatic trunks in a varicose condition (Ricord), or lymphatic listula may re- sult, usually requiring excision for its removal. GONORRHCEAIi RHEUMATISM. At about the same time iu the year 1781, Selle and Swediaur de- scribed an inflammatory articular affection as dependent upon gonor- rhoea. Since then the writings of Hunter, Cooper, B. Brodie, Bran- des, Bonnet, Diday, Rollet, Fournier, and others,* have established the fact that the connection between the two diseases is not a coinci- dence, but that a relation of cause and effect exists. The strongest proof of this relation lies in the fact that certain individuals, not ordi- narily subject to rheumatic attacks, get a peculiar form of rheuma- tism when they get gonorrhoea. They remain well between tiie gon- orrhoea! attacks, but have a relapse of rheumatism whenever a new urethral inflammation is acquired. Brandes gives the history of such a case, where a fresh attack of rheumatism attended six successive gonorrhoeas, and Fournier mentions a case of quadruj^le relapse. I have often seen double, once quadruple relapse. Koniger f chronicles a patient never rheumatic except during three successive gonorrhoeas at two and a half years' interval, once complicated with iritis, once with irido-choroiditis. None of the ordinary causes of articular rheu- matism seem to have any power in producing the gonorrhoeal variety. It is not the effect of cold, or moisture, or fatigue ; nor, indeed, does its immediate cause seem to be any modification in the discharge, or any medicine taken, or any injection used. Tlie only known exciting cause is an inflammation of the urethra, secreting pus, and there is a vague suspicion in the profession that it is something analogous to mild pyjemia. Morris thinks it due to reflex nervous causes. When tliis complaint has once complicated a gonorrhoea, the chances are that every succeeding urethral inflammation will beat- tended by its rheumatism, in spite of all efforts to keep it off. Fortu- nately, all patients with gonorrhoea are not liable to this complication — a small minority only is affected. An ordinary patient with gon- * For bibliography, see " Art Medical," Xovcmbcr and December, 1837, vol. vi. "Ob- servations et Materiaux pour servir il THistoire de rArthropatliic blennorrhagique," Ch. Ravel, and Fournier, art. " Diet, de Med. et de Chir. Prat." f " Ueber die Sogcnannten metastatiscbcn Complicationen der Gonorrhoea," etc., " In- aug. Dissert.," Berlin, 1873. GONORRHCEAL RHEUMATISM. ^7 orrhoea, even having a pronounced rheumatic diathesis, may expose himself to cold, moisture, and fatigue, without getting any rheuma- tism ; or, if ho does get an attack, its course is not varied nor its symptoms modilied by the coexistence of urethral discharge. This fact of individual idiosyncrasy favors the reflex nervous rather than the pyemic theory of etiology. Women possess a strange immunity from gonorrho3al rheumatism. They do sufl'er from it, but only exceptionally. It is supjoosed that the explanation for this may be found in the fact that the vagina and not the urethra is the usual seat of gonorrhoea in the female. Gonorrhoeal rheumatism resembles rheumatic gout more than rheu- matism. The local inflammatory character of the symptoms is usually inconsiderable, and the constitutional sympathy is not of a severity proportionate to the trouble in the joints. The date of appearance of the rheumatic complication from the be- ginning of the urethral discharge is variable. It has been noticed as early as the fifth day, but usually does not come on till a later period. Fournier places the usual date of the outbreak between " the sixth and fifteenth day," rarely during the second or third month, or at any later period. The old idea, that the rheumatic complication is the result of a metastasis of the gonorrhoea, is untenable. There is no diminution of the discharge ]Drevious to or coincident with the inva- sion of the rheumatism, and there exists no indication to increase the urethral flow and thus "save the synovial membranes." The dis- charge is not usually at all modified, although it is sometimes notably diminished a few days after the rheumatic symptoms have set in — which may be explained by the fact that the rheumatism keeps the patient more at rest, or by the revulsive action which any interven- ing inflammatory affection is liable to exercise over a purulent dis- charge. Where the complication comes on late in a clap, it has been observed that its advent is preceded by an exacerbation of the dis- charge for a few days. The seat of the disease is variable — joints taking the first rank ; the synovial sheaths of tendons and muscles the second ; then coming syno- vial bursce and nerves. The eye not infrequently suffers. The peri- cardium (Brandes) and meninges of the brain and cord (Eicord) seem to be involved occasionally. Concerning the joints, Fournier tabulates one hundred and twenty cases, of which thirty-nine are his own. The whole number of joints affected in these cases was two hundred and twelve; the knee, eighty-three times — over two thirds of all the cases ; ankle, thirty-two times — about one fourth ; fingers and toes, twenty-five times — about one fifth, etc. Eecently Fournier * places the seat of predilection in the sterno-clavicular articulation. The large * " Gaz. Hebd.," November 16, ISTJ. Discussion before Hospital Society on Desnos's case of Konorrhoeal endocai'ditis. 88 COMPLICATIONS OF GOXOKRHCEA. joints, particularly the knee, are by far the most often involved, and, when the smaller joints suffer, they do so couseeutively. The disease IS rarely absolutely confined to a single joint ; but still it shows a marked tendency to be mono-articular. Fouruier's division of the disease into three prominent varieties is convenient and practical. The first form — a common one — is a hydrarthrosis, attacking usually the knee, sometimes the ankle or elbow. This form is gener- ally mono-articular. It comes on insidiously ; but the elTusion into the joint, which is usually considerable, may take place rapidly. The pain is slight, but is increased by walking, running, or moving the joint. There may not be enough pain to call the patient's attention to his joint, although this is unusual. The integument over the affected region preserves its color, and there may be no constitutional disturbance. The affection tends to remain indolent, and to undergo resolution slowly, lasting sometimes many months. The second form is more like ordinary rheumatism. More or less local and general febrile reaction is the rule, and this form is usually poly-articular and liable to be attended by trouble in the tendons, eyes, etc. The symptoms are like those of ordinary rheumatism, only more moderate. The pain, at first severe, is usually notably modified by rest — far more so than is the case with ordinary rheumatism. Con- stitutional symptoms occur ; but the fever is moderate, and subsides after a few days, while the local disturbance continues. This relative lack of proportion between the constitutional and the local symi^toms is a strong diagnostic feature of the malady in question. When only one joint is affected, there is sometimes a total absence of general symptoms. When several joints are involved, they become so, as a rule, consecutively. The malady, however, docs not become so gen- eral as it does in ordinary rheumatism. It is more stationary, less mobile, docs not jump from one joint to another. When a new joint is involved, those previously affected continue to suffer — with, of course, occasional exceptions. Eesolution is even more tardy than in ordinary rheumatism. A secondary hydrarthrosis, rare in simple rheumatism, is not uncommon in the gonorrhojal variety. The sweat- ing, so constant in simple rheumatism, docs not occnr, even where there is a good deal of fever, or, if it does come on, it is of short dura- tion. The acid concentrated state of the urine, found in simple rheu- matism, is not noticed, nor does the blood show the same excess of fibrin. Finall}', tlie pericardium, endocardium, pleura3, etc., are rarely involved. Cardiac affections due to gonorrhosii arc recorded by several reliable authorities.* * Baud in, "Receuil de Mem. de Med. de Cliir. et de Pliarm. Mil.," September and October, 1875. Marty, " Archiv. Gen. de Med.," 1876, p. 660. Desnos, " Gaz. Hebd.," November 16, 1877. Morel, " Thbsc dc Paris," 1878. Floury, "Journ. de M6d. de Bor- deaux," September 9, 1883, GONORRnffiAL RHEUMATISM. 39 Slow resolution is the usual termination of the disease, but articu- lar pains, or very persistent stiffness, may be left behind ; or, more rarely, chronic hydrarthrosis, chiefly of the smaller ariiculations (Brandes), anchylosis, or even white swelling — the latter only in lym- phatic or scrofulous patients (Sordet). Acute suppuration does not occur (Fournier). The third form which the affection may assume is that of vague, ambulatory — sometimes very persistent — pains in Joints, which do not appear to have suffered any structural alteration, and of which the function is undisturbed — the knee, wrist, shoulder, foot, and jaw. This pain, which may be the only symptom, is rebellious to treatment, and, after it has gradually subsided, is opt to return, if from any cause the amount of urethral discharge becomes increased. The synovial sheaths of the tendons of the extremities may be affected, either alone, or, more commonly, in connection with what- ever joints are involved. There are tumefaction along the course of the tendon, redness of the integument, occasionally very intense, if the tendon be superficial, severe pain on pressure, and partial or entire abolition of the movement of the muscle belonging to the tendon in- volved. This affection, like the others, undergoes gradual resolution. Hot local anodyne fomentations are indicated. The bursas may also suffer. In this case we have an acute or sub- acute hygroma, which is peculiarly painful and sensitive to pressure for a long time. Two bursae seem most liable to the attack, the one lying between the tendo Achillis and the os calcis, and the other situ- ated beneath the inferior tuberosity of the same bone. This explains the pain in the heel, so often complained of by these patients — al- luded to by Swediaur. Other bursge suffer, but more rarely. The acute symptoms accompanying inflammation of bursse usually yield rapidly to local depletion and sedatives ; later a blister. Fonr- nier mentions a case of gonorrhoeal hygroma of a bursa over the is- chium, which he saw with Yerneuil. The symptoms attending it were so severe as to lead these gentlemen to a diagnosis of deep suppu- ration. They made preparations to incise the swelling, when a sharp pain suddenly appeared in the knee. The operation was postponed. In a few days the hygroma disappeared '^with surprising rapidity," while the knee-joint became acutely inflamed. Evidences of muscular rheumatism may attend the symptoms of rheumatic trouble elsewhere. The nerves do not always escape. Fournier observed sciatica five times among his thirty-nine cases. Diplopia (Fournier), deafness (Swediaur, Fournier), and little super- ficial collections of sernm near the affected joints (Fournier, Eicord, Fereol), have been mentioned as rare occasional complications. The following excellent table, arranged by Fournier, gives at a glance the characters distinguishing gonorrhoeal from ordinary rheumatism : 90 COMPLICATIONS OF GOXORRH(EA. Gonorrhteal JUtevmatism. 1. Cause. — Urethral intlanimation. Xo influence of cold in the production of the rheumatism. 2. Very rarely observed in women. 3. Non-febrile, or much less so than sim- ple rheumatism. Even in acute cases, reac- tion never attains the habitual intensity of rheumatic fever. 4. Symptoms habitually limited to a small number of joints. The affection never becomes general to the same extent as simple rheumatism. 5. Less movable than simple rheuma- tism, going from one joint to another less quickly. No delitescence, no real jumping from one joint to another. G. Local pains generally moderate, al- ways less than in simple rheumatism. Sometimes remarkable indolence. 7. Frequently a tendency to hydrarthro- sis, following the acute fluxion. 8. No sweatiug. 9. Urine not modified. 10. Blood not furuiihing a marked bufCy- coat. ] 1. Cardiac complications very excep- tional. 12. Frequent coincidence with a special ophthalmia, inflammation of the synovial sheaths of tendons, inflammation of bur- sa?, etc. The latter localities may be ex- clusively implicated. 13. Relapse in the course of successive gonorrhoeas very frequent. Simj}k lihcumatism. 1. No etiological relation with the state of the urethra. Habitual causes — cold, in- heritance, rheumatic diathesis, etc. 2. Common in the female, although less frequent than in the male. 3. Rcactional phenomena much more in- tense and prolonged than in gonorrha^al rheumatism. 4. Svmptoms usually involve a number, sometimes nearly all, the articulations. 5. Symptoms, movable — ambulatory fluxions ; rajjid delitescence, jumping from one joint to another. C. Pains always rather intense, some- times excessive, disappearing less rapidly than those of gonorrhoeal rheumatism. *?. Little or no tendency to consecutive hydrarthrosis. 8. Abundant sweats, constituting a symp- tom almost essential to the malady. 9. Urine specially modified. 10. Blood forming a firm, concave clot with buff_y-coat. 11. Cardiac complications frequent. 12. Acute rheumatism does not affect the eye ; the bursa; escape, as do usually the sheaths of tendons. 13. Relapse frequent, but always inde- pendently of the state of the urethra. Treatment. — Ordinary treatment for acute or chronic rheumatic or gouty maladies does not help patients with gonorrhceal rheumatism. Neither salicylic acid nor iodide of potassium, colchicum, nor quinine modify the symptoms. Local measures are of the first importance. The treatment internally is tonic, dietetic, hygienic — in short, rational — with an alkali if the urine is over-acid. The sooner the urethral discharge is controlled the more quickly will the rheumatic symp- toms cease, although the latter may outlast the former many months. Eest is most important, the joint being splinted in the acute stage. Leeches, hot fomentations, or a blister will soon bring on the sub- acute stage, if indeed the inflammatory phenomena have not been subacute from the first. The diet should be low while the patient is confined. Probably the best treatment in acute and subacute cases GONORRIKEAL OPIITHALMIA. 91 is rest, blistering or Paquclin cautery freely applied and often re peated ; in chronic cases where there is effusion, iodine, with the elastic bandage, or sometimes a silicate bandage — the latter particu- larly in obstinate cases — or aspiration of the joint and irrigation with a mild carbolic-acid two-per-cent solution, or a solution of the bichloride of mercury (1 in 10,000), followed by gentle systematic pressure, the joint remaining fixed. In chronic cases and for articular and muscular pains, blistering, actual cautery, rubber bandage, local douche, friction, massage, Russian and Turkish baths, render valuable service. Recently R. W. Taylor * claims phenomenal success in acute cases from the use of ten-to-twenty-drop doses of oil of wintergreen four times a day. GONORRHCEAL OPHTHALMIA. There are two forms of ocular trouble caused by gonorrhoea. The first is rheumatic in charactei-, nearly always (Ricord, Fournier), but not invariably, accompanied by other signs of gonorrhoea! rheumatism, having no connection with contagion as a cause, and affecting the membrane of Descemet, the iris, or the conjunctiva. The second form is conjunctivitis, depending always upon conta- gion. The distinction between these two affections should be kept constantly in view. Rheumatic Gonokrhceal Ophthalmia. — To Abernethy, Mac- kenzie, and particularly Ricord, is due the credit of having first accu- rately described this affection. It is generally associated with the poly-articular variety of gonorrhoeal rheumatism. It may precede or follow the development of rheumatism elsewhere. Contagiou will not produce it. Its essential cause is the existence of a urethral dis- charge. According to Fournier, it is more frequent than gonorrhoeal conjunctivitis, as 14 to 1 ; cold, fatigue of the eye, etc., have no power to produce it. An individual idiosyncrasy seems to preside over its appearance. Should it occur with one urethral inflammation, the chances are that it will reappear with the next. It is far more com- mon in the male than in the female. Sometimes it appears to exer- cise a revulsive action upon the joint trouble, and vice versa, the one disappearing to be replaced by the other, but this is exceptional. In brief, gonorrhoeal ophthalmia is a localization of gonorrhoeal rheuma- tism upon the eye, all the rest of the body (perhaps) escaping. Symptoms. — Inflammation of tlie memhrane of Descemet (aquo-cap- sulitis) is the most common form of attack. Here the conjunctiva is only moderately injected, the cornea is transparent, but more than usually prominent. A cloudy, smoky appearance of the fluid of the anterior chamber is the most characteristic objective symptom. Sight •* "New York Medical Journal," June 4, 1887, p. 617. 02 COMPLICATIONS OF GOXORRHCEA. is slightly troubled, objects looking misty. There is no pain, but sometimes a sensation of uneasiness about the eye. Photoj^hobia is absent or yery mild. Sometimes tliere is a slight flocculcnt deposit on the posterior face of the cornea, with the escape of a little blood into the aqueous humor (Cullerier). The iris is unaffected, perhaps a little slow in its moyements. There is no deformity of the pupil, no change in color of the iris, no otlier sign of iritis — points strongly in- sisted on by Cullerier.* When the i)'is is attacked, the symptoms do not differ from those of simple iritis ; redness of the cornea, radiate peri-corneal injection, contracted deformed pui)il, sluggishness or abolition of the move- ments of tlic iris, change of color, effusion of lymjih into the pupil, plastic deposits in the anterior chamber, more abundant in gonorrhceal than in ordinary iritis (Mackenzie), obscurity of yision. pliotophobia, lachryma*:ion, peri-orbital and ocular pains, Fournier has described a rare conjunctival form of (jonorrhceal ophthalmia. There are simple conjunctivitis, injection of the con- junctiva, uniform, or marked at certain points — the secretion is scanty, muco-purulcnt. There are slight, perhaps no lachrymation, a little itching about the eyes — sometimes absolutely no pain, i)hotophobia, or alteration of vision, no symptom of iritis or of aquo-capsulitis. These varieties of ophthalmia, unlike the contagious conjunctivitis, are rarely mono-ocular ; when so, the form is usually iritis. Both eyes are rarely attacked simultaneously. After one has recovered, in- flammation may attack the other, run its course, and then return to the eye first involved. To get the disease the patient liimself must have gonorrhoea, unlike the conjunctivitis of contagion, which may be produced in any healthy individual by the mere contact of gonor- rhceal pus. Gonorrhoea! ophthalmia runs a rapid course, declining with un- usual Sliced. It may last several weeks, or only a few days. Eelapse is not infrequent.. Of the three forms, conjunctivitis is the least harmful, aquo-capsulitis is not grave ; the iritis alone is lia)jle to leave trouble behind in the shape of adhesions. Treatment is mainly expectant. The eye must bo kept at rest in all cases. The best local applications are emollient lotions and col- lyria frequently used, warm water or steam — with atropine, in case of iritis. Astringent collyria are useless, even harmful. Irritating pediluvia, the judicious use of revulsive cathartics, and a low diet, con- stitute the general treatment. If the symptoms prove obstinate, tlie frequent application of small mild blisters to the temples and forehead is of service. In mild cases, patients do better if not confined. They may even attend to business, if the eye be kept covered. In severe * " Des Affections blennorrhagiqucs." Le9on3 cliniques publid'cs par Eug5nc Royet, Paris, 1861. GONORRUffiAL CONJUNCTIVITIS. 93 cases, housing is necessary, local emissions of blood may ho practiced, and repeated purgation should be resorted to. AVhen the peri-orbital and frontal pains arc severe in iritis, large doses of quinine seem to be of service, with the local inunction of belladonna-ointment, or of a liniment composed of ol. menth. pip. four parts, chloroform and liq. ammonias, of each one part ; or — R Chloroform, tr. opii, ol. oliv., a.i q. a. M. If the pains persist, in spite of these measures, codeine or mor- phine may be used at night, by the stomach, or subcutaneously. GoisroRRHCEAL CoiSTJUNCTiviTis. — This terrible malady is fortu- nately rare. Its sole and only cause is contact of gonorrhceal pus with the conjunctiva. It has no other relation with gonorrhoea than this, and may affect the surgeon or the nurse as well as the patient, provided only a little of the contagious pus touch the conjunctiva. Hence the necessity of forewarning patients of the danger they run in neglecting the most scrupulous cleanliness of the hands after dress- ing the penis, using injections, or passing water. For the surgeon, this precaution is equally necessary, together with the other one of burning all pieces of si3onge, linen, lint, etc., which are brought into contact with gonorrhceal pus, derived either from the urethra or the eye. If this be neglected, the subsequent use of the sponge on a healthy eye may carry the contagion to it, and give rise to a dangerous malady. This disease is truly a gonorrhceal conjunctivitis, and is easily sepa- rable from gonorrhceal ophthalmia, a disease impossible upon a given subject unless he is at the same time himself suffering from urethral inflammation. The so-called sympathetic (metastatic) gonorrhceal ophthalmia is of the latter variety, and should never be confounded with true contagious conjunctivitis. Gonorrhceal conjunctivitis is rare ; of 37,034 cases of disease of the eyes treated at the New York Eye Infirmary, it occurred 59 times, once in 628 cases (Bumstead). It is much more frequent in the male than in the female, on account of the greater opportunities for conta- gion. The right eye suffers more often than the left, since most pa- tients handle the .penis, and rub the right eye, with the right hand. Penanguer * states the proportionate occurrence of the disease in the eyes to be four times in the right to once in the left. The symptoms are those of purulent conjunctivitis intensified. Tlie rapidity with which the symptoms aggravate is often appalling. The slight dry, sandy feeling attending the first congestion of the eye is of the shortest duration, as is the secretion of tears and muco-pus. Within a few hours after contagion the discharge is frankly purulent, and the inflammatory symptoms go on increasing rapidly in severity, * "De rOphthalmie blennorrhagique." These, Paris, 1851. Q-j. COiirLICATIONS OF GOXOKREffiA. until, iu three or four days, often sooner, destrnction of sight is inev- itable. Sometimes the safety of the eye is compromised in a few liours (ten to twelve). The vessels of the conjunctiva rapidly fill with blood,and its tissues become distended with serum (chemosis). The border of the infiltrated conjunctiva overlaps and partly conceals the cornea, the latter lying, as it were, at the bottom of a cup filled with pus. The eyelids have an erysipelatous redness, are very o-dcm- atous, and swollen. The upper overrides the lower. There is spasm of the orbicular muscle. Pus is retained in large quantities. Pain, ocular and peri-orbital, is often intense. The cornea soon falls jnto ulceration, if the chemosis continue. There is, first, a imrulent infiltration between its lamellre, then softening and ulceration, suj^er- ficial at first, and usually situated near the circumference of the cor- nea, perhaps obscured from casual inspection by the overhanging, chcmosed conjunctiva. This ulceration jDrogresses rapidly to perfora- tion, the aqueous humor escapes, perhaps hernia of the iris occurs. The cornea may be pressed out into an anterior staphyloma, or be de- stroyed by the ulcerative jiroccss, or fall out, as a whole, like a watch- glass, allowing the contents of the eye to escape. The general symp- toms are moderate. Fever is usually mild, except in rare cases of suppuration of the globe, and soon gives place to a nervous, depressed, irritable condition, attended by insomnia, agitation, inquietude, more rarely stupor. Diagnoais. — The following table, prepared by Fournier, sets forth the distinguishing characteristics of the two ocular affections liable to be found upon a patient with a urethral discharge. The distinc- tions can not be too strongly insisted upon, on account of the liability to confusion of two conditions, one of which is so harmless and so little benefited by remedies, the other so destructive and so positively under the control of treatment. The specific gonococcus always abounds in the pus of gonorrhoeal conjunctivitis — is absent in gonor- rhoeal ophthalmia. Gonorrhoeal Conjunctivitis. Gonorrhccal Ophthalmia. 1. Essential cause — inoculation of the 1. Contagion plays no part in the pro- conjunctira with gonorrhoeaf pus. duction of the malady, which is developed under the influence of an internal cause, the nature of which is unlcnown. 2. A rare affection. 2, An inf rc(iuent complication of gonor- rhoea, but still much more common tlian the contagious ophthahnia : : 14 : 1. .3. May affect subjects not suffering from 3. Only attacks patients already suffcr- gonorrhoea. ing from gonorrlioea. 4. Usually only one eye involved. 4. Commonly both eyes. 5. The symptoms are those of the grav- 5. The symptoms arc those of an inflam- est kind of purulent ophthalmia. They af- mation of the membrane of Dcscemet, of an feet the conjunctiva primarily. iritis, or of an oculo-palpebral conjunctivitis. GONORRIICEAL CONJUNCTIVITIS— TREATMENT. 95 Gonorrhceal Conjundivilin — ( Continued). G'onorrhoeal OjAlhalmia — (Continued). 6. Symptoms fixed, not going from one 0. SomctimcH the inflainmatoiy phenom- eye to the other. cna are mobile, pa.s.sing from one eye to the other. v. No tendency to relapse in subsequent 1. Frequent relapses in the course of gonorrhojas. subsequent gonorrhwas. 8. No coincidence with rheumatic mani 8. Coincidence with gonorrhfcal rheu- fcstations. matism very habitual, almost constant. 9. Prognosis excessively grave. Often 9. Prognosis without gravity, loss of the eye. 10. The eye is only saved by a most 10. Expectation, or the simplest treat- energetic treatment. ment, sufficient for a cure. Prognosis. — When a severe purulent conjunctivitis develops in an individual with a urethral discharge, or even in a friend, especially if any history of contagion can be elicited, the prognosis is most grave. Unless an energetic treatment be instituted, the eye is lost, and, if aid come a little late, some lesion of greater or less severity and affecting vision is pretty sure to remain behind. Fortunately, both eyes are rarely involved. Treatment. — There is not a moment to be lost. Delay may sacri- fice the eye. The essentials of treatment are four : 1. Eelief of tension. 2. Eelief of chemosis. 3. The early free repeated use of a strong cauterant. 4. Cleanliness. Each of these four is about equally important. The greatest care is necessary in handling the tender, swollen eye. No pressure is allowable. The dressings should be the lightest pos- sible — even the pressure of the swollen lids upon the eye is prejudicial, and must be met by early, free canthojolasty at the external angle,* an operation to be repeated if necessary. All the dressings should be per- formed by a skilled hand, else they will be inefficient. The utmost care should be used in protecting the sound eye from contagion. It may be hermetically sealed with lint and collodion where the nurse is not trustworthy. Old soft rags are most suitable for wiping off the discharges, and these should be destroyed at once by fire. The pus retains its contagious properties for hours after it has dried, and fresh pus has been found to be still contagious when diluted with one hun- dred parts of water. The rapid and virulent nature of the inflamma- tion occasioned by the contagion of gonorrhceal pus has been amply demonstrated by certain oculists, who have treated pannus by inocu- lating the eye with this material for the purpose of exciting an acute inflammation. If the patient is seen early, before his symptoms hare run high, * Critchett ("Lancet," April 3, 1880, p. 62i) in one case in a child had to slit the upper lid vertically to the brow in order to expose the cornea. The eye was saved. 90 COMPLICATIONS OF GOXORRHOEA. and before the secretion is frankly i)urulent — within the lirst twenty- four, at most forty-eight hours — if he is robust, it is advisable to take three or four oimces of blood from the temple, or mastoid i)rocess of the affected side, by leeches or cups. If the effect seem favorable, this local bloodletting may be repeated in ten or twelve hours, and even a third time if necessary. Irritant purgatives, and a low diet at first, are of advantage. Perfect rest of body, and, if jiossible, of mind, should be secured. The sick-room should be obscurely lighted. If the patient is Jiot robust, not an ounce of blood can be spared, a laxative rather than a cathartic should be given, while the diet must be nourishing and supportive, even stimulating if there be much de- pression. Under no possible circumstances is a mercurial course ad- visable, or a continued depressing treatment harmless. The local treatment is the same for all cases. If the patient is seen very early, iced water is to be applied locally upon a thin fold of cloth, which must be constantly changed. As soon as pus begins to form, a solution of gr. x to xx of nitrate of silver should be iiuiuted over the conjunctiva, and the iced water continued. Every few hours the eye must be reiusjjccted, and the nitrate-of-silver solution reapplied. As pus begins to form more abundantly, or if the patient is not seen until suppuration is profuse, the strength of the solution must be increased up to 3 j to the 3 j, or the solid stick may be employed, being care- fully drawn over the entire ocular and palpebral conjunctiva. The cornea is of course spared in ai)plying the caustic. After using strong solutions of the nitrate of silver, the excess should be washed away with a solution of common salt. The object of these powerful apjilications is to restrain the forma- tion of pus and change the discharge into a sero-sanguinolent one. They should be made sufficiently often and sufficiently strong to pro- duce this effect. The iced-water compress should be kept up for a number of hours after each application, then the lids should be anointed with cold cream, and left uncovered, simply shaded from the light. Cauterization should be repeated whenever the discharge gets abundant and thickly purulent. Free use of cocaine somewhat lessens the pain of the cauterizations. The water or cerate will keep the outside of the eye reasonably clear, but the swelling of the lids and spasm of the orbicular muscle tend to confine much of whatever discharge there may be. Hence the value of canthoplasty. It allows dressings to be made easily, prevents the ball from suffering pressure (thus contributing to preserve the cornea), and makes cleanliness easy. The outer canthus should be continued by an incision down to the bone. A skilled nurse from time to time should gently separate the lids, and scpiceze a few drops of warm water into the eye from a soft rag, removing all external pus with the same cloth. A syringe should not be used to wash the eye. GONORRHOEAL COXJUNCTIVITIS— TREATMENT. 97 for fear of spattering. A mild solution of nitrate of silver, gr. v to x, is sometimes of advantage, dro^jped into the eye between the cau- terizations. The treatment must be continued unremittingly, the eye being washed, dressed, and inspected every two or three hours, until the symptoms abate. An anodyne may be required to pro- duce sleep. Chemosis is treated by extensive and deep scarifications performed with the curved bistoury or scissors. These scarifications must be thorough. They should never be made before, always after a cauteri- zation, otherwise the surgeon will have to wait some time for hsemor- rhage to cease, or he will not apply his cauterization thoroughly, and, furthermore, an unnaturally hardened condition of the conjunctiva is liable to be left behind by the healing of the scarifications, the surfaces of which have been cauterized down to the bottom. Some of the che- mosed conjunctiva may be snipped away, but deep scarification with a bistoury, often repeated, is better. When the cornea becomes opaque, use atropine at once, and, with- out waiting for ulceration, puncture the anterior chamber, repeating this operation as often as the cornea becomes tense. It is better to do this, especially if there be ulceration, than to run the risk of hernia of the iris, or possible escape of the contents of the globe. Peri-orbital pains are combated as are those of gonorrhoeal oph- thalmia. When the acuteness of the symptoms begins to subside, milder astringent collyria may take the place of the nitrate of silver ; such as — 5 Alum exsic, gr. vj-xij to the § j. or — 5 Zinci sulph., gr. j iij " " " or — ^ Sodfe biborat., gr. v-x " " " These may be applied to the eye by means of any of the ingenious '■'droppers" which the shops afford, or, if the patient can slightly open and close the lids, he may diffuse the solution over his eye by throwing back the head until the plane of the face becomes horizontal, then closing both eyes, and dropping a little of the solution (not too cold) over the inner canthus of the one to be medicated. Now, by several times rapidly opening both eyes to their widest extent and then shutting them, the fluid enters the eye and circulates over the globe. This method does not succeed with strong solutions, causing pain, and should not be used with solutions which stain the skin. Xitrate of silver should always be applied by an experienced hand, and be brought into contact with every portion of the conjunctiva. The inflammation once reduced to a subacute state, tends to get well slowly. The discharge drags along on an average for from two to four weeks — often longer. In these cases blisters behind the ears, 1 98 STRICTURE OF THE URETHRA. on the temples, seton at the nucha, etc., have been recommended, together with plenty of good food, fresh air, tonics, stimulants, etc. Granular conjunctivitis and anterior staphyloma may be mentioned as not very rare complications of gonorrhanil conjunctivitis. CHAPTER V. STRICTURE OF TUE URETHRA. Definition. — Varieties: Mnscnlar, Organic— Organic Stricture.— Form. —Number.— Seat. — The Lesion in Stricture. — Causes.- Time of Occurrence of Stricture. — Irritable and Resilient Stricture. An unnatural narrowness of any portion of the canal of the urethra constitutes stricture ; or, since the urethra is naturally a shut canal, Sir diaries Bell's definition may be more accurate, and any loss of dilatability may be termed stricture. This contraction of the canal, following the first definition, to constitute stricture, must be unnat- ural, for the urethra has certain points of normal contraction — namely, the meatus, the middle of the pendulous, and the beginning of the membranous urethra, and these are not strictures. They become so, however, if they are unduly small. Thus, an individual with an aver- age-sized penis and urethra, whose meatus will only take No. 10 F., has stricture (congenital) of the meatus, although he may never suffer any inconvenience therefrom. Again, any inflammatory condition of the walls of the canal, or spasmodic contraction of the same, consti- tutes stricture, as does also any growth upon or beneath the mucous membrane — cancerous, tubercular, syphilitic, membranous. A collection of fluid outside the canal may constitute stricture — abscess, serous or hydatid cyst, etc. — anything, in short, which lessens the size of the canal when distended by the stream of urine, foreign bodies, of course, excepted. In all the last-named conditions, how- ever, stricture is only an epiphenomenon, and not the disease itself. In this section, pure stricture only will be discussed. Stricture is of two kinds : 1. Muscular, or spasmodic. 2. Perma- nent, or organic — the latter congenital, or acquired. Inflammatory stricture does not exist as a disease of the urethra. The smallest amount of inflammation will lessen the caliber of the canal, just in proportion to the amount of turgescence of the mucous membrane ; but this is unimportant. No amount of simple inflammation of the urethral mucous membrane gives rise to enough diminution of the size of the canal to occasion serious inconvenience (retention), unless occur- ring in connection with organic stricture, assisted by muscular spasm or complicated by prostatic congestion. A croupous membrane may MUSCULAR OR SPASMODIC STRICTURE. Of) exist within the urethra, and obstruct more or less the flow of urine ; but this is exceedingly uncommon. Eokitansky* speaks of "very rare cases" where "we find primary croup occurring on the urethral mucous membrane " — this chiefly in children. Membranous deposits may occur upon the surface of organic stricture, or behind it ; but these are not to be confounded with true croup. 1. Muscular or Spasmodic Stricture. — Spasmodic stricture is of the commonest occurrence ; an active joredisposing cause is a sensi- tive, high-strung nervous organization, often in connection with an irritable, gouty, or rheumatic constitution, and particularly in those who are sexually astray. The exciting causes are any local irritation, inflammation, foreign body, irritation of the rectum (reflex action), ingestion of certain substances, cantharides, turpentine, quinine, opi- um, etc., mental emotions, malaria. The seat of contraction is in the unstriped muscular fibers which surround the urethra at the irritated point (stricture, foreign body), or at the membranous urethra in the voluntary " cut-off " muscle. Verneuil f believes that spasmodic strict- ure, due to urethral (reflex) irritation, is situated in the membranous urethra, while spasm due to irritation above the vesical neck (also reflex) has its seat in the posterior yesical sphincter of unstrij)ed mus- cle. Eobin and Cadiat J believe that urethral spasm is always situ- ated in the unstriped, never in the voluntary, muscles ; but the case they give in proof is hardly demonstrative. The action of many of these causes may be readily illustrated. Take a nervous, excitable young man with a healthy urethra — a forti- ori, with an irritable bladder or inflamed urethra — and attempt to pass a bougie for the first time, and the chances are that it will be arrested. It may be grasped and firmly held at any part of the canal, but this is more liable to occur just as the instrument is entering the mem- branous urethra, where its point may be detained for many minutes by an involuntary contraction of the cut-off muscles. If the end of the sound is held quietly for a few moments against the contracting muscle, the spasm will yield, and the instrument pass on into the bladder. Any foreign body in the urethra is liable to excite this amount of spasm around it. If any portion of the canal is in a state of irritation, especially if slight organic stricture exist (this is a potent cause of spasm), some contraction is almost certain to take place at this point on the approach of an instrument, and to recur after the sound has passed along, giving the sensation of "grasping" or "biting" upon the instrument, which is so well marked in most strictures. The spasm caused by cantharides is attended by a good deal of * "Sydenham Translation," vol. ii, p. 235. f Sebeaux, " Contracture du Col de la Vessie," Paris, 18*76, p. S2. X "Journal de I'Anat. et de la Physiol," September, IS'74, p. 531. 100 STRICTURE OF TIJE URETHRA. congestion as well. It is styled straniiurv — a term too well known to require further comment. AVhat surgeon has not witnessed spasmodic stricture, caused hy modesty, shame, anxiety, fear, irritated mind (Cooper, Sebeaux), as shown by the total inability of some patients to pass water before a class of students or even in the presence of a physician alone in his office ? In such cases there is not a failure of the detrusor urina? to contract, but there is a failure of the compressor urethrae to relax. The patient contracts his abdominal muscles and his diaphragm, and uses all his will, but to no purpose. Let the surgeon now gently introduce a well-warmed and oiled catheter of medium size into the bladder, and the spirt that will follow, as soon as its eye touches urine, will easily convince him that there is no fault to find with the con- traction of the detrusor. The latter muscle, however, al.D 20 7.0 31 i,\ .is .li: aa 23 ,<5 ap r M i 1 N EW YOHK, STEEL VERSUS SOFT INSTRUMENTS. HJ 10) 20 Am. And to make an American number English, subtract about 2 : 20 Am. = (20 - 2) 18 Eng. In employing conical instruments of steel it should be remembered that the surgeon has the advantage of using a wedge as well as a lever, and, by carefully inserting any given conical steel instrument through a stricture, he practically does (with less violence) the same thing as if he passed a number of blunt instruments, since the conicity of the sound runs through many sizes. Advantages of Steel Insteuments for dilating Stricture. — Since Thompson, one of the most brilliant minds connected with the subject of genito-urinary surgery, decided at one time in favor of the use of soft instruments for dilating stricture, a word will be necessary to state the reasons why the authors of this treatise hold a contrary opinion. In regard to facility of manipulation, that depends on prac- tice, and he will use this, that, or the other instrument the best, who has used it the most. Less harm can be done with flexible than with solid instruments, undoubtedly, and on this account they are to be recommended for the unskilled, and for all, however expert, in the low sizes — below No. 13. In trained hands, however, the steel sound is perfectly safe ; it is smoother than any soft instrument, and cer- tainly can be passed into the urethra with less pain than can any other instrument, and is capable of effecting more dilatation, in the same length of time, with the employment of less force. Steel instruments, made with the curve and conicity already described, possess all the powers of the wedge, and of a lever of the first order. The surgeon holds the long arm, the fulcrum is a sliding one, situated at the junc- tion of the shaft with the curve, perhaps steadied by the surgeon's finger. The immense power which the application of this compound mechanical principle, in the construction of the instrument, gives to it, is not appreciated by surgeons. The ease with which harm may be done, in using force with conical sounds, is rarely realized until after an accident has occurred, and then the surgeon is liable to ascribe the mischief to chance rather than to his own carelessness. Swelled testi- cle, congestion of the neck of the bladder, irritation of the stricture^ even false passage, may be produced by a surgeon in too great a hurry, or using force. It is a rule, from which no departure should be made, either on account of solicitation by the patient, or desire to push the case to a rapid termination, never to use force with any instrument in the urethra — especially with conical steel sounds. The character of the stricture may, occasionally, in the judgment of the operator, some- times require force, but the motive for its use must never be haste, or desire to effect a rapid cure. The weight of the instrument, aided by a little coaxing, will usually exert all the power necessary. " Festina lente " is the golden rule. Patience and gentleness will effect more than force in the long run. 118 STRICTURE OF THE URETHRA. THOMPSON'S RAPID DILATOR. This instrument which Thompson devised for rapid dihitation — his expressed object being to stretch as much and tear as little as possible — still has a useful place among the instruments for the treatment of stricture. Its inventor has practically discarded it in favor of the ure- throtome. In this country it is still used as a dilator, and as a divul- sor (to stretch a strictured point so as to tear it) in appropriate cases. The American instrument is modified by being tunneled, and is made stronger and to open more widely than the original instrument (Fig. 40). Fig. 40. In using it, the slender (size 12) shaft is passed so that its point of greatest dilatability is placed in the strictured area. This is easily accomplished by first locating the stricture with a bulbous sound, and then introducing the divulsor until the inch-marks upon the shaft in- dicate that it has reached the proper depth. Now, by turning the screw-head in the handle, the blades are made to separate laterally to an extent indicated by markings upon the slot in the handle. When it is used upon a deep stricture, as the blades are being again approached after the divulsion has been accomplished, a bit of mucous membrane is liable to be caught in the angle of the blades, near the tip of the instrument. This is to be avoided by slowly pressing the tip of the instrument forward into the bladder as the blades are being approached. Divulsion, or tearing the stricture, is a rough manoeuvre, and has of late years lost favor among surgeons. I formerly thought better of it than now, and at the present date very rarely have recourse to it. Internal urethrotomy is, undoubtedly, a better operation for all strict- ures situated anteriorly to the bulbo-membranous junction, but deeper than that point, although I still believe it to be as safe as extensive internal urethrotomy, yet I believe it not to be as safe as perineal (ex- ternal) section. Yet the instrument has three important uses : 1. To pass over a whalebone guide in cases of very tight strictures, so as to dilate them moderately in the (a) anterior urethra, in order that the rather large shaft of the dilating urethrotome may be made to INSTRUMENTS FOR INTERNAL URETUROTOMY. 119 pass ; in the {h) deep urethra, in order to make it possible to take np the treatment with sounds in gradual dilatation. 2. To divulse stricture of the deep urethra in the occasional cases where that operation seems to be called for when the patient refuses external section, and a choice lies between divulsion and deep exten- sive internal urethrotomy. 3. To pick up and remove * small foreign bodies from the urethra. If divulsion be practiced, it is proper to perform it after the blad- der has been voluntarily emptied, or to pass a soft rubber catheter immediately afterward, and tie it in for forty-eight hours. I have gradually come to the belief that such drainage of the bladder is of assistance in averting urethral fever, both after divulsion and after deep internal urethrotomy. The end of the catheter is left open to drain into a urinal, and the patient is kept in bed for about three days. No sound needs to be passed until the seventh day after divulsion, when, if the operation has been suflBciently extensive, a full-sized steel sound will enter. After this the cure is perfected and maintained with the steel sound. No after-dressing is required. Ilgemorrhage is usually very mod- erate. Holt's, Voillemier's, and other divulsors I consider less accurate in their use, and less suitable for divulsion, than Thompson's dilator. INSTRUMENTS FOR INTERNAL URETHROTOMY. Four cutting instruments only need be described suitable for di- viding strictures in different portions of the urethra. The straight bistoury is the best instrument for dividing strictures at and quite near the external meatus. These should always be cut uj)on the floor of the urethra to an extent suflScient to cut through all the morbid fibrous thickening which constitutes the stricture. The finger is placed beneath the urethra, and, with the bistoury, the stricture is to be slowly and thoroughly cut through until the fin- ger on the outside recognizes that nothing of the former hardened ring is left between the edge of the knife and the integument. Bleeding, generally moderate, is sometimes profuse. The best method of arrest- ing it is to pinch together the cut edges, arresting the flow tempo- rarily. Then wij^e off the glans penis until it becomes perfectly dry. Then wrap it around many times with a strip of rubber plaster one quarter of an inch wide and ten inches long, wrapping in all the head of the penis in a circular manner. This will always and without fail permanently arrest haemorrhage. The pendulous urethra fills up with blood which can not escape, and clots filling the canal. At each act of urination this dressing must be removed, and immediately after * Keyes, "New York Medical Record," March 6, 1875. 120 STRICTURE OF THE URETHRA. urination reapplied. This the patient can do perfectly well for him- self. The meatus tends to heal promptly. My custom is to ]iass a full- sized steel sound through the cut at 24:, 48, 72, and 90 hours' interval, respectively, after which the cut is nearly well, and a sound twice a week will perfect the cure in a week or ten days. CrVI ALE'S URETHROTOME. This instrument has a small straight shaft terminated by a flat- tened bulb wliich conceals a rounded blade (Fig. 41). By means of a mechanism in the handle, this blade may be protruded to an extent indicated upon a register in the handle. The bulb is to be passed Fig. 41. throuofh a given stricture, withdrawn until it encounters the stricture, when the blade is to be protruded, and the stricture is cut by with- drawing the instrument. It is a very safe urethrotome. Thompson uses it (slightly modified) almost exclusively. It is most serviceable in cases of single linear well-defined stricture of the pendulous urethra. Several modifications of this instrument have been devised — bulbs of varying sizes being screwed upon the same shaft. Hsemorrhage is arrested, as after meatotomy, by wrapping a long strip of rubber pla.s- ter about the glans penis. After-treatment is the steel sound of full size passed, as in the case of meatotomy. The sound should not enter the bladder when the stricture which has been cut is situated in the pendulous urethra. This rule applies to the after-treatment in all the varieties of cutting in the pendulous urethra. MAISONNEUVE'3 URETHROTOME. This instrument is serviceable where it becomes necessary to incise stricture situated deeper in the urethra than four inches. It consists of a hollow wire with a linear opening on that side which coiTesponds to the roof of the urethra. The knife, of different sizes, cutting from before backward, and from behind forward, with its exposed obtu.se angle always blunted, is attached to the end of a long stylet which fits into the groove of the instrument. The blade is prevented from slip- ping out by a projecting shoulder on either side, which runs inside the hollow wire. Bumstead has advantageously modified the original instrument by making the knife run only to the beginning of the curve, instead of up to the point, and by making the tube a little more solid. Bumstead's instrument has the blade on the lower side INSTRUMENTS FOR INTERNAL URETHROTOMY. 121 (Fig. 42). This urethrotome is to be used with a scrcw-tii)pod fili- form bougie. It is proper to cut the meatus below, the pendulous urethra above, the curved urethra below. It is introduced, following its guide, and depressed until the straight portion of the tube has passed the stricture. Then the blade is entered, pushed rapidly down, as far as it will go, and immediately retracted. The objection to this instrument is, that if a large blade is used the healthy urethra is incised longitudinally, often for its whole length anteriorly to the stricture ; an acci- dent perhaps of no very great moment, but entirely unnecessary, while, if a small blade is used, the whole thick- ness of the stricture is not cut through. Voillemier has at- tempted to overcome this objection by adapting a shield to the blade from which the latter may be protruded when the stricture has been reached, but the modification is com- plicated and unsat- isfactory (Fig. 43). Another objection, applicable to all in- struments for incising the deep urethra, is the liability to haemor- rhage if the incision is sufficiently deep to be effective. Such hasmorrhage at the bulbous portion of the canal may be very difiScult to control, the same as after all other operations. The best way to control hemorrhage in the deep urethra after deep internal urethrotomy is by a padded perineal crutch, the leg of the crutch resting against the foot-board, counter-pressure being ef- fected by elevating the head of the bed. Fig. 43. The after-treatment is 122 STRICTURE OF THE URETHRA. OTIS'S DILATING URETHROTOME. Tliis powerful instrument (Fig. 44) is a very valuable one for cutting strictures in the pendulous urethra. It has a straight, oval shaft, about size 20 (a smaller instrument aud a corresi)ondiugly lighter one is made, but the stiffer one is the better). The end of the shaft is tunneled for use in the deeper urethra, if necessary upon a whalebone guide. The two segments of the shaft are separated b}' turning the screw in the handle, the extent of se]iaration being registered upon a plate upon the handle. The possible extent of this separation is forty-five. The knife is narrow, concealed in the shaft at a point near the end of the instrument. It is dis- closed by withdrawal, when it rides upon a ridge which is continuous up to the handle. The instru- ment is introduced until the point of emergence of the knife is about half an inch behind the deepest stricture to be cut. The blades are then separated until the stricture is well upon the stretch. The knife is withdrawn, cutting the tense tissues. The instrument may be then still further screwed up if desired, and the cutting continued to any extent — upon the roof of the urethra. The whole roof or a l^ortion of it may be cut. The knife is then re- turned, the instrument unscrewed and withdrawn. Cocaine makes the operation comparatively painless. A full-sized sound is then introduced to prove that the cutting has been effectual. Ila^morrhage is arrested as in meatotomy, and the after-treatment is as before with sounds. Wyeth's urethrotome, a similar and cheaper in- strument, serves very well as a substitute. It is not as strong an in- strument as that of Professor Otis. Fig. INSTRUMENTS FOR EXTERNAL PERINEAL URETHROTOMY. Besides some of the special instruments already described, only two others are requisite to meet the requirements of external section. 1. A simple staff, broadly grooved on its convexity, the groove running off at the end, and the instrument not conical (Fig. 45). This instrument is introduced as far as the stricture, when the latter is impervious, and is cut upon in the operation of perineal urethrot- omy without a guide. It may be used with a guide, the latter being a whalebone bougie, introduced through the stricture (Fig. 40). In EXTERNAL URETHROTOMY WITHOUT A GUIDE. 123 this case it is practically the same instrument as the stafE of Syme,* the eminent surgeon who gave this operation its reputation. Syme's staff is unsafe compared with the means now at our command, and is rarely iised. 2. The catheter-staff of Gouley (Fig. 47). This most excellent instrument is a metallic catheter (they are made of various sizes), Fig. 45. Fig. 43. Fig. 47. grooved on its convexity, the groove being bridged over at its end, forming a loop to receive its guide — a filiform whalebone bougie. Scalpels, probes, and a long, slender, probe-pointed director are required for the operation. EXTERNAL PERINEAIi URETHROTOMY, WITEOTJT A GUIDE. The surgeon who proposes to perform this operation should be thoroughly at home in the anatomy of the perinaeum, and even then should be prepared for possible failure. The patient is tied or held in the lithotomy position, after he has been anesthetized. The scrotum is held up out of the way by the assistant who manages the grooved staff. Ether relaxes spasm, and a last attempt to pass a filiform * " Stricture of the Urethra," Edinburgh, 18-19. 124 STRICTURE OF THE URETHRA. bougie, after the patient has become uncouscious, may be successful, where previous efforts have failed. Should the attempt succeed, the operation at once becomes simi)lo and easy. Failing, the operation without a guide must be undertaken. The perint^um having been shaved, an external incision should be made directly in the median line, from two and a half to three inches long. It should be carried down, layer after layer, until the urethra has been ojjcned into upon the end of the blunt staff previously introduced up to the front face of the stricture. The perinfeum should be turned toward a window, and a couple of hours of daylight always allowed, in order to have an abund- ance of time, if the operation proves complicated. Haste, in this operation, is bad surgery. After the urethra has been laid open, the subsequent steps of the operation are greatly simplified by adopting Avery's suggestion for getting room and light. It consists in trans- fixing each flap of the wound with a stout ligature about three feet long. The ends of each ligature are now knotted, thus forming a long loop on either side, which may be held by assistants. By means of these loops the wound is kept open to the bottom without the neces- sity of thrusting fingers or spatulas into the small s^^ace, where the fingers of the operator alone are necessary. With the urethra opened in front of the stricture, the surgeon care- fully searches for the anterior opening of the latter with a fine probe, or, better, a fine probe-pointed director. If the opening can be found, and the director passed through it, the rest of the operation is simpli- fied at once ; but this fortunate result is rare. Having failed to find the orifice of the stricture, after a patient search, the surgeon feels for the hole m the triangular ligament, below the depression lying above the sub-pubic ligament, and cuts into it through the fibrous mass by successive strokes of the scalpel, always in the median line. At short intervals during the operation, the surgeon gently endeavors to coax his fine director, properly curved, through any opening he may think he sees, into the dilated urethra beyond. After each failure he re- sumes the cutting in the median line, guiding his knife by frequently taking the bearings of the tubera ischii, and with his finger in the rectum. In this way he continues, feeling his way as he goes, until finally his director finds some orifice through which it passes onward into the bladder. When this has been effected, a probe is passed in the groove of the director, also into the bladder ; and now, by separating the two, a gush of urine is seen to mingle with the blood, announc- ing that the bladder has been reached. The director, once in the bladder, should not be removed until after the opening has been increased, and a large instrument (nothing is better than the little finger) can pass into the bladder. A mistake often made in searching for the opening into the urethra with a probe is in trying too high up, too near the sub-pubic ligament. EXTERNAL URETHROTOMY WITHOUT A GUIDE. 125 Having now opened a way into the bladder, all fibrous bunds in the roof of the urethra'* must be cut with the knife, and any fibrous material detected in the floor of the canal, at either extremity of the incision, should be freely divided. Finally, a blunt steel sound, as large as the urethra will admit, should be passed through the meatus into the bladder, the meatus being cut if necessary. This sound should be introduced several times, to make certain that it glides easily and without obstruction. If the stricture is an old one, it is always well to search the bladder for stone after the operation, and to remove any that may be found. Venous haemorrhage may be abund- ant, but it is easily restrained by plugging the wound with lint or tow, and tying the legs together after the operation. The scrotum should be bandaged up out of the way, to prevent the possible infiltration of its loose tissue by blood or urine. The thighs should be elevated, and a cradle used to keep off the weight of the bed-clothes. This operation may be greatly simplified by puncturing the dilated urethra in the median line, if it should be found to be distended with urine behind the stricture, as is sometimes the case. Through such an opening, an instrument may be passed to the posterior face of the ob- struction, and thus serve to guide the incisions from the grooved staff at the front face of the stricture through the callous mass. A perineal fistula may be utilized for the same purpose. After the operation, a large, soft, red rubber catheter, size 30 or 35, should be introduced into the bladder through the perineal wound, and tied in by encircling it close to the wound with two long, narrow strips of soft bandage, which in their turn are tied to a waist-bandage, one of the narrow bandages running up on either side of the scrotum, the other ends of the narrow bandages being passed under the thigh on either side, brought around, and attached to the waist-band in the flank. The end of the tube is left open, deposited in a urinal between the patient's thighs. Such a tube drains the bladder and keeps it empty. It is usually well borne for two or three days, after which it has served its purpose and may be removed. Through it the blad- der can be washed with an appropriate solution in case of cystitis, or retained decomposing blood, or when the urine is putrid. Around the tube a piece of cotton cloth may be tied as in the shirted cannula, and this may be stuffed with a long piece of narrow bandage, making the most effectual pressure in case of haemorrhage. The tube in my experience almost totally does away with the urinary fever. The tes- timony of Berkeley Hill, f who cites the twenty cases of Davies, and of Reginald Harrison J is corroborative of the good effects of a tube * A neglect of this precaution sometimes renders the subsequent introduction of in- struments very difficult. f "British Medical Journal," ISYQ, p. SS4. X Reprint from " British Medical Journal," July 18, 1SS5. 126 STRICTURE OF THE URETHRA. tied in for this purpose. Tiie tube should be removed on the third to the fifth day. After it is removed, the urine at first passes through the perineal oi)ening. The aft-er-treatment consists in the passage of a full-sized steel conical instrument into the bladder, commencing on the fourth day and repeating every three or four days until the wound has healed, thus forcing it, as it were, to heal with a large splice. After the wound has united, to prevent recontraction, the patient must pass di- lating instruments at proper intervals, as after any other treatment designed to effect a radical cure of organic stricture. Infiltration and abscess may occur after the operation, and it is not very uncommon for fever to run high ; but the results are usually excellent, unless the patient have organic kidney or other disease. Diluent, mucilaginous, alkaline cooling drinks, with quinine, tonics, supporting diet, and rest, complete the treatment. EXTERNAL PERINEAL URETHROTOMY, WITH A GUIDE. This is an operation much simpler than the one just described. When external section of a stricture is contemplated, no effort should be spared and no amount of time grudged which is given to attempts at introducing a whalebone bougie. Even after the patient has been anaesthetized, the attempts should be renewed, for ether always relaxes urethral spasm, and, if finally a whalebone guide enters the bladder, the surgeon may congratulate himself and the patient's friends — for what would have been one of the more difficult operations of surgery (section without a guide) becomes at once one of the easiest. A whalebone once in the bladder, the catheter-staff, or a tunneled steel staff, is passed over it up to the stricture. An incision through the perinaeum in the median line readily exposes the end of the staff, and be5'ond it the black guide is seen disapiaearing among the tissues. Avery's threads make it easy to keep the guide in view, and a little careful following up of this conductor soon lets the surgeon into the dilated urethra behind the stricture ; the catheter-staff passes on into the bladder, urine flows through it, and the operation is satisfactorily accomplished. The only precaution worth mentioning is the neces- sary exercise of care not to cut off the whalebone guide in front of the staff by a careless stroke of the knife, as this might at once reduce the surgeon to the necessity of operating without a guide. After-treatment is the same as after the operation without a guide. Harrison's operation of combined external and internal urethroto- my is a modification devised to meet the well-known dangers attend- ant upon deep internal urethrotomy. It consists simply in cutting the strictures internally in any manner to the extent desired, and then passing a broadly-grooved staff and puncturing the perinaeum from THE ASPIRATOR. 127 the outside sufficiently to allow the insertion of a large tuhe into the bladder for the purpose of drainage — and, most particularly, to avert urinary fever of bad type. His showing is an excellent one, and com- mends itself to common sense. The simple puncture of the perinaeum does not add to the gravity of the internal operation, and experience is daily accumulating to show that this thorough bladder drainage is a potent factor for good in operations upon the bladder. At the pres- ent date I invariably use it in all cases of supra-pubic section, and I can not commend it too highly. My personal experience with deep internal urethrotomy is unsatisfactory, and I do not care to employ it in any grave case except in combination with thorough bladder drain- age through a tube in the perinseum. The profession is indebted to Harrison for the admirable manner in which he has called attention to this fact.* Certain other operations on stricture must be mentioned to be con- demned. Cutting out strictures is absurd, for the circular wound leaves traumatic stricture behind. Dupuytren's vital dilatation, which consists in tying in a large instrument pressed against the front of the stricture in the hope that it may pass after many hours, is unsurgical, and has been superseded by better methods. Wakley's sliding tubes are clumsy, and Arnold's fluid pressure less good than any other press- ure. Time has judged the internal use of caustics and condemned them, while the same fate awaits electrolysis, lately revived. My ex- perience with it has been unfortunate, f Puncture of the Bladder above the Pubis. — Puncture of the bladder through the rectum, formerly much resorted to, has been replaced by better methods. J THE ASPIRATOR. This most useful instrument, devised by Dieulafoy, of Paris, exists at the present day in the shops in various forms. Its value in cases of retention, from whatever cause, can hardly be overestimated. It may be used day after day, and several times a day if necessary, the fine needle (I prefer No. 2) being inserted with as much impunity into the bladder above the pubis as is customary in using a hypodermic needle for the purpose of subcutaneous injection. The little wound closes without bleeding after the needle is withdrawn, and subsequent punc- tures may be made quite near to the original one without provoking * "British Medical Journal," July 18, 1885. f " Practical Electrotherapeutics, Ten Cases of Organic Stricture treated by Electroly- sis," Keyes, "New York Medical Journal," December, 1871, p. 569. X As to tbe comparative danger to life in supra-pubic and rectal puncture, Deneife and Van Wetter, "Rev. Mens, de Med. et de Chir.," September, 1877, have collected 97 cases of rectal puncture with 11 deaths, and 152 supra-pubic with 6 deaths. They only cite, at that date, 57 cases of aspiration — no accident. 12S STRICTURE OF THE URETHRA. any local inOammation. Generally, aspiration is only ])racticed as a temporizing expedient in cases of stricture when it is not desirable for some reason to operate at once. In this way the bladder may often be spared needless overdistention. Furthermore, quite often when, in a case of retention with tight stricture, no filiform instrument can be made to pass, if aspiration is practiced, another attempt, made some hours later, is successful. One precaution is necessary in using the aspirator, namely, main- tain the suction while the needle is being withdrawn. W. T. Bull* calls attention to this point in the only case of which I am aware in which a bad result followed the use of the aspirator. In this case an abscess with cellulitis in front of the bladder followed a second aspira- tion in a given case. The patient recovered after several weeks. Dieulafoy's smaller aspirator is very ^■)ortable and convenient for tapping the bladder ; the box containing it measures eight and a half, by four and a half, by one and three-eighths inches. It consists, essentially, of a glass cylinder, with tight-fitting piston and two stop-cocks, a flexible tube, and pointed hol- low needle. The method of using the instrument is the following : First, be satisfied that the fine needle is pervious — not occluded by rust or otherwise. Attach it beyond stop-cock E, or to the flexible tube, as shown in the figure. Shut both stop-cocks, E and E' ; withdraw the piston forcibly, thus forming a vacuum. By a half-turn from left to right, hook the angle A above the point B, thus keeping the piston withdrawn. The instru- ment is now ready for use. The point of election in puncture of a distended bladder is through the linea alba, about half an inch above the symphysis pubis. Into this spot the needle is plunged for half an inch. Now stop-cock E is turned Fio. 48. on, and a vacuum is thus created within the flexible tube and needle. Next, the needle is slowly and cautiously pushed forward until urine is seen to flow into the glass cylinder. It flows slowly on account of the size of the needle, but no pressure is required to help it. The ueedle is next jiushed, perhaps, an inch farther into the bladder, and then there is nothing more to do until the glass cylinder is full, after which E is turned off, E' is turned on, A is unhooked, the piston is driven gently * " New York Medical Journal," September, 18S0, p. 305. THE ASPIRATOR. 129 home, expelling the iirinc at R'. E' is now turned off, the cylinder again exhausted, li turned on, and so on, until the bladder is relieved, after which, the vacuum of the cylinder being maintained, the needle is rapidly withdrawn. The operation may be repeated as soon as the bladder refills. The impunity with which the bladder may be tapped, even with a large instrument, may perhaps be best illustrated by a case reported by Dr. Clarke,* of Geneva, New York. The case was one of reten- tion, from enlarged prostate, where catheterism proved impossible. Dr. Dox punctured the bladder above the pubes, without any previous incision of the skin, with an ordinary trocar, one line in diameter, and evacuated two quarts of urine, after which the cannula was imme- diately withdrawn. This operation was repeated six times in eight days, without any precautions, and was followed by no ill effects. After the eighth day the patient reacquired (and at the date of the arti- cle still retained) the power of urinating by the urethra, as well as he had before his retention. Such an excellent result could not be counted on in most cases, f One case is recorded J in which the blad- der of an old man of ninety was aspirated once a day for five weeks. No cystitis occurred — only a little cutaneous inflammation at the point of punctures. Sometimes suprapubic puncture has to be practiced for the pur- pose of establishing a permanent outlet for the urine in cases where it is inexpedient or impracticable to re-establish the natural right of way. In such cases the aspirator is not suitable, for a permanent tube must be placed to be worn by the patient as long as required. A red rubber catheter serves admirably in ordinary cases, while the wound is healing. Its place is supplied finally, for permanent use, by some suitable tube. I have recently had such a tube constructed (Fig. 49), and found that it worked satisfactorily. The tube is of red soft rubber, the spool is Fig. 49. made of black hard rubber, and the outside continuation tube also of hard rubber. Upon this latter another soft tube is fastened, conducting into a urinal. The hard-rubber spool facilitates attachment by bandage. A long silver double tube, like a tracheotomy tube, may also be employed (Fig. 50). * " Medical Record," June 1, 18'72. f Maisonneuve was in the habit of puncturing bladders in this manner, ^Ith an ordi- nary fine trocar, at the Hotel-Dieu, Paris, in 1866. I Hague, "Lancet," August 20, 1885, p. 385. 9 130 STRICTURE OF THE URETHRA. The tube last pictured was devised by Dr. Van Buren and intro- duced into uu old gentleman with obstructive prostatic disease — an Fio. 50. obstruction that no catheter could be made to pass — in the year 1863. The patient wore it comfortably for many months. The operation is not a difficult one. The mons veneris is shaved, and an incision made down to and through the linea alba. Then the bladder is exposed as in the high operation for stone, and through a puncture a large red rubber catheter (30 F.) is inserted. When the wound has healed around the catheter, the tube to be permanently worn is introduced. Puncture through the symphysis pubis, and below the pubcs along- side of the root of the penis, has not yielded satisfactory results. Puncture through the perina^um and through the substance of the prostate has been advocated by Harrison.* Ho leaves the silver tube in, and affirms that this })unctnre with retained tube caused the en- larged i^rostate to atroiDhy. CHAPTEK YII. STRICTURE OF THE URETHRA. Diagnosis.— Use of Enlbous Bougie.— Sj-mptoms of Stricture and its Results as affecting the Ure- thra, Bladder, Kidneys, Testicles, Rectum, Nerves, etc., including a Consideration of Infiltra- tion, and the Hanulessness of Healthy Urine in Contact with the Tissues.— Causes of Death from Stricture.— Recapitulation of Symptoms and Effects of Stricture. Diagnosis. — Few morbid conditions of the body are more easy of diagnosis than organic stricture of the urethra. In exploring a given urethra for the first time for stricture, I prefer to use a blunt steel sound which will just pass the meatus — that is, when the latter itself is not abnormally small. The blunt sound causes less pain than either the bulbous bougie or the urethrameter. It should be warmed, lubricated, and introduced with all gentleness. If it is obstructed anywhere, there is stricture, for the meatus is normally the smallest part of the canal. When an obstruction is encountered, a smaller blunt sound is selected, and then another, until some sound will enter the bladder. * " British Medical Journal," December 24, 1881, and April 8, 1882. DIAGNOSIS. ],31 It is always well in searching for stricture to commence wii.h a hu-'^o. size and work down, rather tlian to begin with a small instrument. The other method leads to confusion. I have more than once in hos- pital and in my office had a case referred to me as one in which a fili- form instrument even can not be made to enter the bladder, and have at once passed a full-sized blunt steel sound easily into the bladder. The explanation of this is that spasm of the deep urethra frequently fails to allow a fine instrument, especially a pointed one, to pass, while spasm in that region, in my experience at least, always yields to gentle pressui'e slowly and accurately applied with a blunt steel sound. Moreover, a false passage, or a pouched sinus of the bulb, or a dilated follicle, will frequently catch the point of a fine instrument, while a blunt sound will escape the obstacle, and, presenting fairly at the bulbo-membranous junction, will presently pass, perhaps smoothly, perhaps with a little jump as it rides out of the sinus of the bulb into the membranous urethra. Having detected stricture, it may be located, calibrated, and meas- ured, either with a metallic bulbous bougie or the urethrameter in the anterior urethra, or with a flexible bulbous bougie in the deep urethra. Obstructions beyond six and a half inches may generally be set down as due to prostatic enlargement, particularly in patients older than fifty years. If the bulbous bougie or urethrameter be used alone, there is danger of assuming that the point of physiological narrowing, at about the middle of the pendulous urethra, is a stricture requir- ing treatment by cutting when there is no real occasion for the operation. If this point is covered by granulations, however, and bleeds as the bulb passes it, it is in a morbid condition, and may re- quire cutting, although no true stricture exists at the point — only the natural narrowing rendered granular upon its surface by the pro- longed existence of chronic inflammation at this point. These are the so-called strictures of large caliber so popular at the present day, so common in occurrence, a rich field for the young surgeon, and sometimes the occasion of unnecessary cutting, as it appears to me. for the gleet they occasion may often be removed permanently by a few passages of a large sound without having recourse to the knife, and in most instances, when the gleet has been cured by the sound, although the physiological narrowing continues, the patient becomes and remains well without the necessity of further use of instruments in his urethra. Just within the meatus — at an eighth to a quarter of an inch — there is very often a point of congenital narrowing which may be as- sumed to be a stricture, and cut if there is any occasion for using an instrument larger than this point of narrowing will admit — otherwise, it may be disregarded. It is always wise to divide it if stricture exists beyond, because a free meatus greatly facilitates the use of large 132 STRICTURE OF THE URETHRA. sounds and the cure of deeper strictures. Always vrhcu there is a pouched condition of the meatus at the lower commissure, so that a probe introduced within it may be made to catch upon withdrawal at right angles to the axis of the penis — in such cases, the meatus is certainly too small, and for the treatment of any stricture more deeply seated it should be cleanly and freely cut down ui)on the floor of the urethra to facilitate the use p,^, 3, of a sufficiently large sound afterwards (Fig. 51). Symptoms and Kesults of Strictuke. — Stricture may exist for years without giving rise to a single symptom of sufficient importance to attract the patient's attention. In fact, it may be said that strict- ure has necessarily no symptoms until it has become so tight as to sensibly obstruct the outflow of urine and semen, or has been at- tended by so much callous overgrowth as to interfere with the flow of blood through the meshes of the corpus spongiosum. One may have stricture of small caliber of any part of the canal, but espe- cially of the meatus, and yet never sufl'er from it in any way until adult life — perhaps never at all. But, when a tight point exists, al- though it may have been congenital and may never have announced its presence to the patient by any subjective symptom, yet if such a patient becomes enfeebled in health, run down in nervous force, acutely inflamed upon the mucous surface of the urethra from gonor- rhoea or other cause, under stich circtimstances the tight point be- comes an clement of importance in his case, and his morbid symptoms frequently will not yield until this narrowed area is properly enlarged. All this is especially true of tight areas along the pendulous ure- thra. A man may be born with them and die with them (but not of them), and never have a morbid symptom due to their existence. Hundreds of cases might be cited in illustration of this fact, going to show that tight points in the pendulous urethra do not necessarily cause any symptom, and perhaps never do produce symptoms except upon the addition of some other cause.* Then, and not till then, do they require cutting. In short, wiien in examining a given urethra one or more points of narrowing are detected in the pendulous portion, if these points are not the cause of the symptoms of which the patient complains, there is, in my opinion, no occasion for cutting them. The urethra is, I believe, as serviceable with them as without them, and no material advantage comes to a healthy man after their division, while many morbid conditions may be removed without interfering with the so-called strictures of large caliber. In cases of doubt and in ohsciire conditions of deep urethral and bladder trouble it is justifiable to * Cases XVIII and XIX of the first edition of this treatise are sharply in point. SYMPTOMS AND RESULTS. 133 divide these points of moderate anterior narrowing, as a means of more accurate diagnosis — as well as to set aside any possible agency of the reflex irritative sort which these points sometimes seem to exercise upon the deeper parts of the urethra. The symptoms usually described as those of stricture are mainly the symptoms of the results of stricture, and consequently a description of these latter finds its place here. A certain small amount of gleety discharge from the congested (or it may be granular) surface usually accompanies the forming stage of stricture, but this may be so slight as not to attract attention, or may be entirely absent. Exceptionally urethral or other neuralgia depends upon stricture in the forming stage. The results of stricture are mainly mechanical in the first place. The strictured portion is less dilatable than the rest of the canal, and acts somewhat like a dam. The urine coming down with great force, and striking against this unyielding bar, tends to dilate the urethra behind it (Fig. 52), and this directly in proportion as the stricture is slow in forming and dense in structure. If more than one stricture exist, the urethra may be dilated between them. This stretch- ing process tends to dilate the mouths of all the ducts opening into the urethra behind a stricture. In this way the sinuses and mouths of all the follicles become enlarged, and capable of en- trapping the point of a fine instrument. This is also true of the ducts in the pros- tatic sinus, which may be- come so pouched out that the floor of the prostatic ure- thra becomes reticulated, and composed entirely of depressions, sej^a- rated by thin fibrous partitions — these latter re]3resenting what is left of the tissue which existed originally between the ducts of prostatic follicles. The ejaculatory ducts may be distended in the same way ; as may also, though rarely, the seminal vesicles — the urine being forced back into them. Fig. 52.— Taken from a patholoffical specimen, showing stricture of membranous urethra, with dihitation be- hind it, hypertrophy of bladder, dilatation of ureters, pelvis of kidneys, etc. 134: STRICTIKE OF THE URETHRA. The force exerted laterally by tlie urine propelled through the urethra by the contracting bladder js much greater than is generally supposed. To understand this, it is only necessary to call to mind the hydrostatic paradox, Avhich demonstrates the equal pressure of Iluids ou every square line of surface with which they come iuto contact. This forcible stretching of the mucous membrane behind the stricture at every act of micturition, althougli only slight in extent at first, Aveakens the tone of the stretched portion of the canal, congests it, and leads to the formation locally of an excess of mucus. If the urine bo acid and irritating, these elTectS take place all the more rai)idly. Soon a drop of urine is retained behind the stricture in the dilated portion of the canal, the mucus acting upon it as a ferment alkalinizes and decomposes it, liberating carbonate of ammonia. This acts upon the stretched urethra, and produces inflammation. This mild inflam- mation behind stricture is very constant. It furnishes the gleety dis- charge, or the morning drop of muco-pus, which glues the lips of the meatus together. The gleet of stricture gets better or worse according to the general condition of the patient, the degree -of acidity of the urine, and the amount of sexual indulgence or venereal excitement. Exacerbations of gleet from slight causes, or repeated attacks of gonorrhcea, as the patient usually considers them to be, often constitute the most marked feature of the case in a patient with stricture. In fact, it is the rule in mild cases that the patient is wholly unconscious that his urethra is at all narrowed. He applies for treatment, on account of his gleet, for an attack of gonorrhcea, as he calls its (bastard gonorrhcea), and often refuses to believe that he has stricture, or that, if stricture does exist, it is of enough importance to occasion his symptoms ; and he repeatedly asserts that he makes as large a stream of urine as ever. Nothing so well as the bulbous bougie will convince such a patient of his condition. The evidence of this instrument he must admit. The gleety discharge, once commenced behind the stricture, rarely ceases entirely until the constriction has been relieved. The same dis- charge will be seen in the urine in the shape of small, stringy shreds, formed of pus-corpuscles which have been washed off from the con- gested surface upon and behind the stricture, and appear as small white threads in the voided urine. These shreds may be all caught in the first gush of urine, what follows being perfectly free from them. When these white filaments are seen settling down in a glass of urine freshly passed, they constitute strong presumptive evidence of the existence of stricture ; they may be due to other lesions. As the stricture tightens, fresh symptoms are added. A cartilagi- . nous hardness may often be felt from the outside of the urethra at the constricted point. The meatus urinarius looks blue and congested, as does sometimes the whole glans penis, from obstructed circulation. SYMPTOMS AND KESULTS. 135 t The gleet continues, the stream of urine is small, often forked or curving uj) in a curious manner just after leaving the meatus, or there may be several streams running in different directions, or oftener one stream is projected for a certain distance, while the other drops down perpendicularly from the end of the penis. The last few drops of urine are retained in the canal, both mechanically by the obstruction of the stricture, and because the wave of blood, impelled by the con- traction of the accelerator urinse upon the bulb in the final effort at clearing the canal, can not pass along the corpus spongiosum, on ac- count of the obliteration of its meshes at the point of stricture, and thus fails in its function of expelling the last few drops of urine from the canal. By this same obliteration of spongy tissue, erection is sometimes rendered imperfect and painful. The surface congestion of the stretched urethra behind the strict- ure in time extends backward to the bladder, and brings on irritabil- ity (so called) of that organ. The intervals between the acts of micturition grow shorter and shorter, and symptoms of mild cystitis appear. Th\^ frequency of micturition is the symptom of stricture, next to gleety discharge, which is least often absent. A slight narrow- ing of the canal may occasion it, as where the meatus is congenitally small, and it may come on with any stricture, as pure irritability, un- doubtedly attended by congestion about the neck of the bladder, but not necessarily by any true cystitis. The congestion of the urethra behind a stricture easily becomes greater, is kindled into positive inflammation by dining out, a little excess in drink, or a chilling of the legs ; the mucous membrane swells up, the stricture closes, and the patient has retention of urine. If this retention is unrelieved, the bladder becomes overstretched ; after many hours a few drops of urine will escape from the meatus (overflow), and the patient thinks he is getting better. If this condition of over- distention is allowed to continue unrelieved, the contractile power of the bladder may be permanently injured (atony). Retention may he the only disagreeably prominent symptom connected with a case of stricture. The gleet may not have been noticed, the gradual decrease in the size of the stream may have been ignored, when, after exposure, ex- cess, a carouse of beer, retention suddenly comes on. Some patients will have had several attacks of retention before they apply for relief. The spasm and inflammation which caused the narrow canal to become obliterated in these cases cease after a few hours, and then the patient goes on perhaps for a year or more, without having another retention, not suffering noticeably in the mean time. If retention does not come on, the inflammation, once aroused be- hind stricture, gradually, sometimes rapidly, travels back through the prostatic urethra into the bladder, and we have cystitis of the neck. 130 STRICTURE OF THE URETHRA. Now commences what was before absent, or, if present, only to a mild doirree, a frequent desire to pass water, at first every three or four hours, once at night, and gradually at shorter and shorter intervals, until, when the patient seeks relief, he may be passing water in a fine stream every half-hour or tiftccu minutes, with great pain and straining. Blood sometimes Hows with the urine at the beginning or end of the act. HcBmaturia may be, excei)tionally, the most })rominent symp- tom of stricture, indeed the only one noticed by the patient for a long time. I have had several such cases, and have seen the hsematuria c?ase upon relieving the stricture. Along with symptoms of vesical irritation, often before any actual inflammation of the bladder has occurred, are found pains various in character and situation. Pain in the urethra, aching of the glans penis, or in the testicle, along the cord running up into the back. Pains across the lumbar region, in the periuanim, around the anus, and in the rec- tum, over the pubis, etc., and other obscure pains of a neuralgic sort, in the thighs, legs, or in the sole of the foot* (Brodie), all of which pains are cured by the dilatation of the stricture. Urination is often painful (sometimes excessively so), the pain being at the neck of the bladder, in the perinseum, at the point of stricture, or near the glans penis. Erections may be painful, the venereal orgasm attended by pain, the semen not being discharged during the sexual act, but often dribbling away afterward, perhaps stained with blood, or running back into the bladder, to be discharged at the next flow of urine. Impo- tence sometimes accompanies this condition. The sexual appetite is often impaired, sometimes nearly obliterated, in old severe cases. But, in mild cases, the congestion kept up behind the stricture may be just enough to excite and irritate the patient, causing frequent erections, erotic fancies, nocturnal emissions. The constant straining in urination keeps the hjcmorrhoidal vessels congested. This results not unfrequently in an attack of piles, or of prolapse of the rectum ; occasionally, hernia occurs from the same cause. The straining may be so violent that the bowel will protrude at every effort to empty the bladder, making it unsafe for the patient to attempt to urinate except upon a close-stool, for fear of the passage of faeces at the same time with the flow of urine. The inflammation of the bladder caused by stricture is usually su- perficial, but it may become parenchymatous, perhaps accompanied by abscess in the walls of the bladder, or in the connective tissue around it. The bladder-walls, as a rule, thicken, while their dilatability di- minishes, in cases of stricture. The detrusor, constantly called upon to force the urine through a narrow orifice, becomes thickened and * Or in the great toe. The pain is sometimes compared to intense heat, sometimes to icy coldness, sometimes it is actual pain over a given small area. (See Pododynia.) SYMPTOMS AND llESULTS. 137 liyperfcropliied, sometimes to the extent of one half or tlirce quarters of an inch. Trabeculae of muscular tissue project upon the mucous surface of the bladder, and between these trabcculae the mucous membrane maj protrude, forming pouches or sacculi. The bladder may contract to such an extent as to have its cavity almost totally obliterated, its mus- cular walls having undergone fibrous degeneration, which has rendered them non-distensible. In this condition (concentric hypertrophy) we may have a constant flow of urine from the urethra, which the patient cannot control (incontinence), to be carefully distinguished from atony, with overflow. Instead of incontinence, in this condition, the patient may be ob- liged to empty his bladder every few minutes, after a few drachms of urine have accumulated, which seem to be bursting the organ. The urinary salts sometimes deposit in vesical sacculi, or a small renal cal- culus lodges there, forming a nucleus for stone. The more obstruction there is in the urethra, the more pressure is brought to bear upon the sacculi, and the larger they become, so that sometimes they equal, or exceed, the size of the cavity of the bladder. As the sacculus enlarges, its neck remains constant, and, if stone form in it, the stagnant urine (for there is no surrounding muscular tissue to empty it) furnishes constantly fresh supplies of urinary salts to increase the size of the stone, so that finally the latter may fill up the sacculus, constituting what is known as encysted calculus. Instead of contracting, the bladder may (rarely) dilate. In these cases there has not been so much irritability, and the bladder has not been called into such constant use ; or overstretching may have been followed by atony, in which case overflow occurs, apt to be mistaken for incontinence. Inflammation of the mucous membrane is found, in these cases of eccentric hypertrophy also, together with the tra- beculse of hypertrophied muscular tissue and the sacculi. These conditions of vesical and urethral irritation, or others, such as stone, are sometimes, but very rarely, attended by partial paralysis of some groups of muscles of the lower extremities, or indeed by para- plegia. These paralyses have received the name of reflex urinary paralysis, and seem to depend upon the morbid condition of the uri- nary organs, and to be relievable, sometimes even curable, by treat- ment of the urinary difficulty.* Not very infrequently mild syphilitic paraplegia is mistaken for urinary reflex paralysis, especially if the urethra or bladder happen to show any trifling lesion. The urine, in cases of cystitis caused by stricture, is partly decom- posed and filled with blood, pus, crystals, etc., as occurs in cystitis * Brown-Sequard, "Lecture on Reflexed Paraplegia," "Lancet," 1863; and "Lec- tures on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities," Philadelphia, 1861. 138 STRICTURE OF THE URETHRA. from otlior causes. Phosi)luitic stono may form. The ureters eularc:e in connection with old stricture, sometimes to the size of tlie thumb. Their. walls become unevenly thickened and their caliber enormously increased by the constantly retained urine. The pelves of the kidne3's undergo the same distention, the tubuli and secreting jiortions being jnished out and compressed by tlie accumulating urine. After the in- liammaticui at the neck has involved the whole internal surface of the bladder, it may extend up the ureters and enter the pelves of the kid- neys, bringing on pyelitis, or attack the secreting portion as a subacute nephritis with more or less suppression of urine, attended by symptoms of urannia. Finally, and more rarely, may be mentioned abscess of the kidney with perinephritis. ExTRAVASATioisr. — The thinned and inflamed urctiira behind stric- ture may ulcerate, and, during one of the violent paroxysms of strain- ing, give way, and allow a little urine to escape into the cellular tissue around the canal. The patient is often conscious of something having "broken " in the urethra. The amount of extravasated liquid may be very small, or a sudden gush of urine is, perhaps, let out into the con- nective tissue. In the former case we have abscess, or perhaps blind internal fistula, which may continue as such for many months. Its presence is indicated by a hard lump around the urethra, varying from the size of a large pea to that of an English walnut, usually sen- sitive to pressure, sometimes slightly painful at each act of micturitiou. This hard lump more or less rapidly enlarges, though it may remain stationary for an indefinite jieriod, or even decrease in size ; urethral fever comes on, generally described by the patient as "dumb ague" ; the appetite fails, and the general health runs down ; finally, pus forms and finds its way out through the perinanim, leaving a fistula behind. Instead of this slow course, if the quantity of urine which escapes is a little larger, acute perineal abscess forms. The pus may burrow in all directions, and finally find an exit through the scrotum, along the body of the penis, upon the thighs, nates, or groins, or even upon the lower part of the abdomen. Some- times the whole perinseum is riddled with holes through which the urine escapes, perhaps not one drop passing by the natural channel. In these cases the patient makes water sitting, the urine escaping as if through the sprinkler of a garden watering-pot. Civiale rej^orts a case of urinary fistula with fifty-two external openings. The hard lumps outside the urethra, above alluded to, do not necessarily indicate that urine has escaped from the canal. An ab- scess may very rarely start outside the urethra near a stricture, just as pus may form near the anus, not primarily in connection with the gut. In the vast majority of these cases, however, the first lesion is upon the urethral mucous membrane, one of the dilated follicles be- hind the stricture being at fault. A drop of urine is retained in a EXTRAVASATION. 139 follicle, decomposes, and causes it to necrose and Blou;,^h ; another drop of urine is then let in, more tissue is destroyed, and more inflam- matory action set up in the neighboring tissue. This process goes slowly on, a drop of urine from time to time being let into the abscess througli the mouth of the follicle, which is usually kept shut by the surrounding inflammatory swelling. The abscess now is not connected visibly with the urethra ; it breaks externally, and it is only after a few days that the swelling decreases sufficiently to allow a little urine to get in at the fissure in the urethral wall, and to appear at the peri- neal opening. Much light has been thrown by Zcissl upon the agency of this follicular necrosis in allowing extravasation of urine. Such abscesses forming around stricture may break internally and let in the urine in quantity, thus forming blind internal fistula, or they may break externally, or point by both routes. Fistulse are conservative efforts of Nature to establish an outlet for the urine, the natural course being dammed up. They will not close until after the stricture has b.een relieved. They narrow down after a while into little pipes surrounded by callous inflammatory material. Sometimes a deposit of the urinary salts takes place upon their walls, and they become incrusted with calcareous matter. Sometimes they get blocked up, especially if the internal orifice is larger than the ex- ternal ; then a little urine collects within them, and a new abscess is formed which may burrow farther and find for itself a new outlet, establishing another fistula. More rarely a small abscess may form in the prostate, and, going through the stages just narrated, opening into the urethra and into the rectum, constitute what is known as prostatic fistula ; or, more rarely still, some small ulceration in the floor of the bladder may give way into the rectum, making a vesico-rectal fistula. If, instead of a drop of urine escaping from the urethra into an ulcerated follicle or fissure in an ulcer behind the stricture, the ulcer- ated portion has given way largely, perhaps by necrosis of a group of urethral follicles, we have the serious complication known as infiltra- tion of urine. More or less of the altered fluid escapes in these cases outside of the canal, and burrows at once extensively. It is a prop- erty of decomposed ammoniacal urine to destroy the vitality of living tissue wherever it comes into contact with it, unprotected by e^nthe- lium. This property does not belong to limpid healthy urine. Men- zel * demonstrated this fact experimentally. He first used acid urine, injecting it under the skin of a dog in quantities varying from a drachm to an ounce without any bad effect in several experiments. He dissected up the skin of a dog to the breadth of four inches, and injected eight ounces of healthy human urine in four different cases. *"Wien. medizin. Wochenschrift," Nos. Sl-85, 1869, and "K T.Med. Journal," 1871. 140 STRICTURE OF THE URETHRA. The urine was all absorbed within four days in three of tlie cases, in the other liealthy pus formed, lie repeated these exjieriments in the ischio-rectal fossa without bad results in five cases. To test the o})inion of Simon,* that the compression with distention of the tissues in urin- ous infiltration was the cause of gangrene, Menzel performed two ex- periments, injecting healthy urine into the tissues with such force as to raise a tumor of the size of the fa^tal head, and then prevented the escape of the fluid through the wound by means of suture. The quan- titv injected amounted to about half a pint, but in both cases it was absorbed without evil result within three days. The next experiment consisted in cutting down upon the urethra of a dog and sewing up the wound so as to obtain intiltration. At each angle of the wound a fistula formed, but there was no poisoning or extensive death of tissue. lie repeated the same experiment, tying the glans penis so as to cause all the urine to flow into the wound. An immense tumor formed, which only subsided when the glans penis became gangrenous and separated. The dog got well, with simply a fistula. In other similar cases he obtained the same results. From these experiments Menzel concluded : 1. That normal urine does not possess septic qualities, and does not produce gangrene by its chemical properties. 2. That distention by infiltrated urine does not produce gangrene. 3. That gangrene, when it docs occur (on infiltration of healthy urine), is caused by contusion or the accidental inoculation of septic matter. Menzel next experimented with urine containing soda or potash. Urine so alkalinized proved innocuous ; but urine rendered alkaline by ammoniacal fermentation he found to be exceedingly poisonous, and, when injected, to cause large abscesses and cutaneous gangrene. lie also injected putrid urine directly into the blood, and obtained symptoms of blood-poisoning, lie further adds the clinical experience of Prof. Billroth in nine cases of infiltration. In l^ne, the urethra was perforated by a catheter ; in three, there was a crushing injury to the perineum ; in another, laceration of the urethra by a splinter of bone from the pelvis ; in the rest, rupture of the urethra behind a stricture. Death followed in four cases, in two of which there was stricture, and the urine i)robably ammoniacal, A most instructive scientific discussion as to the cause of the fer- mentation of urine is to be found in the admirable thesis of F. P. Guiard,t and many new and interesting facts about the toxic quali- ties of normal urine in Bouchard's admirable contribution J to the subject. Bouchard experimented upon rabbits by injecting normal * " Chinirjrie dcr Nieren." f " La Transformation ammoniacal des Urines," Tln^se, Paris, 1883. \ "Gazette Ilebd.," 1886, vol. xxxiii, Nos. 13 and 14, pp. 205-221. EXTRAVASATION. 14]^ heulthy urine into a vein. An injection of two to three draclims caused contraction cf the pupils, shallow, hurried respiration, and finally death with reduction of temperature and of reflex activity. Bouchard believes that in two days and four hours a man eliminates enough poison to destroy himself — were it i)roperly applied. lie finds diurnal urine to possess narcotic properties, the night urine to be less poisonous than the diurnal secretion, but to cause cramps and convul- sions. He is still investigating this interesting subject. But, notwithstanding all this, the fact remains that so far as the local death of tissue is concerned, while ammoniacal and putrid de- composing urine is deadly in its effect, healthy urine, in moderate quantity, at least, is readily absorbed by the tissues, and does not lead to local inflammation or death of tissue. My house-surgeon. Dr. Par- tridge, made for me many experiments by injecting healthy urine acid and alkaline (not ammoniacal) into the subcutaneous tissues, using as much as sixty minims at a single injection. No abscess was ever caused by these injections ; absorption was perfect. Feltz and Ritter* have injected enormous doses of urea into dogs without damage, unless some of the salts of ammonia are combined with the urea. There appears to be no normal ferment in the blood capable of transforming urea into ammoniacal salts. Pasteur f overthrew Bastian's experi- ments, and showed that without bacteria urine does not decompose. Pasteur and Joubert, J repeating some of the experiments of Musculus, show that the soluble ferment produced by the latter from ammoniacal urine, which is capable of changing urea and water into carbonate of ammonia, is the product of bacteria. P. Cazenave and Ch. Livon ligated a dog's prepuce, allowed the dog to die, tied the ureters and urethra, removed the bladder, and kept it exposed to air for several days at temperatures varying from 80° to 122° Fahr. The urine did not decomjDOse, and no organisms apj^eared in it. These results, experimental and clinical, correspond with daily e'x- perience as well as with my personal experiments undertaken upon the human subject — since the evidence derived from dogs* and rabbits has been doubted — to substantiate the fact that healthy urine, in- jected into the connective tissue without contusion of that tissue, is as capable of absorption as the blandest fluid. This is true at least when a small amount is used ( 3 j), a quantity certainly sufficient to establish that healthy urine, per se, is not destructive to human tissues. Muron,|| a pupil of Verneuil, stimulated seemingly by the * "La France Med.," May 11, 1878. f " Comptes rendus de I'Acad. des Sciences," July 23, 1877. X "Journal de Pharmacie et de Chimie," September, 1876, p. 206. * Dr. L. A. Stimson informs me that, in the winter of 1873, he saw Yulpian, in Paris, inject healthy human urine into the blood-vessels of dogs, in one case three and one-half ounces, without disagreeable result. II " Pathogenic de I'lnfiltration de I'Urine," Paris, 1872. 142 STRICTURE OF THE rRETIIRA. results obtained by ^lonzel. i)ci-fonnod a scries of experiments by in- jecting urine under tiie skin of rabbits. His results corresponded closely to those reached by Menzel, only differing in one respect : for, while Menzel states that only urine in alkaline fermentation has de- structive powers, Muron proved (upon rabbits) that urine, strongly acid, dense, and full of salts, urates, etc., has the same powers to a less degree, attributable, he believes, to the density of the fluid in- jected, wliich by the law of osmosis attracts serum from the vessels instead of itself being absorbed into the latter ; and again to the fact that urine, rich in urates, is apt to decompose quickly.* Gossclin and A. Robin f conclude from experiments that acid normal urine, sj). gr. 1023, is innocuous wheu injected into rabbits, although it may kill if continuously injected for a number of days. Hence it may be affirmed that healthy urine does not, per se, kill tissue, unless that tissue be contused and inflamed (absorption thus prevented and urine allowed to decompose in situ), and that, Avith in- filtration relieved by free incision, tlie prognosis is vastly better if the bladder were previously healthy. After urethrotomy, and operations for stone, how rare is infiltration, when the urine is comparatively healthy and has a chance to escape, although it passes over a raw sur- face on its way out ! The practical deduction from the above is, to let out urine as soon as it has extravasated, and the chances are that serious gangrene may be averted unless the urine was strongly am- moniacal and decomposed before its escape, which is, unliapjiily, too often the case. In infiltration the urine may take any one of five directions : 1. It may when small in quantity get out of the urethra, but not penetrate Buck's fascia (p. 3), in which case it may long remain con- fined to one spot in the perinaBum as a hard, rounded swelling — like the blind internal fistula already described. 2. It may find its w^ay rapidly through the meshes of the corpus s])ongiosum and cause gangrene of that bod}^ with sloughing of the glans penis, preceded by coldness and the a]")pearance of a black spot upon the glans. * That Muron is incorrect in ascribing nccessarili/ destructive properties to dense acid urine, rich in urates, I thinli must be granted. I obtained a specimen of urine from a child with acute inflammatory rheumatism. It was strongly acid, sp. gr. 1040, and de- posited, on cooling, a dense precipitate of pink urates which equaled one fourth of the volume of the liquid. A portion of this was taken a few hours after being passed, warmed until the urates dissolved, and injected by Dr. Partridge, of the Charity Hospital, into the subcutaneous tissue of the arm, in three patients, half a drachm being used in each case ; absorption was immediate and perfect. Twenty-four hours afterward three other patients were similarly injected from the same specimen, with the same dose ( 3 ss each) — only the urine was injected cold with the urates in precipitation. The bottle was shaken and the fluid resembled pea-soup. A little tenderness on pressure for a few hours marked the spot of the injection, but absorption was prompt and complete in each case, without any suppuration. f "L'Urine ammoniacal et la Ficvrc urincuse," Paris, IS'74, p. 39. EXTRAVASATION. 143 ■ 3. It may burrow inside of Buck's fascia, but outside of the cor- pus spongiosum, forming a fistula opening behind the glans penis or on the back of the penis near its root, a hard ridge marking the course of the fistula within Buck's fascia. 4. It may escape behind the triangular ligament into the cavity of the pelvis. 5. It may escape outside of tlie common fascia of the penis, in front of the triangular ligament ; in whioh case it rapidly distends the peri- nseum, the scrotum, and the connective subcutaneous tissue of the penis, and mounts up over the abdomen, and may also, more rarely, perforate the deeper layer of the superficial perineal fascia, and de- scend upon the thighs. When extensive infiltration of this sort occurs, all the parts affected become cedem.atous ; gases form in the connective tissue, causing emphysema, and making the tissues crackle when pressed by the finger. Dark spots soon appear, indicating gangrene, and extensive portions of tissue may slough away unless relief be promptly afforded. The constitutional symptoms are those of shock. A chill usually occurs, followed by great depression ; a cold, clammy skin ; feeble, quick, irregular pulse ; hurried respiration ; furred tongue ; complete anorexia ; symptoms of septicaemia, and death. When the urine escapes behind the triangular ligament, which it does more rarely, it infiltrates deeply around the prostate and rectum well back in the perinseum, around the bladder and up behind the pubis, forming abscess in the cellular tissue of the hypogastrium, or perhaps deep pelvic abscesses. Rupture of Bladder. — Another very rare complication of stricture analogous to infiltration is rupture of the bladder. This occurs in the same manner as the escape of urine from the urethra behind a strict- ure. A comparatively healthy bladder will not rupture from retention (unless, of course, mechanical violence is added — as a fall). It will become immensely distended, and then be relieved by drops (overflow) through the urethra, the latter never being totally impervious to fluid, if time is allowed for inflammation and spasm to subside, and enough continued pressure is brought to bear upon it from within. In those rare cases, however, where a sacculus has become thinned, or an ulcer- ation exists, the bladder may give way under the pressure of disten- tion from retention, and the urine escapes into the peritoneal cavity. The vesical tumor subsides. A fatal collapse usually soon closes the scene.* The urine may escape into the sub-peritoneal tissue, giving symptoms like those of infiltration behind the triangular ligament. The rarity of rupture of the bladder in connection with stricture is shown by the few cases reported. Thompson says he never saw it, * For treatment, see Rupture of Bladder. 144 STRICTURE OF THE URETHRA. and quotes Sir Everard Homo as having observed only two cases. Pitha refers to a ease. * The prostatic urethra is necessarily liyperannie, if not inflamed behind a tiglit stricture, but, besides this, the substance of the prostate may undergo interstitial inflammation (abscess). The inllammation may extend down the ejacnlatory ducts, seize upon the seminal vesi- cles, or, usually passing farther, involve the epididymis. Epididymitis is a very common complication of stricture. It may affect one or both sides, is usually very mild in character, and leaves behind a good deal of knotty induration, which is slow in disai)i)ear- ing, and may block up the canal and entail subsequent sterility. A certain amount of hypertrophy, with induration of the penis, and some oedema of the prepuce, is an occasional complication of striciure. Civiale accounts for these symptoms by the straining in urination, which prevents the return of venous blood, and keeps the penis con- gested. It is more often due to lymphangitis. Constitutional Distcebance. — The constitutional disturbance in stricture is very variable. Just as one patient may have cystitis from an amount of contraction not capable of sensibly diminishing the size of his stream, while another with a stricture only pervious to a filiform bougie, used with care, may pass limpid urine not more than three or four times daily, so also does the constitutional sympa- thy vary. As a rule, the latter depends upon the complications of stricture ; and a patient with very tight stricture, uncomplicated, may enjoy robust health. When, however, the urethra behind a strict- ure begins to inflame, and the bladder to show symptoms of congestion of the neck, and cystitis ; when paroxysms of urethral fever become frequent ; when epididymitis and abscess come on, then the whole organism shows signs of distress. The appetite and strength fail, the skin becomes dry, pale, and harsh, the mouth coated and shiny, and the patient runs down to a shadow, a living picture of misery, while his main business in life is to pass water. Causes of Death in Stricture Cases. — Stricture is not often fatal, except in neglected cases, such as are sometimes encountered in hospitals. Death occurs in various ways. Not to mention the rare cases of sudden death following the simple introduction of an instru- ment, and only alluding to rupture of the bladder, and death follow- ing surgical operations for the relief of stricture, the causes of fatal termination in cases of stricture are three : 1. Extravasation of urine, which, if extensive, kills at once by shock, or, later, by exhaustion ; and blood-poisoning with suppura- tion, abscess, gangrene, pya?mia. 2. Uraemia, from implication of the kidneys, by the extension of inflammation up the ureters. * Quoted from " Mem. dc la Soc. Chir.," iii, 3, 1853. RECAPITULATION OF SYMPTOMS. 145 3. Cachexia and exhaustion, attended by pain, loss of rest, and inability to eat, due to the torment of constant unrelioved desire to urinate, and the agony and labor of the act. No more pitiable sight can be imagined than that of a man with pericystitis, trying to pass water evei-y five minutes through an old tight stricture. Standing up, with his body bent forward, his head leaning against the wall, or on his knees, and half doubled up, his hands clutching at any thing within reach, he writhes and groans in agony, the sweat starting from his face, his whole body quivering and convulsed with pain. After a minute of this torture, he finds he has passed, perhaps, a tea- spoonful of bloody, purulent, putrid urine, perhaps nothing at all, and he sinks exhausted upon his bed, only to renew the effort after five or ten minutes. No man can long endure torture of this sort. If the surgeon does not soon bring him relief, death will be more kind. Recapitulation of Symptoms op Steictuee.— The si/mjjtoms of stricture are, briefly, narrowing of the canal, with dilatation of tlie urethra behind, blueness of the meatus, irregularities in the stream of urine, shreds of pus-corpuscles in the urine, pain, neuralgia of the urethra, retention of urine, overflow, dribbling, imperfect erection, irritability of the bladder, haematuria, impotence — from urethral ob- struction to escape of semen. The reynoter results of stricture are cystitis, with various inflammatory, functional, and structural changes in the bladder, ureters, kidneys, rectum, often terminating fatally ; stone in the bladder, infiltration, perineal abscess, fistula, rupture of bladder, epididymitis, and sterility — from obliteration of the canal of the epididymis. A word must be said here concerning the effect of the sexual ele- ment in aggravating the symptoms of stricture. This is especially true concerning all painful, neuralgic, and functional disturbances. An unmarried man frequently tortures himself with fancied ailments, which he ascribes to sti'icture ; or declares himself strictured when the canal is sound, imploring sympathy and demanding energetic treat- ment. Fancied stricture, next to fancied spermatorrhoea, is a very common hypochondriacal expression of perverted sexuality, such as is found among those who heedlessly allow the brain to stimulate their erotic fancies and sexual needs, without being able to set Nature at rest by satisfying her demands, or who, on the other hand, abuse themselves sexually by physical as well as intellectual excess. These patients require kind and gentle management. They must be put right about the cause of their troubles, and their sexual hygiene must be regulated. This can be accomplished only by marriage, or by purity of thought and absolute continence. 10 146 TREATMENT OF STRICTURE OF THE URETHRA. CHAPTER YIIL TREATMENT OF STRICTURE OF THE URETHRA. Witli Details for all Complications, and a Rfcapitiilation. The treatment of stricture of the urethra, and of its results, may be considered under three heads : 1. Treatment of UncomjjUcated Stricture — {a) Of Large Caliber. (/;) Of Small Caliber. (c) Of the :Mcatus. (f?) Traumatic. {e) Resilient — often irritable. 2. Treatment of Stricture complicated by— (a) False Passage. {b) Retention. (c) Retention — the Stricture being impassable. {d) Infiltration. (e) Abscess. (/) Fistula. (g) Pericystitis. (h) Enlarged Prostate. 3. Treatment of Fistula with Loss of Substance. 1, Treatment of Uxcomplicated Stricture. («) Of Large Caliber. — The majority of strictures which the sur- geon is called upon to treat are of large caliber. The symptom of which the patient complains is persistent gleet, following gonorrhoea, or bastard gonorrhoea, with, possibl}^ some frequency in urination. These cases are of daily occurrence and often pass unrecognized, the gleet being treated, the stricture overlooked. Too much stress cannot be laid upon the importance of exploring the urethra, in such cases of gleet, with the bulbous bougie. One, two, or more strictures are found, the smallest, which is jirobably the deepest, allowing passage, perhaps, to a No. 15 bulb. Treatment here is most simple. After the diagnosis has been made, no further instrumentation is advisable (if the patient can spare the time), until the effect of exploration has been observed. The chances of urethral chill, after first examinations, must be remembered. The patient's general condition and habits must be studied, and his urine tested for acidity or j^ossiblc kidney disease. He must be instructed UNCOMPLICATED STRICTURE. 147 in urethral hygiene, and the nature of his malady explained to him, and he should be informed at the outset, to forestall future disappoint- ment, that, after his symptoms have been removed by treatment, the permanence of his cure, if his stricture is in the deep urethra, may de- pend upon the use of an instrument upon himself at proper intervals, with the view of preventing tendency to recontraction of his stricture. Being instructed not to mind the smarting at his next urination, and given such alkali, balsam, or injection as the acidity of his urine and amount of discharge seem to call for, the patient is dismissed, to return in two days, to have his treatment commenced. The treatment which generally gives satisfaction in a majority of these cases is dila- tation with the conical steel sound. One of these instruments properly warmed is introduced in the manner already detailed. Its size should correspond to that of the bulbous bougie, which has passed tlie strict- ure, and the utmost delicacy, care, and gentleness should be used in its introduction. The wedge and lever should not be forgotten, nor should we abuse power because we possess it. At the strictured and tender points a spasmodic contraction may occur, arresting the instru- ment. To overcome this, patience is better than force. As soon as the instrument has entered the bladder it should be at once gently withdrawn. Nothing is gained by leaving it even for a moment. During withdrawal the stricture is usually felt to "grasp" the sound. This "grasping" is the result of muscular spasm provoked by the presence of the instrument. It will sometimes relax if the sound be allowed to rest a moment. After one sound has been withdrawn, a second and even a third may be introduced, if it is considered safe. No rule, nothing short of personal experience, can indicate how far the dilatation may be pushed at one sitting. The tendency is alwavs to hurry and to use force ; a course detrimental to rapid progress. It may be stated as a rule, subject to judicious exception, that if a cojiical steel instrument of any size larger than No. 15 tvill not enter a strict- ure iy its own weight after a little delay, luhen held in proper position, it should not be used. Every urethra, however, has its own temper, as it were ; some are aroused by the slightest disturbance, while others will bear considerable violence without protest. A surgeon should ac- quaint himself withthe temper of a given urethra by gradual experi- ment, before he takes liberties with it. The mischief to be feared from the employment of large sounds with force, besides false passages, which are not apt to be produced by large instruments, is threefold : 1. The production of epididymitis, a common result of violence to the urethra, and a complication which suspends treatment and con- fines the patient for several days, or, it may be, weeks. 2. The excitement of inflammation in the stricture, which aggra- vates its condition and defeats the end of the treatment employed. 3. The production of chill and urethral fever. 148 TREATMENT OF STRICTURE OF TUE URETHRA. In rare instances epididymitis may come on in spite of care. Tlie complication mnst be properly attended to, and all treatment of the urethra suspended until the jiain in the testicle has nearly subsided and the swelling of the epididymis has assumed an indolent character. It is not necessary to wait for the latter to disappear entirely, and, if extra care be employed in resuming the use of instruments, there is little danger of })rovoking relapse, "While using instruments in the urethra, especially at the beginning of a course of dilatation, the pa- tient should be advised to wear a suspensory bandage to keep the tes- ticles from exposure to injury, which would render them more liable to epididymitis. At each subsecpient visit of the patient, the surgeon commences with a sound from one to two sizes smaller than the last instrument introduced at the previous visit, and carries the dilatation as far as possible without the employment of force — this till the full size is reached. The most irajiortant feature in the treatment of stricture by dilata- tion is, a proper regulation of the intervals to be allowed between the sittings. The intervals usually recommended are too short. Occa- sionally we see patients who attempt to treat themselves, introducing a bougie into the urethra daily, or twice daily, perhajjs at every act of urination, aggravating every symptom, worrying the urethra and bladder into a state of inflammation, and wondering why the stricture does not get well. Some surgeons, unfortunately, are guilty of the same error in a less degree. To solve the problem of the proper inter- val for reintroducing a sound through a stricture, it is only necessary to study the effect of a single introduction. Suppose a stricture which sensibly diminishes the size of the stream of urine, and is attended by gleet. Through this stricture a conical instrument is introduced, which is arrested for a moment, but gradu- ally passes, stretching the stricture, and is distinctly "grasjied " as it is being withdrawn. What follows such an operation ? At the next act of urination the stream is larger, and continues so during twenty- four hours, xit the end of this time the stream is nearly as small as it was before the sound was used ; the gleet is the same, or possi- bly increased. Now, for twenty-four to forty-eight hours the stream steadily becomes smaller, while the discharge grows more abundant and creamy, Duriug the third or fourth day, improvement com- mences ; the stream again grows larger, the discharge becomes thinner and less copious, and this improvement often continues through the fifth and sixth or even seventh days, or longer — after which the vol- ume of the stream commences to diminish and the discharge to be- come thicker. In such a case, if the same conical instrument first used had been reintroduced at the end of twenty-four hours, it would have passed PROPER INTERVALS FOR INTRODUCING SOUND. I49 the stricture witli about the same facility as on the day before ; if after forty-cigbt hours, it would enter with more difficulty ; if at the end of seventy-two hours, it would again enter as easily as on the first day ; if reintroduction were first attempted on the fourth day, the sound would pass more easily than at first ; if on the fifth, with more ease still, and it would not probably be so tightly "grasped " on with- drawal ; while in some cases the greatest ease of reintroduction is attained on the sixth, seventh^ eighth day, or even later. This varies in different cases ; but it may be stated, as a rule, that it is had sur- gery, in treating stricture by dilatation, to reintroduce an instrument — unless it he filiform — hefore the lapse of at least seventy -two hours, and that more rapid progress will he made with the case hy waiting till after ninety six hours — often even until the sixth, seventh, or eighth day. The reason for this rule becomes clear ujaon studying the thera- peutic effect of pressure upon stricture-tissue. The first effect is mechanical (stretching) and sedative (quieting muscular spasm at the strictured point) ; this lasts twenty-four hours. The next effect is reactionary (congestive and spasmodic), resulting in extra tightness of the stricture and increase of discharge ; this lasts from twenty-four to forty-eight hours. The final curative effect is absorptive. Absorption is excited by the increased activity of the circulation about the strict- ure, and continues for two or three days, or longer ; after which, con- traction and growth of stricture-tissue recommence. It is just at the period where absorption ceases and recontraction commences that a dilating instrument can be reapplied most effectively, and this period is, in the majority of cases, on the fifth to the eighth day. In brief, intervals of a iveeTc, especially in cases of old stricture, are generally more heneficial than any shorter period. That absorption takes place during the cure of stricture by dilata- tion may be proved during life by examining the hard cartilagiuous bands often found surrounding the urethra, and constituting stricture. These bands can be distinctly felt, over an instrument introduced through the stricture, and, during the treatment, they may be observed to become gradually smaller, until they become almost imperceptible. They rarely disappear entirely. As to the degree of dilatation which is to be aimed at, every ure- thra has its own gauge in the size of its meatus — provided that meatus be not congeni tally small, or contracted by disease. If there is any cicatricial tissue in the circle of the meatus, or if a probe can make out any pouching below the lower commissure (Fig. 51), the meatus is strictured, and requires treatment. The normal meatus, however, is the smallest part of the healthy canal, and the object in view is, to bring all available pressure to bear upon a morbid narrowing of some other portion of the tube. To do 150 TREATMENT OF STRICTURE OF THE URETHRA. this the meatus must be put lightly upon the stretch. "When the meatus is stretched, the feeling is one of discomfort, which subsides after the instrument has been in place for a moment. If the meatus is overstretched, a distinctly marked, narrow white line will be seen encircling the instrument upon the lips of the urethral orifice, indi- cating that tlie latter have been deprived of blood by pressure. So much distention is unbearable, but the greatest amount short of this should be aimed at. The meatus may often be cut, even when not obviously too small, in order to facilitate the use of a sound larger than would otherwise i)ass, for the greater the extent to which dilatation is carried, the easier will it be to keep the deep stricture ojieu, perhaps even to cure it by dila- tation. The teachings of Dr. Otis in this direction are valuable, altiiough I believe his dictum to be too dogmatic and to be api)lied by him too sweepingly. He establishes a fixed limit as to the proper size which the urethra should possess, and it may be said that such a standard may be safely reached and maintained in any case. The question of the necessity of attaining this high degree of dilatation in all cases is very questionable. Patients can often be cured without carrying them up to the Otis limit, but in some cases their cure is more easily clfected and more permanent if they are brought up to a size which he con- siders a tyije in a given case. The only objection to Dr. Otis's high standard is that it entails an amount of cutting — often in my opinion (guided by a reasonably long and unbiased experience) unnecessary — since the patient can get well without it, and because extensive cutting of the anterior urethra leaves the canal defective in expulsive power. The urine dribbles away at the end of the act of urination from these widely-cut canals more than it does from a normal urethra, and many patients complain of the in- convenience so caused. Strictures of the anterior urethra, if very freely cut, may be radically cured, not so strictures of the deep ure- thra. The latter get well sometimes under all varieties of treatment — in most instances they require the occasional use of a dilating instru- ment for an indefinitely long period, or recontraction occurs. If, then, the surgeon desires to enlarge the jiatient's stricture as widely as he can in safety, and wishes a test as to the limit in size of the sound which he shall use, I know of no better ultimate limit than the scale proposed by Otis, giving it as my personal opinion that, while his limit may be safely aspired to and reached, it is wiser to fall short of the standard by a few sizes, in which case all the advantage claimed by Otis will be ordinarily secured, and some of the disadvan- tages of a urethra unnaturally wide will be av^oided. Dr. Otis's standard is practically as follows.* He bases it upon * " Genito-Urinary Diseases and Syphilis," 1883, p. 441. OF SMALL CALIBER. 151 extensive experiments by measurement with his urethrameter. The size to which a urethra may be brought is ascertained by measuring the circumference of the flaccid penis : Circumference of penis, 3 inches ; the urethra should take size 30. Circumference of penis, 3i inches ; the urethra should take size 32. Circumference of penis, 3^ inches ; the urethra should take size 34. Circumference of penis, 3f inches ; the urethra should take size 3G. Circumference of penis, 4 inches ; the urethra should take size 38. Circumference of penis, 4^ to 4^ inches ; the urethra should take size 40. That these sizes may be safely attained, the long experience of Dr. Otis proves. That they are generally necessary, I personally am not convinced. That they may sometimes be desirable, I believe. The limit, however, I consider a little too large for practical adoption, and I prefer, in cases that will get well without reaching so large a size, to disregard it ; in others, to scale down a few sizes — believing that as much good may be so attained, and some possible harm and often some complaint from the patient averted. As soon as a full-sized instrument will slip through a stricture by its own weight, all symptoms will usually have ceased, unless the stric- ture be very resilient ; but recontraction will almost inevitably take place in stricture of the deep urethra, unless the cure be maintained by the patient. This is easily done, and no intelligent patient objects to it. He acquires the art of gently passing a sound upon himself in a few lessons, and he should be seriously cautioned to perform this trifling but important oj)eration at first weekly, then fortnightly, then monthly, studying his own case to determine how long an interval he can allow without sensible recontraction of his stricture. In this way, in some cases, the use of instruments may be gradually abandoned ; in the majority, it will have to be continued indefinitely, at intervals varying from a week to several months. In this way does the cure become radical. The surgeon is responsible for the cure only on con- dition that the patient carries out this plan ; or, rather, the patient is responsible for the permanence of his own cure, and this he must be made distinctly to understand. (b) Stricture of Small Caliber . — To this class belong strictures ad- mitting any instrument less than No. 15. They are arranged under a special head, not because they require different treatment, but in order to emphasize the fact that by far the greater number of such cases are better treated with soft than with steel instruments. The danger of making a false passage in an obstructed urethra with a small metallic instrument can not be overrated. N'o one can appreciate the ease with which a false passage is made until he has himself made one. Indeed, it is not very uncommon for a patient or surgeon, not well acquainted with the urethra, to make a false passage, and go on dilating it instead 152 TREATMENT OF STRICTURE OF THE URETHRA. of the stiicturc, woudcring meantime that tlie size of the stream is uot increased or the symptoms alleviated. A surgeon who knows every line of the urethra may occasionally assume the risk of using a small metallic instrument in the canal without a guide, but only in excep- tional cases. Below No. 15, soft instruments only should be employed, unless there be a guide through the stricture. Dilatation is carried on as already directed, steel instruments being used as soon as the stricture will admit 15. Progress is slower with soft than with steel instruments ; they usually give the patient more pain ; the intervals between their introduction may be somewhat shorter. Cutting (internal urethrotomy) and stretching (divulsion) opera- tions are growing daily in favor in the treatment of strictures of small caliber ; yet, in a case of uncomplicated stricture in the deep urethra, no matter how tight it may be, if it is not resilient, and is not of trau- matic origin, if any instrument at all can be passed, dilatation is still the best method of treatment. Scarification and divulsion are only helps. They are attended by danger. They do not cure radically. The sound must be used after them. When pursued with gentleness and care, the patient need not lose a day from business on account of treatment by dilatation, nor be confined an hour to the house ; while the risk of exciting complications is at a minimum. The treatment is longer surely, but, if the surgeon will imagine what would be his own wish were he in the patient's situation, he will not hesitate to ado])t the safer but more tedious method. For the class of strictures (uncomplicated) now under consideration, exception may be made in favor of divulsion or internal urethrotomy in two classes of cases : 1. If the patient can not give enough time to carry out dilatation properly. 2. If pretty severe urethral fever follows attempts at dilatation. All the foregoing remarks apply to strictures at and deeper than the bulbo-membranous junction. In the light of modern experience it may be safely stated that all true strictures of the pendulous urethra may be radically cured by free cutting internally. This has been clearly demonstrated by Otis, and the profession is indebted to him for the demonstration and for showing the harmlessness to life even of his extensiA'e operations.' Radical cures are accomplished by free cutting anteriorly — not so in the deep urethra. Therefore the Otis operation is a good one — per- haps not quite up to his typical limit — for strictures of the pendu- lous urethra. This remark applies, however, in my opinion, only to true strictures, not to the moderate narro wings which I have described as physiological points of narrowing, even although these points be covered by granulations, and yield a gleet. Such gleets may usually be OF SMALL CALIBER. 153 cured without cutting. Sometimes they can not be cured even by ex- tensive interniil urethrotomy. In commencing the treatment it may be impossible to enter the bladder with any instrument, either on account of the tightness of the stricture, or because the point of the instrument does not engage in the latter, or is arrested by some fold or lacuna beyond. In these cases gentle perseverance and skill will rarely fail of success. The dif- ferent varieties of filiform bougies, witli the different mana3uvres and expedients of introduction already detailed, will rarely fail to triumph over all difficulties. Sooner or later the bladder is reached,* and the case is under control. On the third or fourth day the same filiform instrument will pass with greater facility, and a larger one will usually follow : the treatment by dilatation is fairly under way. In those exceptional cases Just alluded to, where a filiform bougie only can be introduced after long and persevering effort, it becomes a serious question whether it is not better to utilize the guide thus intro- duced through the stricture, to conduct another instrument upon it, rather than to run the risk of retention from swelling of the stricture after the guide has been removed, and perhaps incur the necessity of operating under less favorable circumstances. The temptation to operate in these cases is great, but the necessity for it is often more apparent than real. True, if the stricture be very tight, retention may result from disturbing it, especially if the urine be acid, but this reten- tion yields to heat and opium, or the same filiform instrument which caused the trouble may usually be reintroduced ; finally, the asjDirator might be used : in any case, after seventy-two hours, a larger instru- ment will rarely fail to pass, and dilatation has commenced to effect a cure. Hence, in many of these cases, where the patient can afford the time, dilatation is the preferable, because the safer, treatment. In the so-called impassable stricture (uncomplicated), where urine passes out, but no instrument can be made to enter the bladder, a fili- form bougie can invariably, with patience, be inserted into the orifice of the stricture. That it has entered is known by the ''grasping'' of the instrument by the stricture. If now the bougie be left engaged during eight or ten minutes, the muscular spasm constituting the "grasp" may yield and allow it to advance ; if not, another attempt may be made in twenty-four or forty-eight hours, when, if it will not pass, it will at least enter the stricture to a greater depth ; finally, skill will overcome it and the surgeon advances to higher numbers. Model bougies are useless. Whalebones are superior to all other means. In any of the above cases, if, after sufficient deliberation, it is de- * In one (personal) case it required ten sittings, most of them over one hour long, be- fore any instrument could be made to enter the bladder. On the tenth effort, the instru- ment passed. It entered the bladder, and at once the stricture was divulsed. In tv.o weeks the patient passed his own full-sized instrument. — Ketes. 154 TREATMEXT OF STRICTURE OF THE URETHRA. cided to onlar^fc the stricture before withdrawinii: the guide, a choice of operations must bo made. If it is only intended to enlarge the stricture sutHciently to make its entrance by a dilating instrument more easy-after a few days, if tiie guide be a soft filiform bougie fur- nished with a screw, a larger bougie or silver catheter may be screwed into it, and the compound instrument carried into the bladder ; or, if the guide, as is usually the case, be a whalebone bougie, a tunneled sound may be slipped over it and gently but firmly carried through the stricture, a little force being used, but at the same time great care takeu not to bend the guide in front of the advancing instru- ment. If it is iuteuded to relieve the stricture at once, the broad rule is — all strictures of the pendulous urethra, if operated upon, should he cut ; all strictures of the fixed urethral curve should he treated by external section or combined internal and external urethrotomy. Bleeding from the pendulous urethra can always be controlled by direct press- ure ; not so easily that from the bulb or membranous urethra. The operative procedures have been detailed (Chapter VI). If a stricture of the pendulous urethra is so small as to require im- mediate radical measures, it should first be stretched by Thompson's divulsor on a guide, until it will admit Oiviale's or Otis's urethrotome. When stricture of the deep urethra is too tight to justify ordinary treatment by dilatation, and when cutting is not practicable for any reason, it may be divulsed, or moderately cut with a Maisonneuve ure- throtome, or moderately stretched with Thompson's dilator or with tunneled sounds up to the point where ordinary treatment by dilata- tion becomes possible. The latter expedients I consider preferable. (c) Stricture of the Meatus. — Stricture at or very near the meatus is usually made worse by attempts at dilatation bej'ond a certain limit, after which it becomes irritated, inflamed, and refuses to dilate. To a still greater degree is this true of congenital or cicatricial narrowing of the meatus. In all these cases, the contraction must be cut, pref- erably with a straight or with any instrument, toward the tioor of the urethra up to or through the fraenum. The orifice should be cut a little larger than it is estimated to have been the original intention of Nature to make it, since slight contraction necessarily takes place in healing. Ha?morrhage, in this operation, is considerable, if the corpus spongiosum be cut into. It may always be arrested with a strip of rubber plaster. Reflex irritation may produce spasmodic stricture in these cases, so that the next attempt to urinate is perhaps inefl'ectual. Removing the plaster, dipping the penis in warm water, and reassuring the patient, will invariably bring a flow of urine. A meatus, properly cut, remains open indefinitely, without the necessity of dilatation. {d) Traumatic Strictures are not usually amenable to treatment COMPLICATED BY FALSE PASSAGE. 155 by dilatation. Thoy are so exceptionally ton;Lrli, hard, and retractile, that a splice or splices must be put into them, by rupture or section, in order to keep them open. Since the days of Syme, it has been cus- tomary to consider perineal section indicated wherever stricture of the membranous urethra was of traumatic origin. This rule still holds good, for, although these strictures may in exceptional instances be overcome by divulsion or by internal urethrotomy, yet the risk of perineal section is not greater, and the after effect is more perfect and more easily maintained permanent. (e) Resilient Stricture. — Strictures which are thoroughly resilient will not dilate. In such cases, if a given instrument be introduced, the stream becomes smaller at once, and on the fourth day the same instrument enters with more difficulty, or perhaps will not pass at all. These strictures are frequently irritable as well as resilient, and always call for internal urethrotomy in the pendulous urethra, combined internal and external urethrotomy, or perineal section in the deep urethra. 2. TkEATMEISTT of StEICTURE COMPLICATED BY — {a) False Passage. — False i^assage, as already stated, results from rough or unskillful use of small instruments in an obstructed urethra. It may be due to " forced catheter- ism," a barbarous procedure, con- demned by its name alone, which consists in passing a metallic cathe- ter up to the ob- stacle, and then forcing it along in the supposed course of the ure- thra, until urine flows through it, if haply this occur at all. It is not used at the pres- ent date. False passages start from the bottom of la- cunae or from the front face of a stricture, from in abscess (Fig. 53). Pig. 53 {Dittel). front of the triangular ligament or from some When a surgeon makes a false passage, he may be 156 TREATMEXT OF STRICTURE OF THE URETHRA. unconscious of the escape of the point of liis instrniuont from the canal, but he will soon perceive that it is behaving unusually. It does not glide along as if in a healthy urethra ; it is obstructed, but yet not held in the same manner as if in the grasp of a stritture. The point, moreover, seems often to be turned out of the median line, and, after the instrument has been introduced far enough to have reached the bladder, a rotary motion, imparted to the shaft, will show that the point is fixed in the connective tissue, and not freely movable, as it would be in the cavity of the bladder. In such a case a linger in the perimeum, or, better still, in the rectum, will almost certainly feel the point of the instrument just outside of the wall of the gut, at the apex of the prostate, or perhaps lying between the prostate and the gut. On withdrawing the instrument, blood flows freely from the meatus. The treatment for a fresh false passage of this sort is, to let it alone absolutely for two weeks, if the patient can make water, and is in no pressing need to have his stricture relieved. Blood will flow for a day or two, then pus for a few days, and at the end of two weeks, in fa- vorable cases, the passage opened by the instrument will have closed. Occasionally it remains open, supjiurating for a much longer time. ITrethral fever, with or without the formation of abscess, is not an un- common result of false j^assage. Infiltration of urine is exceedingly rare. The great danger in these cases is in recommencing instrumen- tation too soon, entering the false passage before it has healed, and thus keeping it open indefinitely. In avoiding an old false passage, wiiich is the seat of chronic sup- puration, its position must be accurately studied out, by observing at what point in the urethra an instrument engages in it, and from which wall of the canal (upper or lower) it starts. The orifice of a false pas- sage once accurately located, may be subsequently avoided by making an effort to present the beak of the instrument at a different portion of the canal, when passing the dangerous point. A new false passage does not grasp an instrument like a stricture, and in this way can often be distinguished from the latter. An old false passage, however, so far as its pathology is concerned, is a traumatic stricture. It has hard walls, and the unstriped mascle of the erectile tissue around it will "grasp" like any other stricture, thus depriving the surgeon of a very valuable means of deciding whether he is in the strictured canal of the urethra or not. Another means, already alluded to, of avoiding a false passage when searching for the orifice of a narrow stricture, consists in filling the urethra with whalebone filiform bougies, thus mechanically filling up the false passage, until some instrument will glide by its orifice and enter that of the stricture. This course, or that of using a spiral- pointed whalebone bougie, with its point out of line (Fig. 20), should COMPLICATED BY RETENTION. J 57 be employed in entering the stricture, whenever the symptoms are urgent, and false passage exists. If a guide passes the stricture, the latter may be stretched with a tunneled instrument, or cut. Tlie size of the beak of the full-sized instrument, subsequently j)asscd, will insure it from entering the false passage. If it is impossible to get through the stricture, and there is reten- tion, it becomes a matter of personal judgment to decide whether to perform external perineal urethrotomy without a guide, or to use the aspirator, and endeavor to pass the stricture at another sitting. (b) Retention. — A patient, with stricture, may be enjoying good health, when suddenly, after exposure to cold, after a dinner or a ca- rouse, or after the passage of a small instrument through his stricture, he finds that he can not pass water. If he does not get relief, his blad- der will fill up, and after twenty-four to thirty-six hours, most of which are passed in acute suffering, a little urine will force its way through the stricture, and he will have overflow, often inaccurately styled incontinence. Such an overdistention of the bladder is liable to give rise to atony and cystitis, and, if the patient is seen before it has occurred, every means should be employed to avert it, and to pre- serve the bladder from an injury the effects of which are sometimes permanent. The most frequent cause of retention in stricture cases is sudden acute inflammation of the membrane lining the stricture, by which the already narrow canal becomes occluded. In this condition, as a rule, a fine catheter, or filiform bougie, can be introduced through the stricture, by the exercise of patient gentleness and skill. If the bladder can be reached, a flow of urine will follow the withdrawal of the instrument. If the bladder can not be reached, the patient should be placed in a hot bath, more hot water being added after he has be- come accustomed to the first heat, and this carried as high as is bear- able. He should remain in the bath from fifteen to twenty minutes, and will often be able to empty his bladder while in the water. Another excellent expedient is the use of the sitz-bath, at a tempera- ture of 100° to 104°Fahr., more hot water being added after the pa- tient has entered the bath, which should be continued only for about three minutes, and may be repeated after an interval of fifteen min- utes. If the heat is sufficient to induce nausea or faintness, it is more likely to produce the desired efi'ect of relaxing the stricture.* A piece of ice in the rectum every few minutes may be tried (Cazenave). Failing in these expedients, if percussion reveals a bladder only slightly distended, reaching not more than half way up to the umbili- cus, opium may be given, one grain being administered every hour until relief is afforded. The nervous excitability attending retention * In a robust and full-blooded subject, it might, perhaps, be advisable to take blood from the perineum by a number of leeches. 15S TREATMEXT OF STRICTURE OF THE URETURA. is relieved by opium. The pain will soon cease, the patient's fears will become quieted, and after the fourth or fifth grain urine will gen- erally flow. Twenty-drop doses of the sesquiciiloride of iron, admin- istered every fifteen minutes, for a couple of hours, at the same time with the ojiium, seem to facilitate relaxation of the stricture. Finally, an instrument can often be introduced under the entire relaxation of anaesthesia. In a case of retention, if a fdiform bougie can be passed into the bladder, the advantage so gained should not be lost, but the stricture should be divulsed at once, if the history of the case show an advanced stricture, and there are no evidences of kidney disease. If no instru- ment can be jxassed, we have impassable stricture, with retention, which requires other means for its relief. In drawing off the urine from a bladder suffering from overflow, it is wise never to empty the viscus entirely, at first, if it has been long overdistended. Fatal collapse has been caused by such a course, and subsequent inflamma- tion of the overstretched mucous membrane is more likely to run high if all the tension be taken from it at once. Half or three quar- ters may be withdrawn, the bladder being emptied entirely on the fol- lowing day. This fear of collapse from emptying an overdistended bladder mainly applies, however, to old subjects suffering from en- larged prostate and stagnation of urine. I have not encountered it in cases of stricture. (c) Retention, the Stricture ieimj impassahle. — No stricture (con- genital atresia excepted) is impervious unless the urethra has been cut across and united anteriorly, all the urine escaping behind it, or unless stricture has gone on contracting for an indefinite period, the urine escaping through large fistulae. Where a drop of urine can pass, the stricture is pervious, but nevertheless it may be impassable to any in- struments we may use, or any skill and patience we may bring to bear upon it, and that, too, where the urine flows in a considerable stream. Treatment of impassable stricture without retention has been already described. When, however, there is retention, the question immediately arises. Is it better to operate on the stricture at once, or to puncture the bladder and wait till the following day, in hope of operating then under the more favorable conditions of a guide through the stricture ? This is a point which requires the best judgment, aided by considera- ble experience, to decide correctly. Here there is no question of any other complication. The surgeon is in face of an impassable stricture, and the patient has retention, and must be relieved, or his bladder will suffer. If the patient has had retention before, his experience then will aid in forming a judgment. If the surgeon is acquainted with the temper of the urethra and the character of the stricture (re- siliency, traumatic origin), he may found his opinion on such previous COMPLICATED BY EXTRAVASATION. 159 knowledge. If the pati'ent is difficult to manage, and there is fear that, once relieved from his present necessity, he may not submit to treatment, it would be only a kindness to him to take advantage of his misfortune to insist upon perineal section at once, and put him in the way of passing a large instrument and keeping off further trouble, thus relieving retention and subjecting the strictui-e to effect- ive treatment by one operation. But external perineal urethrotomy without a guide is an exceed- ingly difficult operation, and is not to be undertaken unadvisedly. If it is the patient's first retention (brought on by exposure), and if he was previously passing a moderately good-sized stream, if the blad- der is not already too full, it is always well to try warm baths and opiates to relieve retention and to leave the stricture for subsequent treatment. Again, if the bladder is very full, and there is still no absolute necessity for external perineal urethrotomy, the bladder should be punctured above the pubis with the asj)irator, and a filiform bougie engaged if possible in the orifice of the stricture, and left to act by continuous dilatation (p. 164). On the following or next fol- lowing day the filiform bougie will generally pass into the bladder, and then the stricture will be under control. (d) Infiltration of Urine. — In stricture complicated by extensive infiltration of urine, we have a condition requiring prompt action on the part of the surgeon. The stricture must be relieved. The infil- trated urine must be drained off, or extensive abscesses, with slough- ing, will follow, and the patient's life be placed in imminent peril — results which may ensue in spite of all precautions. When the infil- tration has occurred behind the triangular ligament and is confined to the cavity of the pelvis, but little can usually be done, except to keep up the strength by brandy, carbonate of ammonia, and beef-tea, trust- ing that Nature will set up a plastic inflammation and thus limit the burrowing of the infiltrated fluid, and allow its escaj)e by the forma- tion of abscess (pericystitis). Even in these cases, however, desper- ate as they are, where the escape of urine has been sudden and in considerable quantity, early operation is often the only chance. They are similar to, and must be treated like, cases of rupture of the blad- der, the neck of the bladder being cut into, as in the lateral operation for stone, all stricture-tissue being divided and a chance given for the infiltrated urine to escape, while further damage from infiltration is rendered impossible. In some cases it is better to tie in a large red rubber tube through the perineal incision, rather than to cut into the vesical neck. If infiltration occurs along the course of the urethra outside of the triangular ligament, and is slight and circumscribed, the urine not having penetrated Buck's fascia, but manifesting itself in a hard, cir- cumscribed perineal swelling (p. 138) behind the stricture, no surgical 160 TREATMENT OF STRICTURE OF THE URETHRA. interference is called for, so long- as the hard lunip is not rapidly in- creasing and the patient can empty his bladder. Shonld retention occur nnder these circunistanees. or the hard luni]) commence to en- large rapidly, external perineal urethrotomy is the only proper re- source. In this variety of infiltration there is often time to build uj> the patient's general condition by the judicious employment of h3'gi- ene, air, tonics, etc., and sometimes to avert the consetjuences of long- continued abuse of stimulants, including delirium tremens, often imminent in cases encountered in hospital practice. Should external perineal urethrotomy be performed, the hard lump must be incised in the median line, and the stricture thoroughly divided. But these indurations do not necessarily sup]nn'ate externally. They usually remain stationary for a long time, often get better under treatment, sometimes (rarely) spontaneously subside, ])robably by dis- charging internally through a small oriticc.* When a large quantity of urine has suddenly escaped, burrowing into the subcutaneous tissue of the perinasum, scrotum, penis, and abdomen, large, free incisions, calculated to insure effective drainage, should be made well down into the subcutaneous tissue, wherever oedema or emphysema is felt, and external perineal urethrotomy must be performed. A thorough division of the stricture ])revents further infiltration. If the scrotum be infiltrated, it should be split into two lateral halves, while other incisions may be made freely into its sub- stance. Too free incisions are not to be feared ; the error is on the other side. Incisions must be bold, deep, numerous, and should ex- tend over all the surfaces involved by infiltration. The operative in- dications, in cases of extensive infiltration, are three : 1. To stop progressive infiltration by extensive dependent in- cisions. 2. To provide an escape for urine constantly collecting in the blad- der, by free central incision of the urethra behind the stricture. 3. To divide the stricture thoroughly, although this may be left for a subsequent operation. In making incisions, a finger in the rectum should search for boggy spots, which, when found, should be opened into. Brandy and car- bonate of ammonia, freely administered in small, frequent doses, will bring down the pulse as the patient rallies from shock. The subse- quent treatment must be sustaining in every way. Gangrenous spots appearing after incision should be poulticed with charcoal or yeast and linseed-meal until they separate, and the raw * Dr. E. A. Banks, of New Yorlc, broufiht a patient for inspection, wlio with tight stricture had two of tliese deep perineal indurations, one as larcc as a pigeon's egg, evi- dently firmly attached to the urethra. Before agreeing to external section, which was advised, Dr. Banks tiied " continuous dilatation," with the effect of overcoming the strict- ure, and causing the disappearance of the indurations after a few weeks. The treatment, however, provoked epididymitis, and caused some urethral irritation. COMPLICATED BY FISTULA. 1C,1 surfaces afterward dressed with simple stimulating applications until they heal. Recoveries after infiltration seem sometimes almost miracu- lous, and life is not to be despaired of eyen in cases of the most exten- sive sloughing. Too much attention can not be bestowed upon keep- ing up the patient's strength. This is his salvation ; it must be maintained at all hazards. (e) Abscess, complicating stricture, has already been described as perineal abscess, and as a hard, circumscribed swelling along the course of the urethra and attached to it. For all these, when complicating stricture, the treatment which usually yields the Vjest results is exter- nal perineal urethrotomy, including the abscess and the stricture in one free median incision. The opening should be made before fluctua- tion can be detected, at any time if the bladder is suffering. Success of treatment usually depends upon the earliness and freedom of the incision : cut deeply in the inedian line. There is nothing to fear. Haemorrhage can always be restrained by tying spurting points or plugging the wound if necessary around a "shirted cannula." In the anterior urethra abscess should not be opened until fluctuation can be felt. Then the urethra should not be opened. In exceptional cases it may be laid cleanly open by a longitudinal incision in the median line, and final closure, without fistula, may be hoped for in most cases. {f) FistulcB, as complicating stricture, are important just in pro- portion as they are large, long, or numerous. A simple fistula with one or two openings, which allows a few drops of urine to escape at eacli act of micturition, need not be regarded. Such a fistula will close spontaneously, in the vast majority of instances, as soon as the stricture has been dilated fully, as Brodie pointed out. The first and essential step in the treatment of all fistulge complicating stricture is, to remove obstruction to the free escape of urine, and then to treat the fistulse, if they do not get well spontaneously. Such after-treatment will rarely, be required unless there has been loss of substance. If, however, after full dilatation has been maintained for some months, the fistulse still allow urine to pass during micturition, the follo'U'ing ex- pedients may be resorted to : Dilatation being maintained, the patient should be further taught the use of a rubber or a flexible olivary catheter of medium size. This he must introduce at intervals, passing no urine except through the catheter, if it can be done without producing urethritis. If this fail, after thorough trial for a month or more, where the stricture has been fully dilated and is not resilient, the hard edges of the fistulous tract should be incised and cleaned, and the fistula left with its external larger than its internal orifice. If the edges are hot callous, and par- ticularly if the fistula is long and deep, cauterization is sometimes effective. This is best accomplished by galvano-cautery, a wire being X02 TREATMENT OF STRICTURE OF THE URETHRA. introduced, suddenly raised to white heat, and instantly withdrawn. Ked-hut iron is not reliable, as it becomes cooled on introduction, and produces least eifect where most is required, i. e., at the internal ori- fice of the -fistula. Another expedient is to bend a silver probe until it readily traverses the whole length of the fistula, coat it with fused nitrate of silver, introdnce it rajiidly, and rotate it duriiis:^ withdrawal. It mast not be forgotten that these means last detailed arc only accessory to the sound, and by no means in themselves reliable for cure. During their use the catheter and full-sized sound should be continued unremittingly. In general, the capacity of the uretlira is underrated, and fistulaj wiiich do not get well owe their intractability to the fact that the stricture has not been brought to the full size of the canal. If the urine can flow out freely enough, it will choose the larger and neglect the smaller channel, allowing the latter to heal. A search iu tue track of fistula? which refuse to close will sometimes re- veal stone as the cause. Where from the mismanagement of ])revious abscess there are nu- merous fistula?, opening in all directions around the penis, scrotum, and perinreum, running through indurated tissue, and, perhaps, lined by calcareous matter ; or where fistulse coexist with abscess in the perin^eum, or a lumpy induration of some extent around the urethra — in any of these conditions sound surgery calls for external perineal urethrotomy. The incision should be central, all abscesses and fistu- lous tracts being opened into this, and everything forced to heal from the bottom. When a fistula has one opening in the rectum, the obstacle to success of treatment is often the passage of fecal matter and gases into the urethra. If, after cure of the stricture, simple means (cautery, incision) fail, a sliding operation of the rectal mucous membrane may be called for, after stretching the sphincter. Thompson mentions a case which got well in a few weeks by position, the patient passing water only while lying upon his face.* John Chiene f cured four cases of perineal fistula, which had resisted ordinary means, by siphon drainage, i, e., tying iu a soft catheter and attaching to it a long rub- ber tube trained over the side of the bed, and terminating in a bottle of carbolized fluid. He claims advantage for the same method in the treatment of recto-urcthral fistula and for chronic cystitis. {g) Pericystitis, or Advanced Interstitial Cystitis. — In nearly all cases of stricture there is necessarily more or less cystitis (inflammation of the mucous lining of the bladder), esi)ecially about the neck, but, in the majority of cases, the bladder complication does not influence in any degree the treatment which the general conditions of the strict- ure call for. Where, however, active interstitial cystitis complicates * " Discascp of Urinary Organ-;," 4th cd., ISYG, p. M6. f Paper read before Medico Ghirurgical Society of Edinburgh, November 3, 1880. COMPLICATED BY ENLARGED PROSTATE. lC)?j a tight stricture, or wlicro the mnscuhir substance of the bladder and surrounding tissues are much involved, rest must be given to the bladder, and this is usually best effected by external urethrotomy, if any active measures are allowable ; otherwise a supporting and stimu- lating general treatment gives Nature the only chance (and that a poor one) of bringing the patient safely through. Particularly in all cases of cystitis is it necessary to make the urine unirritating as it flows from the kidney, to alkalinize it through the stomach, that it may be less alkaline at the meatus. G, Owen Eees* has demonstrated the possi- bility of doing this, by giving alkalies by the mouth, thus rendering the urine alkaline or neutral at the kidney. Alkaline urine, with a fixed alkali, does not irritate the bladder, and consequently less mucus ]s secreted (than when the urine was acid), to act as a ferment, decom- pose the urea, and give rise to the formation of carbonate of ammonia, that powerful volatile alkali which is the agent in decomposing urine most active in irritating and inflaming the bladder, and which, indeed, gives the alkaline reaction to the urine of chronic cystitis. Lemon- juice in quantity and benzoic acid will render the urine of a healthy individual acid ; not so when the bladder is inflamed ; then alkalies are more likely to produce the desired effect. {h) Enlarged Prostate. — The complication of stricture by enlarged prostate is not of common occurrence. The situation is always grave when the two conditions coexist, if the enlargement of the prostate is sufficient to interfere with the passage of instruments into the bladder, and the stricture is situated as deep as the bulb, or beyond it. The tighter the stricture the more serious does the complication become, and, should retention supervene, the difficulty of the situation is appar- ent at once, whether the obstacle to the escape of urine be situated at the strictured point or in the prostate. If the stricture is in the pendulous urethra, it should be cut inter- nally. If the stricture is deep but not very tight, a silver catheter of long curve should be selected, which will enter the bladder through the enlarged prostate, and steel conical dilating instruments should be constructed of the same curve. When the urethra has been ■dilated, the sound may be replaced by the catheter to be habitually used. If the stricture is very small, so as to admit only a filiform bou- gie, especially if there be retention, perineal section, an incision of the prostate in the median line, and tying in a large rubber tube is the proper expedient. If a cutting operation is objectionable for any reason, the method known as " continuous dilatation " may be re- sorted to. Continuous Dilatation. — The execution of the treatment and its * On the " Pathology and Treatment of Alkaline Conditions of the Trine," Guy's Hospital Reports, Third Series, vol. i, 1855, pp. 300, 301. 164: TREATMENT OF STRICTURE OF THE URETHRA. action arc as follows : A filiform bouf;:ie, whalebone or soft, is passed through the stricture, which "grasps '' it tightly, and is tied in. The first action of this instrument upon the stricture is to cause irritation. The muscular fibers at the strictured point grasp the instrument and hold it tightly. This continues for a while and tiien subsides ; mean- time, if the patient tries to pass water, he finds himself unable to do so. Soon the spasm relaxes and the urethra widens notably, so that a few hours later the patient can make water easily alongside the in- strument. A knowledge of this fact relieves all fear of retention in connection with this style of treatment ; the fear is, indeed, on the other side, for if a soft filiform instrument has been tied in, no matter how tightly it was embraced by the stricture at the moment of intro- duction, the chances are th'at at the second or third micturition it will be doubled up and washed bodily out of the canal by the volume of the stream of urine. This is not so apt to happen where there is also enlarged prostate, on account of the smallness of the stream and the atony of the bladder frequently attending that condition. After the instrument has been tied in for twenty-four hours, the stricture will readily admit a larger bougie. This should be tied in the same way. The stricture ulcerates superficially, but widens Avith great rapidity. After it has reached a certain size, it may be treated by dilatation as described above. There are objections to the treatment of stricture by continuous dilatation. Some patients suffer torments if an instrument is tied into the urethra, while urethral fever and epididymitis are often caused by it. On the other hand, some patients support it with per- fect impunity, even when walking about. If severe chills come on during continuous dilatation, it is prudent to withdraw the instru- ment ; if the chills are mild, they may be disregarded. Strictures en- larged by continuous dilatation commence to recontract at once with great rapidity, unless they are kept dilated by the occasional use of the sound. 3. Fistula with Loss of Substance.* Fistulas of the urethra with loss of substance may result from gan- grene, abscess, phagedenic ulceration, simple ulceration (the tying in of a silver catheter for a length of time). They are seen usually as the result of infiltration and abscess complicating stricture. In this va- riety of fistula a hole exists in the floor of the urethra, through which its roof is visible. As has been shown, small fistulas close on dilating the urethra. The same law which causes a traumatic stricture to close entirely, if all urine escape through fistulpe behind it, will the more certainly close a small fistula, unless from obstruction in front of it, and consequent distention of the urethra during urination, fluid be forced into its internal orifice. AVith loss of substance, however, * AH large fistulae are considered here, whether complicating stricture or not. FISTULA WITH LOSS OF SUBSTANCE. Ifj5 dilatation of the urethra, though necessary for cure, will not alone suffice. If the opening is larger than a pea, its closure is often diffi- cult, especially if it lie anterior to the peno-scrotal angle. The causes of failure here are three : 1. The thinness of the natural tissues furnishing only narrow edges for the union of flaps. 2. The difficulty of avoiding contact of urine with the cut edges. 3. The disturbance of the wound on account of changes in size of the organ (erection). Where loss of substance, however, is not very great, if there be no urethral obstruction in front of the fistula, repeated cauterizations may effect a cure. In this way Sir Astley Cooper* closed a fistula as large as a pea with nitric acid, after two operations with harelip pins and interrupted suture had failed. He states that this plan will not succeed unless the integument is loose, and the scrotum forms part of the orifice of the fistula. Dieffenbach f prefers a concentrated tincture of cantharides for small openings, which he applies as follows : The urethra is distended over a full-sized bougie, and the tincture applied with a small brush to the inner border of the fistula. This manoeuvre is repeated several times in the twenty-four hours. The epithelium as it loosens must be scraped away, and the tincture applied to the raw surface until healthy granulations have sprung up, which seem capable of closing the opening. Failing once, the treatment may be repeated. If this is not sufficient, or if, at first, the opening seemed too large to warrant the simple application of caustic, its use may be combined with that of Dieffenbach's lace suture (Schniirnaht), which is applied as follows : After the epithelium has been removed by the application of the tincture of cantharides, as just detailed, and a large, soft bou- gie has been passed into the urethra, a small curved needle, not cut- ting at the sides, carrying a stout (waxed) silk ligature, is introduced with a needle-holder at about three lines from the border of the fistula. The point of the needle must not enter the urethral canal, but, after traveling a short distance in the substance of the corpus spongiosum, it is made to emerge through the integument at a point also about three lines distant from the edge of the fistula. The needle is rein- troduced at the same puncture whence it emerged, and the same stitch is repeated often enough to carry the thread around the fistula at a distance of about three lines from it, and to make it finally ter- minate through the puncture in the integument where it first entered, thus leaving the two ends of the thread emerging from the same cu- taneous orifice, the thread itself lying in the corpus spongiosum, and the urethra not having been punctured by the needle. By gently * "Surgical Essays," London, 1819, p. 205. f "Die Operative Chirurgie," Lcipsic, 1845. 166 TREATMENT OF STRICTURE OF THE URETHRA. pulling upon the two strings, the raw edges of the fistula arc now brought together. The ligature is tied, the knot sinking into the cellular tissue : the sound is withdrawn, and water-dressing employed. The iVaticnt urinates through a catheter. In three or four days the ligature is cut and gently drawn out. Two operations may be re- quired, the first rendering the fistula smaller, the second obliterating it. This lu'ocedure is applicable to all fistulae of the spongy urethra of less than one-sixth inch diameter. "Where the opening is larger, urethroplasty is required. Of the many operations which have been proposed, undoubtedly that of Sy- manowsky is the best. It is applicable to all parts of the urethra. Symanowsky proposed it in 1870 for the anterior urethra alone. Weir * first performed it successfully in this country. Sabine first adopted it for the perina?um, and McBurney,t in an admirable paper, clearly detailed his experience with it in six perineal cases, five of which ■were successful. The operation exposes two large, raw, flat surfaces to each other, and covers the fistula with a double thickness of flap. I have found the operation very easy of execution. A straight incision in the skin is made through the center of the fistula in the pendulous urethra, at its right edge in the pcrinaBum — always in the long axis of the urethra. The parts must be clean washed and shaven, and it is better, if hairs occupy the flap which is to be turned in, that they should be removed by electrolysis as a first step in the operation. The edges of the fistula must be scraped and cleaned of all suppurating granulations. The length of incision in the anterior urethra varies with the size of the fistula. In the perinaeum the incision commences three quarters of an inch in front of, and ter- minates at the same distance behind, the fistula. The incision goes through the superficial fascia. On the patient's right of this incision, the skin and superficial fascia are dissected up to form a half-oval pocket, sufficiently deep to take in the flap, to be turned over from the other side. On the patient's left of the first incision, a half-oval flap is made of skin and superficial fascia. Its greatest width in the perinfflum is three quarters of an inch. This flap is dissected up toward the median line until it can be turned over as upon a hinge. Enough tissue is left at the hinged line to insure the vitality of the flap. The cutaneous surface of this flap is freely rawed with curved scissors, ex- cept over that part which, when the flap is turned over into its place, covers the fistula. Catgut sutures, passed from the patient's right edge of the under- mined flap into the pocket, take in the free edge of the flap to be in- verted, and are again passed through the pocket and out upon the surface near the point of entrance. In this way a number of loops * " New York Medical Record," April 13, 1878, p. 286. f "New York Medical Journal," November 6, 1886, p. 513. SUMMARY OF TREATMENT OF STRICTURE. 107 a,re formed, with which the inverted flap is i)ocketcd and drawn snugly into place. A few more catgut sutures are passed from the surface of the undermined flap through the raw surface of the inverted flap, and serve to bind the raw surfaces together. Finally, the edge of the undermined flap at the line of the first incision is united by many points of suture to the curved edge on the other side, from which the inverted flap has been cut away. Bichloride irrigation, iodoform, cotton, and a T-bandage with pressure, complete the dressing. An opiate confines the bowels at first, and a catheter is used for many days every time the patient urinates, the bladder being washed with a solution of borax each time the catheter is used. One of McBurney's cases took over three months to get well. The other four were healed in seventeen, thirteen, nineteen, and thii^ty-four days respectively. Of course, in all these cases, the entire urethra must be freed from stricture before the cure of the fistula is attempted. In closing a very large fistula of the anterior urethra, the expedi- ent first suggested by Segalas and Eicord * may be adopted, namely, opening the bladder through the perinseum for drainage. At the pres- ent date, in such cases, a rubber tube is tied in ; but this prejoaratory puncture of the urethra can usually be dispensed with by a careful operator. SUMMARY OF TREATMENT OF STRICTURE. 1. Alkalies, diluents, and rest are serviceable in most cases of stricture — sometimes indispensable if there be any serious complica- tion. 2. All uncomplicated strictures, not highly irritable or resilient, should be treated by dilatation with soft instruments up to No. 15, conical steel sounds afterward ; reintroductions being made every fourth to eighth day — the older the stricture the longer the interval as a rule, and intervals of one week being most serviceable in the majority of cases. 3. All strictures of the meatus or pendulous urethra should be cut. 4. Eesilient, very irritable, and, as a rule, traumatic strictures of the deep urethra should be cut externally or by combined internal and external urethrotomy ; other strictures in this region should be treated by ordinary dilatation. 5. Impassable stricture may usually be overcome — where there is no retention — by time, patience, and skill, with whalebone bougies. If finally proved impassable, the treatment is external perineal ure- throtomy. 6. Eetention is treated by hot baths, ether, opium, tincture of the sesquichloride of iron ; failing these, by puncture above the pubis * " Monthyon Prize Essay," 1841. 1(58 TREATMENT OF STRICTURE OF THE URETHRA. with the aspirator ; or by external perineal urethrotomy without a guide. 7. For stricture complicated by abscess, inliltration, or many and large fistulje and for extensive traumatic stricture, external perineal urethrotomy. 8. For inliltration, free incisions, stimulants, supportives, with thorough external division of the stricture, 9. For fistula with loss of substance, local cauterization, lace sut- ure, or plastic operation. Where there is no loss of substance, com- plete dilatation of the stricture is soon followed by closure of the fistula. URETHRAL CASE OF INSTRUMENTS. It is advisable to introduce here a list of such instruments as will be necessary to make up a case suitable to meet the requirements of such maladies, demanding instrumentation within the urethra, as are ordi- narily encountered by the general i^i'actitioner : Gauge. Conical steel sounds, Nos. 15 to 33— or 37— twelve instruments, omitting sizes of even number. One long and several short whalebone filiform guides. One Banks's whalebone bougie. One silver catheter, No. 6, very short curve, tunneled. Several larger silver catheters, not tunneled. One female silver catheter, size 18. Two long, curved silver prostatic catheters, sizes 15 and 27. Thompson's rapid dilator, tunneled. Civiale's urethrotome. Otis's urethrotome. Straight bistoury. Gouley's catheter staff, size 18. Urethral forceps. Some silk elastic, and some Mercier's soft catheters. A few olivary French and a few rubber catheters. Conical soft French bougies (not olivary), sizes 5 to 18. A set of tunneled steel sounds, 6 to 18. Metallic and soft bulbous bougies, 6 to 37, every alternate size. Otis's urcthrameter. Probes, directors, needles, knives, and silk. Eoll of rubber plaster. Tube of vaseline. ANATOMY OF THE PROSTATE. IQO CHAPTER IX. DISEASES OF THE PROSTATE. Anatomy. — Function.— Deformities.— Injuries. — Atrophy.— Hypertrophy.— Bar at the Xeck of the Bladder. — Symptoms and' Results of Hypertrophy.— Course of Symptoms from commencing; IrritabUity up to Retention, Atony, Stone, Uraemia, Death. AisTATOMY. — The prostate (Trpoo-raTT^s, standing iefore), somewhat improperly called a gland, is a body composed mainly of unstriped muscle, placed like a sphincter around the first inch of the urethra and the neck of the bladder. It contains multilobular mucous glands in its substance, and is tunneled by the two ejaculatory ducts — the com- mon canal formed by the union of the duct of the seminal vesicle with the vas deferens on either side. The ejaculatory ducts open, in the floor of the prostatic urethra, on the sides of the little crest in the median line called veru montanum. Here, also, most of the ducts of the mucous glands of the prostate open. The latter secrete a bluish mucus, which serves to dilute the semen and possibly to prolong the vitality of the spermatozoa.* Both the glands and their ducts, in late adult life, habitually contain certain small solid deposits, called pros- tatic concretions, formed in concentric layers, which seem to have no special significance, though they often exist in vast numbers, and of considerable size. They are occasionally encountered in the urine. The lower part of the prostate is surrounded by a few striped muscu- lar fibers — the external vesical sphincter of Henle, The prostate is a muscle. Its main function is to contract on the semen after the latter has collected within and distended the prostatic sinus. This contraction is coincident with the venereal orgasm. It is spasmodic in character, throwing out the seminal fluid in successive jets. The seat of the venereal orgasm is in the nerves of the mucous membrane lining the prostatic sinus, as proved by the fact that it is sometimes excited by the passage of a sound through the prostate, and is not destroyed by amputation of the glans penis. The prostatic utricle, the analogue of the cavity of the uterus, is a little depression lying in the floor of the prostate beneath the veru montanum, opening by a small vertical slit in front of the summit of the latter. This cavity and the orifices of the mucous follicles, dilated by hydrostatic pressure in cases of tight stricture, are liable to catch the fine points of filiform bougies introduced through a stricture. The base of the prostate embraces the neck of the bladder, and sur- rounds the vasa deferentia and necks of the seminal vesicles. The * Fiirbringer, " Berl. klin. Wchnschrft,," July 19, 1886. 170 DISEASES OF TUE PROSTATE. prostate lies below and directly in front of the neck of the bladder, in- closed by a fibrous capsule, in relation with the pubes in front, the rectum behind, and held in ]ilace mainly by the jielvic fascia — or pos- terior layer of the triangular ligament — and the pubio-prostatic liga- ment in front. There is never any fat between the rectum and pros- tate. A large plexus of veins surrounds the prostate in front, and above as well as (partly) below. The prostate is composed of two lateral lobes, and only two. They form one symmetrical body, and never remain distinct in man, as they do in some animals. Thompson, quoting Morgagni, Santorini, Hunter, Cruveilhier, and others, as well as concluding from his own minute investigations, decides absolutely against tlie existence of any third or median lobe in the healthy prostate. In shape and size the organ resembles an Italian chestnut. Its weight is about half an ounce. It lies with its apex looking forward, and may be readily felt during life through the rectum. The finger can always reach above its posterior border, unless the organ is de- cidedly enlarged. The prostate is a genital, not a urinary organ. Like the rest of the genital apparatus, it is small before puberty, and becomes notably developed during that epoch. Its average diameters in the healthy adult* are, longitudinal 25 to 30 millimetres, transverse 32 to 40, thick- ness 20 to 25 ; or, roughly, 1|-, Ij, f inch. The urethra usually tunnels its upper part, but occasionally its lower portion, in which case it is only slightly separated from the rectum, a circumstance which exposes the latter to injury in the cutting operation for stone. The prostatic urethra is surrounded by a small amount of erectile tissue. The arteries of the prostate come from the vesical and middle h£emorrhoidal. Its veins discharge into the surrounding venous plexus, Avhich is made up by their union with the dorsal veins of the penis and the veins of the bladder. The lymphatics communicate with the lymphatic glands on the sides of the pelvis. The nerves come from the hypogastric plexus. DEFORMITIES OF THE PROSTATE. Deformities of the prostate are exceedingly rare. Its roof is open in extrophy of the bladder, but its floor never seems to fail. It is never wanting except in connection with extensive lack of development of the whole genital system, particularly with non-development of the testicles. After complete castration on both sides, the prostate has been seen to disappear, f * Cruveilhier, op. cit, p. 395. f Civiule, quoted by Pitha, op. cil., p. V2Y. INJURIES— ATKOPIIY. 171 INJITRIES OF THE PROSTATE. The prostate by its position is well protected from ordinary casual- ties, and rarely suffers unless the general injury is very extensive, in which case its implication may be considered unimportant. The ivounds of the prostate are incised wounds made in the opera- tion for stone, lacerated wounds in the same operation from introduc- ing dilating instruments, or extracting a large, rough stone, and pene- trating wounds (false passage) made by accident or design in trying to pass a metallic instrument of an improper curve through an ob- structed urethra. The prostate is a patient organ, and bears all these injuries well. Healing after stone operations is exceptionally ra])id, and the prostate may be punctured by a catheter without necessarily any evil consequence, unless it be the seat of chronic disease. Injuries to the prostate get well, usually, if let alone, even where abscess forms in the organ, and abscess is not frequent even after pretty extensive laceration, although the parts are constantly bathed in urine. Inju- ries of the prostate do not excite much constitutional derangement. Very different, however, is the case if the injury extends beyond the limit of the fibrous capsule of the gland. In such cases the worst complications are to be feared (pelvic infiltration, abscess, peritonitis), and if the patient escape with his life he is fortunate. These conse- quences are more apt to occur in the operation for extraction of very large stone. The only treatment consists in seeing that the urine is thoroughly drained off, and supporting the patient's strength, keeping him at rest, and using opium as required. ATROPHY OF THE PROSTATE. Atrophy of the prostate is rare, but is occasionally encountered. Among the recognized causes may be mentioned the atrophy of old age, coinciding with general atrophy of the rest of the body. Here the glandular rather than the muscular constituent disappears. Thompson, in his admirable monograph, which obtained the Jack- sonian prize in I860,* has, by laborious investigation, established the fact that the prostate does not necessarily enlarge with age, nor does it necessarily atrophy. As a rule, it continues about of normal size, but it may occasionally atrophy, physiologically, like other structures in old age, Just as it may, and often does (pathologically), hypertrophy. Atrophy of the prostate, during general wasting disease, especially phthisis, has been noted. Pressure from a tumor, or cyst, or stone, within or near the prostate, may cause its atrophy, as may also the constant pressure of urine behind a tight stricture. Atrophy, after double castration, is possible. Atrophy of the prostate has no symptoms except, possibly, lack of * " On the Diseases of the Prostate," 4th ed., 1873. 172 DISEASES OF THE PROSTATE. force in the ejection of semen. It is an unimportant allection, and has no direct treatment. If the cause can be discovered and removed (pressure), the tendency to atropliy may be overcome. HYPERTROPHY OF THE PROSTATE. The morbid condition to \vhich the ])rostate is most liable is h^'per- trophy, either general, partial, or by the development of circumscribed tumors. In general hypertrophy the glandular elements, instead of being hypcrtrophied, often become atrophied by the excessive growth of fibrous and muscular tissue between them. In marked cases they are completely destroyed, and the prostate is converted into a homo- geneous fibro-muscular tumor. The isolated, circumscribed prostatic tumors, however, always show new^ formation of gland-tissue.* Cause. — The cause of hypertrophy of the prostate is totally un- known. The numerous hj^potheses w^hich have been advanced by authors need not be discussed : they do not cover the ground. No known diathesis, or combination of circumstances, can account for the affection. It is not venous stasis, or excessive use of the organ, or sedentary life. All that can be said is, that the disease does not occur before middle age — rarely before fifty ; Thompson sa^^s fifty-five. The prostate is analogous to the uterus in the female in regard to the nature of the muscular tissue which composes it, and this analogy is further borne out by the tendency of both organs to develop fibrous tumors (so called) after middle life. Velpeau f suggested this analogy, and justly. The portion of jirostatic tissue which hypertrophies is the muscular and not the glandular (or only to a small extent), and although general or partial enlargements of the prostate are the rule, yet it is rather rare for any considerable hypertrojjhy of the organ to be found without the coexistence of one or more circumscribed tu- mors, which correspond to the circumscribed fibrous tumors of the uterus, also composed mainly of unstriped muscle. Bayle says that twenty per cent of women, after thirty-five, have fibrous tumors of the uterus, the cause, of course, unknown. Thom2)son says that thirty per cent of males, after fifty, have fibrous tumors of the pros- tate, lie states that moderate enlargement of the prostate may be expected in one out of three men ; after fifty, marked enlargement in one out of ever}' eight, but rarely before sixty. Thompson believes that the affection rarely commences after seventy. He quotes, from Beith, J the case of an old man who died at one hundred and three, where the only abnormal conditions found were hypertroiihy of the prostate and a sacculated bladder. * Rindflciscb, " Path. Histology," Anier. trans., p. 546. f " Le9ons Orales," vol. iil, Paris, 1841, p. 478. X "Trans. Path. Soc," 1850-'51, p. 124. HYPERTROniY. 173 Size and Shape. — No positive limit in size can bo named. The prostate may be encountered of the size of a man's fist. Thompson has seen the transverse diameter exceed four and a half inches. The weight of twelve ounces has been reached. This excessive amount of enlargement, however, is rare — a prostate as large as a small orange being infrequent. The mass may take any shape, depending upon the part of the organ involved. Smooth and round in general hypertrophy, it be- comes more or less irregular in unsymmetrical overgrowth, or from circumscribed tumors. The portion most frequent- ly involved, either alone or (usually) associated with more or less general hypertrophy, is the posterior median part, known since Sir Everard Home * as the third lobe. This nomenclature, however, is inexact. The prostate has no third lobe, and what Home, from his dissection of diseased prostates, named the " third lobe," is, in reality, a patho- logical formation, and is now more correctly styled median centric hypertrophy. It con- sists of that triangular part of the prostate lying between the ejaculatory ducts, and overgrowth in this situation is believed to be due to the absence of capsule here. It may be found with little or no enlargement elsewhere. In form it is usually an oval, rounded tumor (there maybe two or more), which grows up from the floor of the back part of the prostatic ure- thra and juts out posteriorly into the cavity of the bladder. It may reach the size of a small pear, and indeed resemble a pear in shape, showing a tendency to pedunculation. When hypertrophy invades the lateral lobes, only one may be af- fected, but usually both, more or less general enlargement correspond- ing with the local overgrowth (Fig. 54). Under these circumstances the pyriform central tumor tends to fill up the internal orifice of the * "Philosophical Transactions," 1806, paper viii. It was not disccverod by Home. It was accurately described by Santorini in 1739, and mentioned by Morgagni. Fig. 54 {Coulson). Showing enlarffed prostate with " third lobe." through the base of which a false passage has been made. 174 DISEASES OF THE PROSTATE. iiretlira, leaving a passage on either side along its lloor for the urine. The mucous membrane on either side of the central mass is often drawn uj) between it and the hyjiertrophicd lateral lobes, forming a cresceutic bar at the neck of the bladder. Imbedded in the hypertrophied mass, it is usual to ilnd several small circumscribed tumors, dense, hard, seemingly fibrous in charac- ter, easily enucleated and elastic, so that, when cut through in a clean section of the organ, the cut surface of the tumor overrides the general smooth plane of the incision, as if the little mass had previously been compressed. They are formed of unstriped muscle with some new glandular tissue, and are considered analogous to mammary glandu- lar tumors, or to the glandular bodies which develop (pathologically) in and around the thyroid. These tumors, usually small, may become as large as a marble ; many are found of the size of a pea. Occasioualh^, when the urethra runs an anomalous course through the lower part of the prostate, the upper part alone may hypertrophy. A remarkable instance of this unusual form of hypertrophy is figured by Quain,* quoted and refigured by Stein f (Fig. 55). Fio. 55. Other localized hypertrophies of the prostate are more rarely en- countered in the shaiie of distinctly pedunculated tumors, which grow from any portion of the posterior margin of the prostate, and hung into the cavity of the bladder. They may surround the neck of the bladder like a fringe. ^Median centric hypertrophy may take this form, constituting a sort of ball-and-socket valve at the neck of the bladder. Finally there may develop in the thickness of the bladder- * "Medical Times and Gazette," May, 1872. f "New York Medical Journal," May, ISY^, vol. i, p. 483 MEDIAN POSTERIOR IIYrERTROT'IIY. 175 walls small snpernnmcrary outlying prostatic glandular tumors, vary- ing in number and in si;ic, but only existing coincidently with one of the ordinary forms of overgrowth. BAR AT THE NECK OP THE BLADDER. This affection has become classical since the investigations of Guth- rie,* who described the muscular bar formed by hypertrophy of bladder-tissue just behind the prostate, and the bar of mucous mem- brane already alluded to. All the varieties of bar, of which there are three, may be considered at once, in connection with prostatic hyper- trophy : 1. Centric median hypertrophy, where a transverse bar of hyper- trophied tissue is formed, instead of the usual oval tumor ; this form is rare. 2. The lifting up of a fold of mucous membrane between unsym- metrical lateral lobes, or between the so-called third lobe and hyper- trophied lateral lobes. 3. The form of bar to which Guthrie s|)ecially called attention. This latter may (rarely) exist without prostatic hypertrophy. Its seat is in the muscular fibers which run transversely across the trigone, behind the prostate. These fibers sometimes hypertrophy greatly, the trigone becomes contracted laterally, the orifices of the ureters ap- proach each other, while the hypertrophied bands of fibers stand out like a bar, forming an obstruction, but an obstruction totally uncon- nected with any prostatic overgrowth. Symptoms and Result of Enlarged Prostate. — Hypertrophy of the prostate (like stricture) does harm mechanically, and provokes lesions in other parts. Its symptoms, pure and simple, are unimportant, and do not call for treatment, unless the enlargement be sufficient to obstruct the free outflow of urine, and occasion disease of the bladder (cystitis and its consequences). A description of the special variety of the latter, due to prostatic hypertrophy, finds its place here more naturally than under the head of Diseases of the Bladder. The immediate result of hypertrophy of the prostate is a deviation in the direction, and usually a diminution in the size, of the prostatic urethra. As the prostate enlarges, its antero-posterior diameter elon- gates, and with it the length of the prostatic urethra necessarily in- creases. Thompson has seen it three inches long. The urethra, more- over, tends to become a vertical slit, as its caliber is encroached upon from side to side by the increased size of the lateral lobes. If isolated fibrous tumors grow up from the floor or sides of the prostatic ure- thra, the course of the latter becomes by so much the more devious. When one lateral lobe is hypertrophied alone, or to a greater degree * "On the Anatomy and Diseases of the Urinary and Sexual Organs," 1S36. 176 DISEASES OF THE PROSTATE. than its fellow, the urethra is pushed toward tlie opposite side. When there is posterior median hypertrophy (as occurs in the majority of cases applying for treatment), we have the gi'eatest degree of oblitera- tion of the canal for the least amount of overorowth. Most cases of prostatic hypertropliy probahly never come under the surgeon's notice, in consequence of there being no obstruction to the outllow of urine. Many an old man goes to his grave with enlarged prostate, the exist- ence of which has never been suspected. Of those cases which are seen, median hypertrophy exists in a large proportion. This median central part of the prostate lies at the neck of the bladder directly in the vesical orifice of the urethra (Fig. 56). As it grows upward and Fig. 56. backward, it fill.> the mouth of the bladder, and converts its naturally rounded orifice into a crescentic slit, convexity ujjward. The floor of the prostatic urethra is also unnaturally tilted up, to override this bulkhead which has sprung up in its course. Fig. 57 shows the effect upon the course of the urethra of this so-called third lobe, and sug- gests at once the two great facts which are the key-notes to a correct understanding of the pathology of hypcrtrophicd prostate, and of tlie means of relieving its most prominent symptom — retention. These facts are — 1. That such a growtli occupying the vesical orifice, and jutting out behind and above it, must ob-truct the free outflow of the urine from the bladder. 2. That an instrument of ordinarv curve, introduced from witliout, HYPERTROniY. 177 Fig. 57. — Posterior median hypertrophy. must strike against this obstacle, and refuse to enter the bladder. Con- sequently, a modification in the shape of the instrument is called for. The bar at the neck of the bladder constitutes an ob- struction of the same sort. If sev- eral posterior tu- mors exist, instead of one, the vesical orifice is corre- spondingly modi- fied. If a single pedunculated tu- mor grow any- where around the margin of the ure- thral outlet hang- ing into the cavity of the bladder, it may act like a ball-and-socket valve, causing retention where there is very little general hypertrophy. To follow pathologically the natural history of hypertrophy of the prostate, it must be borne in mind that the blood, re- turning through the vesi- cal veins, finds its way back into the general cir- culation through the ve- nous plexus lying around the prostate ; consequent- ly any enlargement of the latter tends to press upon this plexus, and by so much to obstruct the ve- nous circulation, and es- tablish a constantly in- creasing venous conges- tion of the bladder walls and membranes. Then, again, the deviation in the course of the prostatic ure- thra, and its decrease in size, mainly due to posterior central enlarge- ment, obstruct the free outflow of the urine, and call for constantly increasing efforts on the part of the bladder to force out its contents. 12 Fig. 58.— Healthy prostate. 178 DISEASES OF THE PROSTATE. From these two circumstauces, venous congestion and the need for an exercise of greater muscular power, the bladder walls go on to hy- pertro})hy. The bundles of fibers of the detrusor urina^ increase in size, and jut out into the cavity of the bladder, like the colunma? car- nece of the heart. But these thickened bundles of muscular tissue do not proportionally increase the expulsive power of the bladder, for they are constantly congested, and working at a disadvantage. The muscular libers of the base of the bladder are not able to contract suf- ficiently to bring the floor of the viscus above the level of the dam at its mouth, and hence a little urine is left behind after each act of mic- turition. This residuum (as it is called) announces itself by no symp- tom, and is unnoticed. It becomes mingled with fresh supplies of urine coming down the ureters, and is partially passed off and replaced by fresher fluid. After a time, however, the mucus, from the slightly congested membrane around the base of tiie bladder, being in part re- tained in the residuum, acts upon the latter, setting up decomiDosition of urea and liberation of carbonate of ammonia. The carbonate of ammonia irritates the mucous membrane of the bladder, increases its congestion, and calls forth a new supply of mu- cus, which, in its turn, acts as a fresh ferment, alkalinizing and de- composing more urine. The natural acidity of the urine still further tends to keep up and aggravate the already existing congestion. Un- der these circumstances — the membrane becoming hypera^mic, and thickened around the already contracted mouth of the urethra — more obstruction to the outflow of urine is occasioned, and the quantity of residuum is increased, while the laboring detrusor urin^e is forced into still greater hypertrophy in its fruitless efforts to overcome the increasing obstacle. In this way the bladder becomes gradually dis- tended, the amount of residual urine increasing from mouth to month, and the bladder getting less and less able to empty itself , Hence with hyi^ertrophy of the bladder-walls there is, usually, also dilatation of its cavity. Finally, retention comes on, most often excited by a chilling of the legs, the "cold" which the patient has taken "settling," as it were (where the circulation is already weakened), upon the prostate and neck of the bladder, and superadding an active inflammatory conges- tion to the already existing enlargement. Sometimes the direct cause of retention is spasm of the deeji urethral cut-off group of muscles. The new hyperemia may subside in a few liours, if the patient keeps quiet in a warm place, and with its disappearance the power of void- ing urine returns ; or surgical relief may be afforded, or the accumu- lation may go on to overdistention, and, finally, overflow. This stretching of the hypertrophied but weak fibers of the detrusor takes away more or less of their power of contraction, and the bladder is apt to be left in a condition of atony. HYPERTROPHY. 179 After a retention, if it has not lasted too lon;:^, the bladder may go on expelling the excess of urine above the residuum, just as it did before, but now the amount of residual urine is greater, and the power of the bladder less. The congested membrane around the vesical neck and in the prostatic urethra is kept irritated by the partly decomposed urine, and it takes but a slight cause, a chilling or an excess at table, to bring on another retention. After each attack the bladder is left in a more helpless condition. Besides distention of the bladder with hypertrophy of its walls, sacculi may be developed and grow greatly with each succeeding reten- tion. The efforts which the hypertrophied fibers of the de- trusor are obliged to make to expel the urine, cause the mu- cous membrane to be pressed out between their meshes into little pouches, and if reten- tion come on, these parts, being weaker than the rest of the bladder, suffer most, and may become enlarged into supernumerary bladders com- posed of mucous membrane, connective tissue, and perito- naBum, but covered by no mus- cular coat (Fig. 59). Some- times, though rarely, one of these sacculi may be found larger than the bladder itself * — usually they are only shal- low depressions between the raised bundles of muscular fibers, occasionally little sacs with con- stricted necks. These sacs have no muscular tissue, and consequently no power of emptying themselves ; hence the urine tends to stagnate in them, and to undergo decomposition, depositing crystals of triple phosphate with more or less amorphous phosphate, etc., all of which become glued together by mucus, and thus form a nucleus for stone, which, increasing in size, may finally fill up the sacculus even with its narrow neck (encysted calculus). These changes are all the more certain if some kidney-stone lodge in a sacculus instead of passing off. This process of stone formation which goes on so readily in a sacculus, also takes place in the bladder when its floor is depressed behind a third lobe, in what is known as the **bas fond," or lower bottom. Here, too, the urine stagnates and deposits its salts, as crys- * Gross mentions a case, in a man of eighty-four, where the sacculus held a gallon. Fig. 59 (Crosse). 180 DISEASES or THE PROSTATE. tills and amorplious dust, to be glued togctlior upon a nucleus (kidney- stone), or, as is more usual, to become themselves consolidated by the cement of mucoid pus. In all cases of enlarged prostate, where there has been anj considerable amount of residuum, stone is liable to form. Stone is the logical sequence of obstruction to urinary outflow, aided by vesical catarrh. A stone, or several, may exist under these circumstances without giving rise to any symptom. They are usually smooth, and do not scratch or irritate the floor of the bladder greatly, nor do they add much to the already existing pain. The fibers of the weakened de- trusor can net, during micturition, force a stone thus formed against the sensitive tissues at the neck of the bladder and produce the strik- ing symptoms which characterize vesical calculus when found in a licalthy subject. Enlarged prostate, by obstructing the free outflow of urine and damming up the bladder, tends to distend the cavity of the latter, gradually to dilate and congest the ureters and pelves of the kidneys, and ultimately to excite and maintain a mild inflammation of the cor- tical and medullary structure of the kidneys — which exists, as a rule, in all old cases. This kidney complication is easily aggravated by any increase in the bladder congestion ; and any inflammation of the blad- der is liable to run rapidly up the ureters and further congest the kidneys, bringing on symptoms of mild uraemia, with more or less fever, hot, dry skin, loss of appetite, and a particularly dry mouth and tongue. In these cases there is no suppression of urine, but, on the con- trary, a marked polyuria, as a rule, sometimes attended by a trace of sugar, and usually showing an occasional cast, a little more albumen than the pus and blood in the sj)ecimen will account for, and a sp. gr. of about 1006 to 1016. Swelled testicle sometimes accompanies one of these exacerbations of inflammation, but more usually follows the introduction of an in- strument. The pressure of the enlarged prostate occasions also con- gestion of the hsemorrhoidal vessels, while the violent straining not infrequently brings on some prolapse of the rectum. The distress attending this group of morbid changes is often so excessive that the patient's life becomes a burden to him. The urine is that of catarrh of the bladder, and this catarrh, the inevitable accompaniment of prostatic enlargement at some ])eriod of its existence, is usually limited to the vicinity of the neck. Its tend- ency is to involve more and more of the mucous lining of the body of the organ, from the action of such causes as cold, over-acid urine, re- tention, etc. The urine is alkaline, or, even if faintly acid, it has an ammoniacal odor, and often a fetid, sickening smell, which occasion- ally disappears. When the urine is acid, it is so because it comes IIYPERTROrilY. ISl down strongly acid from tlie kidneys, and all of its acidity has not been neutralized by mingling with the alkaline residuum. Whatever urine has been alkalinized, deposits crystalline and amorphous phos- phates, so tiiat, even in those cases where the urine is still acid, it is murky, cloudy, filled with little strings and clots and clouds of pus, and with gouts of ropy muco-pus (pus agglutinated and made trans- lucent by ammonia). A few blood-corpuscles will nearly always be found, and more or less amorphous urate or phosphate (perhaps both), with (pretty certainly) crystals of triple phosphate entrapped in the "stringy mucus," and, possibly at the same time, crystals of uric acid, oxalate of lime, or other varieties. The above detail represents the course of changes as they occur in a majority of instances of enlarged prostate ; but there may be varia- tions. Thus the whole prostate may be enormously enlarged without any median posterior hypertrophy, and consequently without any ap- preciable diminution in the caliber of the urethra or obstruction to the outflow of urine. In these cases there is no residuum. The pa- tient can empty his bladder entirely ; but the obstruction to the return of venous blood from the bladder-walls, produced by pressure of the enlarged prostate, keeps up a congestion about the floor and neck of the organ none the less. Hence the symptom known as irritability (constantly recurring desire to urinate), is pretty sure to be present, sometimes to an intolerable degree. The bladder hypertrophies, but, instead of dilating, as is the rule, it may contract, and, as there is lit- tle or no residuum, sacculi do not form and atony does not come on. This condition of things, unfortunately, may occur even where there is some median hypertrophy and a small, constant residuum, and may even be found occasionally after the bladder has been overstretched by retention. This is always to be regretted. A bladder that is thoroughly atonied, so that it can only slowly force out the urine through a cathe- ter, is far preferable. Such a bladder is patient and uncomplaining, giving its possessor but little uneasiness. It is slow to take on inflam- mation, while the other form (where full contractile power remains, and irritability is present) is usually a torment to its owner as well as to the surgeon. The bladder contains little or no residuum, the urine continues acid and only slightly murky in appearance ; but the calls to urinate are incessant, night and day, and the bladder can not be made to contain more than an ounce or two of urine without feeling as if it were splitting. Thompson speaks of an old gentleman whose prostate formed an '' enormous tumor " when examined by the rectum, yet repeated explorations failed to find a drop of residual urine. The patient was tormented by an incessant desire to pass water, and expe- rienced great difficulty in the act. Besides the two conditions already alluded to — namely, dilatation 182 DISEASES OF THE PROSTATE. with great tolerance, and contraction with irritability — in the one case the patient urinating rarely, unless there are atony, a large residuum, and overflow ; in the other, great frequency of urination being always present — bqsidos these two, there is one other condition, possible but rare, namely, true incontinence. Occasionally, the unsymmetrical development of the prostatic lobes leads to a slightly patulous condi- tion of the internal orifice of the urethra, and causes true inconti- nence, the i)atient being unable to prevent a slight, constant dribbling away of the urine. In nine cases out of ten such dribbling is the re- sult of overflow ; but still the possibility of true incontinence must be borne in mind. A distinction between the two is easy. Empty the bladder by means of a catheter : if dribbling recur at once, we have incontinence ; if only after some hours, overflow. Course of Symptoms. — During all the time that these pathological changes have been going on, a period of many months, perhaps years, ever since there began to be a little hyperremia around its neck, the bladder has been getting gradually irritable. The patient does not readily notice it, and will never be able to fix a precise date for the com- mencement of his troubles. An old man does not sleep soundly or pay the strictest attention to the performance of his habitual functions, and he so gradually acquires the habit of getting up a little earlier than usual in the morning to empty his bladder that he pays no attention to it. Soon he finds that he wakes up once at night, ]icrhaps twice, with a feeling of fullness in his bladder. He passes water, and goes to sleep again. He is also troubled a little more frequently than usual in the daytime, but he looks upon it as a condition natural to advancing life. He has learned that the little ills of the flesh, if let alone, usually regu- late themselves. He has passed water without trouble for fifty or sixty years, and he thinks that he ought still to be able to manage it without applying to his surgeon. He shrinks from acknowledging a weakness, which he must admit to be, if nothing more, a symptom of advancing age, and so he goes on lulled to security, making water at intervals which gradually but steadily become shorter, getting up perhaps every hour at night, and constantly annoyed by a faint, obscure sense of weight and heaviness about the lower part of his belly, with, perhaps, a fullness in the rectum, and a dull pain behind the pubes. The bladder, now, is never empty ; but the patient does not know it. Only an excess above a certain residuum can be passed off. The old man notices also, perhaps, that he has to wait a little while before the urine begins to flow, that the stream is small, and is not projected away from him with any force, and that, perhaps, a part of the urine dribbles down perpen- dicularly from the meatus, while the rest flows as a continuous stream. Possibly he can not make the "coup de piston," the final s})asmodic clearing of the urethra, and finds that a few drops dribble away upon his clothes after each urinary act. He does not experience quite as EYPERTROniY. 183 much ease and relief as usual after micturition ; but this has come on so gradually that he disregards it. He finds, however, when he is jolted through the streets in a carriage or car, that his calls to urinate are even more frequent than usual. At this juncture he dines out, and drinks a glass or two of wine more than usual, or he neglects a call to urinate, or gets a wetting, or his feet and legs get cliilled (the latter a very common cause of trouble), and suddenly he finds that he can not pass water at all. After vainly try- ing at intervals for a number of hours, if he does not seek surgical relief, at last the urine will begin to dribble away from him. The bladder has been distended to its utmost, the mouth of the urethra has been dragged open slightly, and the excess of urine trickles involuntarily away. This is overflow and not incontinence. Meantime the patient has been suf- fering the torments known only to those who have had retention, and he hails the overflow with delight, believing that his sufferings are about to cease. The hope is vain. The congestion of the bladder neck, brought on by the use of liquor, or by the chilling, and which, added to the already large prostate, has swollen it sufficiently to shut up the urethra entirely, subsides shortly. G-ravity, and the contractions of the abdominal muscles and of the diaphragm, are together able to dispose of a certain excess of urine, which the overstretched bladder, now in a condition of atony, is unable to void. The patient, perhaps, recovers from his overflow, but his residuum is greatly in excess of what it was before his attack of retention, his calls to urinate are more frequent, he is disturbed more often at night. All his former feelings of uneasiness and pain about the hypogastrium and perinseum are increased ; digestion is impaired ; the appetite fails ; and, worn out by loss of sleep, inability to eat, and constant uneasiness amounting to actual pain, the sufferer runs down, aging rapidly, and becoming fretful and irritable, losing all interest in business, and nearly all pleasure in life. A second and third retention come on and aggravate the situation. Perhaps a stone is forming, as is always apt to be the case. The blad- der may ulcerate and pericystitis ensue, and death finally close the scene, the most common mode of death being by ursemia, induced by a little extra congestion of the secreting portion of the kidneys. The foregoing clinical history is that of a type case. It may be variously modified, according to the pathological condition of the bladder and prostate ; there may never be any retention ; on the con- trary, there may be constant true incontinence, or the bladder may take on acute inflammation, after an overdistention, with retention, and carry oS. the patient with acute febrile symptoms. Pyelitis or perinephritis may come in as complications, and quickly close the scene, or certainly precipitate the catastrophe. 184 DISEASES OF THE PROSTATE. CHAPTER X. DISEASES OF THE PROSTATE. Hypertrophy (continiiedV — Diagnosis; Descrijition of Instruments and Mano'iivres employed in their Use.— Exaniiniition of Patient. — Mctliods of retaining Catheters in the Hladder.— Metliods of deciding upon the Charaeter and Extent of Prostatic Deformity as affecting the Course of the Urethra.— Treatment.— Treatment of Complications.— Internal Remedies in Prostatic Disease- Natural Mode of Death due to Ilypertrophied Prostate. Diagnosis. — When a patient of over fifty comes to seek relief for frequent micturition, suspicion falls at once upon the prostate. It is rare that stricture causes trouble for the first time so late in life ; more- over, witli enlarged prostate, the inconvenience will, as a rule, have been first noticed at night — the reverse of what is observed in stricture. As the first step in the examination, the patient should be placed upon his back, with the knees elevated and abdomen relaxed, and a digital examination made through the rectum. B}' this means alone general prostatic hypertrophy can always be demonstrated. In ])lace of the soft, chestnut-like body, hardly recognizable except by the skilled touch, the finger will encounter a rounded, dense mass, smooth and symmetrica], or variously distorted and nodulated. The median fis- sure between the lobes may be more than usually perceptible, or may be wholly obliterated ; while the finger passed up on either side, be- tween the prostate and the walls of the pelvis, recognizes a deepening of the sulcus, and any undue prominence in size of one or the other lobe. Forcing the finger well up the rectum, it may be impossible to hook the last phalanx above the posterior margin of the enlarged pros- tate, while the seminal vesicles can usually be made out on cither side, partly imbedded in the general hypertrophy. Perhaps rectal examination may reveal none of these positive evi- dences of enlargement, median hypertrophy existing none the less. In such a case the finger readily detects the bladder, if it be distended, beyond the prostate ; the latter apparently not at all or but little larger than normal. Pressure through the rectum upon an enlarged prostate does not cause pain, unless there be some inflammation about the neck of the bladder. It often, however, proA'okes a desire to uri- nate. The next step in the examination is to make out the condition of the bladder by palpating and percussing the hypogastrium. Usually this method does not throw any light upon the condition of the pros- tate, unless it is exceedingly large, when pressure upon it tlirough the rectum may be recognized by the hand upon the hypogastrium. The same occurs in those rare cases of excessive hypertrophy of the bladder- IIYrEIlTROPIIY. liNJ5 walls with contraction of its cavity (concentric hypertrophy). As a rule, hypogastric palpation only reveals the fact that pressure above the pubes excites a desire to urinate — from transmission of the force to the sensitive neck of the bladder. Sometimes, however, an oval tumor is found, as large as a child's head, filling up the lower part of the belly, perhaps as high as the umbilicus, flat on percussion, and causing a desire to urinate when pressure is made upon it. This tumor, formed by the overdistended bladder,, may often be plainly seen, but the patient is usually unconscious of its existence. If the finger in the rectum can reach beyond the posterior border of the pros- tate, fluctuation can be felt between it and the other hand pressed upon the hypogastrium. The patient is now asked to stand up and to pass water into a glass vessel. A little gleety discharge may be often fouiid at the meatus, originating from the congested surface of the prostatic urethra. Oc- casionally, if questioned, the patient will confess that he is troubled with frequent erections, the cause of which lies in this same congestion. Sometimes, on the other hand, erections are absent. As the urine is flowing off, it will be noticed that it commences tardily, and in a small stream, which gradually enlarges. There is very little force to the flow. There may be two streams, the one pro- jected, and the other dribbling perpendicularly from the meatus, in- dicating an obstacle at the outlet of the bladder to the escape of urine. If there is retention, the urine will not flow at all, or comes away only by drops. While the stream is flowing, if the patient be requested to strain, instead of becoming larger or flowing with greater force, the stream may be diminished in size and power. Under these circum- stances a ball-and-socket arrangement, or some valvular condition of the overgrowth, may be predicated, which, when acted upon by the pressure of the abdominal muscles through the mass of accumulated urine, tends still further to occlude the internal urethral orifice, so that the stream flows fastest when the least effort is made. If the bladder be inflamed, there may be severe tenesmus and pain during the attempt to urinate, and the rectum may protrude or fa?ces be passed during the act. Hernia may be occasioned by the violent straining. At the end of urination the stream gradually dribbles away into drops, and often the final jet or "coup de piston "' is want- ing, although the latter may be perfect or even exaggerated. If the urine which has been voided be now held up to the light, it will be found to be cloudy, troubled, perhaps bloody, often ammoniacal, and to contain white flocculi of pus, or perhaps gouts of stringy muco- pus, or again it may be perfectly clear. The condition of the urine indicates the amount of cystitis present, while its quantity (in residu- um) and the force of its flow, after the catheter has been introduced, allow an estimate of the degree of atony. There may be considerable 186 DISEASES OF THE PROSTATE. irritability, witli little or no cystitis, and in such cases the urine is nearly or quite clear, generally strongly acid, and of high specific gi'avity. Usually there is more or less pus present, indicating cystitis, and, when the latter is of a high grade, the fluid is often ammoniacal, or has a fetid odor of decomposition, is tilled with pus, more or less blood, fluid or in clots, and stringy muco-i)us, which is often gritty from containing large quantities of triple-phosphate crystals. AVhen the patient has voided all the water lie can, he is again l)laced upon his back, and a full-sized silver catheter of short curve passed gently down toward the bladder. The instrument Avill usually go smoothly along (perhaps halting for a little coaxing at the triangu- lar ligament) until it has reached a depth of from six to eight or more inches, when it will stop. On no account should the least force be employed. A finger is now again introduced into the rectum to feel whether the instrument is in a false passage, which may have been made in some previous attempt at catheterization. If it is found to be in the canal and in the medi- an line, the finger can readily appreciate the approximate in- crease in thickness of that seg- ment of the prostate lying be- tween the instrument and the rectum ; and a diagnosis of ob- struction in the floor of the ure- thra at the neck of the bladder is established. In examining a patient for the first time, it should never be lost sight of that we are dealing with an old man whose urinary passages are in a more or less irritable condition, and probably unused to local disturbance. Any examination whicli is at all rough or too prolonged is j^retty sure to be followed by some aggrava- tion of the sym])toms, and, un- less the condition be urgent (retention), it is often advisable to make only a partial exploration at the first sitting, leaving the rest for an- other day. If made worse by his first examination, the old man becomes far less docile for future management. If, however, there is retention with or without overflow, it becomes the surgeon's duty to make judicious use of all available means to enter the bladder with a catheter. The next step in the examination is to determine the nature of the Fig. CO {T/wtJipson). IIYPERTROPHY. 187 obstruction in the iTrethra, and some instrument must be found which will enter the bladder. Unless the "third lobe" rise very abruptly from the floor of the urethra, the bladder may be entered by a silver catheter with an extra long curve. Such an instrument should be of large size. The surgeon should be provided with several of them of different sizes (from No. 15 to 24), and with varying curves (Fig. 60). One of these instruments will usually slip into the bladder, a flow of urine announcing the success of the operation. Generally the amount of residual urine is small. The degree of irritability is not proportionate to the amount of urine which can not be voluntarily passed ; indeed, it may be greatest where the residuum is at a minimum. It is always a favorable sign for prognosis, as far as the future comfort of the patient is concerned, to find a copious residuum upon the introduction of the catheter. Such cases are always more easily managed than others, provided only the patient can be taught to introduce a catheter for himself, since, by keeping his bladder from overfilling, he can avoid his most disagreeable symp- tom — continually recurring desire to urinate. Should the silver in- strument fail to enter the bladder, a small conical olivary French catheter, with a slender neck and a long fixed curve in its woven structure, designed to keep its point in contact with the roof of the urethra, will sometimes override the obstacle and effect an easy entrance. Failing in this, Thompson's method may be ^ employed. A medium, smooth, blunt English catheter is selected, its stylet removed, and itself bent into an exaggerated curve, the last inch of the curve being more accentuated than the rest. When the instrument has been shaped (Fig. 61), it is held for a moment in cold water, which causes it to retain the curve it has re- ceived until it again becomes warm. The in- strument so curved is oiled, and, without a stylet, rapidly introduced, so as to allow the heat of the urethra to act upon it as little as possible. It reaches the floor of the prostatic urethra before the point has lost its exaggerated curve, and this point, following the roof instead fig. 6i (Thompson). of the floor of the canal, readily surmounts any median hypertrophy and passes over the " third lobe " into the bladder. Another excellent method of overriding median hypertrophy with an English catheter is to introduce the latter armed with a stylet of exaggerated curve. When an obstacle is encountered, the stylet is slightly withdrawn. This manoeuvi'e causes the beak of the catheter to tilt upward sufficiently to surmount the obstruction. 188 DISEASES OF THE PROSTATE. Another instrument devised by Frencli ingenuity, and capable of rendering valuable serviee where perhaps no other catheter will pass, is a catheter known by the name of its inventor, Mercier. It is an . elbowed instrument, having a fixed angle (Fig. G2, A), or two angles (Fig. G3, B), in the woven material of which it is constructed. The English now make similar instruments, usually colored brown, some- 0. TIEMANN \ CO. Fig. 62. times black. They are generally too stiff and their angle is too obtuse ; consequently, though more durable, they are not so useful in difficult cases as the black French instrument. This catheter (similar instru- ments, with one or two angles, are also made of metal) is avowedly constructed to override obstructions in the floor of the urethra, such as posterior median hypertrophy. The point follows the roof of the canal or strikes any obstacle upon its inclined sur- face, and at an angle which allows the instrument to ride over the obstruction. For difficult cases these catheters are invaluable. The instruments already described suffice for general enlargement and for cases of "third lobe," but occasionally the canal may be so deviated by irregular lateral overgrowths that even these instru- ments fail to effect an entrance. For such cases there are several instruments left. Philliiis's cath- "M tt eter, open at both ends, introduced over a two-foot ^/# y^"^ guide, must not be forgotten. The red, soft-rub- ber catheter (Fig. 63) is an instrument of superior value. It is introduced without a stylet, and will sometimes follow the sinuous windings of a prostatic urethra where all other instruments fail. There are three varieties in the market, the prototype of the group, the old French, rough, red rubber catheter known by Nelaton's name, having disappeared. Of the three varieties, the English — now made with bev- eled eye — has the smoothest finish. The American instruments, called the velvet-eyed catheter and the Goodyear, are nearly as smooth. These catheters grow large and soft by use, and grow brittle sometimes by age — the former peculiarity makes them difficult to use on account of their limpness ; the latter makes them sometimes dangerous, for they crack, and pieces may break off and Fig. C3. nYPERTRQPIIY. 189 remain in the bladder. I have removed such pieces on several occa- sions. "When the soft-rubber catheter is too limp to be used, it may be rendered more rigid, without having its flexibility inter- fered with, by the use of Otis's stylet (Fig. G-i), or one that | I have devised for a similar purpose made of the cable of the dental engine (Fig. 65). A new catheter has appeared of late in all shapes — open-ended, olivary, blunt, curved Mercier, etc. — made of woven silk, and covered with an elastic varnish of high finish. This is an admirable instru- ment, possessing all the advantages of the rubber catheter and considerably more rigidity, so that in some cases it is much easier of introduction. Its stiff- ness, however, is in some cases a disadvantage, and it wears out, like all woven catheters, by blistering — a serious defect. Instruments of soft rubber may be worn in the bladder for a considerable length of time without (in many cases) producing much uneasiness or becoming incrusted by urinary salts, if the bladder be washed out with warm water pretty regularly. Self-retaining catheters have not proved successful, and their use has been abandoned. To tie a catheter in the urethra, the simplest method is to tie about it close to the meatus two soft strings. This doubled ligature is then knotted on each side at the level of the corona, and tied loosely under the corona if the latter is prominent ; otherwise the knotting is done a little lower down, and the penis and ligatures encircled with a double roll of narrow rubber plaster. After the plaster has adhered firmly, it should be cut in the long axis of the penis, to allow erection. Or, finally, the ligatures may be knotted to the hairs on the pubes, as Thompson advises. The French catheter- holder of soft rubber gets out of order, and is not better than the soft strings. The Squire jointed cath- eter has been well spoken of. I have never been able to make it pass when other instruments failed. It is made of silver segments of small size, not united together, but held in contact by a little flexible chain, running through the hollow of the catheter, and attached firmly to the last segment, which contains the eye (Fig. 66). The central chain terminates in a wire, which appears at the mouth of the catheter in the shape of a screw, furnished with a circular nut. By loosening the nut and pushing down the wire, all the segments making up the end of the instrument fall apart ; by tighten- ing it they are stiffened up and brought into j^lace, being left in a con- dition more or less flexible, according to the tension of the central Fig. 64. Fig. 65. 190 DISEASES OF THE TROSTATE. chain. This instrament, pushed down into a tortuous canal, is capable of assuming any curve, and following the windings of the passage. It Fig. 66. is not devoid of danger, because the chain holding the joints together has been known to break, leaving the metallic segments in the bladder. YVA_m,U,U>^J,..U^ ;;:^_S. TI£MANN (f CO 3 curve, truded Fig. or. A similar and perhaps better instrument is the metallic catheter known as Gross's catheter, having a sort of spiral end (Fig. 67). It has proved serviceable in some cases. The objection to it is the temptation to employ force in its manipulation. Another ingenious instrument of Mercier's may be useful. It is designed to avoid false passages. A silver tube, of long is furnished with a central woven catheter, which may be pro- and pushed on through an aperture in the concavity of the Fig. 68. instrument near its point (Fig. 68). The solid beak of the instru- ment enters the false passage, the soft catheter is protruded, and passes onward in the urethra into the bladder. Methods of estimating the Size and Character of Prostatic Overgrowth. — It is sometimes desirable, for accuracy of diagnosis, or other object, to get an approximate idea of the exact situation and size of the overgrowtb, together with the direction and amount of the deviation of the pro.-tatic urethra, perhaps for purposes of rough com- parison from time to time, to decide what advance is being made by the disease. A good deal of information, in a general way, may be gained on these points. In introducing the silver catheter of long curve, if the prostatic urethra be deviated to the right or left by the undue development of either lobe, the point of the in.^trumcnt will be coiTespondingly deviated, and the degree may be roughly estimated HYPERTROPHY. 101 by noticing the movements communicated to the handle. T])e increase in the antero-posterior diameter of the prostate may be rudely calcu- lated with the same instrument by noticing the depth to which tlic eye has to penetrate before it finds water — instead of seven or eight inches, perhaps ten, eleven, or more. In studying out the form of overgrowth at the neck of the bladder, all the information necessary may be obtained with a short-beaked, solid sound of the curve known as Leroy d'Etiolles's, or Mercier's, or with the similarly shaped metallic instrument known'as Thomp- son's stone-searcher (Fig. 69), the advantage of the latter being that it is a catheter as well as a searcher, and that, after the introduction, the bladder may be emptied, in- jected full, or distended to any desired extent, so as to facilitate examination, all of this without removing the instrument. The bladder should always contain a few ounces of fluid when this instrument is used. There is rarely any difficulty in introducing it through an enlarged prostate. Like Mercier's catheter, it is peculiarly adapted to glide over obstructions in the floor of the urethra, and this is the variety of obstruction which exists most fre- quently, and which most often o|3poses an obstacle to the entrance of rigid instruments, or those of ordinary curve. In examining an old case of atonied bladder, with en- larged prostate, for stone (and this examination should always be made whether there are symptoms of stone or not), Thompson's searcher is the best instrument to use, and during the search the condition of the internal orifice of the urethra should be examined. In introducing the instrument, if it is necessary to depress the handle greatly, in order to get through the last part of the prostatic ure- thra, it is because the beak of the searcher must rise gradually over a posterior median enlargement. If the beak seems to strike abruptly against a bulkhead, and on a little manipulation, perhaps, to slip, with a start, sud- denly into the bladder, the obstruction is probably a bar. When the beak is in the bladder, it is retracted until it hooks the upper margin of the urethral orifice. The shaft is now held nearly horizontally, and the instrument rotated. (The bladder must contain a few ounces of fluid.) If the prostate be healthy, or the obstruction a bar, this rotation can be performed with- out sensibly altering the direction of the shaft of the instrument. If there be a tumor jutting out anywhere from the prostate (posterior, median, or other enlargement), the beak becomes arrested, and the direction of the handle has to be changed in order to make it over- ride the obstacle. Such deviation will give the approximate position Fig, 192 DISE.iSES OF THE PROSTATE. Fig. rO. and size of tlie outgrowtli. Finall}', in withdrawing tlie instrument-., if the prostate be healthy, it may be retracted easily with the beak downward, while it will hook against any posterior median enlarge- ment (Fig,. TO). AVith the searcher the liypertrophied trabeculfe of mnscuUir tissue of the bladder may be also rec- ognized, and their size and number roughly es- timated. Treatment. — In the present state of our knowledge, hypertro])hy of the prostate is not curable by any means that have yet been used — by iodine, bromine, electricity, or pressure. The advocates of these and other methods have failed to establish their claims. Inflammatory increase in size may be successfully combated, hypertrophic aj^parently not. But still a vast deal of comfort may be afforded to patients ; they can always be greatly relieved, sometimes cured, that is, freed from every subjective symptom. It is only necessary to remember that hypertrophy of the jjrostate is a mechanical malady, obstructive in its character, in order to appreciate at once the great object and end of treatment, namely, to overcome by art the obstruction erected by Nature to the free outflow of urine. The catheter is the natural spe- cific for enlarged prostate, just as the steel sound is for stricture of the deep urethra. The catheter is no novelty in surgery. A need for its use has been recognized for ages, probably in just these cases of old men with enlarged prostate. Very good specimens of lead, copper, and bronze catheters (of long curve) have been found among the ruins of Pompeii. But, to be effective, the use of the catlicter must be intel- ligent, and other means must assist its employment, while, in very rare instances, where there is no residual urine, it is of little or no service. The best method, I believe, to go about relieving the symptoms of ]n'ostatic hypertrophy, is to attempt to blunt the sensitiA'Cness of the deep urethra by the passage of soft bougies or the steel sound at appro- priate intervals, and to overcome muscular spasm of the deep urethra, to which nearly all the symptoms are due in many cases of jorostatic enlargement. I think that the common olivary French bougies, or in many cases the long-curved steel sound is an appropriate instrument for this purpose. Reginald Harrison has devised a soft bougie with a long oval bulb at its extremity (Fig. 71), which he deems especially HYPERTROPHY— TREATMENT. 193 suitable and appropriate for this purpose, ascribing some of the value of the instrument to the fact that its shape allows it to dilate the neck of the bladder on its way out as well as on its way in. I have found in many instances most positive advantage in overcoming irritability, Fig. 71. spasm, and cystitis of the neck of the bladder, in cases of enlarged prostate, in the use of deep urethral instillations of the nitrate of silver with the deep urethral syringe (p. 78), throwing about three drops of a solution of a strength varying from gr. ss in the | j up to gr. X or more in the 3 j, into the membranous urethra, at intervals of from two or three days up to a week or ten days.* The method is not suitable to all cases. Where it agrees it gives comfort, but does not cure, and takes rank with the bougie and sound, but is far better than either in appropriate cases. Next in value comes systematic drilling in the use of the catheter. If the residual urine is small in amount, and the fluid clear, the cath- eter sometimes gives no relief, and may be dispensed with. When there is considerable atony the bladder must be emptied. Here the utmost care must be employed, for many an old man has been brought to his death directly by the zeal of his medical attendant, who has been too precipitate in managing an atonied bladder with a catheter. The best care and the nicest attention often fail to avert lighting up cystitis at the commencement of catheter life, but proper care and attention will save a certain percentage of cases, and many valu- able lives. To test for residual urine the patient stands and urinates. Then, if a catheter is to be used for the first time, a clean, disinfected rubber instrument (or any other) is selected, and washed in very hot water. This I believe to be as good as any antiseptic liquid. The catheter selected is gently passed, the patient being erect or prostrate, as the surgeon may prefer, and the urine drawn off. If the patient is nerv- ous or in any case of doubt, the recumbent posture and rubber catheter * Consult a paper on this subject by E. L. Keyes, "New York Medical Record," May 28, 188Y. 13 194 DISEASES OF THE PROSTATE. are to be preferred. If the bladder is considerably distended, all the urine should not be drawn off at the first sitting ; a half or a quarter of it should be left in. Even when the residuum is comparatively small, I thinl- it better to leave a little hot borax water in the bladder after drawing off the urine. Some of this — a dessertspoonful to the i)int — may be at hand in a bag-syringe. It is not well to leave the bladder empty after it has long been distended. This is particularly true when the bladder has habitually been considerably overdistended — beyond a ])int. Nor is it well ever to empty one of these largely overdistended bladders in the erect posture. Death has been known to follow im- mediately upon the entire withdrawal of the contents of such a blad- der, faintness is not uncommon, and cystitis almost inevitable. After the first passage of the catheter the patient should remain warm and quiet, but not necessarily in bed, for some hours, preferably for an entire day. After a few days the process may be repeated, and presently the bladder may be entirely emptied and left empty. The most common form of the so-called catheter-fever is that which comes on four or five days, perhaps a week, after the first introduction of the catheter, when the patient will become chilly, ill at ease, the urine faintly brothy from mucus and pus, containing bacteria. This condition persists, and becomes aggravated more or less by symptoms of cystitis, which may run high, with blood in the urine and great tenesmus. Chills may recur. The temperature, usually high, is sometimes subnormal from the beginning. Pyelitis may come on, and multiple bacterial abscess in the kidney, and the patient may die in four, six, eight weeks — perhaps even later — after the first intro- duction of the catheter, which has been the direct occasion of his taking off. No expenditure of care is too great to avert this catastrophe. The care consists in (1) always using a disinfected catheter — ^best, a clean new instrument, washed in water nearly boiling ; (2) keeping the pa- tient warm and at rest after using the catheter ; (3) never emptying the bladder entirely (if it contained much fluid on the start) until the second or third sitting ; (4) washing with hot borax water whenever the bladder is emptied, until the patient is habituated to the use of the catheter. If cystitis comes on it must be treated as hereinafter directed. After the surgeon has elected a suitable soft instrument, and estab- lished a tolerance of the bladder to it, and brought the patient through any cystitis or surgical fever which may have been occasioned by the instrument, the next step is to instruct the patient to pass the catheter himself, and to take care of himself locally, probably for the rest of his life. He is directed to cover himself with merino in summer and flannel m winter. His feet and ankles must be especially well pro- tected with suitable Avoolen stockinets. Tlie feet lie farthest from the HYPERTROPHY— TREATMENT. 195 heart, the source of heat. From their pendent position, the venous blood has great natural difficulties in getting out of them. They are that part of the body most easily chilled, yet habitually they are the least well protected, especially by old men. A knowledge of these facts indicates the natural means of remedying the evil. An ordinary case requires no change in diet. Exercise should be taken at will, not on horseback at first, or of a kind attended by jolting, as this tends mechanically to increase the congestion about the base and neck of the bladder, and leads to an aggravation of the symptoms (irritability) The catheter should be used by the patient more or less often, accord- ing to the quantity of residuum, normal intervals of urination being observed as nearly as possible. In ordinarily mild cases, where the frequency of urination comes on mainly at night, emptying the bladder once thoroughly Just before retiring may be all that is required. After this, the patient will sleep quietly until toward morning, when the residuum will have re-col- lected, and then the desire to pass water will again return. Where the residuum is large, a pint or more, it is far better for the patient to rely entirely upon the use of the catheter, introducing it three or four times daily, perhaps five or six, and never attempting to pass a drop of urine without its aid. This becomes necessary where there is a valvular condition of the vesical orifice, or such other deformity as makes it impossible for the patient to pass any water. Here, if the catheter enters easily, the patient is perfectly safe. He goes around carrying his instrument with him. He becomes proud of his ability to introduce it, and does it better than any one can do it for him. Patients may go on in this way for many years. I have known several cases of use of the catheter for about twenty years. Sir H. Thompson* knew a gentleman of ninety who had passed the catheter for twenty-two years, and a gentleman of Norwich told him that he had passed the catheter upon himself thirty-five thousand times, and no harm had come of it. Thompson made some observations with Dr. Messent upon old men in Greenwich Hospital, and found that, while the average age of death there was seventy-three, the average age of death of those who used a catheter was seventy-two and three fourths, a very excellent showing of the harmlessness of using a catheter habitually. Patients who have considerable atony and tolerant bladders have little else to do except to keep their bladders clean by injections of warm water, once or twice daily, to prevent the formation of stone, or the lighting up of inflammation by the decomposing urine, and to keep themselves supplied with catheters. The question now naturally arises. Is it advisable to instruct a * Mentioned at a meeting of the Royal Medical and Chirurgical Society, at which I was present, in May, 18Y9. 196 DISEASES OF THE TROSTATE. patient with enlarged prostate in the use of the catheter, if he has a very small amount of residuum or none at all ? Most assuredly, yes. If there is no residuum, still, with the slow advance of the disease, a time is pretty sure to come when there will be a certain quantity, or when, from the effect of cold, irritating urine, or other cause, retention may come on. It is a rule with no exceptions, that a i)ationt with hyper trophied prostate is never safe unless he can pass a catheter for himself, any more than is a patient with hernia who does not wear a truss. Hence, in all cases, the patient should be taught the use of a soft catheter, be provided with an instrument, and instructed in the manipulation of washing out the bladder, both for purposes of clean- liness and so as to be enabled to employ medicated injections. If the amount of residuum is small, so that no material relief is afforded by the mere draining off of the urine which the patient can not pass, still the force of the above reasoning is applicable, and the utility of wash- ing out the bladder is equally necessary, since the liability to the formation of stone exists as well where the residuum is small as where it is large, if there is any cystitis and retained muco-pus. If no instrument can be made to enter the bladder, and there is retention, the aspirator should be used twice daily above the pubis for a time, meanwhile attempts being made to reach the bladder with the catheter. If all efforts finally fail, a permanent opening must be established above the pubes, or a radical operation done through the perinaeum. The washing out of an hypertrophied and dilated bladder, where the mucous membrane is habitually congested and secreting an over- supply of mucus, is a. point of treatment of cardinal importance. By this means the last drops of residual urine, with the pus and stringy mucus which they contain, are diluted and drained away, and no ferment is left behind to decompose the healthy fluid as it comes down the ureters. The formation of stone is prevented, and the con- gestion existing around the neck of the bladder is soothed and kept from any aggravation which would increase the irritability — that dis- tressing symptom so closely linked with the pathological changes incident to enlarged prostate. The best method of washing out the bladder is as follows : The soft catheter through which the residuum has been drawTi off is used. A double-current catheter is not advisa- ble, for with such an instrument no distention is brought to bear upon the bladder-walls, and the whole mucous surface is not brought into contact with the cleansing fluid. Warm water should be used, since it is soothing as well as cleansing, and does not excite the bladder to speedy contraction upon being thrown into its cavity. A tempera- ture of about blood-heat should be aimed at — a little below 100° Fahr. The best instrument for a surgeon to use in washing the bladder is probably the bulb-syringe, holding about six ounces, with a tapering IIYPERTKOPUY— TREATiMENT. 107 nozzle — so that it may fit any catheter (Fig. 72). The pi.ston-.syringe or the Davidson will answer, but they are not as convenient. The best instrument for a patient to use in washing out his own bladder is the fountain syringe (Fig. 73), with two-way metallic stop-cock and hard-rubber nozzle. The mechanism is obvious. No air enters the Fig. 72. Fig. 73. bladder, and repeated washings may be comfortably effected until the bladder is clean, without any more trouble than turning the stop-cock back and forth. In using this bag, that the temperature of the injected fluid may reach the bladder at about 100°, it must be started in the bag between 110° and 115° Fahr. In injecting a bladder with any instrument, the fluid should be gently thrown in until a feeling of moderate distention is experienced, when it should be allowed immediately to escape, a second and third washing being resorted to until the wash returns clear — then the medicated injection should be thrown in. The patient easily learns to wash his own bladder, and once accustomed to it he practices it voluntarily whenever the urine becomes purulent or foul, because he learns from experience the advantage of keej^ing his blad- der clean. The frequency of the washing depends upon the condi- tion of the urine. At the commencement of treatment in many cases where the irri- tation of using the catheter keeps up or increases the mild cystitis 198 DISEASES OF THE TROSTATE. already existing, and causes a free and continued secretion of pus, it is advisable to pass from simple water to the use of medicated fluids in injection. These may be first employed by the surgeon, afterward intrusted to the patient. Nothing better can be suggested for the patient's use than borax — pure and simple — from a heaping dessert- spoonful to a tablespoonful to the pint, or strong lead-water (Goulard's extract), one to two teaspoonfuls to the pint. The surgeon may use, often with greater advantage, acetate of lead, one sixth to half a grain to the ounce of water ; sulphate of zinc, gr, ss to ij to the 3 j; one to twenty minims of dilute nitric acid to the pint of water ; or, best of all, in some cases, nitrate of silver, from gr. j to gr. v to the pint, or stronger in cases that are tested and studied. Carbolic acid and the bichloride of mercury do not give good results in my hands ; chlorate of potash and boracic acid, silicate of soda, permanganate of potash and quinine, I have abandoned. I have sometimes thought that I derived a little benefit from injecting a solution of the muriate of hydrastin, gr. j-v to the pint, and occasionally from the use of mild solutions of hamamelis. In certain very rare instances it may be deemed advisable to tie in a catheter (p. 1^9). None but a soft instrument should be so em- ployed, preferably one of pure caoutchouc, as they will remain longest in the bladder without becoming incrusted with urinary salts. Cases requiring the tying in of a catheter are those in which introduction is exceedingly difficult, and the patient lives at a distance from the surgeon, or where the neck of the bladder is very tolerant of an instru- ment, and it is desired to prevent the irritation of frequent reintro- duction, and the spasm of the muscles of the bladder and perina^um which such reintroduction occasions. Wherever an instrument is left tied in, whether the patient is walking about or on his back, the cavity of the viscus should be thoroughly washed out with warm water several times daily, and the instrument removed if it api)cars to be causing irritation. Sometimes a caoutchouc instrument may be worn for months, and removed still clean, if the bladder has been syringed out regularly. In those rare cases where there is real incontinence (not overflow), where the patient is constantly leaking slightly, either continuously or by little jets, caused by involuntary spasmodic muscular contractions, or, finally, in any case where the patient's calls recur at short intervals, and the nature of his occupation is such that he is not sure of always being able to reach quickly a place where he can relieve himself, he should constantly wear a urinal. Of the many varieties of this instrument found in the shops, only one accomplishes the two necessary objects of being safe as well as comfortable. Tlie urinal referred to (Fig. 74) was devised by a pri- vate gentleman of this city, suffering from true incontinence. He HYPEllTROPUY— TREATMENT. 199 was accustomed to dine out frequently, and related with enthusiasm the satisfaction he experienced, when conversing in the evening with a lady guest, to feel the urine trickle down his thigh, with the con- viction that it was going to the right place, and could not disgrace him. The construction of tliis urinal is most sim- ple. It is made of soft rubber, in the form of a large pouch, capable of receiving the whole scrotum as well as the penis, and large enough to allow a free circulation of air around the parts, thus preventing sweating or excoriation. From this pouch two broad bands of rubber extend up flatwise, one over the belly, the other over the nates to the waist, where they are attached by buttons to the suspenders. Below, the pouch terminates in a long, flat bag, attached by tapes to the thigh and leg, and reaching nearly to the ankle, so that no urine collecting in it can possibly spill out during any ordinary motion. A metallic cap at the bottom unscrews to drain oS the urine and clean the instrument, which should be washed out daily with a mild solution of permanganate of potash. Treatment of Complications. — During the use of the catheter, one or both testicles may swell. This is not a matter of serious impor- tance, and may be overcome by the treatment for epididymitis. If the pain is severe, or if position alone relieves the pain, as it usually will do, there is no necessity for anything further ; introduction of the catheter may be continued, and the swell- ing will subside. What is liable, however, to give most trouble early in the treatment by repeated catheterization is the congested condition of the neck of the bladder. In most cases, especially where retention has come on, this congestion is considerable, and is readily aggravated, the slight violence done in catheterism lighting up a little cystitis about the neck, or increasing what already existed. Cystitis announces itself by increased uneasiness when the bladder contains only a slight amount of urine, tendency to spasmodic contraction of the bladder-walls, un- less they are atonied, increased amount of pus in the urine, and almost always by the presence of blood in greater or less quantities. This amount of cystitis is most apt to come on during treatment of a bladder already somewhat irritable, where there is not much atony or after-retention. Old cases, where the organ has been overdisteuded by a very large residuum for years, are not liable to suffer much from Fig. 74. 200 DISEASES OF THE PROSTATE. the introduction of the catheter, provided the bhidder is judiciously (not too suddenly) emptied. When cystitis of the neck comes on, calls to urinate will become more and more frequent, the last part of the urine drawn through the catheter will be tinged with blood, per- haps blood will continue to flow into the bladder after the withdrawal of the catheter, so that the next urine passed or drawn will resemble pure blood, or may be nearly as black as ink, if it has been retained for some time ; or, again, if blood flows freely and quickly into an empty bladder, it may fill it to a certain extent, clotting into a solid mass in its cavity. None of these conditions need cause alarm. If the flow of blood is excessive, and the bladder has power to empty itself, it is expedient to intermit the use of the catheter for a time, otherwise it must be con- tinued, employing the utmost gentleness of maniiiulation. Unless cystitis of the neck becomes a prominent complication, the bleeding, on the use of the catheter, will cease in a few days, and then the patient may be allowed to get out of bed and gradually to resume his ordinary habits of life, relying on warm-vv^ater injections to keep the bladder clean and the residuum from decomposing. When the flow of blood and irritation around the vesical neck are considerable, opium, in suppository, is advisable for a few days. If the bladder becomes filled bva clot, no attempts to break it ujo or dislodge it are admissible. It will gradually soften, dissolve, and come away in the urine, which should be kept abundant and alkaline. Sometimes pain is so great that the clot has to be removed, which may be properly attempted by injecting hot water containing about one quarter or one sixth of a fifteen-volume solution of peroxide of hydrogen. In the great majority of cases the above treatment will cover the ground, and afford all the relief the patient can hope to find, general hygiene being regulated, exposure to cold particularly avoided, the urine kept from becoming too acid, and the patient being made his own physician. Some patients can not get along without the occa- sional insertion of an anodyne suppository, but the use of such means of relief should never be placed in his hands unless he is made fully aware of the danger of abusing his power. In some cases, after reten- tion, the bladder will gradually reacquire its contractile power, and the amount of residuum will be lessened, but this is rare. The atonied, overstretched bladder of an old man does not recover its tone like that of a youth, and indeed it is better that it should not. The patient should be encouraged to rely entirely upon his instrument, and not to strain to use his bladder. Some cystitis almost invariably exists, in a greater or less degree, before the patient applies for treatment, and it is, in fact, often for relief from the symptoms caused by it that he so applies. The cystitis gives rise to his frequent calls to urinate, and supplies the in\s and II YPERTROniY— TREATMENT. 201 stringy mucus with wliich his urine abounds. A mild degree of cystitis will subside spontaneously, as a rule, under the improved condition of the bladder produced by draining off its residuum and washing out its cavity. Internal Remedies in Cases of Hypertrophy. — When the cystitis seems to be getting unmanageable, when the calls to urinate arc fre- quent and painful, or in any case when the amount of pain is con- siderable, it is better to use an anodyne suppository, which may best consist of codeine (gr. j-ij), watery extract of opium (gr. ss-ij), or morphine (gr. -|-j). Camphor is occasionally added to these supposi- tories for the purpose of obtaining more effect with the employment of less opiate, or, more often, extract of belladonna, with the alleged object of allaying spasm. The efScacy of both these latter agents is overrated. The object is to allay pain, and pain only justifies us in using opiates. The frequency of calls to urinate may be great, but, if there is not pain as well, there is no indication for anodynes. The amount used should be barely sufficient to control the pain, and should be subdivided into many small doses (three to four in the twenty-four hours), rather than given all at once, or even night and morning. Laudanum or other fluid may be used instead of solid suppositories. The reason why anodynes are of no service by injection into the blad- der is that only a small amount is absorbed, unless the solution in- jected be concentrated, while the bladder epithelium is entire ; but, should an abrasion or ulcer exist, the amount absorbed may be very considerable, producing more effect than was desired. Atropine or belladonna, in sufficient doses, will lengthen the intervals of urination, and modify pain ; but the agent is in many cases uncertain in its action and difficult to manage — in some cases it acts well. One twenty-fifth of a grain of sulphate of atropine in water is a proper dose to com- mence with, increasing gradually until an effect is obtained, and watch- ing the patient for symptoms of poisoning. When cystitis, accompanying enlarged prostate, becomes considera- ble enough to require the use of anodynes, the recumbent position should be insisted upon. The patient should lie upon his back with a hair pillow under the hips, so that they may be raised higher than his shoulders, in this way relieving the bladder from some of the in- testinal pressure, and favoring a drainage of venous blood from the pelvis. The head may be raised, but the shoulders must be low. The skin of the hypogastrium should be kept slightly reddened by the application of a hot, light poultice, containing a sprinkling of mustard, or more neatly by the use of moistened mustard-paper, and a flat rubber bag, containing hot water, which may be laid upon it. Heat, applied also to the perinseum, is agreeable to the patient. These bags afford great comfort. The rectum should be kept empty by the daily use of a hot enema. Water, as warm as can be borne 202 DISEASES OF THE PROSTATE. ill the rectum, often exercises a decidedly soothing effect upon the inflamed bladder. The only internal remedies which seem to be of nnich service are the different alkaline diuretics and diluents. Of the former, citrate of potash, in gr. xx-xxx doses, three or four times daily, according to the concentration and acidity of the urine, is pcrlnqis the best. It may be alternated with bicarbonate of soda, acetate of })olash, or liquor potassa\ The alkali may be given in carbonated water, flaxseed-tea, or in whatever diluent is selected. The variety of this latter class of remedies is innumerable. All of them are doubtless of value, but none possess specific qualities. They should be taken largely. The one ]ierhaps most generally useful as well as agreeable is ordinary flaxseed- tea flavored with lemon-peel (lemon-Juice is to be avoided) and sugar, and taken cold or warm, to the extent of from one to three pints in the twenty-four hours. Buchu, so popular in this country, may be combined with it in infusion, from three to six ounces daily. Thomp- son speaks well of a decoction of the underground stem of the Triti- cum repcns, made by boiling two ounces of the root for a quarter of an hour in a pint of water. This is strained, and the w^hole taken in four doses during twenty-four hours. If the patient tire of one decoc- tion or infusion, it may be changed for another — pareira brava, nva ursi, corn-silk. The old combination of hyoscyamus and liquor potassas, chemically incompatible, is clinically often of decided service. The old form of prescription made with the tincture is not so useful, on account, possi- bly, of the alcohol it contains, as the same made from the extract of henbane. The following formula has proved quite eflScient in mod- erating frequent and painful micturition : 5 Liq. potass£E, 3 ij^ § ss. Extr. hyoscyami, f 3 j- Syr. aurant. cort., ) or, Mist, acacias, Aquae cinnam., ila 3 iij. ) Aquae, au 3 iij. M. S. A tablespooaful in some diluent every eight hours. As has already been several times stated, the urine coming from the kidneys, in these cases of bladder disease depending upon obstruction to the free outflow of urine, is nearly always acid, over-acid indeed, 'oecoming alkalinized in the bladder, and the object of giving alkalies by the mouth is to render the urine less irritating to the sensitive lin- ing membrane of the bladder. Ilence the impossibility, and indeed the inappropriateness, of endeavoring to render the urine acid by ad- ministering acids. By the employment of the above means, aided by a large share of patience, the washings of the bladder being regularly and gently at- tended to, cases of vesical catarrh depending on prostatic obstruction will gradually get well up to a certain point, not incompatible with nYPERTROniY— TREATMExXT. 203 the exercise of all his functions by the patient, and, provided only he attend scrupulously to keeping his bladder clean by warm-water in- jections, leaving him capable of enjoying a life as long, as comfortable, and as useful as if his bladder were sound. This statement, of course, does not apply if either of the three complications, so common with this form of disease, exists — namely, stone, mild pyelitis, or fatty atro- phy of the kidneys. Where stone is present, it must be removed. The radical treatment of enlarged prostate by medicine is in my opinion a delusion. The cases recorded prove nothing. Many a man has enlarged prostate and retention, and uses a catheter for a longer or shorter period, and then under milk diet or improved health he recov- ers his expulsive power and abandons his catheter. I have several instances of this among my patients, none of whom took ergot, while I have given ergot in large and small doses to scores of people for months at a time, and I have yet to see the first case that derived any advantage from the drug that I could appreciate. The same is my opinion of the interstitial injection of ergot or of iodine into the pros- tate (Heine's method). By this method Dittel* once produced acute prostatitis with suppuration. The surgical means for reducing the size of the prostate are radical and often effective. Harrison's f suggestion of puncturing through the substance of the prostate and leaving in a silver tube, to produce atrophy, I have not tried. The method of Mercier — of crushing off a portion of a third lobe, or of a prostatic bar — is not accurate enough, and is too rough to be good surgery. It sometimes yields good results, but the same can be accomplished better, more surgically, and with no greater risk to the patient. The method of Bottini,J of Pavia — namely, incision of third lobe by a galvanic cautery prostatotome passed through the urethra — is open to the same objections, besides requiring special apparatus and some skill as an electrical expert. Good results, however, have been reported from its use. But the best radical methods are undoubtedly either (1) suprapubic cystotomy for ablation of the third lobe, which is of easy accomplish- ment and yields good results, although it is an operation too serious to be lightly undertaken for a malady which itself does not kill, and may be so readily alleviated as to its symptoms ; or (3) perineal section with ablation of any interstitial tumor which may project into the incision,* or most often cutting or tearing away of third lobe or jDro- * "Centralblatt f. Chirurgie," November 27, 18*76. •)• "Lithotomy, Lithotrity," etc., London, 1883, p. 65. X Described at length with many other methods in the excellent article " Prostate," in the " Nouveau Diet, de Med. et de Chir. Prat." * Sir William Laurence had such a case. Reported by FeFguson, " Med. Times and Gazette," April 18 and May 23, 1857. Harrison had another, and others have been reported — Keith, Thompson. 0(jj. DISEASES OF THE PROSTATE. jecting portions of prostate through the incision ; or, linally, slitting through third lobe or prostatic bar, tying in a large tube, and allow- ing a new floor to the prostate to form by cicatrization about the tube. Both these latter operations I have done a number of times, always with relief to the patient, although what may be called a positive cure can not generally be effected. In one instance, however, I restored to a patient who had only urinated through a catheter for four years the power of voluntary urination by taking away his third lobe through a perineal incision, and a number of patients with cystitis of high grade have been greatly benefited at my hands by perineal drainage combined with cutting into the floor or taking away an outstanding portion of prostate. These radical measures I can therefore heartily indorse in severe cases when palliative means fail to comfort the patient or to protect his general health. Mode of Death in Cases or HYPEETROPnY. — The not very infre- quent complication of a low grade of inflammation of the ureters and pelves of the kidneys is always a serious matter. This becomes easily aggravated by cold or imprudence in diet, developing at once symp- toms of mild urtemia, with hot, dry skin, loss of appetite, slee})lessness, great restlessness, dry, red, or pasty tongue, parched mouth, tendency to depression, headache, tendency to wandering of the intellect, con- stipation — all this attended, as a rule, by polyuria, a little albumen, and a few pale casts in the urine. A fatal termination of these symp- toms is a not uncommon mode of death in cases of prostatic disease. The complication is best treated by confining the patient to bed, in a room where the air can be frequently renewed, and the temperature kept high, at 80° Fahr. or thereabouts ; exciting the action of the skin and bowels ; giving diluents in abundance, and a mild (milk) diet. The combination of potash and hyoscyamus acts well upon these cases, and some mild stimulant is not only admissible, but necessary to keep up the general strength until kidney congestion has subsided. These evils are more easily avoided than cured. A more uncommon but a possible cause of death is peri- and epi- cystitis with their complications. A remarkable case of perforation of the bladder after prolonged retention, due to prostatic disease with extensive suppuration burrowing upward into the pleural cavity, is recorded by Duplay.* * "Arcbiv. Gen.," March, 1811, p. 604. CONGESTION OF THE PKOSTATK. £05 CHAPTER XL DISEASES OF THE PROSTATE. Congestion. — Parenchj'matous Prostatitis. — Terminations: in Resolution, f;liroi)ic Prostatitis, Abscess.— Treatment.— Gonorriiocal Prostatitis.— Prostatic and Peri-prostatic Abscess.— Treat- ment of all Forms of Abscess.— Follicular Prostatitis.— Its Liability to be mistaken for Stone in the Bladder. — Treatment.— Tubercular Prostatitis.— Cancer of the Prostate.— Prostatic Con- cretions. — Prostatic Calculi. — Neuralgia of the Prostatic Urethra.— Syphilis of the Prostate. Coi«rGESTiON" of the prostate occurs physiologically during venereal excitement. If such excitement be unduly prolonged without being gratified, even sometimes without erection, if the imagination be given up to erotic fancies, the mucous follicles of the organ secrete more or less of a peculiar, viscid, bluish mucus, without odor, which, mixed with urethral mucus, finds its way out at the meatus. This phe- nomenon is perfectly natural. Physiologically it is analogous to the watering of the mouth of a hungry individual at the sight, smell, or even thought of food. Many individuals, however, whose sexual re- quirements are not met, live in such a state of mental inquietude, particularly in regard to the genito-urinary organs, that this drop of mucus appearing during erection excites in their minds the most lively alarm, and they hasten to their surgeon to demand his aid for sper- matorrhoea, stating that they never have an erection without the in- voluntary emission of seminal fluid. Of this idea it is often hard to dispossess the patient's mind, but an honest explanation of the whole subject will rarely fail to convince him ; while the observance of purity of thought and the avoidance of occasions of sexual excitement, or, better still, marriage, to place him in natural sexual relations, will prove, infallibly, effective of cure. If this physiological hyperemia be kept up for a long time (several hours), the prostate is liable to remain congested, throbbing slightly, feeling full and hot, giving rise, perhaps, to frequent calls to urinate, and attended by a very slight gleety discharge. If the patient urinate frequently, straining to empty the bladder of its last drops, the pros- tatic congestion is maintained and aggravated. All these uncomfort- able feelings, due to prostatic congestion, are relieved by rest ; more quickly by a cold sitz-bath, or by a very hot sitz-bath of short duration. The desire to urinate produced by the contact of water should not be yielded to. Slight congestion of the prostate frequently comiDlicates gonorrhoea, stricture, etc. It is usually ephemeral in character, announcing itself only by a little increased frequency of urination, or it may continue 206 DISEASES OF THE PROSTATE. on to actual inflammation. Congestion may be excited in the pros- tate by sexual excess, masturbation, etc., and this, boinfj kept up and often repeated, may lead to chronic follicular jn'ostatitis, without passing through any acute stage. PROSTATITIS. Inflammation of the prostate is of two kinds : 1. Parenchymatous. 2. Follicular. Paeenchymatol's Prostatitis. — Spontaneous (primary) inflam- mation of the prostate is rare ; inflammation, traumatic, or extending to the prostate from contiguous parts, is not uncommon. Causes. — Among the causes of prostatitis may be enumerated gonorrhoea, stricture, extreme and prolonged sexual excitement, con- centrated acid urine, cold, violence from instruments, stone fragments, etc.: chemical irritants, strong injections, cantharides internally, etc. Gonorrho^al inflammation, after the first week, may run rapidly down the urethra and involve the prostate, particularly if the patient in- dulge in liquor, sexual intercourse, or take violent exercise, or use strong injections, throwing them deep in the canal. Sometimes, dur- ing gonorrhea, without apiircciable exciting cause, the prostate in- flames. The inflammation behind a stricture may run back and involve the prostate in the same way. Sexual hyperaemia, too much prolonged or too often repeated, may lead to it. Course. — Prostatitis commences as congestion. Passing on to true inflammation, it terminates by resolution, exudation of pus on the free surface, perhaps by croupous exudation ; by abscess, or peri- prostatic formation of pus ; or, finally, it may linger indefinitely as a chronic (follicular) inflammation, mild in degree, occasionally becom- ing aggravated. Symptoms. — The organ swells rapidl}^ putting the capsule on the stretch, and often reaching the size of a small orange. It may feel square (Vidal), or be unevenly enlarged. The exjiloring finger in the rectum strikes at once against this mass, which juts into the cavity of the gut, is very tense and hot, and can be felt distinctly to pulsate. It is exceedingly sensitive to pressure — unlike prostatic hypertrophy, which is not sensitive unless inflammation be present. In prostatitis the lightest touch, even the presence alone of the finger in the rectum, at once excites a desive to urinate. Pressure over the pubes brings on the same desire. The patient is conscious of something protruding into the rectum, and may experience an unnatural desire to go to stool. If he endeavor to do this, he strains ineffectively, causing himself pain, but getting no relief, even if he succeed in forcing out a little fecal substance, after suffering great distress in the effort. The peringeum feels hot, and is sensitive to pressure. The subjective sensations. ACUTE PROSTATITIS. 207 locally, arc heat, weight, throbbing. There is a sort of drugging feel- ing oyer the lower part of the abdomen, as well as in the penis and scrotum. There may be pain in the back and limbs. If gonorrhoea be the cause, or stricture with profuse gleet, the urethral discharge ceases at once, or becomes very scanty and thin. It returns, however, as the prostatic inilammation subsides. The stream of urine is small and is passed with eifort. The prostate may swell to such an extent as to obliterate the prostatic urethra entirely for a time, causing reten- tion. Thompson believes tliis to be the cause of all retentions which occur during acute gonorrhoea — in fact, of all retentions supposed to be produced by so-called inflammatory stricture ; but this is certainly wrong, urethral spasm is most often at fault. With this swelling of the prostate is almost invariably associated congestion of the vesical neck, and a constantly-recurring, never-satis- fied desire to urinate. If retention comes on, as it rarely does, this feeling exists as a matter of course ; but, even when the bladder is entirely empty, it feels partly filled, there is no sensation of relief after voiding the urine, and, when a few drachms have re-collected, the urgency of the sensation forces the patient to another effort, equally unsatisfactory. The urine causes j)ain on its passage, but the pain is most severe as the last drops are being expelled, when the circular fibers at the bladder's neck squeeze the tender prostate. It is now that blood is often discharged from the overloaded vessels, coloring the last drops of the stream. A pain like that occurring with stone is experi- enced, both in the peringeum running down the urethra and, often with greatest intensity, on the under surface of the penis in the ure- thra, at about three quarters of an inch from the meatus. Coinciding with all these features, which map out the disease so plainly that it is impossible to mistake it, there is general febrile disturbance, with usually the utmost concern, apprehension, disquietude, and depression with excitement of mind, such as is rarely caused by inflammations of much greater magnitude, and attended by far more severe pain else- where. The patient is irritable, despondent, and suspicious ; often, in fact, wild to an extent amounting to mild acute mania. He can not sleep, he will not eat, and it is with difficulty that he can be kept quiet. Fortunately, his feverish condition induces him to drink abun- dantly of mild, bland fluids. The inflammation may subside before the malady has reached this point. Resolution may come on at any time, even after the above extreme has been reached ; the throbbing pain and heat disappear, and usually a little discharge appears from the prostatic sinus. This dis- charge may continue for a considerable period (follicular prostatitis), or may rapidly cease while the calls to urinate grow less frequent, and the sensation after the act approaches the full relief felt normally. If the inflammation has extended into the seminal vesicles, there may be 208 DISEASES OF THE PROSTATE. spermatozoa in the discharge. A false membrane may form in the prostatic sinus, but this is exceedingly rare. Finally, the inllamma- tiou may extend down the vata deferentia, linger in a chronic form in the seminal vesicles, or pass on to light up epididymitis. If the inllamination, instead of undergoing resolution or passing to a chronic state, continue, abscess is the result. Resolution usually takes place between the fourth and twelfth day, and recovery is com- ])lete in from one to three weeks. Possibly, instead of recovering or continuing as a distinct folliculitis, chronic interstitial inllammation may remain behind, leading to induration and general tumefaction of the gland, which nuiy persist for months or years, and may even be described and treated as hypertrophy. This kind of (false) hyper- trophy giA'es good results with pressure, electricity, etc., namely, ab- sorption of the iutlammatory product, and thus is excited the vain hope of a similar result where true hypertrophy exists. Treatment. — No point of treatment is so essential as rest in any congested or inflamed condition of the prostate. Eepose, as nearly absolute as possible, may bring about resolution where otherwise sup- puration would have ensued. The tripod of safety for a patient with prostatitis is rest in bed, some alkaline diluent for the urine, and enough anodyne to control severe pain and excessive action of the bladder. The rest should be in bed, the patient lying upon his back with the hips raised. The bladder should be restrained from contract- ing as much as possible by the exercise of the will, while forcible efforts at emptying the last drops of urine — to which the patient's feelings impel him — should be interdicted. For the same reason cathartics should not be administered. Copious enemata of hot water carefully given are preferable. The jutting out of the tense prostate into the rectum gives the patient a constant idea that the lower bowel is occu- pied by fieces, and of this notion it is ditHcult to divest him. He must not be allowed, however, to indulge in straining at stool, as this action asrsrravates his condition. As for medicine, none is needed in a mild case except jjlenty of bland fluid — flaxseed-tea, infusion of triticum repens, etc., with some citrate of potash or Vichy water. By these means the irritating properties of the urine are counteracted. The combination of liquor potassaB with extract of hyoscyamus (page 202) seems to suit certain cases. AVatery extract of oi)ium, codeine, or morphine, may be used in suppository, gently introduced, in sufficient (pumtities to modify the urgent desire to urinate. These means, com- bined with a light diet, will bring on resolution in a few days in many cases. GONORKHCEAL PROSTATITIS. — If the prostatic affection comes on during a gonorrhoea, all active treatment of the latter must be aban- doned. It is particularly essential to discontinue urethral injections. From ten to fifteen vigorous leeches may be placed upon the perinaeum. PROSTATIC AND PERI-PROSTATIC AHSCESS. 209 and the bleeding be encouraged by the subsequent application of hot water to the bites. Hot fomentations to the perinseum and hypogas- trium tend to modify ]iain. The skin over the hypogastrium should bo kept constantly reddened by sprinkling 2)owdered mustard upon the poultice there applied, or, more neatly, by the use of mustard- paper, over which is applied a flat rubber bag, containing a thin film of very hot water. If possible, a general hot bath, or hip-bath, should be administered once or twice daily or oftcner. Sleep may be encour- aged at night by full doses of the bromide of potassium, or sodium alone or combined with some bitter sirup (orange-peel), with from gr. Y_xx chloral hydrat. Eepeated rectal examinations of the prostate are to be avoided, and on no account should any instrument be passed into the bladder unless there is retention. In such a case a small French olivary catheter should be gently used, as seldom as possible consistently with comfort. Failing with the soft instrument, a silver catheter must be employed, with suitable regard to the inflamed and tender condition of the parts. Cases might occur where the aspirator would be preferable to catheterisra. PROSTATIC AND PERI-PROSTATIC ABSCESS.* If pus form during parenchymatous inflammation of the prostate, we have a continuance, in a high degree, of all the symptoms of that inflammation, except that the local throbbing is more considerable and that the pains become less tense and of a more lancinating character. A sharp chill or a series of rigors announces the commencement of sup- puration. As the pus forms, it presses upon the already narrowed canal of the urethra, and finally, unless the abscess is very small, ob- literates it entirely, bringing on retention. There may be one or more purulent foci, or the whole substance of the prostate contained within the fibrous capsule may fall into suppuration. These abscesses, left alone, discharge into the urethra, bladder, rec- tum, or through the perinseum. They are often tardy in opening spontaneously, on account of the dense nature of the fibrous capsule of the gland. When such an abscess is opened or bursts, all 23ain and discomfort are relieved as if by magic. Eetention disappears, the heat and throbbing cease to be annoying, and a continuous flow of pus is often the only reminder of the terrible torment which the patient has endured. The pus may exceptionally burrow among the tissues of the perinseum, or, still more rarely, into the pelvis, giving rise to local and then general peritonitis. In exceptional cases, where the purulent focus is small, it may never point ; but, with subsiding inflammation, the pus may be gradually absorbed, leaving behind a calcareous mass, * An excellent monograph on this subject is that of Paul Segond, " Des Abces chaude de la Prostate et du Phlegmon peri-pi-ostatique," Paris, 1880, pp. 260. 14 210 DISE.^ES OF TEE PROSTATE. of a size i^roportionate to the quantity of pus which it represents. These concretions are not usually discovered till after death. They are rarely of sufficient size to interfere materially with tlie contractile function of the gland. After the pus has escaped from a prostatic abscess, if the cavity is small, it usually granulates slowly, fills up, and becomes cicatrized ; the rapidity of the process of repair being often interfered with, if not prevented, by a communication of the cavity with the bladder or rec- tum — or even the urethra, from which urine regurgitates during every act of micturition. If the cavity of the abscess is very great, if, for example, it iuA'olvcs the whole contents of the fibrous capsule of the prostate, the termination may be fatal. Sometimes a slow rejiair sets in, but it is rarely if ever perfect. A small purulent collection in the prostate may empty itself gradually into the urethra by a minute open- ing, and its existence consequently not be made out. The prognosis in small abscesses of the prostate is good, but, where the collection of pus is very extensive, the prognosis must be guarded. Analogous to the above are the perijjrostatic abscesses which occa- sionally come on during the course of gonorrha?a, or in cases of strict- ure. Here the seat of the purulent collection is found to be in the connective tissue around the prostate. The symptoms are, in the main, those of prostatic abscess ; but they are less marked, less intense, and the malady is apt to run a slower course. CEdema, perceptible to the finger in the rectum, is the best distinguishing mark between exist- ing or imminent periiorostatic collections of matter and abscess within the prostatic capsule. Such collections of pus finally press upon the neck of the bladder and cause retention. They may be easily felt by the exploring finger in the rectum, masking the prostate, and jutting into the cavity of the gut. If not opened by the surgeon, they may point spontaneously in any of the directions named for prostatic ab- scess, and subsequently behave in a similar manner. Periprostatic abscess may sometimes owe its origin to suppuration of one of the lymphatic glands described by Lannelongue * (six in number) lying between the base of the prostate and the rectum. He found them large and inflamed in a boy who died of tuberculization of the prostate, seminal vesicles, right ureter, and kidneys. Epididymitis, terminating in suppuration, is liable to complicate prostatic abscess. Abscess of the prostate rarely leads to infiltration of urine. Treatment. — With an abscess, periprostatic or prostatic, near the posterior wall, whenever fluctuation can be felt through the rectum, puncture with a trocar should be practiced at once, to arrest further destruction of tissue, to relieve suffering, and to prevent retention. Where the abscess bursts spontaneously, the treatment is purely symp- * "Bull, de la Soc. de Chir.," tome iv, 1878, p. 600. FOLLICULAR PROSTATITLS. 211 tomatic. "Where the collection is prostatic, and, Inilging into the ure- thra, produces retention, without yielding fluctuation through the rectum, any of the three following courses may be followed, preferably the first : (1) Pneumatic aspiration of the abscess through the rectum ; (2) the use of the same instrument several times daily above the pubes, to evacuate the urine waiting for the abscess to break ; or (3) careful attempts to relieve the bladder with a silver catheter joassed through the urethra. The abscess is pretty sure to be broken during attempts at catheterism, and the urine flows freely immediately after the pus. Where a large cavity in the prostate is left behind by an abscess, it may be washed out daily with a very short-beaked silver catheter, hav- ing its eye near the tip, and, after the washing, injected with some astringent solution to stimulate granulation. FoLLicuLAE Peostatitis. — In this disease, the mucous surface of the sinus of the prostate and of the mucous follicles and ducts is in- flamed, while the substance of the organ for the most part escapes. The affection is familiarly known as prostatorrhma. It can hardly be said to exist in an acute form, so prone is it to run a chronic course. It may come on during gonorrhoea after the inflammation has reached the deeper portions of the urethra, attended at first by symptoms of parenchymatous congestion. The latter soon subside, and the prosta- torrhoea alone remains, with (perhaps) some congestion about the vesi- cal neck, and consequent irritability of the bladder. The main feature of the disease is a slight oozing from the meatus, muco-purulent in character. This discharge is apt to be more profuse during the passage of hardened fseces through the rectum at stool. Defecation may be painful. The patient usually believes the discharge to be semen. It does not contain spermatozoa, but is muco-purulent, full of fatty debris, leucocytes, epithelium, and often prostatic concretions. This discharge is exceedingly rebellious to treatment. If, with follicular prostatitis, as is often the case, a certain amount of chronic parenchymatous inflammation coexist, then we have an affection not common but exceedingly obstinate and diflBcult to man- age. It is evidenced by a combination, in a mild degi'ee, of the symj)- toms of both maladies. A peculiar weight is felt, dragging down toward the perinseum, with painful feelings in the prostate ; walking becomes painful ; crossing the legs decidedly increases the pain, as does finally the sitting posture, and especially the muscular contrac- tions made in raising the body from the sitting to the standing posi- tion, or the reverse. Added to these are symptoms almost identical with those of stone in the bladder. There is the same frequency of urination, less urgent on some days than on others ; the urine contains pus and blood ; blood sometimes flows at the end of the stream ; pain is felt on urination, both at the neck of the bladder and, especially toward the close of the 212 DISEASES OF THE PROSTATE. act, at the end of the peuis, along the under surface of the urethra ; the patient has a tendency to pull and tickle the prepuce and urethra ; the tender prostate, squeezed at the end of urination by the contract- ing bladder, is the seat of extreme sensibility. TJie bladder is liable to expel its contents spasmodically. The cut-off muscles of the mem- branous urethra participate in the general irritability of the part, some- times interru])ting the stream suddenly. As a rule, however, this "ciit-off " does not come until near the end of the act of urination, and is a sort of premature covj) de piston. "With these symptoms the patient is feverish and irritable, unable to get about, as all motion aggravates his symptoms, lie chafes under continement, is perhaps listless and depressed ; perhaps has an excel- lent appetite, and very little constitutional disturbance. In chronic cases the mental depression is a feature of the disease out of all pro- portion to its gravity. A slight gleety discharge accomjianies this con- dition. It may escape observation from the fact that the frequent acts of urination wash it away before it has had time to collect suf- jBciently to show itself at the meatus. The finger in the rectum may find slight enlargement and heat of the prostate, and at times detect extra sensibility. The element of hyperesthesia of the cut-off muscles often accompanies and outlasts this form of prostatic inflammation, keeping up the symptoms perhaps after the parts have returned to a nearly normal condition. In these cases it is sometimes imi^ossible to decide that there is no stone. Search for stone should be instituted. None will be found, but the prostatic urethra will manifest extraordi- nary sensibility, and the patient will be much worse after the search than before. Treatment. — In follicular prostatitis no remedy is so efficacious as repeated mild blistering of the perinaeum. It is best applied by paint- ing cantharidal collodion upon one side of the pcrinajum, confining the patient for forty-eight hours to bed, and painting the other side of the raphe, as soon as the soreness of the first application begins to subside. This course, aided by alkaline diluents, will usually master the affection in a few weeks. In applying the collodion, great care is necessary to avoid involving the scrotum and anus, as the former drops over the blistered portion, while the serum from the blister runs down over the latter. This is best accomplished by binding the scro- tum up tightly, and covering the blistered surface from the start with absorbent cotton and lint, anointing also the anus and scrotum. Where the disease is of particularly obstinate character, and of long duration, the blisters may require to be continued for many weeks. The rectum must be kept unloaded in chronic prostatitis. With blisters should also be combined a supporting diet and tonics. Bumstead speaks highly of drachm-doses of dilute phosphoric acid containing a small amount of strvchniue in solution. If the affection jirove obstinate. TUBERCULAR PROSTATITIS. 213 injecting the membranous urethra with a mild solution of nitrate of silver (gr. v-x to the ^ j) with the deep urethral syringe is a treatment very often of the greatest value. It must he used cautiously at inter- vals of several days. TuBEECULAR PROSTATITIS. — A form of chronic prostatitis occurs in tubercular, scrofulous, debilitated subjects, the chief feature of which is cheesy degeneration, situated primarly in the ducts and fol- licles of the organ. True miliary tubercle does not seem to occur in the prostate. It may be that opportunities of observing it have not presented themselves. The cheesy nodule has thus far alone been found. The disease is rare. Tlie symptoms are those of severe chronic j)rostatitis. If the cheesy matter be small in extent, and situated around the prostatic sinus only, it can not be diagnosticated ; but if the same deposit abound in the substance of the organ, so that the contour of the latter can be felt to be lumpy from the rectum, or, as is more commonly the case, if the course of one or both vasa deferentia can be traced out as an infiltrated hard tube joined to a distinctly enlarged, knobbed, in- durated seminal vesicle, then we may safely assert that tubercular prostatitis exists. In such cases one or both epididymes are also usually the seat of so-called tubercular deposit, and there may be tuberculoid foci in the lungs or elsewhere. Tuberculization of the prostate not uncommonly follows similar morbid changes in the kid- neys, or sometimes precedes it. The course of tubercular prostatitis is very slow. From time to time the symptoms become spontaneously better or worse, but the general tendency is toward steady aggravation. The cheesy masses ulcerate out, form abscesses which break in all directions, leaving open cavities or fistulae. Such cavities evince no tendency to heal. Slight haemorrhage from the urethra from time to time is a pretty constant symptom, but the haemorrhage is followed by no relief. Tubercle bacilli have often been found in the urine in cases of tuber- cular disease of the urinary tract. They are difficult to detect. A thick- ish portion of sediment must be used. A portion of this is crushed between two thin microscopic cover-glasses and caused to adhere by being passed rapidly a few times through the flame of an alcohol lamp or Bunsen burner. A modification of the Weigert-Ehrlich method, introduced by Tolman * of Chicago, is easy of application and quicker than the original method. Make two solutions : 1. Aniline oil, tti, xxx ; distilled water, § lij. Mix and shake thoroughly, then filter. 2. Saturated solution of fuchsine in commercial alcohol, 93 per cent. Take of No. 1 3 ij, and of No. 3 ni xv, and mix. Heat this to * " The Medical Record," Oct. 23, 1886, p. 457- 214 DISEASES OF THE PROSTATE. 50° C. (122° F.), and drop the cover-glass upon it, film of pus down- ward, allowing it to remain one hour. Then wash the cover-glass in pure water and decolorize with a 33-per-eent solution of nitric acid until the film of pus ajjpears nearly without color. Wash again in water. If the red color reappears, the process has been effected. If the red color does not apjioar, then the specimen lias been too long in the nitric acid. Double staining is not necessary for a general examination. Mount in glycerin and exaniiiie witli a high i)owcr — better with an immersion lens. Prog7iosis is bad. Death occurs from the gradual running down of the patient, or from tubercular disease elsewhere ; the latter, per- haps, being of the true miliary type. Occasionally recoveries are made under the continued efficient action of hygienic conditions and proper food. The course of the malady is always exceedingly slow. Treatment. — Curative treatment consists of general rather than local means. For local treatment, the same rules apply here as those laid down for chronic follicular prostatitis. The general measures are hygiene, fatty food, tonics, projDer clothing, life out of doors, travel- ing, change of climate, anti-strumous medication. These means, in- telligently combined, sometimes effect a cure. CANCER OF THE PROSTATE. Primary cancer of the prostate is exceedingly rare. More usually it is secondary to advanced malignant disease elsewhere — especially in the kidney or testicle. As to the relative frequency of this disease, Tanchou,* out of 8,289 cases of fatal cancer, sets down only three for the prostate. Scirrhous, melanotic, and medullary disease, have all been noted ; the latter most frequently. Cancer occurs chiefly in ad- vanced life, sometimes as a complication of already existing hyper- trophy, and doubtless some of these cases have not been recognized. Medullary cancer, as a primary affection, has been observed in the prostate of young children, f Pitha saw one fatal case in a stout man of thirty. Symjjtoms. — The symptoms of cancer of the prostate are at first simply those caused by the increased size of the organ, obstruction to urination, frequency of the act, and pain. Increase in size does not occur as rapidly, or with as acute symptoms, as does inflammatory en- largement ; but more painfully and more rapidly than senile hyper- trophy. When cancer becomes engrafted upon an hypertrophied prostate, its diagnosis during the early stages is impossible. The * Quoted by Pitha, op. cit. f Jullien's article " Prostate," in " Diet. Prat, de Med. et de Chir.," is full of informa- tion on the subject of cancer. CANCER OF THE TRORTATE. 215 diagnosis with liydatids or cysts (diluted follicles — of quite common occurrence, but of no pathological importance) is made by the prog- ress of the affection. The symptoms, then, of cancer of the prostate are not pathognomonic at first, but there are certain important aids to correct diagnosis. Thus, if the affection be scirrhus, the peculiar hardness will be significant ; if medullary cancer, the enlargement felt through the rectum is usually less uniform than in hypertrophy, and certain spots may often be felt softer than others, sometimes amount- ing to a feeling of deep fluctuation. The i)ain on pressure by the rectum is less decided than in inflammation, but more positive than in hypertrophy. Tlie glands in the pelvis and in the groin sooner or later enlarge, and assume cancerous characters. Hence the existence of obscure swellings along the course of the iliac vessels, felt through the abdomen, is an important aid to diagnosis. Cancerous cachexia is slow to appear. Its presence clears up any doubts which may have existed. Cancer of the prostate is not propagated from the bladder. I am not aware of any reported instance in which such propagation has been observed. It does propagate itself from the prostate to the bladder, and two instances are on record (Bennett, Cushing) where cancer of the rectum has secondarily invaded the prostate. The importance of the existence of cancerous growths elsewhere is evident, and especially is this true of cancer of the testicle or kidney. The pain felt in cancer of the prostate is noticed largely in the rectum and about the sacrum, or radiating into the back, or down the thighs. Hsemorrhage from the urethra is a symptom liable to appear both early and late in this affection. The blood flows freely, is arterial in character, and often excessive in amount. It may appear spontane- ously, or, more frequently, during urination. A certain amount of relief to the symptoms is apt to follow such hsemorrhage. The urine is turbid, purulent, often containing considerable debris of tissue. Sometimes a shred of tissue of considerable size is passed, or j^ulled away in the eye of a catheter. From such a shred a diagnosis of can- cer can sometimes be made by the microscope. Diagnosis based on finding so-called cancer-cells in the urine is entirely unreliable. Re- tention is apt to occur from obliteration of the prostatic urethra by cancerous growth. In such cases catheterization is difficult and ex- ceedingly painful, while the operation is pretty sure to provoke con- siderable bleeding. Hypertrophy of the bladder with dilatation, and perhaps stone, may come on, as in other obstructive prostatic disease. The duration of the disease is set down, from first appearance of symptoms to fatal termination, at from one and a half to five years for adults, three to nine months for children. Treatment. — This is symptomatic, and consists in the careful em- ployment of the catheter, if required, even the establishment of a 216 DISEASES OF THE PROSTATE. permanent ojiening above the pubes, with alkaline diluents, tonics, and anodynes in suppository and by the stomach. Patients do not recover from this disease. The prostate has been surgically extirpated with a portion of the lloor of the bladder and the rectal wall, but the operation is not to be justified by any results yet attained. Permanent drainage through the pcrinajum is not suitable in these cases as a rule. Simple cysts in the prostate are not uncommon ; hydatids are rare.* PROSTATIC CONCRETIONS. The adult prostate and portions of the neighboring urethra contain certain bodies called prostatic concretions. Eobin and Oadiat state that Virchow discovered similar bodies in the female urethra. They are visible with the microscope at any time after puberty, but do not attain considerable size until adult or advanced age. Thompson has described them minutely. They are not to be confounded with stone of urinary formation. They are often found of very small size in the voided urine. In such cases they have no jiathological significance. During their forming stage (when they measure from the one-thousandth to the one-hundredth of an inch) they appear under the microscope of an oval or slightly angular form, of pearly luster, and in varying shades of light-yellow color. Tiiis color in- creases in the larger concretions to a deep orange. They have a cel- lular appearance, but no nucleus, and, as they become larger, exhibit concentric rings of different thickness. Often, in the larger concre- tions, many of the smaller bodies seem to have been lying together, and to have become surrounded by concentric layers of yellowish material to form one mass. Often, lines are seen radiating from the center toward the circumference, and in the direction of these lines cleavage takes place when the masses are subjected to pressure. When young they arc very soft, but, as they increase in size, they become exceedingly hard and stony. The young cell-like bodies are not affected by acids, or alkalies, or ether ; but the larger dark bodies are rendered somewhat more translucent by alkalies, while the mineral acids (especially sulphuric) usually occasion liberation of bubbles of gas (carbonic acid) and some shrinkage in size, sometimes disintegrat- ing them into a mass of amorphous matter, which still retains its color and bulk. Hot nitric acid dissolves them, producing a faint yellow color. The larger concretions consist of a protein substance, with phos- phate and carbonate of line. They are often found, visible to the naked eye, in the urethra, around the veru montanum, chiefly after the age of fifty. It may be necessary to make a section of the jirostate * Consult llauxion, "Des Kystes de la Prostate," " These 127," Paris, 1878. rROSTATIC CONCRETIONS. 217 to find them, placing the milky fluid scraped from the cut surface under the microscope. In one case Thompson estimated the number to be seen by the naked eye as amounting to several thousands. These bodies occupy, anatomically, the ducts and follicles of the secreting structure of the prostate. The earthy salts are added to them as they grow. They sometimes attain the size of a pea or small nut. As they enlarge by new accretions upon their circumference, they press upon and cause the absorption of the duct or follicle in which they origi- nated, and several of them may be found adhering to each other in a single sac or cyst. From the above description it may be gathered that these concre- tions resemble salivary or biliary concretions rather than true stone. When they become large enough to constitute sources of irritation, dense, opaque, earthy matter deposits upon them, and they then be- come true prostatic calculi, and may go on indefinitely increasing in size. These prostatic calculi are met with of all sizes and shapes. Several of them may be found separated from each other, perhaj^s imbedded in cysts, which are dilated follicles, or, if many of them are present, causing atrophy of prostatic substance, until the prostate resembles a sack full of small stones, which may be felt rubbing against each other on pressure per rectum, giving an emphysematous-like crackling (Adams). In bad cases, prostatic calculi tend to unite, pro- jecting into the urethra, and forming curiously distorted, branched masses, dipping down into the substance of the prostate, and extending forward into the canal of the urethra, and backward perhaps into the bladder. Such masses have been found four or five inches long. One, removed by T. Herbert Barker, is referred to by Thompson as being composed of nine portions, weighing, collectively, three ounces, four drachms, and one grain. ■ Prostatic stones are exceedingly hard, and have a polished surface. They may be brilliantly white, resembling porcelain, or of a fawn or pale-brown color. They are composed mainly of phosphate of lime, with a small admixture (derived from the urine) of the triple (am- monio-magnesian) phosphate. They very rarely give trouble during life, but when of large size they may give rise to all the symptoms of prostatic obstruction, in an aggravated form, leading, in the same manner, to chronic cystitis, hypertrophy, and sacculation of the blad- der. "When these calculi project into the urethra, a metallic instru- ment, introduced into the bladder, may be felt to grate ujjon them in passing. Treatment. — The natural mode of elimination of these masses is by the formation of abscess. They may ulcerate out through the rectum, or perin^eum, or into the urethra, or even into the bladder. Stone in the bladder not uncommonly coexists with them. When they become large enough to give rise to distressing symptoms, an attempt may be 213 DISE.VSES OF THE BLADDER. made to remove them with tlie long urethral forceps (Brodie), but the best method is to cut down through the perinamm in the median line, and extract everything of a calculous nature which can be found. If any portion be left it becomes at once a nucleus for further incrusta- tion. During such an operation the bladder should always be searched for stone. In exceptional cases, where prostatic stones can be felt in the substance of the prostate through the rectum, an incision may be made through the Avails of the latter, and their removal thus elTected. Certain concretions found in the dilated veins around an old prostate and known as phleboliths, must not be confounded with prostatic cal- culi. They are not infrequently detected after death, and are small white or colored smooth bodies, perhaps as large as a pea, such as are formed in dilated veins elsewhere. The calcareous remains of old abscesses which have been absorbed, and which in rare instances are found in the prostate, must not be confounded with calculi. Finalh', a true urinary calculus may become lodged in the i)rostatic sinus when small, and continue to grow there by deposits of urinary salts, causing absorption of prostatic tissue, and finally becoming imbedded in that organ (Meckel, Adams). Such stones may grow backward into the bladder (prostato-vesical calculi, Yidal), or true stone in the bladder, becoming attached near the neck of the latter, may grow forward into the prostatic urethra (vesico-prostatic calculus). Syphilis of the Prostate. — Although it is possible for syphilis to cause its peculiar deposit in the prostate, yet it rarely, if ever, does so. There is certainly no syphilitic condition of the prostate which can be diagnosticated by any symptoms that I can name. CHAPTER XII. DISEASES OF THE BLADDER. Anatomy.— Anomalies and Deformities, Exstrophy.— nernia of Bladder.— Hypertrophy.— Atrophy, —Wounds.— Kuptiire of the Bladder.— Foreign Bodies.— Retention of Urine.— Incontinence : in Children, in Adults. — Tenesmus.— Chorea.— Hsematuria.— Neuralgia of tlie Vesical Neck. — Cause. — Symptoms. — Diagnosis. — Treatment. Anatomy. — The bladder is a muscular sac lying, in the male, be- tween the rectum and pubes when empty, and distending, when full, into an oval bag occupying more or less of the hypogastrium. Its position is fixed below by the urethra, but mainly by the pelvic fascia, which, after having lined the cavity of the true pelvis, is reflected upward and lost; on the bladder and rectum (as pubo-prostatic and inferior vesical ligaments), and the recto-vesical fascia which binds the prostate and neck of the bladder to the rectum. Above and on the ANATOMY OF THE J3LADDER. 219 sides the peritonaeum covers the bladder, but is attached loosely, espe- cially at the base, so as to offer no obstacle to any change in shape or position of the viscus. A knowledge of the reflections of the perito- nseum upon the bladder is essential to a correct understanding of the methods of relieving retention by puncture. AVhen the bladder is empty, it lies contracted behind the pubes ; the peritonoeum leaves the abdominal walls at the symphysis, and passes at once to the bladder, over which it is spread, and then reflected upon the rectum from the base of the bladder, so that, when the latter is absolutely contracted upon itself, that portion of its base lying between the seminal vesicles is also covered by peritonseum, and there is, properly speaking, no direct relation between the bladder and rectum. Yery different, how- ever, is the condition when the viscus is distended. Then, as its cavity fills up, the peritonasum is carried with it. The recto-vesical cul-de- sac of the peritonseum is deepened, and all that portion of the base of the bladder situated between the seminal vesicles lies directly in con- tact with the rectum. When the bladder is greatly distended, its base becomes thus uncovered for a distance, roughly estimated, of two inches behind the posterior margin of the prostate. In the same way the distended bladder carries up the peritonaeum in front, so that a dis- tance of one to two inches, or even more, above the symphysis becomes bare of peritonaeum in extreme retention. Hence the election of these two uncovered spots for puncture. The medium capacity of the adult bladder is eight ounces, subject to extensive variations from habit or disease. The bladder may become so contracted as to contain only a few drachms, or again capable of holding, without rupture, the better part of a gallon. The muscular coat of the bladder is composed of a set of external fibers which run mainly longitudinally, some of them being continued up the urachus, and an internal set whose general direction is circular. These latter, greatly re-enforced in number, encircle the neck of the bladder and internal orifice of the urethra, and pass under the general name of sphincter of the bladder. Certain fibers, running across the base of the trigonum Lieutaudii, serve to pull upon and open the mouths of the ureters. The mucous membrane of the bladder is of a pale salmon color, re- markably insensitive in health, covered by a stratified pavement epi- thelium, and lying in folds when the bladder is contracted. The glands are not numerous, except on the trigone and near the neck. Their ofiice is to secrete lubricating mucus. They are exceedingly small, and composed of simple clusters of follicles. The coats of the bladder are united by connective tissue which is everywhere loose, except at the trigone. The Yesical arteries come from the hypogastric. The veins termi- nate in a thick plexus about the prostate and sides of the base of the 220 DISEASES OF THE BLADDER. bladder, emptying llnally into the hypogastric veins. The lymphatics lead to the hypogastric ganglia. The nerves, partly sympathetic and partly sj^inal, come from the hypogastric plexus. The neck of the bhulder is tliat jiortion surrounded by the sphincter and base of the prostate, limited anteriorly by the ridge, more or less prominent in the adult, wliicji maps out the posterior limit of the pros- tatic sinus. Tlie trigone (of Lieutaud) is a triangular space lying between the neck of the bladder and the orifices of the ureters. The muscular coat is here transverse, thick, adherent to the mucous membrane. Its pos- terior margin is limited by a more or less prominent ridge running between tiie mouths of the ureters. The ridge can be followed along by the prominence made by the ureters as they penetrate obliquely the muscular coats of the bladder. The *'bas-fond'' of the bladder exists only after middle life, and is that part of the base of the organ lying behind the posterior ridge of the trigone. When the bladder is distended in later life, this portion lies on a lower level than the trigone. The uraclius is the remains of the allantoid prolongation. It often remains 02)cu for a short distance above the vertex of the bladder and sometimes continues pervious throughout, so that, in adult life, the urine still passes by the navel, but this is exceedingly rare. The bladder in the fa>tus and in early life is an abdominal organ, situated mainly above the pubes. As the pelvis enlarges it settles down behind the symphysis, and only rises into the abdomen when distended. The mucous membrane of the healthy bladder is less capable of absorp- tion than any other.* "When deprived of its epithelium, absorption goes on as from otlier nude surfaces. ANOMALIES AND DEFORMITIES OF THE BLADDER, The bladder is almost invariably unique. Large sacculi have some- times been described as supernumerary bladders, and they may indeed reach a size double or triple that of the bladder itself. They may always be recognized by being destitute of muscular covering. They are herniae of the mucous coat through the meshes of the muscular tunic. Molinetti f describes a woman who had five kidneys, five blad- ders, and six ureters. Partial partitions extending into the bladder have been observed. Blasius f relates a case of perfect segmentation of the bladder by a partition, one ureter opening on each side. Po- drazki X refers to several cases by different authors. The bladder is * Excellent article by Mass and O'Pinner, " Centralblatt f. mcd. Wissnschft.," Decem- ber 11, 1881. \ Quoted by Pitha. X "Die Krankheiten des Penis und dor Harnblasc," p. 51, Erlangcn, 1871. EXSTROPUY. 221 sometimes abnormally small, occasionally wanting, in which case the ureters may open directly into the urethra or into the rectum, or into a general cloaca, there being at the same time arrest in the develop- ment of other portions of the genital apparatus. Besides the above, there is one deformity, exstrophy, the occurrence of which is suffi- ciently common to demand a special description. ExsTKOPHY OF THE Bladdek. — This deformity is found in both sexes, but much more frequently in the male.* In the female it is of less importance, as it may be more easily concealed, and docs not pre- vent the performance of the sexual act. Cases of j)regnancy and suc- cessful delivery at term are recorded. The subject will be considered here, however, only in relation to the male. The deformity is an arrest of development in the median line, anal- ogous to hare-lip, and is found in different degrees. In a type case the lower part of the front wall of the abdomen and the front wall of the bladder are absent. The pubic bones are more or less widely sep- arated from each other, their ends being united by a strong band of fibrous tissue. The posterior wall of the bladder, pressed out by the intestines, forms a mottled, red, tomato-like tumor, occupying the position of the symphysis pubis. Inguinal hernia of one or both sides is not uncommonly present, either partial or extending down into the scrotum, which is usually normal, containing the testicles. The penis is more or less rudimentary, and affected by complete epispadias. The ureters are sometimes greatly dilated, forming, as it were, rudimentary bladders. A good illustrative case is figured by Sir Astley Cooper, f The above description applies to a type case. There may be varia- tions in the absence of herniae, a normal union of the pubic bones, the amount of the protrusion, etc. Ordinarily in the adult the mass reaches the size of the palm. "With comjDlete exstrophy there is also always complete epispadias. A condition analogous to exstrojahy may exist where the bony union of the pelvis is lacking, but the anterior walls of the abdomen and bladder are perfect. Here there is a sort of hernia of the bladder forward. In such cases there is always some anomalous condition of the external organs of generation. In exstrophy of the bladder, the patient's condition is miserable indeed. The thickened inflamed mucous membrane covering the pro- truded posterior wall of the everted bladder is constantly covered by decomposing '^ stringy mucus" of alkaline reaction, similar to what is found in vesical catarrh. From the orifices of the ureters, which can be readily seen by pressing back the protruded mass, there con- * Mr. Earle (" London Medical and Surgical Journal," vol. i) alludes to sixty-eight reported cases, of which sixty were male. Isidore Geoffroy St.-Hilaire (" Histoire g^ne- rale et particuliere des Anomalies de I'Organisation chez I'Homme et les Animaus," Paris, 1825) estimates that one fourth of the cases are female. f " Edinburgh Medical and Surgical Journal," vol. i. 222 DISEASES OF THE BLADDER. sttiutly distills a limpid, acid, lioallhy urine. This at once becomes alkalinized by contact with the inflamed mucous surface of the blad- der, and goes into rapid decomjio^^ition, wetting the patient's linen and keeping him constantly surrounded by an atmosphere of amnioniacal, fetid gases, making him disgusting to himself and intolerable to his friends. The integument of the abdomen and thighs becomes excori- ated and inflamed. The friction of garments in Avalking only serves to aggravate the existing difficulties, and the sufferer is in a condition truly pitiable. . By pressing back the inllanicd bladder a small prostate is exposed, lying at the angle of the penis and the vesical tumor, and upon it the veru montanum and ejaculatory ducts may be plainly seen. These patients have erotic fancies and seminal emissions ; but they are in- capable of full erection or of perfect sexual intercourse. Patients with exstrophy of the bladder have been useful to science in facilitating experiments upon the rapidity of the appearance in the uriue of substances taken into the stomach. Thus it has been found that asparagus aifects the urine in eight and a half, turpentine in four and a half minutes, etc. (salts much more quickly). Furthermore, thoy give positive evidence of the fact that the secretions forming on the surface of an inflamed bladder are alkaline, and that the urine coming down healthily acid from the kidneys is at once alkalinized on reach- ing the bladder and promptly decomposed. Hence the rule to give alkalies to correct alkaline uriue where such alkalinity is due to blad- der inflammation, since by this means the urine is rendered less acid and less irritating as it comes from the kidney. Treatment. — Attempts (Sonnenburg) to destroy the mucous mem- brane by cauterization, and leave cicatricial tissue in its place, usually prove unsatisfactory. Plastic operations have been performed with sufficient success (five per cent mortality) to be Justifiable if the patient will take tlie risk of a fatal termination to an operation undertaken to relieve a deformity which does not threaten life. Usually several op- erations are necessary to reduce the aperture to a small size ; but, even wdien the flaps slough, the subsequent contraction of the cicatrix is said to improve the local condition. If an operation is to be per- formed, each case forms a study by itself. Usually a large abdominal flap is dissected up from above the tumor and turned down over it, epithelium inward. The raw external surface of this flap is covered by one or more side-flaps or by integument taken from the thigh ; such flap or flaps are secured in place over the abdominal flap by bringing the raw surfaces into contact, and fixing the whole by sutures. Some sloughing is to be anticipated, and subsequent operations have to be devised to meet the requirements of special cases. The most that can be done is to inclose the bladder, leaving an opening below, through which the urine flows unrestrained, as it is impossible to reproduce a EXSTROPHY— TREATMENT. 223 sphincter. Finally, a suitable urinal is adjusted and worn constantly. Hairs should be removed by electrolysis from any ilsbii which it is pro- posed to turn inward, or they will grow and give trouble later on. John Wood * reports a case which seems to be an exceedingly good example of what may be effected. A boy seven years old was operated upon four times, and the bladder was closed in — all but a small hole large enough to admit the little finger. The patient was able to retain two ounces of urine, but any cough or other contractile effort would expel it in a jet. Pancoast,f of Philadelphia, was the first surgeon •who operated upon this condition, and the names of Ayres, J of Brook- lyn, and Maury,* of Philadelphia, are favorably known in connection with it ; but much of interest has been contributed by Vrolick, J. Miiller, Steiner, Heydenreich, Trendelenburg, John Wood, and others. The most that can be promised by an operation is that the mucous membrane shall be shut in, and a cavity furnished which shall hold a little urine. A urinal must still be worn — at least by day. Yet even this shutting in of the raw surface affords the patient great comfort, and justifies an operation. Sometimes a very simple procedure suffices. Thus Wyman,|| of Detroit, reports a successful operation upon a child of five years by simply paring the edges broadly and uniting with hare-lip pins and superficial sutures, making liberat- ing incisions on each side. Kead ^ cured an extroversion through the umbilicus in the same way. An excellent method seems to be that devised by Thiersch, of Leipsic. MacCormac ^ has reported a success- ful case so operated on. One or two lateral flaps are cut very broad and one third longer than the gaj) they are to cover. They are left attached at each end with oiled lint beneath them until they have thickened up, become very vascular, and granulated beneath. After three weeks the flap (for only one is moved at a time) is cut at its upper end, and swung around into position. There is no difficulty about hairs here, the flap is sure to live, and success is certain so far as any operation can be successful. Both Thiersch and MacCormac agree that it takes a year to complete a case. When an operation is declined, a suitable urinal may be adapted to the parts as left by Nature — such a one as shall shield them from injury, and keep the patient dry and clean. A urinal of this sort exists, and about a dozen patients in the United States, male and female, have attested its sufficiency for all practical purposes. It was originated by Mr. Earle, of St. Bartholomew's Hospital. It is figured by Vro- * "Med. Times and Gaz.," 1865, vol. i, p. 115. f "North American Mcd.-Chir. Review," July, 1859. X "Am. Med. Gaz.," February, 1859. # "Am. Journ. Med. Sci.," July, 1871. II " Medical Record," December 12, 1885, p. 646. ^ "Annals of Anat. and Surg.," June, 1882, p. 211. ^ "St. Thomas Hospital Reports," vol. x, new series, p. 241. 224 DISEASES OF THE DLADDER. lick,* and i\ga\n by McAVhimiio. f It consists (Fig. T5) of a metallic shield, preferably of silver, sufficiently bulged to contain the protrud- ing vesical wall without coming into contact with it. The edge is rounded oil so as to make for itself, by l^ressure, a deep groove around the vesical tumor. From its lower part, which is slightly bellied downward, extends a tube u})on which is fitted a long, flat rubber bag, to be worn strajiped to the tbigh, and to serve as a reservoir for the urine. The bottom of the bag terminates in a metallic screw, which can be removed to allow the urine to drain oil. The metallic shield above is held in place by a truss, which serves at the same time to retain any hernial projections in the groin. The instrument may be kept clean by the use of a weak solution of permangan- ate of potash. "While wearing it, the pa- tient is preserved from any friction. All the urine is collected as it flows, and a con- siderable degree of comfort is obtained. Trendelenburg's posterior double symphyseotomy has never thus far (188T) succeeded in his hands in securing for the patient continence of urine. I think, therefore, it is not to be recommended. Fig. HERNIA OF THE BLADDER. Dislocation of the bladder in the form of hernia may be congenital (rarely), or come on later in life, especially in old age, from exertion, retention, or violence. Abdominal, inguinal (scrotal, sometimes on both sides), crural, perineal, ischiatic hernise, and cystocele through the foramen ovale (Lentin), have been noted. In women, vaginal and femoral cystocele are most common ; in men, scrotal — that portion of the bladder uncovered by the peritonoeum being found in the hernia. The bladder may alone constitute the hernia, or coexist with a jiortion of intestine, perhaps being adherent to it. Cystocele has been opened by mistake in operations for strangulated hernia. Pott records two cases. Stagnation of urine, with inflammation of the bladder and formation of stone, may result from cystocele ; finally the hernia may become (rarely) strangulated. The diagnosis is usually easy, especially with a catheter, since the tumor increases when the bladder is full, and may be emj)tied * Plate 604, " Cyclopsodia of Anatomy and Physiology." f "London Medical Gazette," 1850, vol. xlv, p. 300. HERNIA— nYPERTROniY. 225 by pressure, such pressure causing a How of urine tlirough the cath- eter. Hernia of the bladder was first observed by Sala as reported by Bartholin.* Verdicrf in 1723 gave the subject considerable study. In 1874 Kronlein published a case of strangulated entero-cjstocele, and Ch. Leroux discussed the subject with a case, and Mr. Larabrie, refer- ring to the above, reports l another case from the service of Mr. Duplay, with autopsy. The mechanism of hernia of the bladder is doubtless that laid down by Nelaton : 1. Distention of the bladder above the symphysis. 2. A muscular effort, forcing a part of the (thin) bladder into the inguinal canal. Treatmetif. — Replace the tumor, if possible, and retain it by a truss. If it be irreducible, a suspensory bandage should be worn, and the tumor emptied by pressure during urination. If it become strangu- lated, herniotomy must be performed. A knowledge of the possibility of cystocele is the best safeguard against mistaking it for ordinary hernia. The distinction becomes more difficult if the retained portion of the bladder is much thickened by chronic inflammation, or contains stone. Excision, with inversion of cut edges and suture, would be an entirely justifiable operation. PATENT TTRACHUS. The urachus sometimes remains open in adult life and urine escapes through it. Stone sometimes forms at the umbilicus under these circumstances. I have cited * several cases. The opening at the umbilicus may be pared and sutured, or closed by cautery. HYPERTROPHY OF THE BLADDER. Hypertrophy of the bladder as a spontaneous affection does not exist. It is exceedingly common in connection with any morbid con- dition which prevents the free outflow of urine (hypertrophy of the prostate, stricture, tumors), with stone, or in connection with cystitis from any cause (hernia of the bladder, etc.). The different forms of hypertrophy (concentric, eccentric, with sacculi) are described as part of the disease, in connection with the morbid conditions occasioning them. Civiale speaks of a partial hypertrophy of the bladder, affect- ing chiefly its anterior wall, depending upon chronic inflammation or tubercular infiltration — evidently not simple hypertrophy. * "M^moires Anatomiques," 1656. ■j- "Mem. de I'Acad Koyale de Chirurgie," 1753, t. ii, p. 1. X "Archives Generales de Med.," March, 1881, p. 342. * " International Encyclopedia of Surgery," vol. vi, article " Urinary Calculus." 15 326 DISEASES OF THE BLADDER. ATROPHY OF THE BLADDER. In rare cases in reduced, soft-fibered, debilitated individuals the bladder may be found weak and thin, apparently atvojihied in all its coats, and liable to rupture. Civiale gives the caution of avoid- ing pressure on the bladder walls during catheterization in weak sub- jects, for fear of perforation. Bonnet, ilauf, and Hunter* give ex- amples of sudden rupture of the bladder in young persons from this cause. Atonied bladders, and those whose nervous supjily is cut off by spinal or brain disease, undergo more or less fatty atrophy. WOUNDS OF THE BLADDER. "Wounds of the bladder are not common, since the position of the organ protects it from ordinary accidents, inclosed as it is, when in a state of relaxation, by the bony pelvis. Excepting the violence done by instruments in lithotomy, possibly in lithotrity, or during other operations, the bladder is but little liable to injury except during dis- tention. It may be perforated by a fragment of bone in fracture of the pelvis. Eising above the symphysis pubis it becomes exposed to incised, punctured, and gunshot wounds. Wounds of the bladder are exceedingly dangerous to life, without being necessarily fatal. Bullets and fragments of shell have entered the bladder without producing fatal consequences, f and there formed nuclei for calculus — as have also portions of bone. J Sometimes the bladder is very tolerant of injury. "Wittelshofer * reports a case where for tliree months after a gunshot injury very little inconvenience was experienced, then, after straining at stool, which probably dislodged the foreign body, tenesmus came on with bloody urine, and the patient passed a piece of his drawers by the urethra. Next, a ball weighing five grammes was removed from the bladder by operation, and finally the patient passed a portion of his blue military trousers through the urethra. When the bladder is in- jured through the rectum, the prognosis is rather good. Among Bartel's thirteen cases (collated), ten got Avell. Treatment of injuries of the bladder is that of symptoms and indi- cations—arresting haemorrhage, and making a free outlet for urine, as well as providing an escape for any extravasated fluid. No matter * Quoted by Pitha. f I have recorded in the "Now York Journiil of Medicine," ^lay, 18G5, the case of an adult whose bladder was perforated when distended, by a bullet, during the New York riots, in July, 1863 (the gentleman being a looker-on), terminating in complete recovery. — Van Be REN. X Consult P. Maltrait, " Trauniatismes de la Ve.ssie," Paris, 1881, pp. 219. ** " Wien. med. Wchnschrift." and "Int. Journal of Med. and Surgery," Feb. 19, 1881, p. 187. RUPTURE. 227 whore the perforation may be, if infiltration is going on, it is always better to set the bladder at rest by a free perineal ineision, and digital exploration of the entire inner surface of the bladder. It, then, there is reason to belicye that the peritoneal cavity has been opened, lapa- rotomy is the proper remedy, the peritoneal cavity being cleaned and the bladder wound sewed up. The perineal opening is to be used for tying in a large tube for drainage. In doubtful cases, suprapubic cystotomy is indicated rather than the perineal opening. RUPTURE OP THE BLADDER. A bladder, when overdistended by urine, may become ruptured by external violence, and this especially if it be atrophied or thinned by disease, ulceration, or otherwise ; or the accident may occasionally happen, if the bladder be previously weakened in any part, by the accumulation of urine alone, as in case of stricture. Usually, under such circumstances, the immediate cause has been muscular contrac- tion. The most frequent cause of rupture of the bladder, as com- monly met with in practice, is a fall, the bladder being distended. Imperforate urethra is an efficient cause in the foetus. Among trau- matisms, where the viscus is not weakened by previous ulceration, falls, blows, and crushing injuries, with or without fracture of the pelvis, or even appreciable injury to the soft parts, may be mentioned. The most common position of the rupture is in the posterior wall of the organ, the fissure usually including the peritoneal coat. Other portions of the bladder walls occasionally suffer. The symptoms are sudden occurrence of intense pain in the abdo- men, with urgent desire to pass water, while attempts to urinate are usually, but not always, ineffective. Ordinarily the patient is unable to walk from the first. Collapse soon follows. Death may occur in this stage, or the patient reacts and passes into a state of acute peri- tonitis, or suffers from symptoms of peritonitis with those of infiltra- tion. If he survive the acuteness of this attack, the symptoms merge into those of local peritonitis, constant and often ineffectual desire to urinate being still a prominent symptom. The catheter passes generally without difficulty, and clear urine may be drawn, or urine tinged with blood. Whenever a diagnosis of ruptured bladder can be made, a very guarded prognosis must be given, as a vast majority of the cases terminate fatally. Bartels* makes intra-peritoneal rupture almost necessarily fatal, but Thorp's case.f reported as intra-peritoneal, got well, the peritoneal cavity, it is stated, * Lfwigenbeck's " Arcliiv," vol. xxii, Parts III and IV. Consult also Walter Riving- ton, " Rupture of the Urinary Bladder" (322 cases), London, ISSo-'Si, pp. 160, and Chris- topher Heath's interesting paper, " Med.-Chir. Trans.," vol. Ixii. f " DubUn Quarterly Journal," vol. xlvi, p. 306. 228 DISEASES OF THE BLADDER. having been washed out through a catheter passed by the urethra. It is more than probable that this was an extra-peritoneal case. Extra- peritoneal rupture witbout external wound is fatal in seventy-four per cent of all .cases according to Bartels. AVeir * suggests, as a means of diagnosis, that a measured quantity of water be thrown into the bladder. If a less quantity returns, there is rui)ture. Treatment. — Whenever rui)ture of the bladder can be diagnosti- cated, or even when it is seriously suspected, modern surgery has demonstrated that the only safety lies in opening the bladder. There is no objection to making a perineal opening for ex})loration, and, if the rupture is extra-peritoneal, this alone may effect a cure, as Mason f so strongly insisted, and as a number of cases proved. If, after such au opening is made, the finger detects a rent in the bladder walls threatening the peritona?um, then the bladder should be at once opened above the symphysis, a thorough investigation made, the peritonauim opened if necessary, its cavity cleaned, irrigated, drained, if thought best, and the bladder wound sewed up. A tube should be left in the periureum for drainage. "When intra-peritoncal rupture is diagnosti- cated or suspected, laparotomy is imperative as the patient's only chance. This operation, often unfortunately fatal (Heath, "Willett, W. T. Bull, McGill, Duncan, Bonet), has yielded brilliant success — Walters, J MacOormac^ (two cases), and T. Holmes || (one case). It is undoubtedly good surgery to perform suprapubic cystotomy in all cases of ruptured bladder, and to treat the case then u^jon its merits. Among the interesting successes reported may be mentioned that of Socin,"^ and one by WaJsham.^ PERFORATING ULCER OF THE BLADDER. T. H. Bartleet, of Birmingham, England, reports J the case of an engineer who stooped rapidly to raise an iron bar from the ground, and suddenly felt severe pain low down in the abdomen. Eetention came on, relieved by catheter, but the pain increased. There were retching and constipation, temperature normal, i)ulse 98. Tlie patient had been well before the accident, except for a transient retention five years previously. In eight days he died. On autopsy there was found * " On a Satisfactory Method of Early Diagnosing an Intra-pcritoneal Rupture of the Bladder," by Robert F. Weir, M. D., "Medical Record," January 22, 1887. t " New York Medical Journal," August, 18'72. X "Philadelphia Medical and Surgical Reporter," February, 1802. * Referred to in "Lancet," December 11, 18SG, p. 1118. II "Lancet," July 23, 1887, p. 153. ^ " Krrspndzbltt. f. scbwcizer Acrzte," 14, 1885, and " Ceutralblatt f. Chir," 45, 1885 p. 791. "Lancet," March 12, 1887, p. 539. \ "Lancet," February 5, 1870, p. 210. FOREIGN BODIES. 229 an oval, cloan-cut hole one-half by three-eighths inch in diameter exactly in the middle line posteriorly one inch above the apex. This on the peritoneal side. In the bladder this hole formed the bottom of a funnel-shai)ed ulcer, looking like a gastric ulcer, which obviously antedated the patient's present illness (Bartleet believed), and had gone on without symptoms, causing adhesion of the outside of the bladder at the implicated spot with the ileum. A slight separation of the adhesions had taken place when the man felt his first f)ain, but this had been enough to cause escape of urine and peritonitis. FOREIGN BODIES IN THE BLADDER. Besides the foreign bodies * which find theii; way into the bladder through wounds, or come down the ureters (renal calculi), a host of substances have been encountered in the bladder, introduced through the urethra. All unimaginable articles, such as pins, beads, stones, pieces of straw, heads of rye, heads of wheat, squirrel's tail,f glass, tubing, pipe-stems, lead and slate pencils, portions of chalk, wax, etc., have been found in the male bladder, introduced there through the urethra under the influence of morbid erotic fancies. The budding sexual instinct of a boy yearns for satisfaction, but finds none ; is thoughtlessly stimulated by the youth himself by impure thoughts or books, often kindled by those who are older. An uneasy feeling of a desire to do something leads a timid boy to masturbation, and tempts him to play all sorts of pranks with his sexual apparatus. In this way, substances, of every conceivable description which the orifice of the urethra will admit, are introduced into the canal and again ex- tracted, until, on some unlucky occasion, the object slips beyond the grasp and remains fixed in the deep urethra, or the bladder. The patient's shame will often prevent him from seeking relief ; a small, smooth foreign body in a healthy bladder may create no disturbance at first, and so the patient goes on, supposing that everything has arranged itself, until, in after years, perhaps long after he has forgot- ten his boyish folly, he gets bladder symptoms, is cut for stone, and the latter is found to have formed upon a nucleus introduced from without. Not infrequently, however, a foreign body comes legitimately, as it were, into the bladder ; dermoid cysts containing bones, teeth, and hair, may discharge into its cavity. The broken end of a metallic or, more commonly, a gum-elastic catheter may constitute the foreign body, usually in cases where the individual is obliged to have frequent recourse to a catheter for the purpose of emptying his bladder. A * Consult Poulet, "Foreign Bodies in Surgery," translation, Wood, N. Y., 1880, p. 145. f "Am. Journ. Med. Sci.," April, 18Y6, p. 537. 230 DISEASES OF THE BLADDER. catheter is most apt to break at tlie eye. The okl-fashioned gutta- percha bougie is particularly dangerous, on account of its liability to become brittle when old. Such bougies should not be used. Again, substances of all sorts, bone, seeds, etc., may enter the bladder through ulceration into the rectum, while splinters, bullets, and bone may be lodged there during injuries of the bladder. Treaime?if. — If the foreign body be a portion of catheter or bougie, the patient will usually hasten to tell his troubles and demand relief. If, however, it be some other foreign body, he will probably seek aid for the cystitis it may have occasioned, but will steadfastly deny the knowledge of any cause, often indeed after the foreign body has been detected, or even extracted. AVhen the natuz'c of the substance in the bladder has been learned, an attempt should be made to extract it, to jirevent it from becoming a nucleus for stone. If there be much cys- titis present, rest in bed, with demulcents and some anodyne, for sev- eral days before the operation. Avould be advisable. Anything which will go into the urethra would come out of it, if it could be correctly seized, with its points turned backward, and be drawn upon in a cor- rect line ; consequently, an attemjit should be made to reach all long bodies (pencils), and all small bodies, by using a small lithotrite, or other forceps designed for this si^ecial purpose, of which there are sev- eral varieties kept by instrument-makers. If the object be seized in a faulty diameter, it may be released and caught again. This rule ap- plies to portions of metallic catheters as well. It is exceedingly diffi- cult to catch them correctly ; soft catheters, however, are very easy to extract ; they become doubled up, and may be withdrawn, however caught. The difficulty in seizing a portion of soft catheter is, that it can not be felt on account of giving no click or grating against a metallic forceps ; consequently, in the search for such a foreign body, the blades of the lithotrite have to be shut occasionally over different parts of the bladder surface, and the offending body is pretty sure to be found, finalh% between its jaws. Care must be exercised, of course, not to catch a fold of the bladder. Two substances which may be introduced into the bladder demand a special notice — wax and glass. The former becomes so soft at the temperature of the body that it not only can not be felt, but, if seized, can only be taken away piecemeal, while some portion is pretty sure to remain behind. As to glass, or other brittle substance, the danger of injuring the bladder by splintering the foi-eign body in attempts at extraction with forceps renders all such efforts, as a rule, unadvisable. Consequently, for all foreign bodies of wax or glass, and for all such as can not be extracted after patient effort with the lithotrite, the median operation or the suprapubic should be performed, and this as early as possible, before the foreign body has had time to become incrusted with urinary salts. If, for any reason, it should be advisa- RETENTION OF URINE. 231 ble to postpone the operation, it would be wise to wash out the bladder daily with a view of retarding calculous deposit upon the nucleus. Dr. Douglas, of Rondout, N. Y., in cutting a patient to extract a piece of glass, fearing that pressure with his forceps might splinter it in the bladder during extraction, devised the ingenious expedient of covering the blades of his forceps with soft molasses candy, knowing that if any of this substance was left in the bladder it would melt and pass away. The device was fully successful. RETENTION OP URINE. In retention the bladder fills up, and the urine is not or can not be passed. It must be clearly separated in the mind from suppression, where no urine comes down from the kidneys. This distinction can always be at once established by percussing the hypogastrium. The causes of retention are varied : Voluntary retention, often repeated and long kept up, may result in positive inability to empty the bladder ; all varieties of urethral obstruction — stricture, enlarged prostate, in- flammation or acute congestion of the prostate, even spasm of the cut- off muscles — are capable of producing retention. Finally, true vesical paralysis will give rise to it, unless the cut-off and sphincter muscles are paralyzed at the same time, when there will be incontinence. An- other cause of retention is found in the blunted sensibility of the blad- der, which exists in certain high febrile conditions (typhus, small-pox), in coma, in some syphilitic and inflammatory brain diseases, and in shock from injuries, and in all conditions of spasm of the deep urethral muscles. Symptoms. — In suppression there is always resonance over the pubes; in retention, always flatness. The bladder may be often seen and felt, filling up the hypogastrium, perhaps reaching the navel. Pressure, upon it usually causes a desire to urinate. Fluctuation may be made out between a finger in the rectum and the hand upon the hypogastric tumor. The bladder will not burst from retention of urine, unless it be previously ulcerated or subjected to mechanical vio- lence when full (a fall or blow) ; after it has been overdistended for a time, a certain amount of dribbling will take place through almost any obstruction. From the effect of violence, or if the urethra be ulcerated or sensibly weakened behind a stricture, extravasation of urine may occur through the urethral walls. The treatment has been already considered in relation to stricture and prostatic disease. In all other conditions — atony, paralysis, fever, etc. — a soft catheter of medium size should be passed as often as re- quired, and the bladder should be washed out on each occasion with a hot solution of borax in water. Sometimes a large silver catheter of soft curve passes more readily than a soft instrument. In cases of 232 DISEASES OF THE BLADDER. retention the aspirator will always afford speed)' relief, Cazenave, of Bordeaux,* states that retention may be relieved by introducing a piece of ice about the size of a chestnut into the rectum, repeating the same, if necessary, every two hours. This expedient is useful, but by no means sure. INCONTINENCE OF URINE. Incontinence, like retention, is a symptom, and not a disease. In incontinence a portion or all of the urine dribbles away, or is passed involuntarily. Besides the true, there are two very common forms of false incontinence — the one nocturnal, occurring in children ; the other in adults (stagnation, with overllow), where, after retention for some time, the excess of urine dribbles away. It may be stated, as a rule to which there are few exceptions, that an involuntary flow of urine in the adult indicates retention and not incontinence. NocTURXAL IxcoxTiNEXCE IN" CiiiLDiiEX. — This disagreeable affection often depends upon mismanagement : children not being awakened at sufficiently short intervals to empty their bladders, and acquiring the habit of passing urine without being waked thereby. In other children, again, the malady is sufficiently marked to constitute a disease. In these cases the urine escapes during the unconsciousness of sleep, but not at other times. Such children are not necessarily weak, nervous, or choreic, nor do they belong to any particular con- stitution or diathesis. Treatment consists in paying attention to the child's general hygi- ene, awakening it to pass water late at night and early in the morning, using moral suasion, and avoiding the use of fluids toward evening. Besides these means, absolute benclit may be expected from belladonna, commencing at a small dose, perhaps one tenth of a grain of the ex- tract, if the child is very young, and increasing gradually until some of the poisonous effects of the drug are noticed. Several other means maybe mentioned which are often effective — blistering the i)erina3um, the use of actual cautery, touching it several times about the anus. Recently the use of chloral hydrate has been advocated, the idea being to make the child sleep more profoundly. Another means which has appeared in the medical journals, and has been employed, it is said, with success in breaking up the habit, is sealing the prepuce at night with a drop of collodion. Mechanical appliances, encircling the penis or pressing upon the perinaeum, have the disadA^intage of tending to beget a habit of handling the parts. Cauterizing the deep urethra sometimes helps, and subcutaneous injections of strychnine, f * "Journal de Medecine et de Chirurgie," May, 1871. f Kelp, " Deutsches Archiv f. klin. Med.," Cd. xiv, Heft 3, 4, and Uill, " Richmond and Louisville Medical Journal," July, 1874. CHOREA. 233 Incoktinence in Adults. — Stagnation with overflow or fuLso in- continence has been already considered. True incontinence depends upon — 1. Unsymmctrical development of the prostate, where, after the collection of a little urine, the rest trickles away, there being no dis- tention of the bladder. 2. Concentric hypertrophy of the bladder, where the viscus can not distend, and all urine above a few drachms must flow at once away. 3. Paralysis of the " cut-off " and the sphincter muscles of the bladder with or without paralysis of the detrusor urinse. The treatment of these conditions is detailed elsewhere. It is advisable that the patient should wear a urinal. VESICAL TENESMUS. Cramp of the bladder is simply an uncontrollable tenesmus occur- ring in the course of several inflammatory diseases. Where there is no inflammatory action present, it may be classed along with neu- ralgia of the vesical neck, in which condition it is often exceedingly severe. CHOREA OF THE BLADDER. This affection is rare, and seems to occur only in children. It usually coincides with other choreic symptoms. The following cases give a picture of the disease : , aged sis, a weakly, lymphatic boy, of rheumatic antecedents, growing fast, with a moderate appetite and large head, is brought by his mother, with the complaint that he wets his pantaloons while at play. He sometimes soils the bed at night, but not invari- ably. The boy knows when he wets his clothes, and runs to tell his mother. He invari- ably declares that he "can not help it." He is an obedient, gentle little fellow, old enough to be ashamed of himself, and seems really desirous of holding his water, but, as be remarks, he " can not do it." An attempt was made to correct the habit by having the boy called in at stated intervals from his play, for the purpose of emptying his blad- der, but the involuntary, spasmodic escape of urine still occurred occasionally in spite of the fact that the bladder was not allowed to fill up. This boy had no other choreic symptoms, except in the muscles of his right eye. Ordinarily, his eyes were straight, but, when tired, or excited, or angry, or frightened, his right eye would be drawn out- ward — sometimes outward and upward, the axis of the other eye being straight. This strabismus would come and go rapidly, varying according to the voluntary movements of the eye. Moral suasion and belladonna were equally ineffective in relieving the vesical sjTnptoms in this case, but tonic and general hygienic treatment always bettered the patient, until, in the course of two or three years, his bladder returned to a full pos- session of its normal functions, and his strabismus entirely disappeared. During this period, from different causes, he would occasionally get run down in general health, lose flesh and appetite, and then his involuntary spasmodic emissions of urine day and night, and his tendency to intermitting strabismus, would return. The urine was always normal. 23i DISEASES OF THE BLADDER. In this case there was evidently a spasmodic contraction of the detrusor iirinas of the choreic sort, over which the patient had no control. There was no stone or inflammatory state of the bladder, and no kidney disease. He was never seen in the act of making water involuntarily, so that it is impossible to state whether the stream flowed in jets or continuously. , aged fourteen, has always been a nervous boy. He is exceedingly sensitive in disposition, very bashful, easily excited, or brought to tears — general iiealth fairly good. lie has been under treatment for sonic time past, but without benefit. He is troubled with frequent desire to urinate, in paroxysms — the paroxysms seeming to be the culmina- tion of excessive nervous fidgetiness. They occur especially when the boy is annoyed about anything, and are almost always accompanied by a sensation of chilliness. He frequently wets the bed when asleep, and, when awake, the desire to urinate comes on so suddenly and so strongly that he often soils his clothing. With this he has a strong tendency to twitch the head and shoulders, as in chorea. lie was put upon iron, quinine, and arsenic, with general hygienic directions about food, exercise, and fresh air. In two months he reported improvement. His treatment was continued, and he was ordered gnnnastic exercise. Nothing further was heard from him. ■ , aged eight, is a fat, healtliy, lymphatic boy ; one of a large family of children, of whom nearly every male has distinct chorea, either generalized or afi'eeting special muscles. Some of the older children have outgrown the tendency. The patient is troubled occasionally with slight general choreic twitehings, when from any cause his appetite is low, or his general health poor. Under such circumstances he has frequent paroxysms of intermitting, uncontrollable contraction of the bladder, forcing him to frequent micturition and attempts at emptying the bladder every few moments. Some- times the call comes so suddenly that he wets his clothing, and he also is unfortunate at night. When the boy is enjoying good general health, neither his general chorea nor his frequent calls to urinate disturb him. lie improves under arsenic, quinine, or any general tonic or country air. These cases, to whicli might be added several others, make out a distinct choreic condition for the bladder. It seems to be a rare mal- ady, but this may be owing to the fact that it has not been looked for. It occurs, like most other choreic afPections, in early life, and in conjunction with other symptoms of local or general chorea, more or less strongly marked. Treatment. — Correction of any faulty condition of life by improved hygiene ; iron, arsenic, quinine, cod-liver oil, and other tonics in the way of drugs, with electricity, constitute the treatment, and will probably triumjih over any case. Local measures are not needed. HiEMATURIA, Haematuria is a symptom and not a disease, but it very often pre- sents itself as the most prominent objective characteristic of a morbid condition. Often its course is evident, sometimes so obscure that death alone reveals it. Ha^maturia is the passing of blood with the urine. The blood may be free or in clots. There may be so little that it is only discovered HEMATURIA. 235 by microscopic examination, by which moans the amber biconcave disks are easily detected ; there may be enough to give the urine a peculiar, hazy, smoky hue, which is very characteristic of blood, even when there is no pink or red shade in the specimen ; finally, it may be so abundant as to make the urine look like pure blood, or, if blood have been retained for a considerable time within the bladder, the urine may be colored almost black by it. The blood usually comes from the urethra, the bladder, or the kidneys, and it is often of the utmost importance to decide from which of these three sources it is derived. There are but few distinguishing marks. If the bleeding is from the fore part of the urethra, some of it will reach the meatus between the acts of micturition ; if behind a narrow stricture, or posterior to the membranous urethra, it will not. Blood effused into the urethra clots there, and assumes the shape of a leech, or of a tape or thread. Such clots are apt to come out with the first gush of urine, although, if there be a tight stricture, they may not be able to squeeze through until the stream is running at full force, and consequently would not appear until the middle or near the end of the flow. Blood from the seminal vesicles will be clotted and mingled with the yellow bodies found there, and with spermatozoa. Blood from tlie prostatic sinus is pretty sure to be clotted, perhaps in strings and threads mingled among flakes of pus-corpuscles. When blood comes from this region, the spermatic fluid in sexual intercourse is very apt to be bloody. Blood from the neck of the bladder may or may not be clotted. . Often a few irregular clots will come first ; then smoky urine will flow, and, finally, as the bladder expels its last drops, the prostate and vesical neck being squeezed, a little highly-colored urine, or fluid resembling pure blood, will be voided. Blood flowing from any part of the bladder, and sometimes from the prostatic sinus as well, if it flows rapidly into an empty bladder, is pretty sure to clot in mass, and to dissolve afterward. If, however, it flows very slowly, or into a bladder partly filled with urine, it may not clot at all, but remain freely suspended in the urine, retaining its natural red color ; or, after a few hours, become brown or black by the deoxidizing effect of the urine, the red oxyhgemogiobiu becom- ing converted into brown methgemogiobin. Blood may clot in the pelvis of the kidneys, but coming down from the kidneys does so usually in a fluid state, either as red or black blood ; fibrinous clots may, however, pass the ureters with symptoms of kidney colic. Blood from the kidneys has no special physical character by which it can be distinguished from blood coming from the bladder, except in those cases where blood-casts of the uriniferous tubules are found. These are pathognomonic. The quantity of blood flowing from a cancerous kidney varies very greatly, sometimes disappearing for weeks, and then recurring violently. 236 DISEASES OF THE BLADDER. Raver * says tliat. from a comparative examination extending over a length of time, of all the urine passed by patients with calculous pye- litis or cancer on the kidney, he noticed several times (plKsieurs foi)^) that the urine voided three hours after eating was more than ordinarily loaded with blood. "Wlien the blood comes from the kidneys, there is often pain or heaviness of the lumbar region of one or both sides. Blood may flow from the ureter if a calculus be retained there. Raver has noted sev- eral such cases, in two of which there were also exuberant granulations in the ureter, which bled. The origin of blood in tlie urine may in some cases be cleared up by a clever expedient resorted to by Thompson for the ditferential diagnosis of pus from the bladder or kidneys in obscure cases. A soft catheter is gently introduced just within the bladder neck, the urine drawn off, and the cavity washed out very gently with tepid water. If the water can not be made to flow away clean, the inference is that the blood comes from the cavity of the bladder. If it will flow away clean, then the catheter is corked for a few moments, the patient being at rest, and the first drachm of urine which collects may be drawn off and examined. The bladder is now again washed out, and, if after a single washing the second flow of injection be clear, while the drachm of urine was bloody, the inference is again complete that the blood comes from one or the other kidney. Bloody urine is always albu- minous. The causes of hmmaturia are very numerous. Among the most prominent may be mentioned all traumatisms of any character of the kidney, ureter, bladder, or urethra, all acute inflammations of any por- tion of the urinary tract, or of the seminal vesicles, from acute ne- phritis to gonorrhoea and urethral chancre, certain forms of pyelitis ; all chronic inflammations of these same regions, especially if there be ulceration ; overdoses of turpentine when the blood comes fron[i the kidney, or cantharides when it comes from the bladder ; stricture (kidney, bladder, urethral, or stone), strongulus or filaria of kidney, abscess, cancer, or tumor of the kidney or urinary tracts ; varicose condition of veins near the bladder ncck,t villous tumor of bladder; finally may be mentioned spontaneous, so-called essential, haemor- rhage, sometimes recurring periodically once a month, like feminine menstruation, J the hemorrhagic diathesis, critical hoemorrhage in cer- tain febrile or other diseases (typhoid, variola). These discharges may come from any portion of the urinary mucous membrane. Paroxysmal hematuria, due to malaria, cold, exposure, etc., hemoglobinuria, emo- * "Maladies des Reins," Paris, vol. iii, 1841, p. 333. t Laiigier, ''Gaz. des HOp.," No. 81, 1854, and Stein, "New York Medical Record," September 23, 1882, p. 339. X Rayer, op. cit., p. 333. NEURALGIA OF THE NECK. 287 tional hsematuria,* etc., arc medical, not surgical, forms of disease. Ilaematuria is endemic in some localities, South America, Isle of France, etc. (due to the parasite Bilharzia hmmaiohia). Treatment. — The successful treatment of hajmaturia depends upon discovering a cause which may be removed. In any case, however, alkaline diluents are serviceable by rendering the urine less irritating. The different haemostatics are usually of no service, but they may be tried, and occasionally with advantage. Lead and opium (aa gr. j-ij), three or four times daily ; ergot (fluid extract tti xx to 3 j), or subcutaneously (gr. v of ergotine) ; aromatic sulphuric acid, 3 C -]' doses; tincture of matico, 3 j- 3 C doses; alum, sesquichloride, sub- sulphate, and other preparations of iron, tannin, gallic acid, creo- sote, Oak-Orchard mineral water, Eockbridge Alum mineral spring ; last, but not least, turpentine. Rest on the back is often necessary above all things, and in this position ice may be applied with advantage to the hypogastrium, peri- naeum, and in the rectum. Lallemand employed nitrate of silver in the bladder, and iron and alum solutions have been injected with more or less benefit. It is necessary to repeat here one caution already given in another section : If the bladder becomes filled up with a large clot of blood, let it alone ; no harm will come of it. It will dissolve and come away ; any attempt to pump it out through a catheter, or break it up, or dissolve it, if successful, will only allow the blood to re-col- lect, and is fraught with the danger (for the patient) of exciting in- flammation by violence. The best treatment is opium, to control desire to urinate, rest, and diluents. HoUman f injected gr. xvi of pepsin in one case, and in a few hours a dark, viscid fluid escaped readily through the catheter. Pm'oxide of hydrogen is said to dis- solve clot. NEURALGIA OF THE VESICAL NECK. This most common affection of the bladder has received its clearest exposition from Civiale, who has devoted nearly a hundred pages to it in his '•' Traite des Maladies des Organes genito-urinaires," Paris, 1858. Phillips X treats of it as "contracture du col de la vessie," a title first given the disease by Caudmont, another Parisian surgeon, whose views are given in English by Dr. Slade,* of Boston. Gross | gives a case under the title of neuralgia of the bladder, using the term neuralgia in its English sense, to which the idea of pain is attached. The French * I have a case ; Basham and Rayer have reported cases, f "Nederland Weekblatt," IS, 1SS2, p. 272. X "Traite des Maladies des Yoies urinaires," Paris, 1860. * " Boston Medical and Surgical Journal," July, 1855. II " Diseases of the Urinary Organs." 238 DISEASES OF TUE BLADDER. expression ''ncvralgie" docs not necessarily include the idea of pain, but signifies simply a nervous disorder — functional, not organic. The anatomical scat of the disease is the prostatic sinus around the seminal ducts as well as, and indeed more strictly than, the neck of the blad- der. The nervous element of hyperesthesia of the deep urethra and vesical neck bears a large share in producing the symptoms of nearly all bladder diseases. Neuralgia in its pure form has very clear out- lines, but the part it plays when engrafted ujion other bladder and urethral diseases throws confusion into their diagnosis and clironicity into their type. The causes of neuralgia of the vesical neck are numerous, but none holds the same prominence as does the perversion of the sexual in- stinct and appetite, its overstimulation by excess, or, more often, its imperfect satisfaction — in short, irregular or ungratified sexual desire. The action of these causes is to congest and keep in a more or less constant condition of irritation the prostatic sinus in the neighborhood of the seminal ducts. This congestion extends readily in both direc- tions, involving the cnt-ofE muscles in front and creeping backward into the neck of the bladder through the inner orifice of the urethra. Rarely, if ever, does this affection occur in its typical form (simijle irritability of the bladder, without inflammatory lesion) — rarely does it so occur where the sexual element is not at fault. It attacks men young and old, married and single, but the great majority of cases will be found in young bachelors, recently-widowed gentlemen, and old bachelors. Where the youth of the patient or the married state would seem to throw a sexual cause out of possibility, almost invari- ably there will be found, by close questioning, on the one hand mas- turbation or the encouragement of budding erotic fancies by impure thoughts and associations ; on the other, excess, infidelity, or imper- fect and unsatisfactory sexual relations. So close is the connection between an unnatural sexual condition and an unhealthy state of Lhe neck of the bladder, that it needs but little practical observation of cases to convince one that these influences alone are to blame for the origin of some and for the long continuance of many other morbid vesical conditions. Second to this sexual cause in producing neuralgia of the vesical neck comes the arthritic or gouty diathesis, that general blood con- dition attended by acidity and concentration of the secretions, local congestions so often of the tegumentary structures, with neuralgic and irritable habit. Finally comes a long line of causes including everything capable of inflicting a structural change upon the tissues of the neck of the bladder or in its neighborhood (stricture, abscess, large j)rostate, inflammations, stone, worms, inflamed hnsmorrhoids, fissure of rectum, etc.); and though these in themselves are not necessarily complicated by neuralgia of the vesical neck, yet they keep NEURALGIA OF THE NECK. gOQ np congestion there and often arc thus complicated, where the urine is irritating, the constitution arthritic, or especially the sexual appe- tite at the same time perverted or ungratified. The nervous hypo- chondria, with despondency, the excited and suspicious tendencies so marked and remarkable in nearly all men at any time of life in con- nection with functional or organic trouble in the genito-urinary tracts, are only explicable by recognizing that Nature has implanted in man the sexual want which controls many actions of his life, impels him to continue his species, and cries out in distress whenever it is trifled with, ungratified, or overstimulated, or whenever its existence seems to be menaced. A man will feel more depressed at seeing a little excess of phosphate in his urine which he thinks, in spite of all proof to the contrary, indicates a local "weakness," than he will at loss of memory or mental incapacity which he can recognize himself and be fully conscious of. There are few men who would not rather lose a leg or an eye than a testicle ; while functional or organic disease of the bladder, testicles, or penis, causes more mental inquietude and distress to its possessor than does a cavity in a lung. Why should this be, except that Nature has endowed man with an instinct of terror at the idea of losing his sexual capacity, and has established a law for the regular and judicious performance of the sexual act, which he must obey or else suffer in some way the penalty ? This suffering may not be evinced by symptoms in the organs of generation themselves, and prob- ably will not be unless through excitement of these organs by abuse or irregular use, or unless, through their stimulation by erotic fancies, the patient attract the morbid nervous tendency to a local explosion. A man perfectly pure in thought and deed would not suffer from vesical neuralgia, unless, of course, some physical lesion of the parts should first occur to excite local congestion. Old maids and priests suffer from sexual distress as much as young and old bachelors and widowers, but they very rarely give any local signs of trouble. Their symptoms may be scattered over all the organs, and may impair any or all of the functions. Symptoms. — Pure neuralgia of the vesical neck is synonymous with the condition vaguely known as irritability of the bladder. This affection is totally denied by some authors, who affirm that a lesion exists in all cases, and that it is simply a confession of ignorance to talk of pure irritability. The charge can not be justly made. A cause for irritability can always be discovered, where there is no ap- preciable lesion, by studying the sexual wants and relations of the individual. It is expedient, however, to drop the term irritability of the bladder as meaning a disease, and to retain it in the signification only in which it has been adopted in this country — as indicative of that symptom, common to nearly all bladder affections, frequent desire to urinate, where the cause lies in the bladder — hence not ia 240 DISEASES OF THE BLADDER. diabetes or hysteria. This at ouce reduces irritability from a disease to a symptom, aud the term may be used in ordinary description as synonyniDUS with "' frequent desire to urinate.'' Irritability maybe found in connection with inilammatory alTections caused directly by the inllammation or in the same affections ke])t up and aggravated by neuralgia of the vesical neck. The symptoms of a pure case are as follows : Frequent desire to urinate, the attack coming on sometimes suddenly, sometimes grad- ually, without appreciable cause, or i)erhaps commencing in an inilam- matory condition of the parts (gonorrhcea), but not subsiding with the latter. This desire to empty the bladder may or may not be attended by a slight burning pain in the act. In severe cases there is powerful tenesmus (cramp). The relief after urination is usually not perfect, and the desire soon returns. There is often a certain slowness in the act, the bladder contracting without force, and the stream being small, or, on the other hand, the bladder may contract spasmodically Avhen the call conies, throwing out the urine with great force. Again, there may be spasmodic contraction of the cut-off muscles leading to inabil- ity to urinate, or hesitation in the act. There are some prominent peculiarities about these calls to urinate. They rarely disturb the patient at night. Once asleep, he rests quietly, but, if from anxiety or other causes he is restless and w^akcful, he is obliged to empty his bladder frequently, by night as well as by day. When under the stimulation of liquor, the urine can sometimes be held for a number of hours. When pleasantly occupied, or deeply inter- ested in anything, as at the theatre, in agreeable company, or engaged at some earnest w'orkj the bladder is often but little if at all trouble- some. On rainy, damp, or cold days, the calls to urinate are more frequent, perhaps once an hour. The same occurs during idleness, and especially during mental worry or disquietude. The spirits are usually depressed, the patient anxious, perhaps hypochondriacal. The urine is usually clear, rarely shows any purulent deposit (unless the affection has lasted for mouths or years), but often contains an excess of amorphous phosphates. This deposit sometimes alternates from week to week with a deposit of urates. Sometimes both ingredients exist in excess. Crystals of oxalate of lime are not uncommonly jires- ent. There is no soreness over the pubes, though pressure there will sometimes call forth a desire to urinate. In the rectum there is often a slight sensation of heat and uneasiness. There is frequently a dull, dragging, uncomfortable feeling in the perina3um — but pressure there is not painful. Erections may be frequent or absent — the latter to such an extent that the patient may believe himself impotent. There may be abnormal feelings of heat and tenderness about the scrotum and testes. Added to these, there may be all sorts of functional dis- turbances of the bowels, often constipation, with feelings of lassitude. NEURALGIA OF THE NECK. 241 and general weakness. Sjiasmodic stricture of the urethra may oome on as an accom])animent of this condition, while great irritability of the cut-off muscles exists as a rule. Nocturnal emissions are not infre- quent. On exploring the urethra with a full-sized, blunt, steel sound in these cases, it is customary to find the whole canal sensitive and irrita- ble. The muscular fibers contract about the instrument, and oppose its progress. At the membranous urethra, the cut-off muscles con- tract spasmodically, often sufficiently to bar the progress of the sound entirely, and give the idea of organic stricture. As the instrument advances, the cut-off muscles may be felt to quiver in slight partial contractions, while the patient complains greatly of pain. When the beak of the sound enters the prostatic sinus, the patient is very apt to feel faint. He may indeed go into syncope, or have an attack of nau- sea ; or, perhaps, a sexual orgasm may be induced, in which case the prostate and cut-off muscles contract violently upon the sound, caus- ing the patient considerable joain. As the sound jiasses the neck of the bladder, either the natural feeling of a desire to urinate will not be perceived or (usually) the sensation will be highly exaggerated and painful. Sometimes spasm of the bladder will be induced, and the instrument will be forced out, or a jet of urine may gush out along the urethra outside of the instrument. On withdrawing the sound, a little blood will often be found upon the beak, but the patient as a rule feels relieved, and will often experience for hours thereafter an ease and local comfort such as he has been a stranger to for months, perhai3S for years ; his interval of urination being decidedly length- ened, although the smarting at the next urinary act will be greater than before. The above general outline of symptoms will include most cases of pure neuralgia of the vesical neck, where there is no lesion, and has been no serious antecedent disease. As for the symptoms of a nervous element complicating the differ- ent structural diseases of the genito-urinary tract, a detail is impossi- ble. Suffice it to say the symptoms drag out, the disease tends to run a chronic course, attended by morbid excitability of the prostatic ure- thra, and an irritability of the neck of the bladder which is out of proportion to the lesions existing. This irritability is not constant ; it is worse one day, better another, and subject to variations which no physical conditions can account for. Where such prolongation of the symptoms and an excitable state exist in connection with organic dis- ease of the parts — but out of proportion to them — a profound study of the case will often bring out some sexual distress which is finding this means of expression. Pure and simple neuralgia, if continued long enough, may finally lead to a mild cystitis around the neck of the bladder — especially if the patient give way to his frequent calls to urinate, and strain to void 16 242 DISEASES OF THE BLADDER. tlie last drops of urine, thereby nicchanically bruising the congested vesical neck and exciting it to inflame, just as too frequent stools pro- duce an analogous condition of tlie lower end of the rectum. After such inflammation has been kindled, and true cystitis exists, the neu- ralgic element persists with it as a rule. The history of the advent of the attack, the excessive sensitiveness and irritability of the cut-off muscles, and a diagnosis by exclusion, will rarely fail to detect neural- gia of the vesical neck as the acting cause of cystitis where it is so. Such cystitis may be prolonged for years and finally end in death, as in Gross's case, believed by that eminent surgeon to be of malarial origin. These cases require more careful study than pcrluqis any other affection of the urinary organs, and are in many instances mistaken for and treated as organic disease. Diaf/nosi,y direct continuation of the inflammation backward upon the mucous membrane. The inflammation is confined to the region of the neck, and does not attack the body of the bladder. It never appears until after the first week of a gonorrhcea, rarely till after the third week, when the urethral inflammation has reached the lower portions of the canal. It is more frequently seen in practice as a result of simple extension of inflammation later in the course of the disease. Often, however, a second or provoking cause has been in action, and without its assistance the complication of gonorrhceal cys- titis might have been escaped. These provoking causes are anything which will irritate the urethra ; the use of alcoholic beverages, sexual intercourse, abortive treatment of gonorrhoea, catheterism, jolting, violent or even sometimes moderate exercise, where the urine is acid, and the patient nervous and excitable. Any of these causes may light up a mild cystitis of the neck in any patient with urethritis. Symptoms. — The symptoms of gonorrheal cystitis vary from a hardly appreciable irritability — with congestion — up to the very high- est grade these symptoms (of irritability) can assume, Avith a tenes- mus so constant as to amount to actual incontinence, the patient voiding a few drops of blood or milky fluid every few minutes. The tenesmus is particularly painful, although the mere passage of urine is often attended by great pain. A noteworthy featjire of gonorrhroal cystitis is the absence of general phenomena. Fever is sometimes inappreciable, and rarely runs high. Anxiet}'^, malaise, and nervous distress, are, however, disproportionately prominent. Constipation is habitual. The urethral discharge becomes greatly lessened, or even disappears on the advent of the bladder symptoms ; as the latter dis- appear, however, the former returns. Gonorrhceal cystitis varies in duration from a few days, in abortive cases, up to many weeks, and sometimes leaves permanent trouble behind in the pelvis of the kidney or in the seminal vesicle. Acute prostatitis can always be differentiated from cystitis of the neck, gonorrhceal or other, by the rectal touch, which detects a hot. GONORRHEAL CYSTITIS— TREATMENT. 24:7 throbbing, swollen prostate in the one cuse, nothing of the sort in the other. That form of cystitis produced by cantharides is really a strangury. Great congestion of the vessels of the bladder's neck exists with con- stant tenesmus. It is rare to meet cases of this kind at the joreseiit day. Older authors refer to them produced by the administration of "love-potions" by '' witches." Constant priapismus accompanies the tenesmus, and the result in the worsb cases may be sloughing of the penis, and death. There may or may not be erotic excitement. The pathological cJianges produced by acute cystitis upon the blad- der-wall and its membrane are, briefly, capillary injection of the mucous surface, changing the pale salmon-tint into a brilliant crim- son, the color being perhaps uniform, perhaps in patches, with a more or less punctate appearance. There may be ecchymotic spots, purple- colored patches mixed with red. The mucous membrane is softened and swollen. These changes usually commence at the neck and often remain limited to this locality, but may extend over the whole in- ternal surface of the bladder. The glandular follicles near the neck become involved, enlarged, and surrounded by a red areola. In cer- tain high grades of inflammation the membrane may be ulcerated, or patches of false membrane encountered. This croupous character has been especially observed in the cystitis caused by cantharides. True patches of diphtheritic exudation have been observed secondarily in the bladder. There may be sloughs of the mucous membrane, or of more or less of the thickness of bladder-walls, or interstitial thick- ening, with or without abscess (interstitial cystitis), or abscess around the bladder, with more or less peritonitis. Purulent venous thrombosis has been found,* With these evidences of acute cystitis may be mingled the marks of older chronic inflammation ; such as a thickened, condensed, tough structure of the mucous membrane and bladder-walls, colored in purple and red, or of a bluish-gray, slate-colored tint ; trabeculization, sacculation, ulceration, perhaps pus in or around the bladder- walls ; possible gangrenous patches ; the mucous membrane may be incrusted with urinary salts, etc. Treatment. — The general treatment of acute cystitis from any cause — gonorrhoea as well — is the same. It rests firmly, as already indicated for prostatitis (p. 208), upon the tripod of rest in bed, with elevation of pelvis ; alkaline diluents ; enough anodyne to relieve pain and tenesmus. To these may be added local application of heat. If there be any removable cause (presence of a catheter tied into the bladder), it should be taken away. If the cause be stone or a foreign body, no attempt should be made to remove it until the intensity of the inflammation has been quieted by the means above alluded to. If * Walsham, London Path. Soc, April 29, 1SY9. "Lancet," May 10, 1879, p. 665. OJ-S DISEASES OF TUE BLADDER. cautliaridcs, turpentine, or ciibcbs is boiu^t; taken by tlie patient, it should be discontinued during the acute stage of the affection, to be resumed in the subacute stage. Copaiba sometimes works wonderfully well in quieting acute symptoms, but it can not be relied upon. As- paragus should not be eaten by a initient with acute cystitis ; common salt, strong coffee, and lemon-juice should be also avoided. There is no occasion for any local or general abstraction of blood, but the medi- cines and measures detailed at pages 201, 202 should be studiously enforced. If the cystitis be a strangury from cantharidcs, plenty of opium — or camphor in emulsion — and a very free use of diluents, must be relied upon. In all cases repeated use of a full hot bath has a soothing effect — or of the hip-bath. The rectum should be kept free by copious warm enemata, and opiates should be given by the rectum and not the mouth. Absolute rest, with the hips raised, and alkaline diluents, alone suthce in mild cases. If abscess form in or around the walls of the bladder, an opening should be made externally through the hypogastrium, rectum, or perin^eum, at the earliest possible mo- ment, to prevent perforation of the mucous membrane, and the possi- ble danger of infiltration. The most effective special treatment for gonorrhceal cystitis is the instillation into the membranous urethra in the manner already indi- cated (p. TT), with a deep urethral syringe, of a few drops of a solution of the nitrate of silver, at a strength varying from one to forty-eight grains to the ounce, every few days. The effect is often magical. Ten grains to the ounce is usually strong enough.* The key to the treatment of pe?'ici/stitis is to open abscess wher- ever it tends to point, making the opening carefully and very early. CHRONIC CATARRH OF TEE BLADDER. Of all the affections to which tlie bladder is subject, chronic ca- tarrh holds the first rank in regard to frequency. It never occurs as an idiopathic affection, but is invariably a secondary result arising from other morbid conditions of the urinary passages. Once started, it does not tend to get well spontaneously, but to become slowly and steadily worse. Fortunately, its causes are well known, and most of them easy of demonstration. Many of these can be removed, and with them the chronic inflammation which they keep up. Some cases arc incurable on account of permanent structural alterations in the bladder-walls, or where the cause can not be reached. All, how- ever, may be benefited by careful and judicious management, and there are few abnormal conditions of the body whose amelioration is attended by more satisfaction on the part of the surgeon, or more gratitude on that of the sufferer. * Consult a paper by me, "Xcw York Medical Record," May 28, ISSY. cniioxic CYSTITIS. 249 Causes. — Almost all the organic diseases of the urinary passages are attended, during some part of their course, by more or less chronic catarrh of the bladder ; so much so, that a study of the altered con- dition of the bladder forms a part of the picture of the disease, and has to be considered with it. Hence, most of the varieties of chronic catarrh are disposed of elsewhere under the heads of other diseases. For their study the reader is referred to the proper section (stone, stricture, prostatic disease). All causes of chronic vesical catarrh may be arranged under three main heads : 1. Mechanical, including obstructive prostatic and urethral dis- eases, stone, morbid growths in the bladder or rectum, or around tlie bladder, hernia of the bladder, exstrophy, retention of the urine, sud- den taking off of the pressure of accumulated urine from an habitually overdistended bladder, neuralgia of the vesical neck. 2. Cliemicctl. Very acid urine (rarely), decomposing alkaline urine, from the liberated ammonia frequently ; atony, paresis of the muscu- lar coats and true paralysis, inasmuch as they invariably tend to i)ro- duce decomposition of the urine by stagnation. 3. Reflex, from kidney disease, stone, pyelitis, urethral anterior constriction, tight meatus, inflammation in seminal vesicles, etc. Many, in fact most cases of chronic cystitis, result from the com- bined action of both mechanical and chemical causes. In obstructive disease from stricture or large prostate, added to the mechanical stretching, the chemical action of the decomposing urine is always at work. The same may be said of retention. Eetention alone, in a healthy bladder, will not necessarily cause cystitis, although it may do so from the mere mechanical violence done by stretching. The con- stant slight violence due to voluntary retention pushed beyond a nor- mal limit, and often repeated, will eventuate in cystitis. The same holds good of the sudden but extreme retention occurring in coma, shock, the acute fevers, etc., if it be not relieved. In these conditions of unconsciousness or delirium, the well-informed physician is always on the lookout for the state of the bladder, frecpiently palpating and percussing the hypogastrium to see that all goes well. It is very gratifying, in these cases, to observe the instantaneous i-elief which may be afforded by inserting a soft catheter, and emptying the over- distended bladder. Even if overflovy has come on, the regular use of the catheter, preventing prolonged overdistention, may avert the im- pending cystitis and atony. Yet, in practice, not a few cases of cystitis will be found to take their origin in retention, during fever or unconsciousness, not promptly recognized. On the other hand very acid, or even slightly decomposing urine, would not excite in- flammation in a bladder unless its circulation and tone were already impaired, as by atony, paralysis, etc. Finally, one other causative factor of cystitis deserves a word ; namely, extension of chronic in- 250 DISEASES OF THE BLADDER. flammatiou backward from a v.rcthra or prostate already chronicalh' inUamod. Of the two sets of causes tlie mcchanic((l act far more frequently, the chemical usualh' coming in to assist them in their work. Clironic cystitis from mechanical causes is disposed of elsewhere (stricture, hypertrophied prostate, inflammatory, tuhercular, cancerous or other prostatic disease, cystitis from stone). Trauinatic violence in the bladder, as elsewhere, is attended by inflammation. Morbid growths in or around and pressing upon the bladder, cause chronic cystitis by obstruction to free escape of urine, by calling an extra amount of blood to the part, and by the mechanical bruising which the bladder-walls sustain against them. Again, the tumors themselves may inflame, or their discharges cause decomposition of the urine, thus exciting chronic catarrh. In hernia of the bladder there is mechanical obstruction to circulation, with distention, and de- composing urine. In exstrophy there are friction with clothing, ex- posure to the air, and mechanical obstruction to circulation. A blad- der gradually accustomed to habitual overdistention may give its owner no ajipreciable annoyance, but the mechanical stretching here has modified and weakened the circulation of the part, and produced atony, and when all the tension is suddenly let up, and the bladder allowed to collapse, the blood is very apt to rush suddenly into and overdistend the weakened vessels, and result in a condition of in- flammation, the iy])Q of which, however, at first, is more often acute than chronic — and grave at all times. In long-continued neuralgia of the vesical neck, the mechanical active cause is the constant and continued bruising of the bladder- neck, by often repeated, perhaps violent and spasmodic contractions in micturition. Added to this sufficient cause . is a second one, namelv, an extension of congestion backward from the engorged mem- brane of the jirostatic sinus. TJie chemical causes conducing to cystitis have been alluded to in connection with overdistention of the organ (stricture, enlarged pros- tate). Very acid urine rarely causes cystitis, being more apt to pro- duce urethral inflammation ; acting, however, upon an already con- gested bladder, it always tends to heighten the grade of the congestion or inflammatory process. Decomposing urine will sooner or later light up cystitis, on account of the irritating properties of the am- monia wdiich it evolves, and in atony or paralysis there would be no cystitis without the action of this cause. The first edition of this treatise contains a case clearly demonstrating this fact (Case XXXI). A fertile source of chronic cystitis is chronic inflammatory or irritative kidney disease, notably pyelitis — by reflex irritation. This is often overlooked even by the most experienced observers, the urethra is cut, the bladder injected, the perinaeum incised, when it finally turns out CHRONIC CYSTITIS. 251 that- the trouble was not cystitis at all, but a stone in the kidney, pye- litis, or pyelo-nepliritis, or nephrosis. Symptoms of Chronic Cyditin. — The symptoms of chronic cys- titis resemble those of the acute form, in a degree proportionate to the grade of the inflammatory process. There may be only a little in- creased frequency of urination, with slight cloudiness of the fluid, as seen in the history of enlarged prostate ; or the calls may be very fre- quent, and. the pains excessive, varied, and constant, as in the acute disease. In fact, chronic cystitis is liable at any time to be lighted up into an acute state by the continued, action of its own cause, or by the supervention of others (effect of cold, violent exercise, abuse of alco- hol, acid urine). The urine of chronic cystitis always contains pus, either freely suspended through the fluid, or, more often, in gouts and clots of stringy muco-pus, more or less mingled with crystals of triple phosphates and with blood. Pus which is passed in the liquid state may become converted into "stringy mucus," while standing, by the alkaline decomposition of the urine, or the process may be imi- tated artificially in a test-tube^ by adding ammonia or liquor potassse to urine containing free pus. The latter immediately becomes trans- lucent, coherent, and is indeed the substance commonly called "stringy mucus." Diphtheritic casts of the entire bladder have been passed by females during life, and found in the male after death. I have heard of one such being passed by a male, but I did not see it. Fibrinous shreds passed by the male are not very uncommon. Treatment. — Chronic cystitis being an affection always entertained by some other morbid process, its treatment consists in the removal of the cause. Some of these causes are removable, others are not. In the latter case the treatment is palliative, and addressed to symj)toms. After the removal of the cause the chronic cystitis will get well in early life, or at any age, unless there has been organic, permanent change induced in the bladder-walls (hypertrophy, sacculation). For these lat- ter cases, or where the cause can not be removed, the i^alliative treat- ment is as follows : For acute exacerbations, the same as for acute cystitis, based on the tripod attitude, alkali, anodyne ; for the forma- tion of abscess in or around the bladder- walls, besides the above, an early and carefully made opening ; for the continuous chronic state the treatment consists in keeping the urine, as it comes from the kidneys, slightly alkaline, washing out the cavity of the bladder with warm water, then with medicated injections (p. 197), if an instrument can be introduced ; and in the use of a small amount of anodyne in suppository at night, when the pain is great. The balsam of coj^aiba, cubebs, tur- pentine, and the infusions of buchu, triticum repens, uva-ursi, flaxseed, etc., may also be sometimes of use. The value of counter-irritation over the hypogastrium must always be kept in view. These means- 252 DISEASES OF THE BLADDER. aided by as much rest as is consistent witli health, change of air, and hygienic details in regard to food, etc., will elTect all the relief that can be atforded. Where there is an element of neuralgia of the vesical neck in the case, it must be suitably treated (p. '212). The peculiar- ity of chronic cystitis, depending, as it always does, upon some other morbid condition, renders its special description unsatisfactory, and begets a necessity for constant reference to the other allections which underlie it. Some of the modern suggestions, which may be used with advantage in some cases in a general way to reduce chronic cystitis, are, fluid ex- tract of corn silk, milk diet, nai)htlialine, benzoic acid and the ben- zoates, salicylic acid. An admirable bladder irrigation is, gr. ss. to grs. iij nitrate of silver to the pint of water. Cydotomy for Chronic Cydith. — This operation has grown in favor of late years, the drainage being usually accomplished by tying in a soft, red-rubber catheter of large size through a median incision made in the perineum. The floor of the prostate is sometimes cut down a few lines by a median incision, and the bladder drained and irrigated with medicated solutions. Many successful cases are re- corded. I have operated a number of times, occasionally efCecting com- plete cure, but generally only producing palliation of the symptoms. The priority of this operation is often disputed. Vague statements are made that it was done long ago, by Miche-ange Aasson, Eoux, Medoro, a surgeon of Padua, Borsiori, Ucelli, and others. But the weight of authority seems to credit the conception of the operation and its first performance (see Horovitz* and II. Royes Bell f) to Bou- chardat, in 1803, Willard Parker, \ of New York (operation Novem- ber 23, 1850), and Fergusson, in 1855, all of wiiom operated inde- pendently of any suggestion from the other. Then came McCraith, of Smyrna, and very many others. Atony of the bladder is, as the name implies, simply a lack of tone in the organ. It is muscular paresis, and it is to be widely distinguished from paralysis, an afl'ection of central and not of local origin, with which disease it is commonly confounded. Truly, a stretched muscle which will not contract is paralyzed ; but, to avoid confusion, the term atony must be retained, paralysis only being applied where there is nerve- lesion. Every bladder suff'ers in a mild degree from what may be called physiological atony as the individual growls older. A healthy boy can throw a stream from his bladder to a much greater distance than he can when he becomes an adult, even taking into consideration the increased size of the prostate and enlarged caliber of the urethra, and the same remark holds true of adult life, when compared with * "Wiener med. Wochcnschrift," 13 and 14, 1883. f London " Lancet," February 17, 1882, p. 282. X "New York Journal of Medicine," July, 18")!, p. 83. CHRONIC (JYSTITIR. 25'3 healthy old age. The bladder being accustomed to a constant, slight distentipn, loses its expulsive power measurably with advancing age. Besides this mild condition of atony, however, there is a pathological form duo to overstretching of the muscular coats, either gradual and continued, or sudden and extreme (retention), or to constant congestion, as with hypertrophied prostate. Any one may observe the phenomenon of atony in his own person. If. the urine be voluntarily retained for some hours after the bladder is full and the natural desire felt, it is noticeable, when an opportunity presents itself, and an attempt is made at passing water, that it is necessary to wait some time, perhaps several minutes, before the stream begins to flow. When it comes, it com- mences very gradually, and without force, getting stronger as the flow continues ; finally, the last drops dribble slowly away. This is the mildest pathological degree of atony, and is caused by a paresis of the overstretched detrusor urinse. In men of sedentary habits, or those engrossed by absorbing occupations (students, actors), where the calls of nature are habitually disregarded, this slight degree of atony, often reproduced, may finally lead to a permanent lack of the expulsive power. Sometimes actual retention may come on, starting involuntary retention, the bladder having lost its tone so far as to refuse to contract when an opportunity oft'ers. Passing water habitually in the recum- bent position, while lying in bed, is believed to be an occasional cause of atony. Predisposing circumstances are general weakness and laxity of the body. In some cases there seems to be an actual predisposition to this condition, while in others fatty atrophy may induce it. The form of atony occurring with hypertrophied prostate does not necessarily depend upon mechanical overstretching. It is due to the constant congestion of the hypertrophied muscular coats of the bladder, kept up by the obstacle to the return-flow of venous blood from the bladder-walls, formed by the size of the prostate. With this cause, a certain degree of continual distention of the bladder-walls often goes hand in hand, and, where there has been retention, this circumstance takes its place as the most prominent cause. Often, atony from overstretching owes its origin to retention of urine occurring in the course of acute disease (typhoid, variola), or temporary loss of sensibility (coma, concussion, compression) not rec- ognized and relieved ; or, most frequently, to retention complicating stricture in the young, enlarged prostate in the old. Nervous influence has no necessary connection with atony. The injury is mechanical ; the overstretched detrusor urinas loses its power, and is unable to expel the urine. Symptoms. — The symptoms of this affection have been considered under the heads of its most constant causes, stricture and prostatic hypertrophy. To recapitulate for all cases : in complete atony, the expulsive power of the bladder being lost, the viscus fills up, and we 254 DISEASES OF THE BLADDER. liave the condition named by Civiale " stagnation with overflow." The excess of urine, after the bladder has held all that it can as a passive sac, flows over, ujion some muscular eifort of the jiatient (sneezing, violent coughing, laughter), or trickles })assively away. In numy of these cases of stagnation with overflow, the bladder is patient, and holds, perhaps, two or three pints constantly, without giving its owner any considerable uneasiness. What little excess collects over this amount occasions the normal desire to urinate. This is elTected by voluntary contraction of the diai)hragin and abdominal muscles, and perhaps an ounce or more of fluid is ejected in a dribbling stream. This brings relief for an hour, when the elTort is repeated, with a like result. Such patients arc ai)t to complain that their bladder is so small that it will only contain a few droi)s of urine, after the collection of which they are obliged to empty it, which they believe they do. Par- ticularly are these frcciuent calls pressing if, as is very apt to be the case, there is some cystitis along with the atony. All the signs of an overdisteuded bladder are present with complete atony. The crucial test is the introduction of a catheter. As soon as the eye of the instrument reaches urine, the flow through the tube com- mences. It does not spurt out as from a normal bladder, but drops down nearly peri^endicularly from the end of the instrument. A cough or a long breath will make it flow faster, as will also, very materially, pressure of the hand over the hypogastrium. Treatment. — The object of treatment of atony is to attcmjot to restore contractile power to a muscle Avhich has been overstretched. The first indication is, obviously, to keep the muscle from any further violence, by catheterization performed three or four times daily. In the young we may always hope for a cure ; in middle age for amelioration ; but in old age with enlarged prostate the injured muscle rarely recov- ers its tone — nor, indeed, is it always desirable that it should do so. Besides keeping the bladder from being again distended, avc have a very effective means of hastening the return of the contractile power by the employment of cold injections into its cavit}^ If there be much cystitis with the atony, the cold should be used sparingly, but otherwise the bladder should be filled at each sitting Avith several successive injections, commencing at the first sitting with water of 90^ Fahr., after this has flowed out, following with water at 85° Fahr., and a third time at the same temperature — never more than four ounces of fluid being tiirown in at one injection. The w'ater may be retained from one to two minutes, and then be allowed to drain off. This process may be repeated daily, starting at a temperature 5° Fahr. lower at each sitting and pro- ceeding as directed above. "Water may be injected as low as 40° Fahr., but it should be allowed to run out again immediately. It acts as a local douche, but is useful in youth and middle life only. This treat- ment may be continued for months, and it wmII yield good results if PARALYSIS. 255 any such arc possible. The cold douche ai)i)licd to tlie hypogastrium, sacrum, and perinaeum, is a good adjuvant to the injections. Local ap- plications of electricity may also be employed, an insulated electrodo being carried into the bladder, and the current passed directly through its walls to the other electrode in the rectum, or to a moistened elec- trode over the hypogastrium. No internal medication is of any serv- ice, unless jDOSsibly a mild alkali to keep the urine from exciting cys- titis, or perhaps a little cantharides, strychnine, or ergot, for its specific effect. Tonics and general hygiene may be necessary in spe- cial cases. PARALYSIS OF THE BLADDER. As atony is common, so is true paralysis of the bladder uncommon. It occurs only in connection with nerve-lesion, or rarely as a functional nervous affection (reflex urinary paralysis, Brown-Sequard). The causes of paralysis of the bladder are brain disease attended by hemi- plegia (rare), partial paralysis from reflected peripheral nervous irrita- tion acting through the spine (exceedingly unfrequent), any disease or affection of the spinal cord (inflammatory, apoplectic, syphilitic, cancerous, from pressure. Pott's disease, fracture of spine, tumor), especially if such spinal disease be attended by paraplegia, partial or complete. This latter set of causes, which may be summed up in the one word paraplegia, is by far the most active and efficient. Vesical paralysis may come on gradually, as sometimes in Pott's disease and in certain syphilitic paraplegi^e, or (most commonly) suddenly. In the former case the bladder discharges its contents from day to day more feebly, the change taking place perhaps so gradually that the patient does not notice it. Soon some of the urine is retained, only an excess over a certain fixed quantity being voided. This residuum goes through the changes of stagnating urine, and by decomposing lights up cystitis, the more readily on account of the weakened state of the bladder-walls due to impaired innervation. The patient now notices that his urine smells foul, is more or less muddy, perhaps full of thick, ropy mucus, and that he has frequent calls to urinate. Perhaps the paralysis may go no further, but the cystitis will continue to be steadily progressive unless arrested by appropriate treatment. On the other hand, the paralysis may go on to become complete, when retention will at once appear. Very rarely there is paralysis of all the muscles, and true incontinence results ; but this is so exceptional that it may be said not to occur. Most commonly, as the paraplegia comes on suddenly, so also does the vesical paralysis, and a bladder, at a given moment perfectly healthy, becomes at once incapable of con- traction. Eetention ensues, the urine overdistends the bladder and then overflows, dribbling away. The bladder becomes inflamed by 256 DISEASES OF THE BLADDER. the decomposing retaiiuHl urine ; pns, stringy nincns. earthy plios- phates, vibriones, triple-])hosphate crystals abound. The weakened bladder-walls may ulcerate extensively, or become incrustcd with earthy salts, or stone may form. It is in some such deplorable condi- tion as this that the bladder usually first receives surgical notice and attention, whereas the whole list of symptoms might have been avoided (except the loss of contractile power) by the application of the proper means at the proper time. Treatment. — When a patient, from any cause, becomes wholly or partly paraplegic, his bladder should not be allowed to become dis- teniled. The catheter should be passed soon after the accident, and reintroduced three or four times daily, always with great care, on account of the insensibility of the parts, and the danger of lighting up cystitis mechanically. At the same time the bladder should be thoroughly washed out with warm water once or twice after each intro- duction of the catheter. Colder water may be used later, but this remedy, so useful in atony, has little power over true paralysis of the bladder ; on the contrary, it may do harm. Warm water is used sim- ply for purposes of cleanliness, to take away the ferment, mucus, and to prevent cA'stitis. This can be done, probably, in every case that is properly managed. Ordinary tar water used for irrigation some- times yields admirable results in averting cystitis, AVhere the patient is not seen until stagnation and overflow have occurred, it is more diflficult to keep down the inflammatory outbreak, but the sooner it is attempted the more chance is there of success. After catarrh of the bladder has become thoroughly established, the treatment becomes mainly palliative, but even here much can be done by the systematic, regular use of the catheter, Avith thorough washing of the bladder, first with warm water, and then with borax, or other mildly stimulating injection, as directed in cases of catarrh, with atony and enlarged prostate. Chronic cystitis being, as has been shown, a secondary disease, the main reliance of treatment, in any case, consists, after the removal of the cause, in the surgical measures already enumerated, injections into the bladder, medicated or otherwise, position, and external counter- irritation. The tercbinthinate and stimulating diuretic drugs habitu- ally employed, though of service in certain selected cases, are of far inferior importance. The value of these drugs is secondary, and is greatly overrated by the profession ; they do more good as diluents than by any specific virtue, and, being generally combined with ano- dA^nes, the rei^utation which they enjoy is really more often due to virtues of these latter than to any special power of their own in con- trolling vesical symptoms. PNEUMATURIA. 257 PNEUMATURIA. Pueumatnria is one of a number of names given to a malady in which air, or an odorless gas much like air, escapes from tlie urethra when it has not been introduced into the bladder by a catheter, and when there is no vesico-intestinal fistula. I brought the subject before the profession in America* in 1882, recording two cases. In one I had a post-mortem examination, and found no communication with the intestine. In the- other there may have been such a communica- tion. The patient is since dead, and I could not obtain an autopsy. The last of these patients had no sugar in his urine ; in the first case I did not look for it. Eecently I have had another case without sugar — a gentleman with prostatic disease, who uses a catheter. Occasion- ally, he passes gusts of air by the urethra. Eizat f states that, in Chopart's edition of 1855, annotated by Segalas, there are two cases — one a farmer in good health, who had no other malady than that of passing wind by the urethra ; the other an architect of seventy, who passed gas each time that Segalas sounded him. The symptom disappeared when the urine became acid. Brierre de Boisemont J refers to Eibes's case in the "Miscellanea curiosa," p. 85, of an infant ''qui n'avait pour toute maladie que cette emis- sion de gaz" — the urine being healthy. Eaciborski's case in Bou- chut's treatise, "Du Nevrosisme," * is an excellent one in point. Finally, an exhaustive consideration of the subject appeared from the pen of F. Guiard, || who comes to the conclusion that the malady is a fermentation of saccharine urine within the bladder, since he had seen several patients who passed gas, and whose urine contained sugar. This may be so. I never have seen the malady except in a patient who used the catheter, and I have not excluded sugar in the only case in which I had an autopsy. It is then quite possible that the germ of fermentation is introduced by the catheter, and that where sugar is present gas is formed, which escapes later spontaneously or through the catheter. In 1884 C. Alem, in a Parisian thesis, considers the subject, but adduces nothing new. HETEROLOGOUS DEPOSITS AND TUMORS IN THE BLADDER-WALLS. These are tubercle, fibroma, cyst, cancer (epithelioma, carcinoma), sarcoma, enchondroma; benign tumors like myoma; myxoma has been found ; finally, papilloma (villous growth). * "Pneumo-uria," "Medical News," December 16, 1882, p. 675. f " Journ. de Med. de Paris," February 24, 1883, p. 209. X "Thfese de Paris," No. 201, 1825, p. 15. * Second edition, Paris, ISYY, p. 245. |] "Ann. des Maladies dcs Organes Genito-Urinaires," 1SS3, pp. 243, 255, and 363. 17 258 DISEASES OF THE BLADDER. These different new formations cause symptoms more or less severe according to their situation and size. Thus, by pressure on a ureter, they may lead to distention of that canal and of the pelvis of the kid- ney, with (possibly) linal rupture of one or the other, or atrophy of the secreting portion of the kidney. Again, the growth may be near the neck of the bladder, presenting an obstacle to the escape of urine, which may even lead to complete retention ; while, on the other hand, if it springs from tlie fundus away from tiie sensitive ]iortions around the neck, it not only does not oppose any obstruction to the free out- flow of urine, but, in exceptional cases, may give rise to little if any cystitis. Some of these tumors, again, become engorged with blood from motion or other cause, and then all the symjitoms are aggravated. When a free flow of blood takes place, the symptoms remit and the patient feels better. The above remarks apply to the whole category of foreign growths taken together, and to no particular class. Tubercle. — Tubercle of the bladder does not occur as an isolated affection. It is not very often encountered in connection with pul- monary tuberculosis, but comes on more frequently with tubercular ulcerations of the intestines, and is especially common with similar disease of the kidney or prostate, or even with advanced tubcrculariza- tion of the testicle, cord, and epididymis. The glands and follicles, usually, near the neck of the bladder and orifices of the ureters first suffer. Groups of little whitish elevations, surrounded by a red areola, may be seen at first, and these, going on to increase, coalesce and break down into cheesy degeneration and ulceration, sometimes leading to perforation of the bladder. The diagnosis is mainly made by exclusion. The bladder symp- toms are simply those of chronic cystitis, more or less severe according to the situation of the deposit. There is rarely much blood in the urine. The exploring sound may sometimes detect the ragged ulcera- tions, and appreciate the thickening of the bladder-walls. Beyond this, exploration is usually negative ; no tumor is felt either by the sound in the bladder or by rectal or hypogastric palpation ; while the debris of tissue found in the urine has no distinctive characters. The diagnosis usually rests upon the general condition of the patient, and the state of the whole geni to-urinary apjaaratus. Advanced i)hthi6ical disease elsewhere, of the lungs, intestines, etc., but particularly of the epididymis, with a ridgy, knobbed feel of the seminal vesicle and vas deferens of the same side, especially if there is evidence of prostatic trouble, and, above all, any suspicion of tubercular pyelitis — any of these concurring symptoms makes the diagnosis probable, while all of them would make it certain. Tubercular geni to-urinary disease occurs most frequently in youth and early adult life. Treatment. — The treatment is the same as for phthisis elsewhere — j)roper warmth, fatty food, fresh air, out-door life, tonics, etc. Lo- TUMORS— CYSTS— CANCER. 259 cally, anodyne suppositories, if pain be great, rest, alkaline diluents ; finally, syringing the bladder with warm water occasionally, unless the introduction of the instrument produces too great pain. These patients rarely recover, but they continue to live sometimes far beyond expectation. Fibrous Tumors. — These tumors are not common, but occasion- ally one or more of them are found in the bladder, where they give rise to trouble mechanically, being perfectly benign in character, com- posed of connective-tissue elements, growing in and from the submu- cous connective tissue. They appear first as slight elevations. These enlarge and grow into the cavity of the bladder, sometimes becoming pediculated. They are to be distinguished from the irregular poljrpoid overgrowths from the posterior urethral orifice of the prostate, and from supernumerary prostatic tumors. Syynptoms. — Careful sounding with a Thomj)son's searcher, or, perhaps better, a lithotrite, may detect the position, size, and perhaps the number of the tumors. The amount of cystitis is usually not so great as in tubercle, while the cachexia and occasional jirofuse bleed- ing of cancer are wanting. Children and young adults are most liable to be affected. With Nitze's cystoscope tumors of the bladder may be plainly seen. The latest improvement of the instrument* gives a field a little lai'ger than a silver dollar, and with its use the inside of the bladder may be plainly seen. Nitze indorses only the instrument made by P. Hartwig. Treatment is palliative — alkaline laxatives, anodyne suppositories if necessary, warm washing of the bladder, use of catheter, etc., and, in suitable cases, suprapubic cystotomy and removal of the tumors. Cysts are rare in or around the bladder, but occasionally they are found. They sometimes contain bone, teeth, muscle, and hair, which occasionally find their way by ulceration into the bladder, and consti- tute nuclei for stone, or give rise to pilimiction.f Hydatid as well as simple cysts have been encountered. A striking case of cyst of the bladder is reported by Knox, operated on by Listen. J Diagnosis was made by a catheter, which was being passed for retention. The in- strument struck against a soft, movable mass at the neck of the blad- der. Liston decided to perform epic3'Stotomy at once, and removed, a large cyst very like the bladder in volume, form, and appearance. Cancer is rare in the bladder, but still it is more common than benign forms of tumor, or other foreign growths not inflammatory. It may originate in \h& bladder, but more often is an extension of dis- ease from the prostate or bowel. When occui^yiug the bladder it may grow from any portion of the walls, but usually springs from near the * "Berl. klin. TVchnschrft.," Feb. 21, 1SS7. f " ilemoire de la Soc. de Biologie," 1S50, Raver. X "Medical Times," August 2, 1862, p. 104. 260 DISEASES OF THE BLADDER. neck or orifices of the ureters. Different varieties of cancerous growth liave been enconntered. The encei)haloid, or soft sarcoma, is not very uncommon. Seirrhus and the epithelial disease are also more often observed ; colloid occurs. The cancerous nodules develop under the mucous membrane in the walls of the bladder, and often grow to the formation of a considerable tumor. Ence])haloid, especially, may grow out in a fungous manner, until it fills the whole cavity of the bladder. Cancerous growths go through the same i>hases here as else- where, finally ulcerating and destroying life by loss of blood or ca- chexia, or wearing out the patient by extreme pain. The symptoms vary but little from those of other tumors. There may be the same mechanical obstruction to the escape of urine, due to the position of the growth, and calling for the use of the catheter, the same cystitis, more or less intense, according to the position and size of the tumor and the extent of ulceration ; but in several particulars the symptoms of cancer in the bladder are special, and the diagnosis more easy than for other tumors. The pain is more severe, is referred to the back, loins, and thighs, as well as to the pubic and perineal region ; enlarged glands may sometimes be felt along the brim of the pelvis. The bleeding is usually intermittent in character ; at first there may be long intervals of months between the paroxysms. The blood flows suddenly and profusely, in clots and fluid, attended by great pain. After each bleeding the severity of the symjitoms lessens. Between the attacks there is more or less oozing, sometimes enough to keep the urine constantly red ; sometimes, during the earlier months of the disease, only to be detected by the microscope. Tlie introduc- tion of a catheter is very apt to occasion haemorrhage, and should be avoided as much as possible. Sometimes shreds of tissue, projecting from the borders of an ulcerated, cancerous nodule, will be caught in the eye of the catheter, and be pulled away. The microscopic examination of such shreds may sometimes throw light upon the nature of the tumor. In the middle and later stages of the disease the cancerous cachexia may be marked, and the bleeding more con- stant and profuse, while the intervals between the paroxysms will be shorter. Finally, in seirrhus, the hardness can be felt by the finger in the rectum, and in the common form of cancerous disease, medul- lary, the size which the mass attains renders it nearly always easy of detection long before it has advanced far enough to be fatal. This growth has been mistaken for enlarged prostate. Its general size, shape, and position may be studied out with the searcher, while the finger in the rectum will sometimes recognize a peculiar, soft, semi- elastic tumor behind the jirostate, and be able to appreciate pressure made upon the tumor above the pubis. Cancer, here as elsewhere, is a fatal disorder. The treatment is mainly symptomatic and jmlliative, keeping up strength by all known tonic and hygienic means, and using CANCER. 201 the same sedative and local treatment as for other tumors of the blad- der, emioloying special means as they are required by special cases. Opium ranks first in usefulness. The question of the propriety of operation naturally comes in here. Much has been written of late about tumors of the bladder, notably the monographs of Stein,* Thompson,! Kuster,J and Guyon.* The revival of suprapubic cystotomy has given new impetus to opera- tive interference with the bladder, explorative and otherwise. The high operation is always justifiable in the case of benign tumors. My experience in their removal has been happy. || Thompson advocates the perineal method, but, however good this may be for exploratory pur- poses, it certainly does not compare favorably with the suprapubic method when anything positive is to be done, or even for exploration. Yet many successful extirpations of benign tumors have been per- formed by both methods. When the question is the removal of cancer, then it is probably better to confine operative interference to palliation. Much comfort can be given in these cases after they become obstructive by growing into the orifice of the urethra by a median perineal section, extensive scraping, and wearing a tube tied in. I have so operated a number of times. . Or a suprapubic operation may be made, and the growth be extensively scraped, drainage being carried on by a permanent soft tube worn above the pubis. When in a case of vesical cancer it is decided to make permanent drainage for the relief of symptoms, I believe that this drainage gives more comfort when effected by a tube worn permanently above the pubis (p. 129). Many efforts have been made to resect portions of the bladder. Dogs were first successfully experimented on. On January 7, 188.2, Dr. Fisher brought up the subject in the Society of Physicians at Buda-Pesth, stating that the operation had been done by Pott, Chopart, and Desault, but then abandoned. Fisher narrated his experiments on eight dogs, and advocated the operation in certain cases. Sonnenburg,'^ of Berlin, excised suprapubically the entire bladder, except a portion of the posterior wall, the trigonum, and orifices of the ureters and the sphincter (opening the peritoneum), in a woman of sixty. He drained through the urethra and abdominal incision, and when the case was reported after three weeks it was doing well, but a few weeks later the patient died of exhaustion. * "Tumors of the Bladder," William Wood & Co., New York, 1881. f " Tumors of the Bladder," Churchill, London, 1884. ■[ E. Kiister, " Volkmann's Sammlung klinischer Vortrage," " Ueber Harnblasen-Ge- sehwiilste," etc., pp. 267, 268, 1886. * "Sur la Diagnostic et le Traitement des Tumeurs de la Vessie," "Ann. des Mai. des Organes Genito-Urinaires," November, 1886, p. 651. II E. L: Keyes, "New York Medical Record," May 28, 1887. ^ "Berl. klin. Wochenschrift," No. 52, 1884. 262 DISEASES OF THE BLADDER. Autal removed by the suprapubic operation onc-tliird of the blad- der of a mail of sixty-one extra-peritoneally, iiicludiiif]: a tumor thereon attached (the nature of the tumor is not stated in the " Centralbhitt").* The bhidder was sutured, and the patient rej)ortcd as holding water three to four hours seven weeks after the operation. rapiUoma {ViIIuus Growtli). — This tumor may be partly hard, with villi (yet benign and pedunculated), or a velvety, flat set of villous tufts. Villi are also found upon a carcinomatous base. Villous growth, papillomatous or otherwise, is not very uncommon. It is a soft, pulpy body, which may grow to be as large as a small orange. I have successfully removed one such by suprapubic section. It is consti- tuted by innumerable villi, which branch otf in every direction, are attached to the submucous connective tissue of the bladder, are iden- tical in structure with the villi of the healthy chorion, and are exceed- ingly vascular. Several tumors may co-exist in a single bladder, or a portion of bladder-surface may be found velvety, from being covered by small villous processes similar to those on the tumor. The most usual site for these tumors is the base of the trigone, between the orifices of the ureters. There is nothing cancerous about their struct- ure. Their cause is unknown. They never lead to secondary cancer- ous deposits elsewhere. They do not spontaneously ulcerate. The lymjihatic glands are not implicated. There is no characteristic cachexia. "When they kill, death seems due purely to loss of blood and exhaustion from pain. The symptoms of villous growth are like those of other vesical tumors, except that they are less often obstructive, and that the urine has blood in it almost constantly. No tumor can be felt, as the mass is too soft to be recognized either by the finger in the rectum or the searcher in the bladder. Sounding almost invariably aggravates the symptoms, and gives rise to a fuller supply of fresh blood. Shreds of the tissue sometimes come away with the urine, and may show characteristic appearances under the microscope. The structure of the growth is simply an enormously wide, thin-walled vessel, curved on itself to form a loop, and covered by three or four layers of cylindrical epithelium, seemingly placed directly upon it. The suffering is often intense, and vesical tenesmus very marked. Nitze has seen this form of growth and diagnosticated it by the use of his cystoscope. Haematuria is the only symptom at first, usually intermittent, with long intervals. The duration of the malady is great. In the Museum of St. George's Hospital, London, there is a specimen (Series XII, No. 113) of solitary pedunculated villous growth in a bladder, taken from a man of eighty-one, whose first attack of hasmaturia occurred twenty years before his death, and who had no new attack of bleeding until * " Centralblatt fiir Chir.," September 5, 1885. COMPOSITION OF CALCULI. 2C3 four years before he died. Cases of eight, eleven, fifteen years' dura- tion arc very numerous. Treatment. — Without doubt, in any case of villous tumor, myxoma or myoma diagnosticated or strongly suspected, tlie suprapubic explo- ration and removal is the proper resource. Rest, palliation, and as- tringents are only temporary expedients. CHAPTER XIV. STONE IN THE BLADDER * Materials of which Calculi are formed.— Causes of Stone, interual and external.— Number.— Size.— Shape.— Weight.— Degree of Hardness. — Possible Consequences of Stone, including Symptoms, Pathology, and Modes of Death.— Symptoms considered in Relation to Diagnosis and Selection of Mode of Cure.— Sounding.— Circumstances prejudicial to a Choice of Lithotrity. The presence of a foreign body in the bladder is recognized by common consent as the cause of the most painful suffering to which humanity is liable. The foreign body in the great majority of cases is generated entirely within the urinary passages, most frequently in the kidneys ; sometimes it is introduced from without, as when such sub- stances as slate-pencils and hair-pins have been inserted into the urethra, under the influence of morbid erotic impulse, or a bullet, a portion of shell, or fragment of bone, has found its way into the blad- der by gunshot-wound. In either case the result is a concretion of stony hardness resulting from the more or less rapid deposit or crys- tallization of the salts of the urine upon a nucleus, forming what is known, in common language, as stone in the bladder. In ninety per cent of cases of stone the nucleus has been most probably an aggrega- tion of crystals of uric acid, which, happening originally in the kidney, has passed, with or without attendant symptoms of renal colic, into the bladder, and failed to escape by the urethra. Of the remaining ten per cent of nuclei, extraneous substances constitute, perhaps, the largest proportion, then blood-clots, or other organic products, such as a mixture like mortar, of altered, ropy pus, with a precipitate of * Chapters XIV, XV, XVI, XVII, and the Preface are the only parts of the first edition of this work wi-itten by Dr. Van Buren. The last three of these chapters require to be en- tirely recast, since lithotrity is practically obsolete, and litholapaxy, its natural heir, demands its place. Chapter XIV I prefer to leave as nearly intact as possible. It is an admirable condensation of the subject, and as true now as when Dr. Van Buren penned it, except as to some minor points in relation to choice of a method of cure. Litholapaxy had not been discovei'ed when Chapter XIV was written, but long before his death Dr. Van Buren recog- nized the value of Bigelow's operation, and adopted it in toto. I must refer those who desire my personal views in regard to the subjects treated in Chapter XIV to my article " Urinary Calculus " in the " International Encyclopfedia of Surgery," vol. vi, p. 1-45, where I have discussed them at some length. — E. L. Keyes. 0(54 STONE IN THE BLADDER. uriuarj i^liosphatcs, or an aggregation of crystals of oxalate of lime from the kidney. As to the subsequent growth of the calculus, there is endless varia- tion, both as to its rate of rapidity and the nature of the materials which serve for its increase. These materials, derived from the saline constituents of the urine, combined with an uncertain amount of ani- mal matter — the secretions from the vesical mucous membrane, pus, or blood — are deposited around the nucleus in concentric layers of varying thickness. As the chemical constitution of the urine is liable to constant change, the additions to the bulk of the calculus are cor- respondingly uncertain. Calculi consisting entirely of oxalate of lime, which are rare, are slowest of growth ; next, those composed of pure lithic acid ; while stones of mixed character, in which the concentric layers are formed, according to the constitution of the urine prevailing at the time of deposit, of lithic acid or oxalate of lime, the amorphous urates, phosphate of lime, or the triple phosphate of ammonia and magnesia, are very common, and of more rapid but uncertain growth. Calculi composed mainly or entirely of the phosphates grow most rapidly and attain the largest size. The pliosphatic salts, always present and held feebly in solution in the urine by an excess of phosj)horic acid, are liable to be constantly and largely precipitated in the bladder whenever any considerable por- tion of its lining membrane is the seat of suppurative inflammation. The soda of the liquor pui'is takes the acid away from these superphos- phates, and the residual phosphates are thrown down at once, mostly in the form of an amorphous insoluble powder. Moreover, urine thus deprived of its normal acidity undergoes more jiromptly putrefactive fermentation, and the ammonia, always generated during this jorocess, effects its peculiar reaction upon pus, when present, converting it into an adhesive, ropy, mucoid substance, a characteristic ingredient in the urine of so-called catarrh of the bladder, to which, indeed, that form of cystitis owes its name. Here we have at once two most important factors in the formation of vesical calculus. The remarkable insolubility of lithic acid,* and of tlie neutral phosphates as well, are noteworthy facts in connection with the eti- ology of stone. The urates would rarely precipitate or crystallize at the temperature of the body, without a nucleus to invite them. The phosphates, by the aid of mucoid pus, do so more frequently ; the large number of phosphatic calculi often found in the suppurating bladders of old people would seem to establish this fact. Whatever favors the generation of uric acid in the organism would seem, there- fore, to serve in some degree as a cause of calculous disease. Gout and rheumatism, undoubtedly, do this. According to Prout, lithic acid is the essence of gout ; f and gouty subjects are notoriously liable * From the Greek \ldos, a stone. \ Prout on " Stomach and Renal Diseases." CAUSES. 20 )0 to gravel and calculous affections in all tlicir forms. The occurrence of stone in the bladder, in successive generations in the same family, is thus explained. A tendency to excess of litliic acid belongs also to early life ; it is one of the recognized peculiarities of infancy. Cases of congenital stone in the bladder are on record. The frequency of calculous disease in children is thus explained. In Thompson's table of 1,82? cases of lateral lithotomy, 473, or more than a quarter of the whole, were children under five years of age.* At the other end of life, obstructive disease, generally from enlarged prostate, is a frequent cause of stone in the bladder. The conditions are highly favorable to the formation of stone in a patient suffering from enlargement of the prostate ; the change in shape Avhich the bladder takes on, the catarrh- al inflammation of its lining membrane, which almost inevitably sooner or later supervenes, together with the inability to completely evacuate its contents, whether from the obstruction at its outlet, or loss of contractile power, or both combined, all favor this result. These circumstances would seem to explain why vesical calculus is more frequently encountered at the two extremes of life. In Civiale's table of 5,376 cases of stone in the bladder, 2,314, or nearly one half, were under the age of puberty — the largest number at any one year of life being 321 at five ; while of the remainder, the next highest num- ber, 184, occurs at the age of sixty, f Inflammations affecting any portion of the mucous membrane lining the urinary passages would seem to favor the formation of calculous deposit. Stricture of the urethra, for this reason, and also from its obstructive influence, is a recognized cause of stone. J The influence of mineral ingredients in water habitually employed for drinking and cooking is generally sup- j)osed to cause calculous disease ; but of this there is no adequate proof. In certain regions of our country stone is very infrequent, as in JSTew England ; * while in Ohio, Kentucky, Tennessee, North Caro- lina, and Alabama, the disease is not uncommon. It is certainly very rare in the negro. || Without reference to race, the same unexplained tendency to calculous disease exists in certain localities in Euroi^e, as in Norfolk, in England, Wiirtemberg, and Moscow ; while in Den- mark it would seem to be less frequent. There are no chemical or meteorological facts yet determined by science concerning either water, soil, or climate, which would justify an attempt to explain these dis- crepancies. Disease of the brain or spinal cord, paralyzing the lower extremities and bladder, favors the formation of stone. Here inflam- mation of the bladder, from stagnation and decomposition of the * Thompson's " Practical Lithotomy and Lithotrity." f "Traite de TAffection calculeuse," Paris, 1838, p. 646. X I have lithotomized two adults who were the subjects of stricture. — Van Bcrex. * Morland, " Diseases of the Urinary Organs," Boston, 185-8, p. 387. II Gross on " Diseases of the Urinary Organs," Philadelphia, p. 343. 266 STONE IX THE BLADDER. urine, is tlie iranicdiate exciting cause. To what extent the coexistent diminution of nerve-power aids in the process is not so clear. There is little doubt but that the free use of animal food and nuilt liquor, coincidently with excessive fatigue and profuse sweating, is likel}' to cause a concentrated quality of urine prone to crystallize readily, especially in a healthy child, or in an adult of gouty habit ; and it is not improbable that in a coincidence of favorable conditions of this kind many cases of stone take their origin. Civiale expresses the opinion that calculous disease in children not unfrequently dates from such sudden crystallization. Foreign bodies introduced into the bladder, from without, become incrusted with the salts of the urine in an incredibly short sj^ce of time. A catheter left in the bladder will show deposit on its surface on removal at the end of forty-eight hours, and the incrusted material consists almost entirely of phosiihatic salts. Stones which take their origin in this manner always increase rapidly in size, and they have been met with at all periods of life, except, perhaps, in very early childhood. The late war in this country furnished several examples of bullets, fragments of bombshells, etc., which had penetrated the bladder and become nuclei of stones. Pins, fragments of fish-bones, chicken-bones, and other articles swallowed as food or by accident, have found their way, by ulceration, from the intestines into the blad- der, where they have given origin to calculi. Even foetal bones have ulcerated into the bladder from the uterus, and pieces of wood and bone have been forced mto the bladder as the result of accident ; and, finally, through recto-vesical fistuljB, fruit-seeds, and other hard ma- terials mingled with the contents of the bowel, have become nuclei of vesical incrustation. The most frequent cause of the presence of ex- traneous substances in the bladder is to be found, unfortunately, in the unnatural gratification of the sexual desire. It may be safely assumed that every material substance that could possibly enter the human urethra has been used for this purpose, and a certain propor- tion of articles so used have found their way into the bladder.* * I removed a phosphatic calculus of large size, from a man of sixty-seven, at Bcllevue Hospital, in 1847, which had formed upon a head of wheat-straw; and some years later I operated upon a boy of seventeen, at the New York Hospital, in the center of whose calculus was found a piece of a slate-pencil, an inch and a half in length, which he con- fessed to have introduced into his urethra some years before, at school. Within the same year my colleague, the late Dr. John Watson, removed from a young man, at the same hospital, a phosphatic calculus of a shape so curiously elongated as to suggest an unusual nucleus. On section it was found to contain a piece of an ordinary lead-pencil, several inches in length. I have in my posses.^ion a phosphatic calculus, sent to me by my friend Dr. Taylor, of Memphis, Tenn., removed from a woman, in which the calculous matter is deposited around a fragment of althea-root, four inches in length, and con- verted into a brush at one end — an instrument used by a certain class of women for brushing the teeth with snufi — a practice not uncommon in some localities. — Van Bdren. NUMBER, SHAPE, SIZE. 207 The short, direct, and capacious urethra of the female, which, by affording to nuclei formed in the body so ready an escape, renders stone in the bladder a rare disease in women, serves precisely an oppo- site purpose under these circumstances, so that in this class of cases the proportion of females is much larger, evidently because a foreign body can slip through the female urethra and be lost in the bladder much more readily than through the longer and more tortuous pass- age of the male. Hence, while in the aggregate we meet in practice but one case of vesical calculus in women to twenty in men, it may be confidently asserted that the proportion of cases in which a calculus has formed on a foreign body introduced from without is larger in women. There are several other forms of vesical calculus composed of materials existing only exceptionally in the urine, or in quantities so minute as to very rarely form concretions, such as cystine, xanthine, uric oxide, silicic acid, and carbonate of lime, for the study of which we must refer to works devoted specially to the chemistry of the urine.* Number, Shape, Size, Weight, and Degeee of Hardness. — Vesical calculi are usually solitary, of a compressed ovoidal shape, and in size varying from that of a large pea — just too large to escape by the urethra — to a magnitude limited only by the capacity of the bladder. In weight and density they vary according to their chemical composition, the weight of a calculus conveying no accurate idea of its volume. The mulberry calculus, consisting of oxalate of lime, so called because the inequalities of its external surface sometimes resemble those of the fruit from which it is named, is the heaviest in proportion to its volume, the hardest, and most dense in structure ; next in order of hardness and density is the calculus of pure uric acid ; then the composite calculi, composed mainly of urates ; finally, the lightest of all, and also the most friable, the phosphatic. The hardest stones are more apt to be solitary, and they are generally the smallest in size. These considerations are of practical value as bearing on the availa- bility of the crushing operation, for there are some calculi of oxalate of lime, and even occasionally one of pure lithic acid, so dense and hard as to resist the strength and power of the best constructed litho- trite. Mulberry calculi, nevertheless, vary in hardness, and Civiale reports several cases in which he crushed large calculi of this sort at one operation, f The length of time during which a patient may have suffered from symptoms of stone affords no positive evidence as to its * Neubauer and Vogel, " A Guide to the Qualitative and Quantitative Analysis of the Urine" (New Sydenham Society), London, 1863, and Thudichum, "Pathology of the Urine." f Loc. cit., p. 193. Sir Henry Thompson also reports four calculi of oxalate of lime in 184 cases of stone treated by lithotrity, "British Medical Journal," June, 1871, p. oTl, and Ivanchich has recorded many others. Sechster Sammelbericht v. w. 50 Fallen v. Blasensteinzertriimmerung, Wien, IB'ZS. 2G8 STOXE IX THE BLADDER. size, nor is tlie reverse of this assertion true ; for, as already stated, mulberry calculi and those of lithic acid grow slowly, and seem even to remain stationary for long periods, while those of compound char- acter, and specially phosphatic calculi, gain size more steadily and rapidly. The last two varieties include the large majority of vesical calculi as encountered in practice ; the stone consisting of pure lithic acid is met with perhaps once in eight or nine cases, while the mul- berry calculus not once in twenty. In considering the size and hard- ness of vesical calculi, it is to be borne in mind that they arc always lighter, harder, and even somewhat smaller, after removal from the body and thorough desiccation, tluui when saturated with urine in the bladder. A calculus may be friable extcrnall}-, while its nucleus may prove to be exceedingly dense and hard. For example : a patient may have carried a calculus of pure uric acid or oxalate of lime in his bladder for months, growing very slowly, and causing so little irritation as to scarcely trouble the transparency of his urine. Suddenly, from cold or other causes, the vesical irritation is increased ; pus is formed ; the phosphates are precipitated, and the calculus begins to grow rap- idly from accretion of the more friable phosphatic salts. In crushing a calculus of this kind its fragments would naturally give evidence of different degrees of hardness. As to multiple calculi, while a solitary stone is the rule, two may possibly be encountered in every six or eight cases as they occur in practice, and a larger number with increasing rarity. They are cer- tainly more common m advanced life, but there are no known con- ditions upon which their presence may be predicated. Plurality of calculi would seem to result from the somewhat rapid and successive generation of renal nuclei and their transmission to the bladder, from the spontaneous fracture of calculi in the bladder, which occurs more frequently than is generally supposed ; * and from the influence of the bladder's contractions upon a soft magma, composed of earthy phosphates and altered mucoid pus, which is more or less constantly present in cases of chronic cystitis from prostatic or other obstruction.! * F. S. Watson, of Boston, recently showed a striking case, with photographic illustra- tion, of spontaneous fracture to the " Society for Medical Improvement " in Boston, No- vember 22, 1886, referring to other previously reported cases — those of Ord, etc. I have the photograph and history. Dr. Watson could not furnish me the reference of publication. f The influence of this latter cause of multiple calculi was happily illustrated in a case recently brought under ray notice by Dr. Blake, of this city, of an old lady of eighty, who had suffered for a long time with procidentia of the uterus, in which the bladder was also involved. On repeated occasions, after retention of urine caused by their ac- cumulation, she had discharged quantities of minute shot-like phosphatic calculi through the urethra, and after death the bladder contained hundreds of these little rounded masses, averaging about the size of No. 6 shot. — Van Bcren. CONSEQUENCES. 200 When their number is small they influence each otlier's shai)e, and grow to be many-sided rather than round or ovoid, the obvious result of mutual contact or friction, giving rise to flattened sides or facets. When a stone presenting this unusual form is removed by lithotomy, it suggests at once the probability of the presence of others in the bladder. If very numerous, on the contrary, and apparently Just in proportion to their number, they tend to revert to the rounded form. When a calculus varies from the common ovoid by unusual elonga- tion in shape, it is suggestive of the presence of an exceptional nu- cleus — something introduced through the urethra. In calculi of this character the mass is ordinarily friable, being composed entirely of phosphates. At the same time this friability does not always justify the employment of lithotrity as a 'remedy, for the nucleus may be a substance which can not be crushed, as in some of the instances already mentioned, and notably in the case of Henry Thompson, where a stick of sealing-wax was found in the center of the mass, a substance which at the temperature of the body is quite soft.* Vesical calculi present great variety as to roughness of surface. Sometimes as smooth as a well-worn pebble, they are generally rough, from crystalline deposits, and these asperities are in some cases ex- ceedingly prominent and sharp. In very rare cases calculi assume fantastic shapes without any obvious cause. Occasionally the stone becomes fixed at the neck of the bladder, and from this situation it sends forward a prolongation into the prostatic urethra by which its shape is molded. In regard to the size of urinary calculi, very little more of practical value can be said here that does not come more properly under the heads of diagnosis, and selection of mode of cure. Surgical works on this subject teem with rare and curious cases of calculi of great size and weight, the largest of which will be found to have been taken from dead bodies, and the next in size pretty uniformly to have brought about fatal results by their removal during life. It will always be necessary to refer to old authors for extravagant examples of this kind, for, in proportion as the means of relief which surgery can offer become more safe and sure, they will occur more rarely. Possible Coxsequekces of Stoxe, iis^cludixg Symptoms axd Pathology. — Uneasy sensations, referable to the neck of the bladder, desire to pass water recurring with unusual frequency — both due to the strange impression upon the nerves of the organ, and generally ascribed to what is called ''irritability" — are the first evidences of * In a case reported by Dr. I. Porter, Jr., of Massachusetts, a phosphatic stone three and a half inches in length by one and three-quarters inch in width, and weighing three and a half ounces, was taken from a male after death. It was found to hare been formed upon a stem of the Archangdica purpurea, two and a quarter inches in length. — " Boston Medical and Surgical Journal," March 4, 1858. 270 STONE IX THE BLADDER. the prcscnco of a foreign body in tlie bltuldcr. When small and movable, as it nsnally is, the foreign body is liable to be carried by the flow of nrine to the outlet of the bladder, and thus to cause sudden stoppage of the stream, accompanied by a twinge of sharp pain shooting along the course of the urethra, and felt most acutely at its outlet. The muscles at the neck of the bladder are thrown into spasmodic contractions by the presence of the foreign substance, and grasp it closely ; if its surface is rough, the contact brings blood from the sensitive and vascular membrane, and this, when the spasm re- laxes, is voided with increased difficulty with the next urine that flows. The neck of the bladder is its most sensitive part, and the recurrence of this rough contact sooner or later begets permanently exaggerated sensibility, together with increased vascularity — in other Avords, in- flammation. Inflammation, under these circumstances, always begins at the neck of the bladder, and indeed may be for a long time confined to this locality ; but it tends, sooner or later, to invade the body of the organ ; and thus, as the stone grows in size, after a longer or shorter period of simple irritation, cystitis is established— brought about by prolonged repetition of mechanical violence, both from contact of the stone, and from the bruising by spasmodically excited muscles in the act of voiding urine, which is repeated with unnatural frequency and effort. Inflammation of the bladder from the presence of stone is always gradual in its approach, and chronic in its char- acter. The healthy bladder is patient under violence, and slow to take on true inflammation, so that cystitis is chronic from the first ; and, though liable to acute paroxysmal exacerbations, is essentially chronic in its manifestations throughout. During the first weeks or months of the stone's presence in the bladder, Avhile as yet there is no cystitis, but irritation only, the urine remains clear and bright, show- ing only a slight increase of mucus, or of epithelial debris, and occa- sionally a little blood. The blood is more likely to be present after rough or violent exercise, or a jolting ride. But, after the beginning of cystitis, pus-corpuscles will always be found, generally in sufficient quantity to render the urine turbid to the eye, and always recognizable bv the aid of a microscope. Meanwhile the muscular coat of the bladder is taking on gradual hypertrophy from increased use, and its interlacing fibers begin to stand out in relief ; while the irritated organ, intolerant of distention, discharges its contents at still shorter intervals, and thus a tendency to habitual contraction is established. The constant presence of pus in the urine occasions more rapid in- crease in the size of the stone from phosphatic precipitation, and the lining membrane of the bladder, now entirely involved in chronic in- flammation, loses its normal tint of salmon pink, and becomes deep red, granular, or perhaps even villous, with occasional ecchymosis, and sometimes patches of yellowish surface-exudation. Most of the exuda- SYMPTOMS. 271 tion, however, takes place in the submucous web of connective tissue around the enlarged follicles, adding materially to the thickness of the bladder-walls. It is a noticeable feature in the behavior of the bladder under irri- tation, that it has its periods of excitement and quiescence without any obvious cause, the inflammatory phenomena manifesting themselves by paroxysms rather than by steady progress, and thus Justifying the old expression, ''a fit of the stone." The varying conditions of the sexual organs — so closely associated with the bladder — may throw some light on this peculiarity, as may also the degree of nervous im- pressibility of the sufferer by irritating causes. Be this as it may, it is certain that the period of life between puberty and the sixtieth year, during which the sexual organs are active, is the period during which stone in the bladder is attended by the greatest amount of suffering, and the operations required for its relief by the greatest danger. The time required to bring about the changes in the bladder above described varies greatly. A child may carry a calculus for years, and yet the urine remain bright and free from pus ; in an adult, months may accomplish extensive alterations, but in advanced life, where the urinary organs are especially prone to take on morbid changes, and where, indeed, these may be already present as consequences of strict- ure or enlarged prostate, it is fair to expect the most serious local re- sults from the formation of stone. Here the advantage of diminished sexual excitability and increased tolerance is counterbalanced by the lack of vigor which belongs to age. Pre-existing lesions of the obstructive sort in an old man may have already given rise to chronic cystitis, with contraction of the bladder and thickening of its walls ; or, as occurs not uufrequently from pros- tatic obstruction, the bladder may have given ujd the struggle to over- come the obstacle, and may have fallen into atony, with loss of con- tractile power and indefinite expansibility. The pain and suffering in the first of these two conditions are infinitely the greater, for the spasmodic contraction of the hypertrophied muscular walls of the bladder tends to grind the diseased mucous membrane against the newly-formed stone, often to force the stone into painful contact with the more sensitive neck, and thus add to the existing obstruction, and increase the difficulty and frequency with which the urine is voided. In the latter condition, the contractile element being absent, the pa- tient is compelled to draw off his urine with a catheter, and is thus free from the constantly recurring desire to urinate, with its accompanying spasms and tenesmus, and suffers, instead, a milder pain at longer intervals. It is worthy of notice how closely the muscular element in the bladder is connected with the pain of stone. It is a desideratum to be able to abolish it at will. At present we can accomplish this end 272 STONE IN THE BLADDER. only temporarily aud imperfectly by opium, and (perhaps) in some degree by electricity. In the complicated cases of vesical calculus which we are now con- sidering, other changes in the bladder are liable to take place. Of these some are constant, otlicrs only occasional. Of the former, the most important is the local dilatation at its base — a sort of hollow or scooping out, which forms immediately behind the enlarged prostate, called by the French the ''bas-fond" of the bladder. This becomes necessarily, both in the upright and horizontal positions of the body, the deepest as well as the most deiDcndent portion of the cavity of the bladder, and it is therefore usually occupied by the stone, when pres- ent ; and the stone is thus, in a measure, prevented from contact with the sensitive outlet of the bladder. The excavation of the bas-fond is often so considerable that an ordinary sound introduced into the blad- der can not be made to strike a calculus lodged here, the convexity of the instrument passing above it, and failure in diagnosis has often re-- suited from this cause. A sound with a short curve, like that of a lithotrite, so that its beak can be reversed in the cavity of the bladder and swept across its base, is the instrument to be employed whenever the presence of stone is suspected in conjunction with an enlarged prostate. Calculi may, and often do, form in the little pouches Jut- ting out between the meshes of hypertrophied muscular fibers known as sacculi, and sometimes become so large as to be permanently en- trapped in their cavities. In the cases, and they are not infrequent, in which the bladder has lost its contractile power, unless the catheter be employed at regular intervals, the bladder is constantly in an overstretched, water-logged condition, relieving itself, irregularly and imperfectly, by si^ontaneous overflow. Civiale calls this '^ stagnation." Under these circum- stances, and, indeed, whenever the outlet of the bladder is the seat of obstruction, the ureters, subjected also to overdistention, become dilated and tortuous ; the inflammation of the mucous membrane of the bladder extends to and gradually involves their altered and weak- ened walls, and, continuing to extend, finally invades the pelves of the kidneys. The secreting structure of the kidneys, predisposed to dis- ease by disturbance of functions, now soon participates in the advanc- ing disorder, and functional disturbance of serious import, attended by evidences of uremic poisoning, foreshadows the fatal result which is imminent. This is, j)robably, the most usual course by which the end of life is reached in vesical calculus not interfered with by art, especially when associated with obstructive disease, i. e., stricture or enlarged prostate. Ulceration of the chronically inflamed mucous membrane of the bladder occurs in a small proportion of cases. A few instances arc on record in which calculi have worked their way out of the bladder through ulcerations involving all of its coats, and have SYMPTOMS. 273 boon ultimately found in the vagina, the pcrina3um, the umbilicus, and even in the groin. Urinary exti'avasation does not seem to have oc- curred in these cases, the whole process being apparently conservative, an effort on the part of Nature to get rid of the foreign body. Proba- bly abscess in the thickened walls of the bladder, opening inward, first receives the calculus, which travels as the abscess burrows in search of an outlet. These conservative efforts of Nature are always of great interest to the surgeon, as they not only justify, but suggest the efforts of art in search of modes of cure. When death has occurred from stone, numerous small abscesses are often found in the thickened and altered walls of the bladder, and also in the substance of the kidneys. Multiple abscesses not unfrequently form in the enlarged prostate, and instances are not very rare in which the whole prostate has broken down into an abscess. Abscess outside of the bladder, in the neigh- borhood of its neck, from pericystitis, and pelvic cellulitis terminat- ing in abscess, are complications of possible occurrence ; and in chil- dren, where the peritonseum covers so much larger a proportion of the bladder-base than in the adult, both acute and chronic peritonitis have been encountered, not only caused by stone, but produced by opera- tions for its relief, both by the knife and the lithotrite. Symptoms consideeed in Eelatiok to Diagnosis and Selec- tion OF Mode of Cure. — The symptoms of stone in the bladder are pain, increased frequency of the desire to void urine, difficulty in the act of micturition, occasional presence of blood in the urine. Pain. — As to the pain caused by stone, it is uncertain, variable, and capricious. Sometimes entirely wanting, it is not unfrequently constant and agonizing. In a majority of cases its principal seat is the neck of the bladder, extending along the course of the urethra ; but it often will happen that a patient, when asked to fix the point of his greatest suffering, will indicate the under surface of the glans penis, just behind the frasnum. This explains the tendency of most calculous patients of the male sex to habitually squeeze and rub this part, as this sort of manipulation seems evidently to dull the edge of extreme pain. Unhappily, young subjects are thus prone to acquire the habit of self-abuse. Children with stone habitually pull upon the prepuce, and its unnatural elongation is usually regarded as one of the signs of the disease. The rectum is a common seat of uneasy sensa- tion, if not of acute pain ; this is especially noticeable in prostatic cases, where there is a das-fond, for here the stone lies almost in con- tact with the walls of the lower bowel. When the bladder has become inflamed and altered, more or less dull pain is felt above the pubes, radiating to the hips, sacrum, thighs, and perinseum. The pain in vesical calculus is aggravated by motion, whether active or passive, and it is relieved by quiet and rest ; especially by rest on the back with the hips raised. But the greatest pain of stone is usually felt in the act 18 274 STONE IN THE BLADDER. of passing water, and mainly toward the close of the act, when the blad- der, empty of urine, grasps the stone with violence, and forces it against the sensitive orifice of the urethra, as if determined to eject it. Often a veritable spasm seems, in this crisis, to seize all the muscular tissues in the neighborhood of the outlet of the bladder. "While suf- fering from this pain, the child, unrestrained by modesty, and giving full vent to his feelings, will grasp his genitals and dance around the room, howling with anguish. In estimating the value and significance of pain as a symptom of stone, it must be borne in mind that jiain of a similar kind, although less in degree, is also present in cystitis of the neck of the bladder, from any cause, and also in simple nervous irritability of the neck of the bladder from sexual causes — "neuralgia of the vesical neck" — au affection too often ignored. In this latter condition the pain and fre- quency of voiding urine are sometimes greater than in actual inllam- mation. The sensibility to pain, or impressionability of the sufferer, is also to be taken into account, and, above all, the condition of the genital organs, as to healthy innervation ; for, unsatisfied sexual long- ings, and unnatural practices employed to gratify these longings, beget a peculiar hyperajsthesia of the genitals, in which the urinary organs largely share. 3IispJaced sensations are sometimes caused by the chronic inflam- mation due to stone or other cause, the more common expressions of pain being absent, as in Brodie's case, where a long-existing neuralgia of the foot was relieved by the discovery and cure of an old stricture of the urethra.* Nor, finally, must it be forgotten that stones have been found in the bladder after death in persons who had given no evidence of the existence of the disease during life. Increased frequency of desire to void uj'ine is also a symptom of the diseases of the neck of the bladder just enumerated, as well as of stone, and the pain in the act is also, as a rule, greatest at its close, just as the tender parts are grasped spasmodically by the extending muscles. But in stone this final spasmodic pain is infinitely more acute, it lasts longer, and seems to be more apt to be mitigated by pressure at the head of the penis. The presence of a little blood in the urine in conjunction with pain at the close of the act, especially after active exercise or riding over a rough road, is very significant of stone ; but this conjunction of symp- toms is also occasionall}' present in other bladder, urethral, and kidney diseases. {See H^matukia.) Perhaps the most characteristic symptom of stone is the sudden arrest of the stream of urine while in full flow, accompanied by simul- taneous spasmodic contractions of the muscles at the neck of the blad- * Sec an excellent article, " Pododynia," J. B. Curtis, " Boston Medical and Surgical Journal," April 7, 1881, p. 316. SYMPTOMS. 275 der, with coincident sharp and severe pain. This group of symptoms is produced by the falling of a movable body in tiic Ijladder, over the orifice of the urethra, so as to close it suddenly as by a ball-valve. In the rare case of a polypus, or of a prostatic tumor growing from within the neck, the tumor in either case being attached by a slender pedicle, the same phenomenon has been known to occur.* It will thus be seen that, of the cardinal symjotoms of stone, there is no one that is absolutely pathognomonic of the disease, and that clinical study and experience are necessary to the proper estimate of their significance. Study of the patient's habits, history, constitution, and hereditary tendencies, will materially aid in forming a judgment as to probabilities. The same symptoms would possess a very different value before puberty and after the age of forty ; for, in childhood, all the diseases mentioned above as likely to be confounded with stone could be at once excluded, and the irritation caused by excessive acidity alone would remain to be considered. In estimating the pathological condition of the urinary passages as affected by the presence of calculus, the microscopical and chemical examination of the urine must not be neglected. The existence of true inflammation can always, by this means, be distinguished from simple irritation by recognizing the presence of pus-globules in any quantity ; and the character of these globules would seem to furnish some evidence as to whether they are the result of mere surface irrita- tion, or of deeper and more serious lesions of tissue, f Pus in the urine may come from the secreting structure of the kidney, as when it assumes the form of tubular casts ; from the pelvis of the kidney ; from the ureters, bladder, or urethra ; and, except in the case of casts, its source is to be distinguished mainly by the coexisting evidences of * Willis deposited in the Museum of the Royal College of Surgeons, London, a bladder taken from a man of sixty-seven, dead of cancer of the kidney, in which there was " a small polypoid body growing from its inner surface, directly over the orifice of the urethra, and covered by a shell or crust of the triple phosphate. ... He had long suffered from occasional attacks of retention of urine and symptoms of stone. . . . Retention of urine was the urgent symptom of the case." It was always relieved by the introduction of a small flexible bougie, alongside of which the urine would escape. The bougie evidently pushed away the ball-valve, and was substituted for the catheter, as it answered the same purpose, with less irritation. — " Urinary Diseases and their Treatment," by Robert Willis, M. D., London, 1838, p. 284. \ " Quite normal pus-corpuscles of a perfectly circular outline, which, after treatment with acetic acid, exliibit the characteristic nucleus, composed mostly of two or three nucleoli, admit of the conclusion that the disease giving rise to their formation is of a mild form — a simple catarrh of the mucous membrane. But when the pus-corpuscles are irregular in form and outline, and on treatment with acetic acid show an irregular nucleus, or an indistinct granular mass in their interior, or when such corpuscles are mixed with irregular debris, not particularly defined, then purulent destruction is evident, and the integrity of the organ where this formation takes place is in great danger, or lost alto- gether. Such pus would be the product of ulceration and tuberculosis." — Vogel, quoted by Thudichura, "Pathology of the Urine," London, 1858, p. 259. 276 STONE IX TUE BLADDER. local lesions. In pus from the pelves of the kidneys the globules are free and not collected in masses, and the whole deposit is heavy, sink- ing rapidly to the bottom of the vessel, and often presenting to the naked eye a peculiar greasy ai^pearance. Pain on pressure over the site of the kidney, or the presence of any unusual swelling or tumor in this locality. Avill aid in recognizing ]>yelitis, which is almost invari- ably accompanied by more or less hectic and emaciation. Pus from the urethra is apt to assume the shape of floating thread-like filaments visible to the naked eye. .These are washed from the surface of the urethra by the passing urine, rolled over and over, and thus spun into threads. Moreover, pus from tlie bladder can alwa^'s be distinguished from that furnished by the urethra by collecting the urine which passes first and contains the washings of the urethra in a separate vessel, and comparing it with that which comes afterward. A very common error in practice is to mistake the gelatinous mucoid material wliich results from the reaction in the bladder of ammonia upon pus for true mucus, and thus fail to recognize the existence of cystitis, perhaps already well established and extensive. Tlie student of urinary diseases who will take the trouble to agitate in a test-tube a drachm of pure pus derived from any source with an equal quantity of aqua ammonige, and observe the result, will hardly fall into this error. True mucus, which is always present in healthy urine, collecting in a floating cloud of variable density as the urine cools, is furnished by the mucous follicles, which everywhere line the urinary passages. That furnished by the urethra is notably increased by erotic excitement. Mucus from the urinary passages proper is liable to be temporarily in- creased by greater density or more irritating quality of the urine ; thus, the morning urine will always show a larger cloud of mucus. The presence of a foreign body in the bladder notably increases the amount of mucus in the urine. Pure mucus is always translucent, and its diagnosis may be established by the number of epithelial cells imbedded in its substance. The mucus-corpuscle can not be distinguished, singly, from the pus-corpuscle, and perhaps neither of them from a young epithelial cell ; but, in mass, the difficulty ceases. The amount of mucus present in urine is rarely sufficiently large to lead to its being mistaken for gelatinoid pus. "When there is any doubt, the habitual presence, in any considerable quantity, of pus-globules will readily settle the question in favor of the latter ; gelatinous pus in any quan- tity, moreover, is never found, except when the urine is alkaline. It is generally associated, therefore, with the earthy phosphates ; and, when the prismatic crystals of the triple phosphate of ammonia and magnesia are found imbedded in it, the presence of ammonia, arising most probably from decomposition of urea, may be safely assumed. Finally, in cases where mucoid pus is largely present, the daily wash- ing out of the bladder with tepid water will often restore the normal SOUNDING. 277 A acidity of the urine, by removing the ammonia and otlior irritating causes, and, simultaneously with this change, the mucoid pus will dis- appear, to be replaced by a deposit of ordinary pus, usually diminished in quantity by the soothing influence of the fomentation. Attention to these facts will tend, in obscure cases, to facilitate the diagnosis of stone. The presence of the symptoms of vesical calculus which have been detailed, or of any of them, when their cause can not be clearly made out after mature consideration, justifies a formal exploration of the interior of the bladder by means of a sound. Such further examination, it should rather be said, becomes a duty ; for the paramount importance to the patient of the early discovery of a stone in his bladder, in view simply of the comparative safety with which he can be relieved of a small stone before its presence has caused morbid change in the bladder, renders an early resort to the only certain test of its presence an imperative obligation upon his surgeon. Sounding. — The operation of sounding a pa- tient for stone requires a light hand and gentle manipulation. It should not be resorted to dur- ing a "fit of the stone"; nor, if there be any suspicion of cancer of the bladder, without great circumspection, for severe hgeniorrhage and aggra- vation of symptoms have followed, in such event. Previous preparation is advisable in persons who suffer much, by rest, diluents, alkalies, if indi- cated, or possibly anodynes. In all serious cases a period of comparative quiescence of the symp- toms should be chosen for the operation. An anaesthetic is required for adults only exception- ally ; for children it is desirable in the large ma- jority of cases ; and, as a matter of complaisance, perhaps, for women. The instrument should be of metal, with a short curve, like that of a litho- trite, and slightly bulbous at its beak. The "searcher" of Sir Henry Thompson (Fig. 76), the best sound in use at present, is capable of serving a double purijose ; for it is hollow like a catheter, with an eye near its beak, and a metal I)lug fitted to its open end, so that the urine in the bladder can be drawn off, if in excess, or warm water injected, if necessary, during the operation. Mercier's "sonde coud6e" has a different curve, and, although not a catheter, is an excellent searcher (Fig. 77). The patient should lie on his back, with his hips slightly raised, on a firm bed or lounge, so placed that the operator may act from his Fig. 77 Fig. 76. 278 STONE IN TUE BLADDER. right side, for the sound is preferably iutroduced from this side, in order that the operator shall be in position to use his right hand most advantageously, and without changing sides when the sound shall have entered the bladder. The manipulation emiiloyed in intro- ducing the sound is the same, with trifling moditication, as that re- quired for the lithotrite (Chapter XVI). When in the bladder, the sound is to be pushed gently onward, until the posterior wall of the bladder is reached, when, withdrawing it sliglitly, its beak is to be turned carefully, first to one side and then to the other, until the lateral wall or floor of the bladder is touched, by rotating its shaft between the thumb and finger ; then it is withdrawn an inch — more or less — and the same manoeuvre repeated ; this is done again and again, if necessary, until the concavity of the sound comes in contact with the neck of the bladder, when it is withdrawn entirely. For a patient under middle age, this mode of examining with the sound Avould be adequate to the discovery of a calculus, if present, in a large majority of cases. Nevertheless, it is a safe rule of practice, never to decide the question after a first examination in which the result has been negative, but to ask for a second or even a third opportunity for search, before giving a positive opinion; and not to lose sight of the great advantages to be derived from ether or chloroform.* But, in a male patient over the age of forty, there is always a possibility that the bladder may have undergone a change in shape at its base — such as has been already described as forming a pouch behind the enlarged prostate — and here another manoeuvre of great jiractical value is to be added to the operation. Instead of Avithdrawing the sound entirely, when its concavity has reached the neck of the bladder, as first directed, its beak is to be again carried forward to the center of the bladder, and, the handle of the instrument being well depressed between the thighs, its beak is to be rotated by a complete half-turn of the shaft, so as to assume a reversed position and touch the floor of the bladder ; keeping the handle of the sound sufficiently depressed to render its * Early in 1847 a boy of two and a half years was brought to me, with a history of great sufferinji, as from stone, since shortly after birth, but, althoudi examined half a dozen times, none had been discovered. The little fellow strugjrled violently, and he was necessarily held by main force. As soon as the sound entered it, hi.s bladder was seized by spasm and its contents forcibly discharged, and simultaneously the contents of the rectum also. The sound was so firmly grasped by the empty bladder that its beak could not be moved without force, and with great increase of outcry. Under these circum- stances I bethought me of the new remedy which I had seen used a short time before by Morton, upon a patient of the late Valentine Mott, and brought it to bear upon my refractory patient. The result — with which we arc now so familiar from daily use — was then novel, and it was wonderfully satisfactory. A small movable stone was struck by the sound almost as soon as it entered the relaxed and insensible bladder. A week latci- it was removed by the lateral operation, under ether, and a prompt recovery followed. The patient subsequently served creditably during the late war. I believe this to have been the first case of lithotomy with anaesthesia. — Van Buren. CHOICE OF METHOD OF CURE. 279 beak readily movable, this is now to bo gently swept from side to side, as when it occupied the first position, and it will pretty certainly strike a calculus, if any be present, in a pouched has-fond behind an enlarged prostate. Tlic beak of the sound is then to be carried again to the center of the bladder, with its handle still depressed, and restored to its first position by a half-rotation of the shaft of the instrument, and then carefully withdrawn. The whole operation should never exceed three minutes. When performed with due gentleness, it should cause but little pain, unless the patient is unusually sensitive, or the bladder in a state of acute inflammation. In the latter case, if delay be not admissible, the propriety of anaesthesia should be considered ; for the condition of painlessness affords the operator undeniable advantages in attaining his object, although, with an unpracticed hand, it possi- bly increases his liability to do harm. It is desirable that there should be from three to six ounces of urine in the bladder when the sound is used^ or, in other words, that the patient shall have retained his water from an hour and a half to three hours. If too full, a small stone is more likely to escape recognition ; if the bladder contains less than three ounces, the sound is less easily manageable without rough contact with its walls. It happens some- times, on the first contact of the beak of the sound with the walls of a sensitive bladder, that the organ is thrown into a state of spasm, and the urine forced out through the urethra, alongside of the shaft of the sound. "When this accident occurs, it is better to defer the operation ; or administer an anaesthetic, and, reintroducing the sound, inject througli it four ounces of blood- warm water, and then jiroceed with the exploration. If a calculus be struck shortly after the sound has entered the blad- der, the operator has then a chance of forming at once some idea also of the condition of its walls, and of the size, roughness, and degree of hardness of the stone ; for the sharp click of a hard stone is not difiicult to distinguish from the muffled sensation received from a soft one, and, if the beak of the sound in contact with the stone is made to glide along- side of it by slow advance or withdrawal, a pretty accurate idea of its size, and of the degree of roughness of its surface, may be acquired. After the operation of sounding, it is safer that the patient should have warmth applied to the hypogastrium and to the feet, and that he should keep his bed, at least for the remainder of the day ; in short, he should be treated as after the use of the lithotrite. Choice of Method of Cure. — When the presence of a stone in the bladder has been demonstrated, the questions at once present them- selves : Can the patient be cured by the crushing operation ? must he submit to lithotomy ? or, is it more judicious to employ no surgical operation in the case, but simply to palliate symptoms by such medical treatment as may relieve from pain and prolong life ? 280 STONE IN THE BLADDER It may be safely assumed, in general terms, that a cure by operation may be undertaken in any case of stone in which the patient is not of extreme age, where the stone is not of unusual magnitude, and where the patient is free from evidence of any organic disease by which life is likely to be "terminated within a limited period not very far distant. But we are compelled by the requirements of practice to reduce these questions to a narrower limit. Cases are constantly presenting them- selves in which the patient's age is not extreme, and his general health sufficiently vigorous, but his stone so large that it can be removed only with the aid of the knife — by an operation the mortality of which modern science has not been able greatly to reduce. Here the judg- ment of the surgeon is to be guided by the following considerations : the degree of the patient's suliVrings, the probable amount of relief to be exijccted from palliative measures, and the temper and circumstances of the patient, as measuring his probable capacity to properly care for himself, and command the comforts of an invalid. In the case of an old man able to command all the comforts of life, with a large stone, suf- fering only moderately, and able still further to lessen existing suffering by skillful care, it would be obviously the part of wisdom and humanity to hesitate in advising an operation. The simple fact that an operation can be done is no reason why it should be done in the face of very serious risk to life ; and it is hardly necessary to say that the temptation to perform a capital operation, even at his urgent request, should never weigli for a moment against the best interests of the patient who places his life in our hands. The considerations Avhich influenced Franklin and D'Alembert to decline lithotomy at the hands of Desault, at Paris, in 1784, still hold good, for the mortality of this operation has not diminished since the da^^s of Cheselden. Having determined, then, that it is proper, in certain cases, to decline an operation for stone, Avhat course should be adopted after an examination has ascertained the presence in the bladder of a movable calculus of moderate dimensions ? The amount of inconvenience caused by the operation of sounding should be observed, as indicating, in a general way, the condition of the bladder, and the measure of the patient's tolerance ; and further exploration should be deferred until all increased trouble that may have been caused by it shall have subsided. Meanwhile the patient's history and present general condition should be carefully studied, and the vital organs subjected to physical explora- tion. Especial attention should be devoted to the kidneys and bladder, both by physical exploration, externally from the abdomen, the loins, and rectum, to detect tenderness on ju-essure, or tumor, and also by careful and repeated microscopical and chemical examinations of the urine. Much information will thus be obtained as to the condition of the bladder, the constitution of the urine, and an accurate idea of the size and state of the prostate. AVhen the proper interval has CHOICE OF METHOD OF CURE. 281 elapsed, a full-sized sound or bougie is to be introduced tljrough the urethra for the purpose of testing the temper and capacity of this canal, and to detect the existence of stricture, if present. If the patient be sensitive, this may be relocated several times, at proper intervals, as it serves to diminish abnormal irritability of the urethra, often present from habitual contact of altered urine ; to educate the passage, as it were, to tolerance of instruments ; to familiarize the patient to his sur- geon ; and to lessen the nervous dread, which always exists in some degree, of his manipulations. If the urethra has been proved, to be healthy, and of normal capacity ; if the patient can retain his urine from one and a half to two hours, and is in fair general condition, the introduction of a lithotrite may be undertaken. Its object is to seize and measure the exact size of the stone ; to ascertain, while the stone is in the grasp of the lithotrite, if there be any other stones present in the blad- der (for it is only by this manoeuvre that the presence of other calculi can be certainly demonstrated); to recognize any abnormal condition of the internal surface of the bladder, such as undue prominence of its muscu- lar fasciculi, or possibly the existence of sacculi ; and to determine with more accuracy the degree of tolerance of the organ, in view of the fea- sibility of lithotrity. An instrument of moderate size, and with per- fectly smooth blades, should be selected for this operation, and it should be introduced and managed, while in the bladder, in the manner here- after described. The lithotrite should not be kept in the bladder longer than three minutes. If this exploration is satisfactorily accom- plished, if the stone does not measure more than one and a half to two inches in diameter, is solitary, and the bladder has proved tolerant of the presence of the instrument and of the whole proceeding, it may be safely concluded that the case is a proper one for the crushing operation. Thus far the patient has been assumed to present conditions en- tirely favorable to lithotrity, viz., good general health, a tolerant blad- der, a urethra of normal capacity, and a moderately soft stone, not more than an inch in diameter. But cases of this kind constitute but a small percentage of the aggregate encountered in practice. It is neces- sary that the surgeon should have an accurate perception of all the conditions that justify this mode of cure ; and that he should be ready to reject without hesitation those cases which do not properly come within its scope. The choice of a mode of cure in a given case is not a matter to be decided by personal preference or by partisan feeling — it must be determined entirely in the patient's interest, and after careful study of the case, especially in reference to the following points, which include the conditions usually presented, favorable or otherwise, to the crushing operation : the period of life ; general or local disease, especially of bladder and urethra ; degree of tolerance of instrumental manipulation ; size and quality of the calculus. 282 STONE IN THE BLADDER. A few words will be necessary on each of these points : The age of the patient will determine the mode of cure in about one half of tlie cases which present themselves in general practice ; for the most reliable statistics teach that '*onc half the entire number oc- curs before the thirteenth year is com])leted."* Now the limited proportions of the male urethra before puberty, the excessive sensibil- ity of the child's bladder, and the want of docility and self-control at this time of life are all unfavorable to lithotrity ; Avhile it is just in this class of cases that the cutting operation has attained its greatest suc- cess — a mortality varying from one in eleven to one in twenty-eight, the mean mortality of the whole period of life, below the age of four- teen, being about one in fifteen. As a rule, then, to which exceptions are rare, lithotomy is the i)referable method of cure for male children under the age of fourteen. The exceptions are, when the stone has been discovered just after its formation, while still very small, so that one or two operations with a slender lithotrite will certainly remove it. In these operations an anesthetic would be required. In the future progress of lithotrity these exceptions may become more numerous, f III case of general disease, involving vital organs and threatening life, the performance of any surgical 023eration, with the ol)ject of removing a stone from the bladder, must necessarily be regarded as an exceptional proceeding, warranted only by the certainty of being able to remove immediate danger to life, or to relieve extreme jiain, not otherwise relievable, with the prospect of prolonging life for a limited period. Where any operation is determined upon under these circumstances, it would probably be more judicious to take the chances of securing relief at once by lithotomy. An excei)tion here would be a case in which there was great tolerance of the bladder, such as generally accompanies atony of that organ — a condition in which the practiced lithotritist could do pretty much as he pleased. By local disease of the urinary organs is understood, practically, stricture of the urethra, enlargement of the prostate, intense or jier- sistent cystitis, and organic alteration of the kidneys. The existence of confirmed organic stricture at one or more points of the urethra is a serious impediment to lithotrity. A fully distensi- ble canal, with healthy walls, is an indispensable requisite for the easy introduction of the instruments employed in crushing calculus, as well as for the ready escape of the detritus resulting from the operation. The question may be asked, Can not the stricture be cured, and the * Thompson, " Practical Lithotomy and Lithotrity." f This hope has been verified. D. F. Kecgan, " Lancet," December 4, 1886, p. 1068, " Litholapaxy in Male Children," etc., gives a table of fifty-eight cases — youngest, one year and three quarters ; oldest, fourteen ; average age, six and a half years — all finished in one sitting, except one cai?e, which required three. Smallest stone, five grains ; largest, seven hundred grains, in a boy of nine and a half ; average, one hundred and eight and a half grains — all cured but one, a boy of four. — Keyes. CHOICE OF METHOD OF CURE. 283 patient afterward be subjected to lithotrity ? The answer is, to restore the walls of a strictiired urethra to their original suppleness, distensi- bility, and smoothness of surface, is a remote and rather uncertain possibility, if indeed it be a possibility; and the arrest of fragments at any point in the urethra where a stricture has once existed is an accident always liable to occur. Yet there are instances on record in which this impediment has been overcome with more or less success ; and a surgeon of tact and experience may, in a case entirely favorable in other respects, successfully compromise with this disadvantage when existing in a moderate degree.* In old cases of stricture, where stone has formed in the bladder cystitis, of more or less intensity is neces- sarily present ; and here a resort to the knife is imperative — for an additional reason also, that, by a modification of median lithotomy, the stricture may be possibly treated successfully by external incision at the same time that the calculus is removed from the bladder. In 1869 a gentleman with an old and obstinate stricture, complicated with chronic cystitis, came to New York for relief. It was with diflSculty that the smallest bougies could be introduced into the bladder. From the constantly recurring exacerbations of intense pain in micturition, and the occasional presence of phosphatic sand in the urine, the suspicion arose that a stone had formed in the bladder. As the stricture was not amenable to treatment by dilatation, in consequence of the presence of false passages and extreme sensibility of the urethra, a very small whalebone bougie was introduced to serve as a guide, and on this division of the stricture was effected by perineal section, and the incision afterward prolonged to the neck of the bladder, whence were removed two phosphatic calculi of moderate size, which had been promptly discovered after divis- ion of the stricture. The patient made a good recovery, and learned to introduce for him- self a full-sized steel sound, No. 17. It would have been impossible to treat such a case by lithotrity. Enlargement of the prostate is not an objection to lithotrity so long- as it offers no obstacle to the ready passage of the necessary instru- ments into the bladder. Nor is the condition of atony, or impaired contractility of the bladder, so common a complication of the enlarged prostate, to be regarded as an unfavorable circumstance. On the con- trary, it is in cases of this kind that the trained lithotritist is some- times able to manage successfully the largest calculi removable by the crushing operation. [These remarks refer to old-fashioned lithotrity. — Ketes.] Chronic cystitis of a very intense and persistent character, ivithout stricture or any obvious cause save the presence of the stone, is a valid objection against lithotrity. f While the bladder is acutely intolerant of its contents, suflBcient urine can not accumulate within its cavity to afford an area in which the lithotrite can be safely manoeuvred. Apart from the danger of still further increasing the intensity of the * Walter J. Coulson, F. R. C. S., op. cii., p. 52, rf seq., has cases illustrative of this point. f This is no longer true, since litholapaxy has taken the place of lithotrity. — Ketes. 284 STOXE IX THE bladder. iuflammation by interference, tlie simple attempt to introduce the instrument into the bladder is liable to bring on acute spasmodic con- tractions, by which its contents are forcibly ejected. Means must be employed, therefore, to lower the grade of the inilammation, to im- prove the quality of the urine, and to diminish the fro(iucncy of the calls to urinate, before the feasibility of lithotrity can be determined ; and, if this improvement can not be accomplished after a reasonable trial, the crushing operation must be abandoned. There is a wide margin here for skill and tact in the enii)loyment of medical treat- ment to improve the condition of the bladder. When a degree of tol- erance has been attained in which the intervals between the calls has reached an hour and a half, the contents of the bladder equaling about three ounces, and the improvement is iirogrcssive, then the use of instruments in the gentlest manner may be tried. Cases are on rec- ord in which, where the calculus has been small and the patient other- wise healthy, the fact having been clearly established that the cystitis was being kept up solely by the stone's presence in the bladder, an- aesthesia has been employed, and the calculus removed successfully at one operation. This is an exceptional application of lithotrity, justi- fiable only in the hands of a master of the art.* Long-continued obstructive disease of the urinary organs, cither from urethral stricture or enlarged prostate, is often complicated, not only by chronic cystitis, but by deeper lesions, involving vital organs ; dilated and tortuous ureters, evidences of chronic pyelitis of low grade, with atrophy and other profound alterations of the kidneys. During life, however, the existence of these serious complications can not be made out with any absolute degree of certainty ; habitual tenderness on deep pressure over the kidneys, tendency to chill on slight provoca- tion, increased frequency of pulse toward evening, nausea and cajiri- cious appetite, with feeble digestion, and similar evidences of failing health, which can not be otherwise adequately explained, are symp- toms from which the existence of these lesions may be inferred. Any operation undertaken upon a person in this condition is liable to be followed by rapidly fatal symptoms, due most probably to urEemia. The form of renal degeneration known commonly as Bright's dis- ease, a malady entirely different in its pathological signification from that sequence of morbid changes due to urinary obstruction which has just been described, seems, in fact, to be rather rarely associated with calculous disease. It often occurs in connection with cardiac lesion, and is readily recognizable by unmistakable symptoms, of which the most characteristic are the presence of albumen in the urine, and of casts of the uriniferous tubes in its sediment. When present, it con- stitutes a grave objection to operative interference of any kind. What we require to know especially concerning the stone, in the * Modem experience in litholapaxy always justifies it. — Keyes. CHOICE OF METHOD OF CURE. 285 next place, is its size and degree of hardness ; or, if there be more tliun one, their aggregate volume, so that the amount of debris which would result from their crushing might be estimated with some approach to accuracy ; and this knowledge, already attained in some degree by ex- ploration with the lithotrite, is to be used conjointly with what has been learned as to the condition and degree of tolerance of the blad- der ; for the surgeon would be justified in attacking a much larger phosphatic calculus in the tolerant or atonized bladder of an old man than one of uric acid of smaller size in the more irritable bladder of a younger subject. Again, a calculus of uric acid breaks into wedge- shaped fragments, with acute angles ; and the mulberry calculus, from its extreme hardness, yields but few, and consequently large fragments, with very sharp edges ; the result of a crushing in either case would involve more risk of subsequent inflammation than the less irritating and more pulverulent detritus of a phosphatic stone. It becomes obvious, therefore, that in fixing a rule which shall determine the choice between the crushing and cutting operations, as based upon the size of the stone, a standard must be adopted which shall vary with its quality. It is safe to say that all stones under an inch in diameter may be crushed ; but it would not be judicious to conclude that all stones beyond this size must of necessity be reserved for lithotomy. Here is room for the exercise of sound judgment, and to this end an accurate diagnosis must be made as to the nature of the calculus, as well as to the condition of the bladder. For this purpose, careful microscopic study of the patient's urine, and inquiry as to when it first became turbid, and what changes it has undergone, will give much assistance. The habitual presence in the urinary sediment of the octahedral crystals of oxalate of lime, the prisms of the trij^le phos- phate, of the common and varied crystals of uric acid, or of the puru- lent sediment of the amorphous urates, would add much certainly to the diagnosis of the probable nature of the calculus ; while a close and searching inquiry into the history of the patient, his antecedents, his earlier symptoms, and their different phases as the malady progressed, the possible occurrence of previous attacks of renal colic, and the habits of the patient, as influencing them, with a review of his inher- ited or acquired constitutional peculiarities, could hardly fail to elicit valuable information. The probability of a central nucleus of uric acid, from its extreme frequency, is very great ; but the possibility of finding a nucleus in the shape of a foreign substance which had got into the bladder from without, such as a fragment of bone or wood, which it would be im- possible to crush, is not to be forgotten.* * In the collection of calculi in the Museum of the Royal College of Surgeons of Lon- don, according to the catalogue, out of 649 calculi, 212 are composed of uric acid alone, and in 65 others it forms the nucleus. Urates are given as constituting the entire cal- 286 TREATMENT OF STONE OTHER THAN RADICAL. CHAPTER XY. TEEATMEXT OF STONE OTHER THAN EADIGAL. The Preventive Treatment of Stone. — The Electrolytic Tri'iitment of Stone.— The Solvent Treat- meat of Stoue, General and Local.— The Palliative Treatment of Stone. Efforts may be made looking toward the prevention of stone formation in two directions : (1) In correcting an inherited or dia- thetic tendency to acid primary stone formation, wlien this is knowai to exist ; (2) in overcoming local physical conditions vrhose continu- ance threatens the complication stone as a secondary symptom — alka- line, secondary stone. When litliiasis exists, when a patient constantly passes acid con- centrated urine more or less charged with crystals, when he has already passed one kidney stone and fears the formation of another, what may be done to aid him ? I need not here discuss the colloidal theory, because that theory has not yet reached the practical stage. The scientific writings of Ord and Carter are full of suggestion, but another master must teach us how to apply them. The best that can be done practically at present may be accom- plished by — 1. Dietetics. 2. Exercise. 3. Encouraging elimination by other aveuues. 4. Diluting the urine constantly. 5. The use of solvents, and attempts to dilute the colloids. (1) Thompson, who has given this matter much attention, believes that the uric-acid formation lies essentially in the liver, and that it is by correcting that organ that we may hope to overcome the diathesis. He adopts, in the main, the Carlsbad notions, and cuts off sugar, fat, and alcohol, rather than the meats, and, in truth, such a dietary usu- ally proves more effective than the old-fashioned one, which interdicted culi in 14, and the nucleus of 187 out of the 649 ; 13 are composed entirely of oxalate of lime ; it forms the nucleus in 62. In a successful case of lithotomy which occurred in this city during the late war, under the care of Drs. Livingston and Markoe, a quadrangular fragment of bone was found in the center of the calculus. It had been broken off by a bullet, which had passed completely through the bladder, leaving the piece of bone to become the nucleus of a stone. The size of this fragment was too great to permit its withdrawal through the ure- thra in the jaws of a lithotrite, and its consistence too solid and resisting to allow of its being crushed. PREVENTIVE TREATMENT. 287 nitrogenized food because uric acid was a nitrogenizcd product. Ikit the foolishness of this is apparent when we reflect that tliore is neces- sarily enough nitrogen eliminated every day in the urine to supply uric acid without end, provided only the colloidal and other conditions are present upon which the formation of these crystals depends. Practically, then, it is found that a proper diet consists of meat, poultry, fish, eggs, bread, and all the cereals, all the fruits and roots, green vegetables and salads, with butter and milk in moderation — the latter notably in some instances, in my opinion, keeps up uric-acid tendencies. If any of the above-mentioned articles proves hard to digest, that fact alone is enough to condemn it in the individual case. Sugar is harmful ; most wines and liquors are pernicious ; some- times a little light white wine is allowable, or gin or old whisky in selected cases. Heller proved that an exclusive diet of rye bread caused all uric acid to disappear from the urine, this substance being re- placed by hippuric acid, a solution of which is a natural solvent of uric acid. (2) Exercise, probably by improving digestion and giving plenty of oxygen to the blood and tissues, is a factor of such generally recog- nized value in preventing uric-acid formation that its mention alone is required. Discussion is unnecessary. (3) The liver has a large share in uric-acid formation, and, by pre- venting it from becoming what is called torpid, a long stride is made in the preventive treatment of stone. The function of the bowels should therefore be closely attended to, and occasionally encouraged, if need be, by a blue pill or some calomel, or the combination of a mer- curial with a few grains of compound rhubarb pill. Added to this, a course of Glauber salts may be given occasionally, or small, graded, pro- longed courses of the sulphate-of-soda bitter waters (Hunjadi, Fried- erichshall). Garrod * speaks strongly in favor of long courses of the benzoates of sodium and potassium for the purpose of acting as uric- acid solvents. (4) Many persons prone to discharge uric acid and urates in excess, and to have habitually concentrated urine, are not free drinkers of water, and in the case of such persons some good may be done by encoui-aging them to take a glass of water between meals and another on retiring. This renders the urine by so much the more dilute, and by as much it militates against precipitation of the urinary salts. Filtered rain-water is better than ordinary water for this purpose. Distilled water is ex- cellent, and some of the mineral-spring waters better still — such as Wildungen, Poland, Bethesda — the still natural waters ; after being charged with carbonic-acid gas, their diuretic property is much les- sened. (5) A quick way to dissolve acids in the urine is to administer * " Uric acid," etc., "Lancet," April 21, 1883, p. 670. 258 TREATMENT OF STONE OTHER THAN RADICAL. alkaline medicines, particularly such as have also a diuretic efifect, such as the acetate or the citrate of potash. Here belong also all the alka- line salts and the alkaline waters, such as Vichy and Butralo Lithia. As preventive means to stone formation, the alkaline method is defect- ive in that it is by no means essential, and if long continued in many instances it finally ceases to act, or may have the further harmful effect of disturbing digestion, and sometimes directly causing ana.nnia. When alkaline medicines are given, it must be remembered that they produce their maximum effect for good in a given quantity if admin- istered about two hours after the end of a meal. The boro-citrate of magnesia in about ten-grain doses is well borne if a long course of alkaline medicine is desired. The crystals of oxalate of lime do not cease to appear under an alkaline course. They constantly occur in connection with jihos- phaturia. Dilute mineral acids, nerve tonics, bitters, exercise, and air, are the best means with which to fight this tendency. Beale* believes that the free use of carbonate of ammonium will in'evcnt cystine formations. To dilute the colloids, which seem to preside over crystallization, all that at present can be done is to keep the urine dilute and bland, keep digestion perfect, prevent catarrhal conditions of the stomach and intestine, and avert fever — or feverishness from whatever cause. Whether hydrangea is valuable in this direction or not, I have not yet decided. Cider habitually used seems to serve a good end, possibly in this direction. The preventive measures useful against secondary phosphatic stone formation are better known and more certain of success. No amount of phosphates in the urine can cause secondary alkaline phosphatic stone. The latter only occurs in connection with a catai'rhal state of the mucous membrane somewhere along the urinary tract. There- fore, the means of prevention of secondary stone include the surgical treatment of all obstructive urethral disease (stricture), of enlarged prostate, the removal of tumors, of all nuclei, of foreign bodies, the relief of residual urine by the timely employment of the catheter, the treatment of vesical catarrh by irrigation, medicated injections, etc. Added to this, some good — much good, indeed — may be attained in some cases by the judicious use of a milk diet, of abundant diluent drinks, of tonics, of alkalies or acids as indicated, and sometimes of such medicines as the balsams, the bcnzoates or benzoic acid, the salicy- lates, naphthaline, etc. The Electrolytic Treatment of Stone. — Although the electric cur- rent influences crystallization, and although Bouvier-Dcniortiers and Dumas and Prevost, as well as Erckmann, have shown that stone may be pierced and disintegrated by the galvanic current, yet the method * "Lancet," August 30, 1884, p. 263. SOLVENT TIIEATMENT. 289 is a failure for all practical purposes, and not worthy of general adop- tion under any known circumstances. The Solvent Treatment of Stone. — Since Pliny's ashes of snail-shells even, to the present day, the wise and foolish alike have searched un- ceasingly for something which, taken by the mouth, might be capable of dissolving a stone in the kidney or bladder, and the substance has not been found. The Joanna Stephens remedies worked wonders in the last century, until Parliament bought the secret for £5,000, after which they quickly fell into disuse and are now forgotten. Each of the four patients, whose cures were attested by the trustees appointed by government to investigate the matter, died with stone in the bladder, as proved by autopsy in each case. It is quite plain that secondary phosphatic stones, being alkaline and needing an acid solvent, can not be dissolved by any internal medicine. They may be acted upon by local injections of acids, but not so effectively as by other means, which require even less instru- mentation. The most serious efforts of modern times to dissolve small acid stone (in the kidney) by medicine taken into the stomach are those of Koberts* and Garrod,f of England, and they are most praiseworthy. The former uses long courses of the citrate (gr. xl to 1 every three to four hours) of potash, substituting bicarbonate if the citrate j)roves too diuretic ; the latter uses the same salts of lithium in a smaller dose. Beale J uses carbonate of ammonium to prevent cystine precipita- tion, gr. 1 three times a day in one case for three years. All these means are in a good direction, but there is little hoj^e of effecting any serious good with them if the stone is large enough to be worthy of the name. Yet the treatment frequently gives comfort to the patient, and is not to be wholly condemned. Mineral waters sometimes disintegrate a stone by causing its spontaneous fracture. The palliative treatment of stone, in cases not fit for operation, is a Judicious combination of alkalies, rest, milk diet, anodynes, and tonics, addressed to the individual needs of each case, with such use of the catheter, vesical irrigation, and medicated injections as may be called for. * " Urinary and Renal Diseases," second American edition, pp. 298-321, 18'J'2. f "Lancet," April 21, 1883, p. 669. X "Lancet," August 30, 1884, p. 363. 19 290 LITHOLAPAXY. CHAPTER XYL LITHOLAPAXY. Modem Improved Lithotrity.— Cases suitable for this Operation.— Instruments used, and their Method of Emploj'iuent.— After-treatment.— Complications.— Litholapnxy in Women.— Kelapse. Lithotrity is dead, having disappeared from surgery as its bril- liant child and successor, litholapaxy, established its claims. History and discussion on matters of this sort are out of place here. I have written what I have to say on these matters elsewhere.* I must here confine myself to conclusion, since there is no space for controversy. A stone in the bladder to-day must either be let alone, removed by litholapaxy, median or lateral lithotomy, or the suprajjubic operation. Litholapaxy is suitable to all ages. Children less than two years old have been successfully operated upon by it, and old men of ninety "with equal success. It has given better results statistically at both ends of life than any other operation for the removal of stone, and its position is now established in all j)arts of the world. To its discoverer, Prof. H. J. Bigelow, of Boston, in my opinion, the surgery of stone owes more than to any other man in this or any other age. It is the outcome of mechanical ingenuity adapting suitable means to a recog- nition of the fact, not before api)reciated, that the urethra may be widely distended, and the bladder tolerate any amount of prolonged manipulation skillfully performed, provided only that all the dehriH be taken away and the bladder left empty after the operation. This is litholapaxy — to catch the stone with an instrument passed through the urethra, to fragment it sufficiently for the detritus to pass out through a tube, and to suck out the debris by some suitable apparatus. Nearly every operator of i^rominence has his own lithotrite, and many of them have devised washing bottles and special tubes. With any form of apparatus the operation may be done, and with more or less rapidity and success, according to the operator. On these differ- ent questions it is impossible to enter freely here, as it is impossible to describe all the instruments employed at various hands. I shall only describe here Bigelow's instrument, out of respect to its author; my own lithotrite, which I believe to be as safe and more easy to use ; Bigelow's bottle, which is by far the most perfect that I have seen, and his tubes, with two of my own. Cases SuitaMe for Opercdion. — No age is a bar to litholapaxy. Any stone may be crushed if it can be caught in the jaws of the * "International Encyclopaedia of Surgery," vol. vi, p. 145 ct scq. INSTRUMENTS REQUIRED. 201 litliotritc. I have crushed a stone two inches in one oi" its diumeters. The stone may be so hard that the lithotrite can not break it, but I have easily crushed an oxalate-of-limc stone an inch in diameter; modern instruments are made of great strength. Multiple stone is particularly suitable for litholapaxy. There is, in short, no contra- indication except very great size of the calculus or phenomenal hardness, and such conditions as a foreign body for a nucleus unsuitable for crushing (glass, lead), and, finally, concomitant conditions, tumor, intense vesical inflammation calling for sub- sequent drainage, etc. Preparatio7i of the Patient. — A little rest in bed, a day or two if possible, is a proper part of the preparation for litholapaxy. The patient should be freely flushed with some bland diuretic water (Po- land, Bethesda), and, if possible, habituated to a milk diet, which will serve him well after his opera- tion. He may take alkalies or benzoates if the urine calls for them, and Just before his operation his intestinal tract should be cleared out. I have abandoned the use of quinine before the operation in most cases. I have lost faith in its power to prevent chill. Instruments required. — The essential instru- ments for litholapaxy are a lithotrite, a washing bottle, and tube. It is desirable to have at least two lithotrites, a light and a heavy one, and a num- Fia. 78. Fig. 79. Fig. 80. ber of tubes. An old operator never works without having two bottles, for one may give out at any time and ruin his operation unless a com- panion instrument is at hand. It is proper also to have a few cathe- 292 LITHOLAPAXY. ters aud sounds, a searcher, a pus basiu and ball syringe, rubber cloth, etc. Bigelow's lithotrite (Fig. 78) works by a wrist motion ujion an egg- shaped handle ; the jaws are heavy (Figs. 79, 80) ; the male blade has blunt indentations, the female blade is non-fenestrated. Admirable work can be done with this instrument, and, doubtless, those who become familiar with the wrist motion like it as well as they do the wheel. Some of the instruments have an extra curve at the extreme tip of the female blade to facilitate the passage of the instrument through a large prostate. I have used an instrument with this extra tip, and find it sometimes rather a disadvantage when small, flat pieces of stone are to be picked up upon the floor of the bladder, because with the new curved tip the jaw of the female blade is lengthened. I always use a fenestrated instru- ment. The male blade is made after the Eeliquet pat- tern, is rather smooth and little likely to do injury except in careless or ignorant hands. The instrument can not clog. I have two sizes (Figs. 81, 83). I have also enlarged the wheel and strengthened the shaft above the point pos- sessed by old lithotrites. I sometimes use the old-fashioned duck-bill lithotrite with non-fenestrated female blade to catch the last fragment. Any good instrument will do the work, and there are a number now in the market. The now perfected washing-bottle of Bigelow is, in my opinion, the best in the world. The washing- bottle has gone through many evolutions since its prototype was de- vised in France by Cornay (the lUheretie) in 1845, and a year later by Sir Philip Crampton in Dublin. Even Bigelow's bottle has so changed Fig. 83. Fio. 81. METHOD OF OPERATING. 293 that its own original would not be suspected of bearing any relation- ship to it. The bottles of Thompson, Guyon, Otis, Hill, and others all will Fig. 83. work, but none so well, in my hands, as the instrument of Bigelow (Fig. 83). Bigelow's tubes I find also as good as those of any other device. I prefer the curved tubes for common use in old men, as I think their introduction bruises the prostate less than the straight tube. I have devised a straight tube (Fig. 84), for which I have only to say that, introduced and drawn out to the vesical orifice of the urethra, and held there very accurately, it will sometimes get out a last frag- ment which a tube of the same size, not fully open at the end, will not deliver. This tube is not easy to use. The surgeon not familiar with it is quite sure to pull its open end out into the prostatic sinus, and then wonder why it does not work. It has a wooden obturator, armed with a washer and a stop-cock, which allows its use without wetting the bed — a thing hardly possible with the ordinary straight- tube. It is otherwise a simple tube open from end to end. I have constructed another tube also with washer and stop-cock, which for all purposes of introduction is a short, curved sound. For washing it is a straight tube, and I find that it returns fragments ad- mirably. The Method of operating. — The patient, etherized, is placed upon a rather high, long, narrow table, with his hips slightly elevated, the 294 LITIIOLAPAXY. shoulders low. Two assistants are required — one to attend to the ether, the other to keep the washing-bottle full and hand instruments. Through a soft catheter the urine is drained away, and the bladder thoroughly washed with a warm solution of borax. A tube may be introduced to test the caliber of tlie urethra if there is doubt on this subject. A few ounces of fluid are left in the bladder. A lithotrite, selected in accord- ance with the size of the stone, is introduced very much after the man- ner of a steel sound, except that, after the jaws of the instrument have entered the membranous uretlira, the further introduction is effected by a combination of the motions of de- pressing the handle and pressing for- ward the instrument so as to make the heel of the jaws of the instrument slide along the floor of the urethra and prostatic sinus until the bladder is fairly entered. Now the instru- ment is slid back along the floor of the bladder until the jaws have reached the back wall. Then, gentle tappings along the side will quickly indicate the position of the stone. When the latter is found, the jaws of the litho- trite are turned away from it, opened, returned while open over the spot where the stone was found, and, being gently closed, the stone will be grasped. Tlie screw power is now thrown on by the aid of the button in the handle, and a half-turn given to the screw. This fixes the stone. As the half -turn is being given, the Fig 8i 3^^^ °^ ^^^^ lithotrite are to be gently ^^^ gg moved away from the bladder-wall toward the center of the bladder. If a portion of mucous membrane has been entrapped along with the stone, the operator instantly appre- ciates it by noticing an obstacle to the easy rotation of the shaft of the instrument. In such case the jaws are unlocked, the stone allowed to drop out, and another effort made to catch it more cleanly. If the instrument rotates freely to the center of the bladder, the screw power is firmly applied, and the stone fragmented. METHOD OF OPERATING. 295 The lurge fragments full on cither side, and are easily picked up and again and again fragmented. With a fenestrated instrument there is no occasion to stop to clear the jaws or to test them for clogging. The work goes evenly on until the operator presumes that he has manufactured enough diihrin to make a creditable wash, and then a tube as large as the uretlira will admit is entered, the washing-bottle coupled, the stop-cock turned, and by alternate compressions and relaxations of the bulb the frag- ments are sucked up into the bottle and fall into the receiver beneath. Care must be taken to allow no air to enter the bladder. In the case of small tubes this is best averted by pausing in the introduction when the eye is yet within the prostatic sinus, and filling the tube by the aid of a small syringe. If the tube is large the bottle is simply coupled before the eye reaches the bladder, and the stop-cock being turned on the operator waits a moment until he hears the air which was con- tained in the tube rush up within the bottle, where he knows that it will remain out of harm's way in the air-space at the top. Now the bulb is compressed, the prostatic sinus is flooded, and the end of the tube, as it were, floated in through the open gate at the bladder's mouth. If the tube becomes clogged by a fragment, which the competent operator at once recognizes by the increased resistance to his j)ressure upon the bulb, a forcible compression of the latter will often dislodge the impacted body. Should this manoeuvre fail, the bottle must be uncoupled and a catheter or other instrument run down the tube to drive out the impacted piece. Under no circumstances should a tube be withdrawn with a sharp fragment impacted in its eye. Such a blunder entails certain scratching upon the deep urethra, and is more likely to cause urethral fever and serious subsequent complications than anything else which is likely to occur in connection with the operation. The lithotrite is again introduced, some more debris made and removed, and so on until no further click of fragments can be heard as the water swashes in and out of the bladder, either by the operator, who at once perceives them, or by the ear of an assistant placed over the bladder while the washing is being kept up. If a curved tube is used and turned toward one side of the bladder, or even held upright if the viscus contains but little fluid, as the water is rushing out into the bottle, the bladder-wall is sucked against the eye of the tube, and, fluttering there, gives several sharp clicks, which to an unaccustomed ear resemble the sound caused by a frag- ment of stone striking against the tube. An old operator is never so deceived. Finally, the bladder is drained and left emptj of fluid. Hgemorrhage may be excessive during the operation, but this is extremely -rare if the operator is careful. In some cases no care can 296 LITHOLAPAXY. avert it, and it may be suflficientl}' profuse to cause the prudent sur- geon to terminate his operation before the hist fragment is removed, leaving a little dcbn's to be taken away at a future sitting. Such a termination, however, is unfortunate, as one of the chief advantages of this operation is that by it the bladder is left free from all debris after the operation, a potent factor in averting subsequent inllamma- tion. If the blades clog (which fenestrated instruments avoid), they must be freed by repeated sharp movements back and forth of the male blade. Generally, such clogged blades have been violently jiullcd out through the urethra, leading sometimes to abscess, high urethral fever, even death. Ileavily clogged blades in my opinion call for perineal section in the middle line, when the charged jaws may be safely pulled through the easily dilatable neck of the bladder and liberated in the wound. If an instrument breaks in the jaws, the patient should be cut at once. After-treatment. — This consists in a free use of mori:)hine for one or more days, a little pilocarpine subcutaneously immediately after the operation, the use of a soft catheter and bladder irrigation with borax solution if there be retention or if the urine be ammoniacal or putrid, milk diet, diluent drinks (mineral water), and rest in bed for a week. I consider it unwise to let a patient up— especially an old man — before a week has passed. He may seem well before that time, but his soreness may return, and mild cystitis occur, if he gets up too soon. I have in many exceptional instances turned my patient out on the second day — but I do not think well of this. I have indeed oper- ated in my office several times under cocaine — and with no anaesthetic in the case of small stone — but this again only in exceptional cases. Impacted fragments in the urethra, one of the horrors of old-fash- ioned lithotrity, should never occur with this operation. If the blad- der is left empty of fragments, such a comi^lication is obviously im- possible. Should it ever occur, the foreign body may be pushed back into the bladder or removed from tiie urethra with a Thomj^son's rapid dilator, or in one of the methods alluded to under that head earlier in this treatise. After litholapaxy all the complications niay occur which are found with various operations upon the urinary tract, from catheterism up- ward. Urethral fever, mild or pernicious, retention, haemorrhage, cystitis, peri-urethral abscess, epididymitis, or even the graver compli- cations, suppression, surgical kidney (pyelo-nephritis), possibly even pyaemia, septicaemia ; but as a rule a careful operation has no sequence but a little temporary discomfort for a week or less, followed by cure. I can not remember when I have had a patient in bed longer than a week after litholapaxy. TREATMENT OF KTONE. 297 The operation is entirely applicable to women and young female children. I haye operated upon a girl of four years, and an old lady past sixty. Relapse. — Relapse after litholapaxy only is possible under throe circumstances. A fragment is left by the operator. This is to be avoided by testing the patient with the washing-bottle and small tube a month after he believes himself to be perfectly well. If a fragment has been left, it will then be discovered, and may be easily taken away. A new stone may form upon a new nucleus which comes down from the kidney. This is not strictly a relapse, and the operation is in no way responsible for it. Phosphatic re-accumulation may occur in old cases of vesical catarrh, the cause of which (notably enlarged prostate) can not be removed. Here again the operation is not respon- sible, since the same relapses occur after lithotomy. CHAPTEE XYII. LITHOTOMY. The Lateral Operation.— Cases suitable for it.— Instruments employed.— Operative Method.— After- treatment.— The Lateral Operation in Children.— The Median Operation.— Cases suitable for it.— Operative Method.— Complications of Lithotomy.— Relapse after Lithotomy. In the consideration of the treatment of stone, the subject of lithotomy is introduced last, because it is an operation of far less im- portance than its powerful rival litholapaxy : to the latter it is yearly yielding more and more of the cases which, by common consent, for- merly fell solely within its own domain. That lithotomy is an impor- tant operation, and eminently surgical, is undoubted ; that it requires a cool head and steady hand for its proper performance, none will dis- pute ; that it is often brilliant in its results is equally self-evident ; but the function of the surgeon is not to perform brilliant operations, but to cure disease and relieve pain with as little risk to life as possible, and this litholapaxy accomplishes far more certainly, in the hands of the average operator, than does any variety of lithotomy.* As the means of diagnosis improve and become more widely spread, stones are detected earlier, and yearly the number of calculi is greater which come within the scope of litholapaxy — an operation which, carefully and gently performed upon a proper subject, is nearly as harmless as any grave operation can be expected to be. A mortality of not over six per cent for all cases and ages ought to be aspired to. All the * Consult the section upon this subject in my article, " Urinary Calculus," in the "International Encyclopaedia of Surgery," vol. vi. — Ketes. 298 LiinoTOMY. large operators show better results — results which improve the more they operate. Lithotomy is respectable for its longevity ; but it is idle in a text- book of the present day to discuss the unfavorable o])inion of Ilip- ])ocrates, who believed that wounds of the bladder were deadly, or the barbarous method of "cutting on the gripe," the ''api)aratus minor," or the " apparatus major" of musty antiquity. Nor, again, does space allow a detailed description of the many cutting operations which have been proposed and successfully performed for the removal of stone from the bladder — operations bearing the names of many illustrious meu, and modilications of these the names of many more, to whom all honor is due. Practically, the surgeon requires but three o])eratjons to meet the necessities of all cases, and these three only will be de- scribed — they are the lateral, the median, and the high operation for stone. For the statistics I have collected upon lithotomy, I must refer to another place.* Lateral Litliotomij. — At the present writing it seems that the glory of lateral lithotomy is dying away. The operation is only required for male children, where the operator is unwilling to employ litholapaxy, possibly for a few foreign bodies, and occasionally wiien bladder drain- age is required. The latter, however, may be as well or better at- tended to by median incision and a tube. Large stones now call for the high operation, and vesical and prostatic tumors may be reached as well through the median as through the lateral incision. Multiple stone is suitable for lithotrity. Eucysted stoues call for suprapubic cystotomy. Young children do well by any operation, but the lateral is un- doubtedly the best, as the incision is not liable to injure the seminal^ ducts, and a free outlet is afforded for the extraction of the stone. If the latter is quite small, the median operation is perhaps as good ; but, where it is largo, the violence done in dilating the vesical neck is objectionable. It is exceedingly rare for children to have infiltration of urine, although the limits of the prostate are undoubtedly often surpassed by the incision in the lateral operation. Peritonitis from violence is what is to be feared in children, and there is little danger of this (even with large stones) from the lateral operation. The median section, however, in children has the advantage of being generally attended by less haemorrhage, and is useful for small stones ; the older the child, the less objectionable the operation. The lateral operation is ascribed to Pierre Franco, of Provence, about the middle of the sixteenth century, and claims the names of Jacques in the seventeenth century, and Rau, his pupil, in the eight- eenth. It was popularized and practiced with great success in Eng- * Consult the section upon this subject in my article, " Urinary Calculus," in the '• International Encyclopaedia of Surgery,'' vol. vi. — Keyes. INSTRUMENTS. 299 land, by Chcseldon, in the last century, and it is his operation whicli is still performed. Insti'uments employed. — The instruments necessary for this opera- tion are the searcher (Fig. 09), a staff of proper size with a long curve deeply grooved oh its convexity (Fig. 86), the groove encroaching on the right lateral aspect of the staff toward the point. 'J.''he handle of the staff should be broad, heavy, and marked with deep, crossed lines, so that it may be held firmly with greater ease. The groove should not run off at the beak, but stop abruptly, leav- ing the last quarter of an inch blunt and round. I Fig. Fig. 87. Fig. 88—^. Fig. 88— S. Fig. 89. Fig. 90. The scalpel should be firm, seven or eight inches long, with a stout shank and solid back, the blade about three inches long (Fig. 87), the cutting edge about one and a quarter inch. Blizard's probe-pointed knife (Fig, 88—^, English pattern), long, straight, with a stiff back and (Fig. 88— .5, American) a ribbed handle. The bkmt gorget, possibly useful where the patient is fat and the perinseum deep (Fig. 89). The scoop (Fig. 90), several 300 LITHOTOMY. forceps of different sizes, with extremities rougliened in the inside to hold the stone firmly, one with crossed handles (Fig. 91), so as to be opened sufficiently in a deep perinanim without stretching the wound unduly ; another with its blades sharjily curved (Fig. 92), so as to catch stones behind the pubcs or in the ''bas-fond." The heavy in- struments, formerly used to crush stones found to be too large to be extracted through the lateral incision, are no longer called for, such stones being properly dealt with by suprapubic lithotomy. I think Fig. 91. Fio. 92. Fig. 93. Fig. 94. it a safe rule that, if two of the diameters of a stone are even a little over an inch and a quarter each, the patient will do better by the high operation ; and it is quite possible that the future may narrow the limit. A metallic tube, one-third inch diameter (Fig. 93), with an open end and a large eye — furnished with an obturator for easy introduc- tion—through which to wash out debris. Another tube, one-sixth inch diameter, provided with a globular head, about a half-inch diam- eter, having large holes in the globular head pointing backward (Fig. 94), and a piece of rubber tubing on its proximal extremity — this to be used with a Davidson's syringe to wash out debris. A shirted cannula THE OPERATION. 301 for haemorrhage (Fig. 95), and a tenaculum which unscrews at the handle (Fig. 96, Keith's tenaculum), and several forciprcssure for- ceps for the same purpose ; Pritchard's anklets and wristlets (Fig. 97) ; some soft rubber and other catheters, brandy, hot and cold water, sponges, towels, ligatures, ether, etc. These make up the necessary list of instruments. At least five assistants are necessary : one for the ether ; one to steady each knee of the patient ; one — the post of honor — to hold the staff ; one to sponge and act as gen- eral assistant. The Operation. — The patient is })repared beforehand as for any other capital operation, and in addition has the perinaeum shaved and receives a full enema about two hours before the operation, to clear the rectum, after which he abstains, if possible, from again passing water. He should be etherized in bed, and then car- ried to a small, firm table, and com- fortably arranged on an old blanket. The anklets and wristlets are adjusted (or the hands and feet bound together with bandage). The pelvis is now drawn to the lower edge of the table, facing the light, a piece of old carpet and a pan with sawdust placed be- Fig. 95. Fig. 96. ^^ neath to catch the blood and urine. The operator passes the staff, feels the stone with it, and then intrusts it to his assistant of honor, and, taking his seat on a low stool, facing the pa- tient's pelvis, with all his instruments systematically ar- ranged within easy reach of his right hand, is in readiness to commence. Should the staff fail to strike the stone, it may be withdrawn and the searcher introduced. Should this also fail to detect it, after a careful and pro- longed sounding, the operation should be deferred. Some of the best 302 LITHOTOMY. operators have been deceived in their diagnosis, and have cut patients in wliom no stone existed ; so that it has become a cardinal rule never to cut a patient in whom the stone can not be felt after he is upon the table. The sound may fail to detect it, if it lies in a deep ba.'i- f 0)1(1, but not so the searcher. The holder of the staff usually satisfies himself that the sound strikes the stone. It is not essential that the end of the staff should rest against the stone. As long as it is certainly in the bladder, noth- ing more is required. The chief assistant stands at the patient's left, holds the staff vertically, steadily, and firmly hooked up under the symphysis, with its long curve a little bellied out in the median line Fio. 98 {T//o?npson). of the perinfeum, and keeps the integument of the latter taut by pull- ing the scrotum up around the staff. The assistants steady the knees, while the operator impresses his mind finally with the shape and size of the long outlet of the pelvis by running his fingers down the rami of the ischium, touching their tuberosities, feeling the symphysis pubis and the coccyx. The surgeon should picture to himself a pelvis lying before him, in position, denuded of soft parts (Fig. 98), and recall the general inverted heart-shape of its outlet (Fig. 99). The operator now introduces the left index-finger into the rectum, assures himself that the sound enters at the apex of the prostate and passes centrally through its canal, and that the rectum is empty and collapsed. Then, withdrawing his finger, he searches, with the thumb or finger of his left hand upon the raphe of the perineum, for the THE OrERATION. 303 groove in the stafP, which, in a thin person, can always be obscurely felt. If lie can not feel it, he takes the handle of the staff from his assistant, and, by depressing it several times, while he makes i)ressure upon the perin83um, he satisfies himself of the position of the groove, and returns the staff to his assistant. The scalpel is now entered a little to the (patient's) left of the raphe, from one and a quarter to one and a half inch in front of the anus, the point of the knife, guided by the nail, being made to enter the groove of the sound and open the urethra at the first cut. If the point enters the groove, it is to be pushed along for a quarter to half an inch — if it fails to strike the groove, it is made to pierce more or less deeply — and then, with a single bold stroke, the first incision is made laterally to the right, about three and a half inches long, terminating exactly mid- way between the tuber ischii and the anus. The scalpel is again entered into the groove, and the urethra amply opened. The practiced lithotomist sometimes uses the same knife to complete the operation, but, as a rule, it is better, at this stage, to change the scalpel for Blizard's knife. The probed point of the latter, following the guiding index-finger, is passed into the groove, and the surgeon takes the handle of the staff, depresses it somewhat, and, fol- lowing the groove, pushes his knife along until its point is arrested by the abrupt termination of the groove at the end of the staff. He now increases the angle between his knife and the staff by depressing the handle of the former, and, remembering the position and shape of the prostate, he cuts his way out, his incision through the prostate being at about an angle of 30° with the horizon, his external incision at an angle of about 50° A glance at Fig. 99 shows at once the relation between the incisions and their relation to the prostate and anus. A gush of urine usually follows this incision. If the external incision has not been bold enough, it may now be enlarged with a few strokes of the scalpel. If the above directions are followed, there is little danger of that disagreeable accident, cutting into the rectum. Fig. 99 {Thompson). 304 LITHOTOMY. Instead of dividing tlic prostate with tlic knife, numerous inge- nious lithotomes have been devised, which incise to a greater or less distance, according to a previously arranged gauge, or can only cut to a limited extent, as in the bisector of Wood, and that of Post, of New York. The single-cutting ''lithotome cache," of Frere C6me, and the double instrument of Dupuytren, with their many modilications, of which that of Briggs, of Nashville, is simple and eflficient, all of these are undoubtedly good ; but the surgeon should learn early to depend as much as possible upon his brains and his lingers, and as little as possible upon instruments, if he would acquire self-confidence, without which any operation for stone is unsurgical. Hence it is advisable for the young surgeon to familiarize himself with the use of the scalpel aud Blizard's knife, and to do all his cutting v\ith these instruments, or even with the scalpel alone, remembering that the greatest average lateral dimensions of the adult prostate are only one and a half inch, and that a depth of incision one half, or at most five eighths of an inch, into one side of the prostate should be a limit never surpassed — dilatation will do the rest. Having now completed the incisions, the index-finger of the left hand should be gently introduced into the bladder, and the sound withdrawn. The finger usually comes at once in contact with the stone. The bladder's neck is now to be dilated slowly but thoroughly with the finger — if the perinaeum be deep with fat, with the blunt gorget, carried in along the groove of the staff. If the stone has been previously measured, and is less than one inch in diameter, or if there are many small stones, the surgeon should proceed to extract at once. If, however, the stone is above one inch in diameter, Blizard's knife should be reintroduced on the finger, and the prostate cut on the (pa- tient's) right side. After being satisfied that the neck of the bladder is nicked, the prostate sufficiently cut, the whole wound dilated and dilatable, the forceps is passed into the bladder as the finger is with- drawn. One blade is depressed into the floor of the bladder, the other is widely opened, and usually, on closing them, the stone will be caught. Failing in this, search laterally and further back in the bladder must be made, the direction of the blades being changed, until the stone is seized. In cases of deep perinaeum the small end of the scoop is introduced until it touches a stone, and then the forceps is followed along upon the scoop as a guide until it enters the bladder and strikes the stone. It should never be forgotten during these manoeuvres that the bladder, usually already much inflamed, is often nearly empty, clasping the stone, and that any roughness or force may inflict serious (perhaps fatal) injury upon the patient. The utmost gentleness, de- liberation, and care are necessary during this stage of the operation ; indeed, the catching and skillful extraction of the stone is often a more delicate proceeding than any other part of the operation. THE OPERATION. 305 If it is found that the stone lius been seized in a faulty diameter, it should be dropped or pushed out of the jaws of the instrument, IDerhaps rolled over with the finger, and another attempt made to catch it correctly. Extraction should be slow, the traction being made iu the line of the external incision, downward and outward. Lateral motions should be given to the forceps during extraction, the force being about two thirds lateral, one third extractive. It must be remembered that the most fatal source of danger in lithotomy is bruising and lacerating the neck of the bladder in forcible efforts at removing the stone ; and if, after the exercise of a sufficient amount of force — the amount to be learned only by experience — the stone will not engage in the outlet of the bladder, it is far more brilliant mor- ally, and better surgery, to perform the high operation for the removal of the stone, and leave the perineal opening for drainage, rather than to put the patient's life in danger by insisting upon extracting the stone according to the plan first conceived. After one stone has been extracted, if it is found to be smoothly rounded and presenting no facets, there is probably no other present ; if it has facets, the reverse is almost, if not quite, certain to be the case. Phosphatic calculi are often multiple, uric acid less commonly so, oxalate of lime often single. In any case, after extracting one stone, careful search should be made for another with the searcher and the small end of the scoop through the perineal wound. Should any stone break during extraction, and in those rare cases where a quantity of cUhris is found in the bladder, partly adherent to ulcerated patches of mucous membrane, the large end of the scoop is to be used to spoon out the earthy matter, and then copious injections of tepid water are to be thrown into the bladder with the Davidson's syringe through the large tube (Fig. 93), or the bulbous-headed irrigator (Fig. 94), until the bladder is clean. When the stone is found to be encysted, or fixed in position by some faulty contraction of the bladder behind the pubis, or in the fundus, the dexterity of the operator may be taxed to seize it with the forceps, but intelligent efforts, gently and carefully prolonged, will usually overcome the difficulty. If the stone is deeply encysted, it may be impossible to liberate it. The neck of the cyst may be nicked in several places, efEorts made to gnaw off any projecting jDortions of stone, and gradually to insinuate the narrow blades of a small curved forceps to extract it. Each case must be coolly studied out at the time ; no definite rules, covering all contingencies, can be given. The high operation may be required. Hcemorrhage during the operation is rarely profuse. The lower part of the bulb is generally cut into. Spurting-points should be tied as they occur, or twisted. When the bleeding-point is deep in the wound it is difficult to tie, and removing the tenaculum may loosen 20 306 LITHOTOMY. the ligature. To meet sucli an emergency, it is jn'opcr to tie in a tenaculum, and for this purpose Keith's idea (Fig. 96), of having a tenaculum from which the handle may be unscrewed, is a good one. Thompson says, " I believe I have saved a life on one or two occasions by tpug in a tenaculum." In one instance the instrument was left in ten days, when it came away spontaneously. The forcipressure forceps answers the same purpose even better than the tenaculum. Digital pressure for several hours of tlie pudic artery against the ischio-pubic ramus may serve to arrest arterial luvmorrhage, otherwise runcontrollable. Ice and iced-water irrigation is an adjuvant which may be resorted to. Even the pudic artery may be tied by taking a short, stout, curved needle with a holder, introducing it through the soft parts cldse to the anterior border of the bone, bringing it out about three quarters of an inch deeper, and then firmly tying the liga- ture which it carried. Venous Jicemorrhage, unless profuse, may be disregarded ; if severe, it calls for plugging of the wound. This is effected with the "shirted cannula" (Fig. 95), or any female catheter will do, with a sufficiently large square piece of muslin having a hole in its center, tied firmly around the tube, at about an inch from the extremity which enters tlie bladder — or even a soft sponge perforated by a female catheter. This is introduced deeply into the wound, and the flaring sack around the central tube is closely packed with small pellets of lint, sponge, or oakum, the whole kept in place with a snugly-applied T-bandage. Generally all oozing may be arrested by simply bringing the thighs together, and bandaging the knees, thighs, and ankles. The mutual pressure of the two surfaces of the wound answers admirably well. After-treatment. — If the patient seems to be sinking during or immediately after the operation, before he has emerged from his an- aesthesia, and, consequently, when he can not swallow, an excellent means of stimulating him consists in passing through one nostril a soft French olivary catheter (about size 15 F.) past the pharynx into the oesophagus, and throwing into his stomach small doses of brandy with a syringe. The catheter may be left m during the whole operation, and does not interfere with the administration of the ether. One cau- tion is necessary : It is prudent, before injecting the brandy, to notice whether any air comes out of the catheter during expiration, as the instrument may possibly have passed into the trachea ; if time allows the slower absorption, injection into the rectum may be substituted. The patient is placed upon a mattress, with the hips upon a rubber cloth and folded compress, and napkins placed under him, which, by being frequently changed, indicate the amount of ha?morrhage. Urine passes freely at first through the wound, always more or less tinged with blood. The wound swells so much sometimes, before suppura- LATERAL OPERATION IN CUILDREN. 307 fcion is established, that part of the urine on the second day flows throuo-h the meatus, or, indeed, retention may come on. The latter is relicA'ed by gently introducing a female catheter or a finger through the wound. Opium may be given from the first to control pain, to be pushed judiciously on the appearance of any evidence of peritonitis. Diet should be light, but sustaining. If the patient has been addicted to stimulants, he should not be deiirived of them in moderation, and the same is true of opium.* The wound usually closes by granulation. As suppuration comes on, there is not infrequently a slight chill, with (surgical) fever, but the patient is, on the whole, comfortable, and delighted to be free from his old pain. Sometimes the wound becomes coated with urin- ary salts. This is prevented by frequent sjrringing with warm water, to which a few drops of dilute nitric acid have been added. (Certain complications are described after the median operation.) liATERAIi OPERATION IN CHILDBEN. In children the staff is smaller, with a shorter, sharper curve, as the bladder lies high ; hence, the staff must be hooked well behind the symphysis. The incisions are made in the same manner as in the adult. The lower end of the rectum is often prolapsed in children with stone ; this is reduced before the first incision, and kept in with the finger. There is little danger of cutting it, with the exercise of any ordinary care. The incision at the neck of the bladder usually, if not always, cuts entirely through the limits of the prostate, which is very minute before puberty, but it is a matter of no importance. In- filtration of urine does not occur after it. There is much more danger in making too small an incision, and lacerating and bruising the parts during extraction of the stone. The lateral incision of the prostate avoids the seminal ducts. There is danger in children, if the mem- branous urethra and bladder-neck have not been sufficiently cut, that an attempt to introduce the finger and dilate the latter may require so much force that the membranous urethra is torn across and the bladder pushed before the advancing finger. The mention of this * A patient, past middle life, from whom I removed, by the lateral operation, eight phosphatic stones weighing collectively two ounces three hundred and twenty grains, had been so tortured by pain during a number of years by his malady, which had been unrec- ognized, that he acquired the habit of opium-eating. His daily dose was seventy grains of opium and two or three ounces of laudanum. After the operation his pain ceased, and his opium was rapidly cut do\vn to a very small daily dose. But, although he did well in every other respect, his wound absolutely refused to granulate during several weeks. On this account he was allowed to resume his large doses of opium, and, when he reached nearly his habitual quantity, his wound rapidly granulated and went on to speedy union ; after which his opium was again reduced. — Keyes. 308 LlTllOTUMV. accident will insure against its occurrence. Another caution must be given, namely, that the first opening into the urethra should be suffi- ciently ample to insure its easy discovery upon search, so as to avoid the necessity of making several openings at different angles in a small urethra — an accident which might be followed by stricture. All care is necessary in extracting the stone. IIa3morrhage in young subjects is very devitalizing. All the blood that is possible should be saved. Children cut by the lateral operation rally with surprising rapidity. Every surgeon of large experience recounts cases where, on visiting the child twenty-four hours after the operation, he finds him up and play- ing about the room — possibly out of doors with his companions. Ac- cidents, however, do occasionally occur with the young, and due care should be exercised in the after-treatment to meet all symptoms ap- propriately — especially any indication of peritonitis, a complication of lithotomy proportionally much more common in childhood than in later life. THE MEDIAN OPERATION. The median is known classically as the Marian operation, devised in the sixteenth century, and afterward largely adopted and improved in Italy. Allarton has been its apostle in England, and the modern ojieration is known by his name. In this country j\Iarkoe first brought it into particular prominence, and the names of Little and Walter are also connected with it. Each of these three surgeons has enjoyed re- markable success with this operation. The median operation is suitable for very small stones in children where litholapaxy is not considered suitable, for small stone in adults when the bladder requires subsequent drainage through a tube, and for cases in which there is prostatic or other tumor to be dealt with by the same operation. Instruments kequired. — The only instruments necessary, differ- ing from those employed in the lateral oi^eration, are three : a staff, director, and knife. The staff, of appropriate size, has a central groove, with a broad flare. Markoe (Fig. 100) and Little (Fig. 101) have each adopted a staff. The groove of the latter is deeper, furnish- ing, its author believes, greater convenience and certainty in dividing the membranous urethra. A ball-pointed probe, or a dh'ector, known as Little's (Fig. 102), is generally employed, and a straight, stout, sharp-pointed bistoury, generally made to cut slightly uj)on the back for a short distance from the point. Operation. — The patient bound in the lithotomy position, and the staff introduced in contact with the stone, the operator passes the index-finger of the left hand into the rectum, familiarizes himself with the feel of the parts, and accurately locates the apex of the prostate, just where the staff enters it. He now transfixes the perinaeum about MEDIAN OrERATION. 309 half an inch above the anus, with the sharp-pointed bistoury, the cut- ting-edge upward, entering the point of the same, guided by his finger in the rectum, into the central groove of the staff, at the apex of the prostate. The double-edged point is now advanced very slightly into the groove, so as certainly to enter the urethra, and barely nick the apex of the prostate. Finally, the knife is made to cut forward and divide the membranous urethra within, and, the han- dle being elevated in the vertical plane, the blade is swept around so as (theoretically at least) to avoid the Fig. 100. Fia. 101. Fig. 102. bulb, and cut its way out along the raphe, the external incision being from one and a quarter to one and a half inch long. Thompson pre- fers making the incision from without centrally inward. The director is now passed along the staff into the bladder, and, these two being separated in an angular way, the neck of the bladder is dilated, some urine flowing out during the process. The staff is now withdrawn, and a finger introduced through the wound, with which the dilata- tion is completed, without cutting the prostate or the neck of the bladder. The stone — necessarily not very large — is withdrawn, as in lateral lithotomy, and the general after-care of the patient is the same. 310 LlTnOTOMY. The operation yields excellent results; the patient sometimes re- tains control over his urine from the lirt^t. The wound usually heals rajtidly. Tlio objections to the operation are : its oeneral inapplica- bility except for stones which lithotrity is more ca})able of managing, and the temptation to use violence during the extraction of a too large stone. ^Vhere ratiier largo stones are extraced by this method, incon- tinence, sometimes lasting several years, may occasionally ensue, and it is claimed (Toevan *) sterility. COMPLICATIONS OF LITHOTOMY. Shock, exhaustion, septicemia, pyannia, erysipelas, possibly tetanus, may be encountered after lithotomy, and recpiire to be met according to general surgical principles. Unusual complications in the way of luvmorrhage, besides those already alluded to, may occur in connec- tion with the ha?morrliagic diathesis, or in those rare cases of irregular arterial distribution where the main pudic trunk is defective, and its place supplied by an accessory pudic lying close along the border of the i)rostate, or where the artery of the bulb is given off farther back than usual, or the main artery of the prostate enters the gland in a position exposing it to injury. These complications are met by- especial attention to the means of arresting heemorrhage, already de- tailed in describing the lateral operation. Secondary hemorrhage sometimes comes on several days after the operation. Thompson has had four cases, two of which were fatal. The wound is small ; liga- ture can rarely be applied. Thompson advises perchloride of iron, carried in upon lint at the end of a probe, or the actual cautery. Perchloride of iron might be injected. South reports arrest of the hcemorrhage in several cases by pressure on the pudic artery, long continued. Peritonitis, more common in the child, may complicate the opera- tion in the adult. The rectum may be Avounded, or the perineal wound may inflame from mechanical injury or diathetic cause, result- ing possibly in sloughing of a part of the rectum. Fistula may be left behind, retention may follow the operation, or temporary or even per- manent incontinence, and even occasionally sterility, from obliteration of the ejaculatory ducts by section or subsequent inflammation. Epididymitis may come on, as after any operation involving the pros- tate, bystitis may run high from injury to the bladder during ex- traction of the stone ; chronic disease in the kidney may be kindled into an acute state. All of these complications are to be met accord- ing to suggestions already laid down in other parts of this treatise. By far the most common complications after operation are inflam- mation of the parts around the bladder neck (cellulitis), and infiltra- * "Lancet," April C, ISIS, p. 498. INSTRUMENTS. 311 tion, both due to tlio same cause — mechanical violence in extracting too large a stone, or jagged fragments, through an insulTicient open- ing. Lack of vitality in the patient undoubtedly conduces to these results, and infiltration may be due to an incision surpassing the limits of the fibrous capsule of the prostate. But that infiltration is more often dependent upon tearing and laceration during the extraction of large stones, is advanced by Thompson, supported by the fact that in children infiltration is rai'e, although the incision, as a rule, in the lateral operation, generally surpasses the limits of the prostate, and notwithstanding the fact that in children the cellular tissue is particu- larly loose. Relapse of stone is liable to occur if any fragment is left in the bladder, and no part of the ojDcration requires more care than the thorough evacuation of debris, in any case where a stone has been, broken intentionally, or accidentally crushed during extraction. If, after healing of the wound, any symptoms referable to stone should continue, a careful search may detect the fragment, while yet small, and furnish an opportunity for the use of the lithotrite. CASE OF INSTKUHtENTS FOR STONE. The following instruments might be grouped into one case. They are sufficient to meet all the ordinary requirements of stone : Thompson's searcher. Two lithotrites, heavy and light. Bigelow's washing bottle and assortment of tubes. Urethral forceps. Lateral lithotomy staff, small and large. Median lithotomy staff. Lithotomy scalpel. Straight, sharp-pointed, narrow, stiff-backed bistoury. Blizard's knife. Blunt gorget. Little's director. Scoop. Lithotomy forceps, with crossed handles. Lithotomy forceps, with curved blades. Crushing forceps, with extra piece. Tube with globular head, for washing bladder. Shir ted cannula. Keith's tenaculum. Several forcipressure forceps. s# 312 SUPRATUBIC LirnOTOMY. CHAPTEE XYIir. SUPRAPUBIC LITHOTOMY. Cases Suitable for the Operation.— Operative Method.— After-treatment. This operation, designed in 15G1 by Franco, after passing throngh a varying history, is in onr day, notably on account of the admirable modification lent to it by Petersen, again rising in prominence, so much so that its ardent admirers even claim its applicability to all cases, young and old ; to all stones, large and small. The folly of such a proposition seems to me self-evident. When litholapaxy gives an average mortality at all ages of less than six per cent — lateral lithotomy in children below puberty being almost a minor operation, for death is phenomenally rare — how can it be proposed to substitute the high operation until it has shown better results than had been reached in 1885, when the mortality w^as about twenty-f5ve percent?* Doubtless it is much better now. My own early experience with the operation was unfortunate, but in the winter of 1886-'7 I operated three times in severe cases, and all recovered,! and since that date my results have left nothing to desire. In my opinion the operation is suitable for all large stones, that is, those which have two diameters greater than one and a half inch, or it may be safer to make the limit even smaller in the future, for the mortiility after lateral lithotomy increases rapidly with the size of the stone — not so in the high operation. Most stones, however, even of these diminsions, are suitable for litholaj^axy ; therefore it must be added that only very large stones, and moderately large ones which can not be crushed, are to be removed by the high operation. Encysted stones, stones complicating tumor, and foreign bodies — tliis list, it will be seen, takes in nearly everything except the stones which litholapaxy can cojje with. Instruments required. — The only special instrument required for the high operation is the rectal colpeurynter of Petersen (Fig. 103), a rubber bag, capable, when distended, of holding about a pint. The bags commonly used are those of Guyon, or a pear-shaped bag bearing Thompson's name. Among ordinary instruments required may be cited scalpel, scissors, curved needles and holder, curved sharp bis- toury, sponges on holders, lithptomy forceps, soft catheter, and forci- pressure forceps. * Art. " Urinary Calculu3," " International Encyclopaedia of Surgery," vol. vi, p. 200. f "Journal of Cutaneous and Genito-Urinary Diseases," July, IBS'?, p. 242. THE OPERATION. 313 The Operation. — The hair is shaved from the pubis and j)cri- nseum, and the patient prepared as for other operations upon the bladder. The abdomen is washed with an antiseptic solution (one in a thousand of bichloride of mercury). A soft catheter is passed, and throu,"-h it the bladder is washed with a four-pcr-cent boric-acid solution, hot, or a warm solution of borax in water, un- til the wash returns clear. The colpeuryn- ter is now passed into the rectum. I have never thrown in more than twelve ounces, and I believe this to be a safe limit and an ample one. I prefer less rather than more. Now the blad- der is distended by throwing in a berat- ed solution. I have rarely used more than ten ounces, but the amount to inject may be varied according to the known capacity of the bladder, or until (in a thin person) the outline of the viscus appears above the pubis. It should never be forgotten that the rectum has been lacerated bj overdistention of the colpeurynter, and the bladder ruptured in the hands of most competent surgeons (Monod, Cheselden, Verneuil), and an error should be made, if any, on the side of safety. Now a central incision about three inches long is made in the middle line, terminating at the pubic symphysis. The superficial fas- cia is cut through with the skin, the deep fascia more carefully. The sulcus between the recti muscles is sought, but, if not easily found, a central incision is made cleanly through the muscle parallel to its fibers. No separation of the muscles should be made except what is absolutely necessary, for such separations favor the possibility of subse- quent infiltration. Particularly is it desirable not to poke about with the fingers or instruments in the prevesical space behind the symphy- sis. This is the most dangerous area after the operation, the one in which pus is most likely to form and be a source of possible compli- cation. Fig. 103. 314 SUPRAPUBIC LITHOTOMY. After getting fairly through the muscles, a thin fascia is observed with yellow fat beneath it. This fascia is freely tlivitled in the middle line, then the pulp of the finger is placed between the yellow layer of fat and the symphysis, and the fat is rolled upward toward the upper angle "of the incision. This layer of yellow fat contains the poritonanim. Guyon's niancBuvre of rolling it up is admirable. I have practiced it a number of times, and I have never seen the peritonasum in any operation when I have done the cutting, cxccjjt in two in- stances in which the bladder was cancerous and the i)eritona?um ad- herent. If the peritoneum is opened it is not an important accident. The wound is antiseptically washed and sutured with tine catgut, being kept out of the way in the upper angle of the incision during the re- mainder of the operation. After the yellow fat has been rolled up the bladder is exposed, often covered with distended veins. With short-curved needles in a holder, a portion of the bladder is taken up in a broad loop on either side, the silk knotted in long loops, and these are used to hold up the sides of the incision into the bladder. If the veins are small they may be disregarded, and the bladder boldly cut into between the ligature loops. If haemorrhage is much dreaded they may be secured before the bladder is opened by passing beneath them a piece of fine catgut with a short, sharply-curved needle, and tying the gut. A number of such liga- tures may be employed, and the loss of blood be reduced to a minimum. Xow the bladder is freely opened, the finger enters, finds the stone, and rolls it into a suitable position. With a forceps it is easy to seize and extract any stone or foreign body, and to inspect the inside of the bladder as well by using a reflector, an electric light, or tlie Trendelen- burg position — that is, having the patient's knees bent over the shoul- ders of a tall man, who lifts the pelvis high, leaving the shoulders low. The intestines suck back the upper wall of the bladder, and atmos- pheric pressure distends its cavity so that the orifice of the urethra and the orifice of each ureter can be plainly seen, and the jets of the urine as they spirt from the latter, upon manipulating the kidney. Shall the bladder-wound be sewed up ? I formerly thought and said "No to this question, but it was upon insufficient data. I have now sewed up the bladder by using catgut, a continuous suture, and not passing the suture through the mucous membrane, but only partly through the muscular coats. I have used this method in three con- secutive cases, and only had a slight leakage from the lower angle of the wound for two or three days in two of the cases ; the third united throughout by first intention. I leave the external wound open in doubtful cases, where there is considerable dread of leakage, but ordi- narily close it, passing a rubber drainage-tube well into the prevesical space, and a short drainage-tube between the cutaneous lips above. THE OPERATION. 3I5 When the external wound is united, I include skin, fuscia, and recti muscles on both sides in the sutures, putting in a few superficial ones if required. Dress antiseptically. Before the bladder is united, if it is to be done — and many sur- geons prefer to leave all the wounds freely open — tlic colpeurynter is removed from the rectum and the catheter from the urethra. My own personal preference — after having used no drainage, ure- thral drainage by catheter tied in, drainage through a tube passed through the trigone and out at the anus, and considered the French method (two tubes passed through the wound) — my own preference is to drain through a perineal puncture and tube tied in. I have oper- ated only in three cases in this way, all severe cases, one a large tumor, one diffuse villous growth, one a stone over two and a half ounces in weight, and all recovered.* The objection to a perineal opening is that it is a source of extra hasmorrhage. I have devised a method of performing drainage in this region which I think does away with this objection. I pass a staff with a broad, flaring, central groove into the bladder. With a finger in the rectum as a guide, having its tiji placed upon the apex of the prostate, a straight bistoury, such as is used in median lithotomy, is passed close along the superior wall of the rectum until it enters the urethra and the groove of the staff near the apex of the prostate. Now a long silver probe with an eye-hole at one end, having been pre- viously prepared by having a fine stout string threaded through its eye, which string in its turn passes through the tip of a red rubber cath- eter, about size 27 French, and out through its lumen — being knotted inside the lumen so that it will not pull through — such a probe, a lit- tle curved at its tip, is passed along the blade of the knife as a guide into the urethra and bladder. A finger passed through the abdominal wound easily hooks up the probe, and by the aid of the string and the knot the catheter is drawn through the small punctured wound which it accurately fits — arresting all haemorrhage by its own pressure. The chief danger of this operation is not its performance, which is exceedingly simple, but in the possibility of cellulitis afterward. In my opinion, thorough drainage and a small amount of tearing during the operation are the best means of averting this. The after-treatment is the common surgical dressing of the ab- dominal wound, and irrigating the bladder once or twice daily with a mild current of hot borax-water. The perineal tube should be taken out at the end of four days to a week ; the lower drainage-tube is left in the abdominal wound twenty-four hours. If urine escapes through it, the perineal tube is returned ; if not, the abdominal tube is taken out twenty-four hours later. I have had my patients uniformly up and about during the fourth week — but an earlier cure is possible. * Loc. cit. 316 DISEASES OF THE URETERS. The higli operation is entirely suited for application iji the female sex in cases of Yery large or encysted stone and foreign bodies, or the complication of tumor. CHAPTER XIX. DISEASES OF THE URETERS. Anatomy.— Anomalies.— Chronic Inflammation.— Dilatation.-Stricturc— Wounds. The ureters are the excreting ducts of tlio kidneys. They run down on either side behind tlic pcritonanim from the kidney over the brim of the pelvis to the base of the bladder, and pass through its coats in an oblique, valvular way, making two of the angles of the triffonum Licutaudii, of which the internal orifice of the urethra is the third. The structure of the ureters is mainly muscular. There is an inside mucous membrane, then come the circular and longitudi- nal layers of uustriped muscle, bound together by connective tissue. Xot very infrequently the ureter is double or triple; the abnor- mality existing through the whole length of the canal, or, more commonly, the several branches uniting above at a distance of one or more inches from the pelvis of the kidney, to form one canal from that point on into the bladder. Occasionally there is but one ureter. Sometimes the ureter ends in a blind extremity, in which case the kidney can not functionate, and atrophies. W. U. Baker* mentions a case where a ureter opened abnormally near the urinary meatus in a woman. A cure of the resulting incon- tinence by turning the ureter into the bladder by a cutting operation. Baker refers to a similar case observed by Jackson, and quotes Emmet for a case of ureter entering the vagina near the cervix. When the genitals are absent in the male the ureters often open into the rectum. The diseases of the ureter are few and unimportant, being for the most part a continuation of other disease. Wounds of the ureter alone are very uncommon. Morris cites the case of the Archbishop of Paris, and a doubtful one by Ilennen, as the only ones on record. Chronic inflammation of the ureter extending upward from the bladder, or downward from the kidney, exists, but is hardly worthy of considera- tion. Pressure (by tumor or otherwise) upon any portion of the ureter causes the canal above to become enormou.^ly distended, so that it may reach the size of the thumb or even larger. This occurs markedly in exstrophy of the bladder, and is sure to happen if a kidney-stone becomes lodged in the canal on its way to the bladder. * "New York Medical Journal," December, 1ST8, p. 575. WOUNDS. 317 Stricture may follow the injury done by a calculus in its passage, or malignant or tubercular disease may extend to the ureter from the bladder or kidney. A valvular arrangement of the lining membrane of the ureter has been noted.* The blood in haematuria may come from the ureters. The ureter may be ruj^tured by external violence, or severed by a wound — injuries leading often to fatal extravasation of urine, or to ureteral fistula if recovery takes place. A case of scir- rhous tumor of the right ureter, observed by OUivier, is mentioned by Sebeaux,f leading to (reflex) retention of urine, and directly to pyelitis and death. Nepveu reports | two cases of traumatic anuria, one of "which, was due to the transverse section by a gouge of the left ureter without involving the bladder. Flaps and valve-like folds are sometimes found within the ureter, notably at the upper end. They sometimes lead to hydronephrosis. The ureter may be bent upon itself at an angle in cases of displaced kidney. Any obstacle to the free outflow of urine through the ureter tends to occasion hydronephrosis. Stricture of the ureter has been noted. F. S. Watson, of Boston,* reports a case of double hydro- nephrosis, due to organic stricture of the ureter on both sides. No cause could be assigned. There was no reason to suppose that calcu- lus had been the cause. In one ureter, two centimeters above the bladder, there was a stricture admitting only a fine knitting-needle. The ureter above this point was dilated to the size of the small intes- tine. Watson refers to four other cases of stricture of the ureter in literature — those of Kroner, Galliard, AyroUes, and one from "St. George's Hospital Eeports." CHAPTER XX. DISEASES OF THE KIDNEY. Anatomy. — Anomalies. — Floating Kidney. — Nephrorraphy.— Injuries. — Suppression of Urine. — Nephralgia.— Pliosphatic Urine.— Osaluria.— Gravel and Kidney-Stone. — Nephritic Colic— Nephro-lithotomy. — Pyelitis, Pyelonephritis, and Perinephritic Abscess. — Pyelitis, Pathological Lesions. — Causes. — Calculous Pyelitis. — Perinephritic Abscess. — Treatment of Pyelitis. — Hydro- nephrosis.— Kidney Cysts.— Hydatids.— Tubercle.— Cancer.— Other Timiors of the Kidney.— Nephrotomy.— Nephrectomy.— Syphilis of the Kidney. The scope of this work does not warrant a description of all organic and functional kidney-diseases. Only such surgical diseases are here dealt with as are most frequently encountered by the practi- * "Lancet," April 10, 1886, p 688. t "Contractures du Col de la Vessie," Paris, 1876, p. 44. X "Gaz. Hebd. de Med. et de Chir.," February 16, 1877. * "Boston Medical and Surgical Journal," November 26, 1885, p. 505. 318 DISEASES OF THE KIDNEY. tioner interested in genito-urinarv surgery, such morbid states as are liable to be attended with, or comi)licated by, functional or organic bladder-disease, or such as may require instrumental interference for their relief. Anatomy. — The kidney lies on either side in the lumbar region, liigh up, its upper border reaching above the last two false ribs. It has the familiar shape of the kidney-bean, is surmounted above by the suprarenal capsule, like a cocked hat, and lies outside of the peri- tonamm, surrounded by fat, with its hilum directed inward. The healthy adult kidney weighs from four to six ounces. It is sur- rounded by its own investing fibrous capsule, close inside of which lies the secreting or cortical portion of the kidney, dotted by its in- numerable Malpighian bodies, and containing the convoluted urinif- erous tubes ; these terminating in the converging straight tubes which unite to form the pyramids, the medullary portion of the kidney. The pyramids terminate in nipple-like protuberances called papilla, which dip into the cavity known as the pelvis of the kidney, each jxipilla surrounded by a cup-like cavity in the pelvis known as a calix. All of these calices unite to form the cavity of the pelvis of the kidney from which the ureter is given off. The two kidneys are sometimes united at their upper extremity, forming what is called the horseshoe- kidney, usually lying astraddle the spine. Sometimes there is but one kidney, in which case it is much larger than usual. Occasionally there are three or more. Greenfield* has called attention to the fact that where there is congenital absence of the kidney the ureter is absent, and the seminal vesicle of that side deficient. Beumer f has collected forty-eight cases where the kidney, and nearly always the cor- responding ureter, was absent, and Eayer J mentions a girl — case of M. Moulon, of Trieste — who died at fourteen, having no kidneys, no ureters, and no bladder. A fluid resembling urine had during her life flowed freely from her umbilicus. Instead of being fixed behind the peritoneum in the lumbar region, the kidney may be only loosely con- nected there, and may become displaced in the abdomen, and freely movable (floating kidney). Still more rarely the kidney is found in an abnormal position in the cavity of the bony pelvis, or elsewhere. If one kidney is absent, atrophied, or diseased, the other remaining healthy, the latter undergoes gradual conservative hypertrophy, greatly increasing in size. The floating kidney** is often the seat of pain, which may be intense at times, and paroxysmal in its occurrence. The tight dressing of women, the pregnant condition, and heavy strains, as in lifting, may cause the kidney to become displaced dovvn- * " Lancet," October 21, 1876. f Virchow's "Archiv," Ixx, Heft iv. J "Diseases of the Kidney," 1841. * An aflmirable treatise on this subject is "Die Wanderniere der Frauen," Landau, Berlin, 1881. Consult also F. P. Guiard, "Du Rein mobile," P«ris, 1883. CONTUSIONS AND WOUNDS. 319 ward and forwaid. The weight alone of a, diseased kidney may cause its displacement. A painful floating kidney may be kept more or less in place by a bandage or a truss with a large pad. When a kid- ney is healthy, but the seat of pain, on account of being out of place, from congestion or a twist in the ureter, the proper treatment is nephrorraphy. NEPHRORKAPnY. — ^This operation was done first by Ilahn, of Ber- lin. An incision is made about an inch below the last rib, parallel to it, and about four inches long. After reaching the soft yellow fat about the kidney, two pairs of forceps and the finger may be used to tear through the fatty capsule. The renal capsule being reached, it is attached to the edges of the wound by several sutures of strong cat- gut. The wound is to be dressed open, powdered with iodoform, and stuffed with gauze or lint — or otherwise antiseptically dressed. CONTUSIONS AND WOUNDS. The kidney is sometimes wounded by an accident not necessarily fatal. When the patient survives such an accident, more or less in- filtration of the tissues by urine is liable to follow. The kidney itself inflames, causing partial or entire suppression, with blood in the urine, hot skin, high pulse, thirst, headache, pain running down to the tes- ticle, vomiting, etc. Perhaps abscess results. Contusions are more common. The kidney may be ruptured or lacerated by a fall, by crushing violence, or by a severe blow. Such rupture may be caused where the signs of external violence are insignificant. If the anterior surface of the kidney be ruptured, the urine may escape into the peri- tonseum, giving rise to fatal peritonitis ; if the posterior, the subserous tissues will be infiltrated, and chills, with high fever, will precede the formation of pus. The contusion may injure the vitality of a portion of the kidney, but not be attended by actual laceration. In such a case there would be more or less acute traumatic nephritis, terminating possibly in abscess. Seventy-one cases of injury to the kidney without external wound are collated by H. Maas, of Freiburg,* going to show that recovery from such injury is not uncommon. In all the cases but six there was hgematuria without clots. Injury to one kidney only, when un- complicated, proved fatal in only about 20 per cent. A case of re covery after pistol-shot wound of the left kidney is reported by A. E. Cummins, f The symptojns of laceration of the kidney vary in degree according to the extent of damage done. Collapse usually comes on at once with strong tendency to vomit, as in injuries of the testicle. There * " Deutsche Ztsehrft f . Chir.," Bd. x, Hefte 1 und 2 f "Boston Medical and Surgical Journal," June 15, 1876. 320 DISEASES OF THE KIDNEY. is pain ovov tlio iiijurod organ, pain running down the ureter into the testicle and in the testicle itself, retraction of the testicle; often pain across the liypogastrium, and a heav}', numb feeling in the thigh. The urine, which may require to be drawn at first through the cathe- ter, will be' usually bloody, scanty, and dense, possibly containing blood-casts of the uriniferous tubules, and frequently long, thin clots — casts of the ureter. Signs of peritonitis are not uncommon. 2'he pj'ognosis, if the laceration be extensive, is almost necessarily fatal; if it be slight, the patient may survive. Treatment consists in absolute rest, ojiium to quiet jiain, and the use of the catheter and enema ta to secure evacuation of the dis- charges. No cathartics should be given, fluids should be used epar- ingly, diuretics avoided, cold ap])lications should be made over the injured organ, and fluid extract of ergot administered. Frequent and careful examinations must be made over the site of the injured kidney, and an exploratory incision as soon as the existence of pus is suspected. An early and free incision is of great importance, as pus tends to bur- row downward and forward, giving rise to great constitutional irrita- tion. If no pus be discovered, the infiltrated urine may be evacuated, and, in any case, an early, free, and deep incision can do no harm. Ilenry Morris,* whose section upon this subject is one of the best in medical literature, suggests the performance of lumbar nephrectomy if the patient has "profuse and continuous hcematuria, especially if the bleeding is rapid and arterial." SUPPRESSION OF URINE. In suppression no fluid comes down the ureters into the bladder. Suppression may be caused by fright or strong mental emotions, by in- jury to the kidneys, or the onset of an inflammatory attack, by the effect of cold or other cause ; sometimes, especially if the kidney be the seat of previous chronic disease, by operations on the bladder or ure- thra, or even by the introduction of a sound or lithotrite {aee Uretheal Fever), by the passage of kidney-stone, etc. The symptoms are depression, languor, with apprehension, more or less fever, with hot, dry skin, and hard pulse. There may or may not be chill, vomiting, headache, and pain in back and loins, with constipa- tion. No urine is voided, or only a little high-colored secretion. In- stead of these active symptoms, suppression may come on gradually from advancing chronic kidney disease, the amount of urine passed from day to day gradually diminishing. In the latter case there is usually anasarca, in the former not. Meanwhile the urea and prod- ucts of tissue-metamorphosis are accumulating in the blood, and the patient becomes poisoned by them. Drowsiness and stupidity, per- * "Surgical Diseases of the Kidney," 1886. NEPHRALGIA. 32] haps delirium and coma, come on ; there may be convulsions, and the patient dies in from two to five days, unless the flow of urine can be re-established Before death the skin and breath have a urinous, ca- daveric smell ; there may be localized paralysis. In spite of this customary course of events, instances of total sup- pression for very many days have been recorded with a favorable issue. I remember to have seen reports of two such cases after scarlet fever, one of seventeen, the other of thirty days, but I can not vouch for them. H. Morris alludes to the very problematical case of Vieusseux of Geneva, suppression for seventeen months, with recovery. Diagnosis is easy. In retention the bladder is full, and can be felt above the pubes, the difficulty usually being to introduce a catheter. In suppression, the catheter glides in readily, but the bladder is found nearly or quite empty. Treatment. — Dry cups and hot fomentations over the kidneys. Hot-air bath and hydragogue laxatives, to favor excretion of urea by the intestinal mucous membrane ; the free use of warm drints, flax- seed-tea, etc. ; and, if there be no inflammatory condition, full doses of the acetate or citrate of potash and of infusion of digitalis, consti- tute the treatment. Turpentine should be avoided. Hyoscyamus may be given, and morphine subcutaneously. In old cases of chronic bladder and kidney disease, suppression is an exceedingly dangerous symptom, and does not yield readily to treatment. It signifies extension of .inflammation to the excretive structure of the kidneys, and is the normal termination of this class of diseases. NEPHRALGIA. Pain over the region of the kidney is a symptom by no means con- fined to diseases of that organ. It is found with many morbid bladder and prostatic conditions, and very often is simple lumbago, not depend- ent upon any internal malady. In bladder and prostatic diseases the pain in the back is more likely to occupy the sacral region, particularly the sacro-iliac synchondrosis on one or both sides. In lumbago the pain is usually much worse in damp weather, or on the approach of a storm ; is aggravated usually by motion of the trunk, particularly in rising from a sitting posture. There is a popular impression that all kidney-diseases are attended by pain in the back, the severity of the disease regulating the amount of pain. This impression is incorrect. Some kidney-diseases are attended by pains in the back, others are not. There is, however, a variety of pain in the back which has its seat in the kidney, and which is known as nephralgia. This pain is deep seated, felt in the back over the kidney, usually unilateral, often ex- tending down around the side, following the course of the ureter, sometimes continuing on into the testicle, sometimes complicated by 21 322 DISEASES OF THE KIDNEY. bladder-symptoms suggestive of stone in tlio bladder, or of ehrouic cys- titis of the neck. The pain varies in intensity, and is usually made worse by fatigue. Pressure generally aggravates, sometimes relieves it. Often the patient can not lie in bed upon the affected side. The l)aiu is usually a dull, deep ache, occasionally sh:ir]i, darting, pricking in character. It may come on gradually or suthlonly, and remains, ac- cording to its cause, from a short time up to many years, perhaps un- til death. Nephralgia is in reality a symptom, but may come on in a severe form independently of any organic disease. Cau.sei^. — The main causes of nephralgia are very acid urine, kid- ney-stone, organic kidney-disease (pyelitis, cancer, any morbid deposit or tumor), and many other morbid conditions, special diseases, abdominal aneurism, etc. It may owe its origin to, and be kejjt up by, perversion of the sexual function, or ungratilied sexual desire. Over-acid urine is in itself a sufficient and a not infrequent cause. The urine in health is slightly acid, especially 'after fasting. As a rule, however, in the healthy state there is an alkaline tide (as Eoberts has denominated it) to the urine, which comes on after each meal, and lasts several hours. The heavier the meal the later but the more last- ing the tide. In the morning, with American habits of living, it occurs at about 10.30 o'clock. The urine, then, shortly after breakfast, should be normally neu- tral, or even faintly alkaline, and, if then quite acid, a diagnosis of over-acid urine may be safely made.* The causes of over-acidity of tlie urine are the rheumatic diathesis, old age, the use of wines and liquors, but especially of fermented malt liquors, ale, beer, etc., and of sweet, sparkling wines (champagne). The latter of the above- mentioned causes act directly as irritants to the urinary tracts by pro- ducing large quantities of sharp-pointed crystals of uric acid which mechanically scrape and irritate all portions of the mucous membrane. The urine may be over-acid while its true character is masked by some bladder or kidney inflammation which furnishes enough (volatile) alkali to neutralize the whole flow. This source of error has to be constantly guarded against. There are no inflammatory conditions, acute or chronic, of any portion of the urinary passages which are not distinctly aggravated by over-acid urine, while some of them are caused in the first instance by it. Hence it becomes a part of the hygiene of the urinary passages to see that the alkaline tide exists, say at eleven o'clock in the morning, and, if it does not, to cause it * If the patient has ne;ilcctcd to pass water before breakfast, the very acid urine col- lected (lurinp; the night may not be neutralized by the alkaline tide. Simple mention of this fact will preclude error; nor is it necessary to test only the urine voided during the few hours after breakfast, for this is alkaline often where habitual over-acidity exists none the less. The practical test is this : urine should be voided on rising in the morn- ing, and not again till 10.30, at which hour it should be neutral, or very faintly acid. NEPHRALGIA— TREATMENT. 323 to do so by attention to hygienic laws and the internal administration of a suitable medicine. In all cases of nephralgia where careful ex- amination fails to detect any tumor of the kidney, or any disease of the bladder or prostate, suspicion should fall at once upon an over-acid state of the urine as being the cause, or possibly retained kidney-stone with pyelitis, or pyelitis from some other cause. Diagnosis. — To decide between these affections, a careful examina- tion of the urine is necessary after excluding bladder and prostatic disease. In pyelitis there will be constantly more or less pus in the urine. In nephralgia due to over-acid urine the alkaline tide is usu- ally absent ; crystals of oxalate of lime and of uric acid may be found in tlie urine when passed, while the color is usually deep, and the spe- cific gravity constantly high. There may be also in the urine more or less pus proportionate to the amount of irritation produced by the acid urine and the duration of the complaint. Such urine when left to stand in a glass may become almost solid on cooling, by the precip- itation of pink amorphous urates, or, if the latter ingredient be not suffi- ciently abundant to produce this result, a blue line, like the bloom on a plum, will form around the top of the glass just at the edge of the urine. Finally, after a few hours such urine may begin spontaneously to deposit large red. crystals of uric acid upon the sides and bottom of the glass. Prognosis. — The deep-seated, dull, boring pain over one or both kidneys may last for years, kept up by over-acid urine, in patients of sedentary habits whose nervous tone is depressed by overwork, alco- hol, or tobacco. Nephralgia very often coexists with irregular use of the sexual organs, or ungratified desire. The treatment is slowly but surely effective unless there exists or- ganic mischief. It consists in a properly regulated hygiene, much out-door exercise, Turkish, Russian, or other baths, dry frictions of the skin daily with hair gloves, rather light diet, the avoidance of overwork and of the abuse of alcoholic beverages (particularly fer- mented liquors) and of tobacco. In persistent cases of pure nephral- gia in young adult males the hygiene of the sexual organs is almost invariably at fault, and requires attention. An acquaintance with this fact is the key to successful treatment in many cases. The means detailed above, aided by half-drachm doses of citrate of potash three times daily, or the plentiful use of Vichy or other alkaline water, will usually sooner or later get the better of the complaint. If a laxative is needed, about 3 vij of Friedrichshalle water, to which a little hot water is added, may be taken with benefit one hour before breakfast every morning. In some instances when the digestion is at fault a mineral acid in a bitter vegetable infusion does more good than the exhibition of alkalies. 324 DISEASES OF THE KIDNEY. PHOSPHATIC URINE. In connection with the above, the converse state, over-alkaline urine, shonkl be referred to. Here the nrine is habitnally neutral or alkaline, while the alkaline tide is unduly marked. Tiie lluid is pale, of light speciHc gravity, and often, after standing a few hours in a glass vessel at ordinary temperatures, it commences to decompose. Such urine, when i)assed, often has a faint mutton-broth or chicken- soup odor, and the last drachm or more of the How is very apt to be as white as milk, from an excess of precipitated amorphous phosphates. This white flow is not constant. It may come only with the alkaline tide after breakfast. It is a cause of unceasing anxiety to many pa- tients, who believe it to be seminal fluid. Tiie urine when set aside shows the glossy, iridescent, phosphatic pellicle very quickly, instead of the faint bluish line at the top of the fluid on the glass, which is produced by urine rich in urates. Phosphatic urine is apt to contain crystals of oxalate of lime wiien passed, and to show at once or shortly afterward innumerable bacteria, the rapid development of which is undoubtedly due to the presence of phosphate of lime. Phosphatic urine alternates from time to time with over-acid urine, so that the same patient may have for a few days a dirty-brown sediment of urates in his chamber, which he sometimes mistakes for blood, and then for a few succeeding days a dense white deposit which, if his sexual rela- tions be not perfectly natural, he is pretty sure to consider seminal fluid. The alternations sometimes seem to depend upon the greater or less amount of mental worry an 4 physical exercise, the quantity and quality of the food, and the condition of the digestion. Some- times both deposits exist in excess at the same time, so that the dis- charge may be creamy as it comes from the bladder, and deposit an enormous amount of urates and phosi^hates, recalling the solid urine of snakes and birds. The symptoms found with phosphatic urine are usually those of lassitude, listlessness, a feeling of general weakness often attended by despondency. There are usually, also, dull, continuous pain in the back of the head, and unsatisfactory digestion. Phosphatic urine depends usually upon nervous exhaustion, and is often associated with weak digestion, a diet formed mainly of the sac- charine and starchy food, with a dislike for meat. Excessive use of tobacco aggravates any existing tendency to the production of phos- phatic urine ; masturbation, or excessive venery, often leads to it by exhausting the nervous force ; mental anxiety and worry produce it temporarily. Thus, students who study all night, before some critical examination, are certain to have an excess of phosphates in their urine on the following day. In the same way, any continued mental ten- sion, anxiety, or fatigue, may produce it. As may be inferred from OXALURIA. 325 its etiology, this affection is mostly confined to youth and early adult age. The treatment consists in removing the cause, if possible, re-estab- lishing mental quietude, cutting off tobacco, tea, and coffee, encour- aging pleasant out-door relaxation, with travel, change of scene, and air. As medicine, phosphoric acid, dilute hydrochloric acid, with or without a little strychnine, iron, or quinine, and perhaps some bitter vegetable infusion or tincture, are usually employed, and would seem to be indicated as appropriate tonics. The cause of phosphatic urine is evidently associated with morbid action of the ganglionic nervous centers, affecting the secondary assimilation of food, and those reme- dies which are most effectual in correcting this curious and unpleasant condition are measures which place the patient under the influence of more favorable conditions of life temporarily. Hence, a trip to the mountains, camping out, sea-voyage, etc., are more potent in securing relief than any drug. OXALURIA. The octahedral crystals of oxalate of lime, together with (less fre- quently) the dumb-bell crystals, the little spherules and the amorphous dust of the same, are not infrequently found in the urine, either alone or coexisting with crystals of uric acid, and with deposits of amorphous phosphates or urates. Such urine is often acid, dense, and high- colored. Sometimes the crystals appear accidentally in the urine from the free use of rhubarb, or indeed of tomatoes. Usually, but not necessarily, the crystals appear in cases of disturbed or exhausted nerve- power and imperfect digestion. They are found also with some dis- eases of the brain and spinal cord. Nervous prostration, produced by excessive venery, is quite likely to be associated with them. In short, nervous, irritable, hypochondriacal individuals, especially of the gouty temperament, particularly if young, with perverted, overstimulated, or ungratified sexual desires ; if overfed, under-exercised, and leading a sedentary life — such patients frequently have oxalate of lime in their urine, and suffer from an interminable series of unusual complaints, with which they are pretty sure to torment their physician as well as themselves. The oxalate of lime is not a cause of the disorder, but rather a symptom. These cases are met by hygiene, change, and a proper regulation of all that has gone astray. If enough of any alkali be given to render the urine abundant and limpid, the oxalate of lime will occasionally disappear for a time ; and this course is advisable, as well as the frequent use of baths, to free the blood as much as possible from any effete materials which may have been collecting there. The true curative treatment, however, is purely hygienic, and based upon a correct appreciation of the causes. As a rule, the less medicine taken 326 DISEASES OF THE KIDNEY. the better. The mineral acids and strychnine seem sometimes to do good as tonics ; an out-door life sometimes cures. QRAVEL AND KIDNEY- STONE. The solid substances naturally held in solution, and excreted with the urine, are sometimes precipitated in the crystalline form in the kidney-tubules, or at other jjortions of the urinary passages, and voided as crystals, always visible with the microscope, sometimes to the unaided eye. This is gravel. The cause of its precipitation lies in the fact that the urine becomes too concentrated — too heavy in organic con- stituents. As most frequently met with in practice, gravel is com- posed of uric acid, and forms the red sand which quickly collects around the sides and bottom of the vessel containing the urine. The gouty constitution predisposes to the formation of this red sand, especially when aided by a sedentary life and high living, more nutriment being ingested than can be disposed of, especially meats and alcoholic bever- ages, among which new fermented liquors and sweet, effervescing wines hold the first rank. Gravel is more frequently seen in summer than at other seasons, on account of the greater activity of the skin, which leaves less fluid to be excreted by the kidneys, and consequently leads directly to a concentration of the urine. The tendency to the forma- tion of gravel is often hereditary. The symptoms occasioned by gravel are those set down for nephral- gia, and, added to them, often symptoms of a low grade of cystitis or urethritis — the smarting, burning sensations on urination being espe- cially prominent. All bladder or urethral inflammations are greatly aggravated by the existence of "red sand" (sharp crystals or concre- tions of uric acid) in the urine. Treatment. — xVfter what has been so frequently repeated in previous sections, of the ill effects of highly-acid urine, it is needless to delay long with the consideration of gravel. An abundance of alkaline dilu- ents for a few days will always cause the red sand to disappear, and the sym^jtoms occasioned by it will shortly afterw^ard cease to be trouble- some in pure cases of gravel. The true treatment is preventive ; that is, so regulating the food, drink, exercise, and h3'giene of living, that the offensive ingredient may cease to ajipear. To effect this, the con- stant use of some mild, pleasant, alkaline fluid (such as Vichy water) is often desirable. It is well to take a draught of this, or some other fluid, before retiring, and between meals, for the purpose of diluting the urine of fasting.* From gravel to kidney-stone is but a single step. It is only neces- sary for some of the crystals to be detained for a time in the kidney and there form a nucleus, and we have at once kidney-stone. Such * For treatment, consult section on the preventive treatment of urinary calculus. GRAVEL AND KIDNEY- STONE— TREATMENT. 327 detentions of crystalline material in the kidney do occur. Attentive examination of sections of kidneys after death will sometimes reveal numerous yellowish or brown striae running from the papilla? toward the base of the pyramids. These depend upon the precipitation of amorphous urates in the straight kidney-tubules, and are usually caused by the pont-mortem cooling of the body, which diminishes the solu- bility of this ingredient and occasions its deposit. In still-born infants, and in children dying within forty-eight hours after birth, these striae are not infrequently found composed of uric acid. A similar precipi- tation of urates, uric acid, or oxalate of lime, may occur during life. If it be washed out by the urine accumulating above, we have some sand or amorphous dust in the voided fluid. But such concretions may become impacted and permanently lodged in the urinary tubules. Here they may cease to grow, or may increase in size in the kidney- substance, leading, perhaps, to the formation of cysts, by occlusion. Finally, these concretions, when washed down by the urine, may fail to escape from the pelvis of the kidney and become lodged in one of the calices or in the pelvis itself. A nucleus once existing in this situation becomes a foreign body, and goes on increasing in size by the deposition of new crystals or amorphous matter furnished by the urine. The precipitation may occur primarily in the infundibula or pelvis of the kidney. The number, size, and shape of these kidney-concre- tions vary infinitely. Several hundreds of them have been found in a single kidney after death. They vary in size from a pin-head to a nut, and may reach the weight of several ounces in old cases. They are usually smooth, oval in shape, or with facets from mutual friction, if several of them lie together ; or they may assume every variety of prolongation and arborization. They may be rough on the surface, especially if composed of oxalate of lime, or, if they excite pyelitis, their surfaces may become incrusted with triple and amorphous phos- phates. Blood-clot, portions of hydatid cysts, or little masses of con- crete pus, may serve as the nucleus for renal calculus, or act as the colloid in which the crystals form. Tlie symptoms of kidney-stones are variable. As long as they are small and do not excite inflammation, or become engaged in the orifice of the ureter, the patient may not be informed of their joresence by a single unnatural sensation, so that an auto^Dsy may first reveal an un- suspected kidney-stone. Occasionally they attain large size, and even destroy extensive portions of the kidney by pressure, without occasion- ing any symptom to attract the patient's attention. Again, symptoms of kidney-stone, with joaroxysms of pain, may exist for a time, and then cease, either because the stone has occluded the ureter and led to atrophy of the kidney, or because it has become encysted and has ceased to irritate the mucous membrane, or to oppose the escape of 328 DISEASES OF TUE KIDNEY. urine. Sooner or later, however, kidney-stones usually manifest their presence in one of three ways, either by setting up inflammation of the pelvis of the kidney (calculous pyelitis), by their passage into the blad- der (nephritic colic), or by remittent or persistent nephralgia. The aching i)ain in the small of the back, with all its aecoin]ianying symptoms, as detailed under the head of nei)hralgia, may depend on kidney-stone. This pain is usually made worse by pressure, but there is no distinctive character to it which enables the surgeon to decide positively whether the pain depends upon retained stone or other cause. When, however, the cause lies in kidney-stone, while the crystals in the urine remain the same, it may sometimes be noticed that the blood- disks, oval, round, and spindle-shaped epithelial cells and scattered pus-cells, Avhich the urine is pretty sure to contain, become increased in quantity after exercise, while they sensibly diminish, or perhaps entirely disappear, after rest in bed for a few days. The microscope in these cases ahvays shows the characteristic rounded epithelial cell from the kidney pelvis — a cell one half or one third larger in diameter than the ordinary pus-cell. Treatment. — This may be summed up in what has been said in connection with the subject of urinary calculus, under the head of solvent treatment ; and what is to be said after the section on nephritic colic concerning uephro-lithotomy. NEPHRITIC COLIC. When a kidney-stone engages in the orifice of a ureter and attempts to pass into the bladder, it gives rise, usually, to well-marked symptoms. Kidney-pains may sometimes be occasioned by the dislodgment of a calculus from an infundibulum into the pelvis of the kidriey, or from one portion of the pelvis into another. They become most severe, however, when the ureter is entered. The pain is marked by its paroxysmal character. It commences suddenly, perhaps seizing the patient while at a meal, or at any time when seemingly in the best of health, perhaps most frequently shortly after rising in the morning. It shoots down the ureter into the scrotum and to the end of the penis. The testicle of the affected side is often strongly retracted. Some- times in a severe paroxysm the whole scrotum and penis are drawn up into a hard knot, as it were, giving the patient the idea of squeezing, dragging, twisting, of these organs. The pain may also extend down the thigh on the affected side. There is usually an incessant desire to pass water, with sometimes almost entire suppression. What little urine is voided comes away high-colored, and in small quantities at a time, often tinged with blood and mixed with epithelium from the kid- ney. Pain attends urination, chiefly toward its close, running down to the end of the penis. During the paroxysms, especially if severe, faint- NEPHRITIC COLIC. 329 ness, nausea, and vomiting come on ; tlic skin is covered with a cold sweat ; the patient tosses restlessly about, seeking relief, but finding none.* In the intervals of the paroxysms there is a sense of soreness and discomfort, perhaps amounting to continued pain, or the relief may be more positive if the concretion be small. Usually, after a number of paroxysms, lasting from a few hours to many days, suddenly all pain ceases at once. The calculus has droj)ped into the bladder, and the suffering is over. Instead of this happy termination, the stone, after having engaged in the upper end of the ureter, may drop back into the pelvis of the kidney. Relief of the severe pain follows, but the patient's condition is an unenviable one, for perhaps the stone is too large to pass. Again, the paroxysms of j)ain may extend over a long series of days or weeks, coming on, perhaps, at a certain hour every day, or at longer intervals. In one (personal) case, the paroxysms came every Sunday, in the afternoon, for several weeks. This perio- dicity may be so marked as to give rise to the idea of some malarial ele- ment in the case. It is needless to add that quinine does not control the paroxysms. In this way the symptoms may linger along indefi- nitely, tiring out both patient and surgeon. A termination always to be feared is, impaction of the calculus in the ureter. In such cases, the patient will indicate some spot along the course of the ureter where he feels constant pain, increased by local pressure. The pain will be less severe than during the paroxysms, but it will be constant. A stone is most apt to halt near the outlet of the ureter into the bladder. If the ureter is blocked up almost entirely, the function of the kidney on that side will be interfered with. The ureter above the obstruction, and the pelvis of the kidney, will fill up with urine, subjecting the secreting structure of the kidney to pressure, and perhaps occasioning drowsiness, headache, with symptoms of mild ursemia. If the other kidney be diseased, or its ureter obstructed, these symptoms wall be by so much the more certain to ensue. If the other kidney and ureter be sound, enough urine may trickle past the stone to prevent these symptoms from being marked. In such cases the ureter above the stone gradually dilates, as does also the pelvis of the kidney, pressing upon and causing the gradual atrophy of the kidney-substance, so that after death the ureter may be found as large as the small intestine, containing perhaps several stones, while the kidney is replaced by a fibrous sac, more or less distended with puru- lent fluid, inflamed or ulcerated ; or perhaps by a mass of semi-solid pus (pyo-nephrosis), or hydro-nephrosis may come on. The effect upon the ureter at the point of impaction of the stone is to cause ulceration, with perhaps the growth of granulations, which bleed easily and may give rise to haematuria. Sometimes, after being lodged for a while, a * If the paroxysms be severe and long continued, more or less fever, -with great thirst, hot skin, and quick pulse, results. 330 DISEASES OF TUE KIDNEY. stone will finally pass, but the ulceration of the ureter left behind by it may go ou to the formation of stricture and the production of the same results as if the stone had remained. After a stone has finally entered the bladder, the symptoms cease. The constaiU desire to urinate is rarely a;:rg"ravated by the presence of the small foreign body, although sometimes irritability is increased. Anything which will pass the ureter will also pass the urethra, if the latter be not strictured. Such, indeed, is usually the case, and, after the cessation of the pains in an attack of kidney-colic, the urine should be carefully watched ; for the little calculus, which caused so much distress in getting into the bladder, may reach the outer world without giving any evidence of its passage. It is always a satisfac- tion to find the stone, both to confirm the diagnosis and to insure against the fear of subsequent stone in the bladder. Sometimes the stone is large enough to cause considerable pain in passing the urethra, or indeed it may become lodged there. Lastly and not uncommonly, the stone once in the bladder and the patient relieved, he recovers from his irritability and forgets his pains, thinking himself well. In this dangerous state of unconcern he lives perhaps for years, the stone constantly growing by new accretions, but not occasioning much dis- tress, until finally, from some new exciting cause (cold, exercise), or in the natural course of events, he suddenly breaks down with a sharp attack of acute cystitis, and upon search a stone of some size is found in the bladder. Diagnosis. — Kidney-colic is not liable to be mistaken. In severe nephralgia from highly acid urine or gravel, there may be similar paroxysms of pain, but the testicle is not so apt to be retracted, nor the paroxysm to be so severe. The passage of blood-clots or of hydatids through the ureter, as well as kidney-stone, occasions true colic. An inspection of what is passed by the urethra can alone clear up such cases, which are exceedingly rare. The patient's previous history or antecedents often furnish valuable presumjttive evidence. An indi- vidual having once passed a stone is always liable to have another one form, unless he regulates his life so as to avoid the causes of acid con- centrated urine. Absolute diagnosis may be made in some instances in the female by sounding the kidney through the ureter by Simon's method, but the manceuvre is difficult of execution, and is rarely at- tempted. The greatest difficulty of diagnosis lies in distinguishing the early stages of tubercular pyelitis from kidney-stone, but a close study of the history, a microscopic study of the cells from the kidney- pelvis, will often lead a close observer to the correct conclusion. Perhaps the one most constant symptom of kidney-stone is the pas- sage of blood more or less freely from the kidue}'', mingled with cells from the kidney-pelvis coming from the first and second epithelial layer — this sign coming on notably after jolting exercise. NEPHROLITHOTOMY. 33 1 Treatment. — During tlio i)aroxy.sms, prolonged immersion of the whole body in very hot water, or the local use of dry cups and hot fomentations, may produce relaxation. If the pain become unbear- able, ether by inhalation should be given, sufficient to moderate it. Kneading the course of the ureter is occasionally of service. A sud- den change of position may sometimes dislodge a stone after it has be- come engaged in the orifice of a ureter ; but, once engaged, it is bet- ter that it should pass. Opium or belladonna may be used by the rectum when the pains are protracted and the attack promises to be a long one. It is of the first importance to promote a free secretion of urine, so as to act upon the stone from behind by an abundance of liquid pressure. This is effected by warm drinks, half-drachm doses of acetate or citrate of potash every few hours, or half-ounce doses of infusion of digitalis, until free diuresis is produced. The use of diuretic mineral waters is not of much service during an at- tack of kidney-colic, but the free use of light beer is sometimes very efficacious. These means should be persisted in intelligently, if the stone become impacted in the ureter. If the stone fail to reach the bladder, being retained in the kidney or impacted in the ureter, or in any case of kidney-stone where the diagnosis is quite clear, the proper treatment is nephrolithotomy. After one attack of nephritic colic, the patient must be instructed in the proper course of life to follow in order to avoid the formation of another stone. The diet should be low and largely vegetable, and the use of all alcoholic stimulants interdicted, especially the use of new fermented liquors. Plentiful out-door exercise should be taken, and the reaction of the urine be watched. Vichy water or some mild alka- line diuretic should be adopted as an habitual beverage to keep the urine abundant and diluted. The patient should also acquire a habit (Roberts) of taking a full draught of water between meals, and on re- tiring, so as to dilute the urine of fasting, which is normally concen- trated and over-acid. The alkaline tide after taking food insures against the formation of stone during those periods. NEPHROLITHOTOMY. This operation owes much of its present repute to the successful efforts of Henry Morris, who states that at the date of his treatise upon the " Surgical Diseases of the Kidney " * it had been performed twenty-one times with two deaths : one from an overdose of morphia, one from suppression of urine and disease in the other kidney. These cases are exclusive of those in which the kidney was the seat of abscess or formed a tumor in the side. The operation was first performed by Morris in 1880. He advises * Op. cit., pages 471 and 525. 332 DISEASES OF THE KIDNEY. an incision four and a half inches lonir. parallel with the last rib and f hreo quarters of an inch below it. The outer edge of the quadratus Inmborum may be incised if the muscle is in the way at the bottom of the wound. After all haemorrliage is arrested, the operator tears through the perirenal fat witli two pairs of forceps. Tiiis fat be- comes soft as the kidney is approached, unless there has been peri- renal inflammation, in which case it may be dense and tough. AVhen the kidney is reached, its w'hole posterior surface and the pelvis are explored with the ])ulp of the finger, feeling for any inequal- ity of surface or extra hardness or resistance at any spot. The ab- dominal wall must be supported during this manipulation, to keep the kidney from being pushed forward by the exploring finger. If nothing is found indicating the presence of stone, the kidney- substance should be punctured in numerous places, and the several calices of the kidney similarly explored — all this in a systematic man- ner. If this manoeuvre fails to detect stone, the fingers are passed around the outer edge of the kidney, and the front surface explored by palpation, and the kidney may be squeezed between the thumb and finger. In spite of all this a stone may escape detection. Morris says that he removed by nephrectomy a kidney having imbedded in it a calculus as large as a marble, which he was unable to localize either before the kidney was removed or after it was out by pressing it upon the table or between the thumb and finger. Morris advises that, if no stone be found, the kidney should not be removed until each of the calices has been opened and explored. "When the stone is located, the overlying kidney-substance should be incised with a straight bistoury and the stone removed with finger or forceps. The kidney-substance should be incised in preference to the pelvis of the organ, if the stone can be conveniently reached through such an incision, because the wound heals more promj)tly. If the stone be large or branched, it is better to break it and remove the pieces separately. After-treatment. — A drainage-tube should be left in and the whole wound closed by sutures. Urine will cease to flow through the wound in a period varying from a few days to a few weeks. Anti- septic dressings are applied, the drainage-tube running through them into some boracic cotton or other absorbent dressing. Under the whole a large pad of German moss peat may be placed to absorb the urine. The dressings must be changed often. Complications like hgemorrhage, cellulitis, abscess, are met by ap- propriate surgical means. Fistula may follow, but is not common. Morris mentions one case of hernia (easily reducible) following the operation. PYELITIS— CAUSES. 333 PYELITIS, PYONEPHROSIS, AND PERINEPHRITIC ABSCESS. Pyelitis is an inflammation of the pelvis and calices of the kid- ney. Like most other inflammations of the urinary passages, it is usually encountered in practice in the chronic form, undergoing per- haps from time to time acute exacerbations. The pathological ap- pearances in the acute form are, a uniform redness of the mucous membrane, frequently dotted in a punctate manner with little eccliy- motic spots, or perhaps with free blood on the surface of the mem- brane. There may be false membranes attached to the surface of the pelvis or blocking up a ureter, otherwise the fluid contained in the kidney is a mixture of urine, pus, blood, with more or less epithelium. In chronic pyelitis the membrane is thickened, tough, pale, bluish- gray, crossed by branching vessels. There may be spots of ulceration. Eayer describes vesicles of the size of a pin's head studding the mu- cous membrane in many chronic cases. Rarely the ulcers are covered by deposits of triple phosphates. Sometimes the surface of the mem- brane is distinctly granular. There are found, perhaps, within the pelvis of the kidney, cancerous or cheesy tubercular deposits, hydatids or other entozoa, kidney-stones incrusted or not with phosi3hates, etc. Where there has been obstruction of the ureter, the condition known as pyonephrosis is liable to be encountered after death, namely atrophy, more or less complete, of the secreting or tubular portions of the kidney with dilatation of the pelvis and calices, the kidney being, perhaps, replaced by a large pouched sac filled with semi-solid pus or pus and blood, with precipitated phosphates and urates. The septa between the pouches may be calcified or imperfectly ossified. Some- times the pus is absolutely solid, and seems to be stratified, so that it can be removed in layers ; often it is cheesy, with soft spots. Some- times the pus collected in the kidney pelvis has ulcerated its way out, giving rise to perinephritic abscess. It may point externally, leaving behind a fistulous tract which usually remains permanent. Occasion- ally after pyelitis the kidney atrophies instead of becoming pyone- phrotic. Pyelitis is more often double than single. If it depend upon a cause acting on one side only (impacted stone), the other kidney may be healthy, although enlarged by conservative hypertrophy. Pyelitis is usually kept up by some cause, and the problem for treatment is not so much to remove the inflammation from the pelvis of the kidney as it is to remove the cause which occasions it. Causes. — Pyelitis is not an idiopathic disease. Of all the numerous causes which may produce it, three are in constant action in the com- munity, and furnish the bulk of the cases. These are — 1. Chronic prolonged obstruction to the free escape of urine from the bladder, and chronic inflammation of the latter organ, or acute inflammation, notably gonorrhoeal. 334 DISEASES OF THE KIDNEY. '2. The retention of kidnoN'-stone, or, more nircl}', its impaction in a ureter. 3. Tubercular disease, neoplasms, and other local irritants. (1) The first of these causes is constantly at work in stricture and prostatic hyper troi)hy. Here the bladder becomes inllamed, the dam- ming back of the urine is felt by the kidneys, and their mucous mem- branes are kej)t constantly more or less congested, until finall}', from some provocation, such as cold or retention, or the use of instruments in the bladder, an acuter phase of inflammation is set up in the latter organ, which is very prone to travel rapidly up the ureters and locate itself permanently in a chronic form upon the pelves of the kidneys. Here it remains in a subacute state, suffering occasional exacerbations of acuteuess, and liable to become complicated by inflammation of the secreting structure of the kidue}', attended by uraemic symj^toms and speedy death. Pyelitis under these circumstances is mild in charac- ter, does not occasion any severe symptoms, and goes, for the most part, unnoticed by i)aticnt and surgeon. Its presence may always be inferred in old cases of obstructive j)rostatic and urethral disease, and it must be remembered that in these diseases danger to life is more to be apprehended from this than from any other quarter. In several cases of acute p^'elitis due to the extension of gonor- rhceal cystitis upward, I have noticed a remarkable absence of fever, pain, or any symptoms directly pointing toward the kidney ; on the contrary, the cases have been almost always treated as if the bladder were alone involved. I can not say that this condition is uniform, but it is not uncommon — a mention of it is enough to put the surgeon on his guard. (2) One of the most frequent causes of such pyelitis as manifests itself during life by positive symptoms referable to the kidney, is stone retained in the kidney. By the same mechanism as in the bladder will stone in the kidney sooner or later give rise to inflammation of the mucous membrane upon which it rests. Stone impacted in a ure- ter inevitably leads to the same result by distention of the pelvis of the kidney with retained urine, and by the secondary decomposition of the fluid, the mechanism being similar to that causing cystitis with atony, from prolonged retention of urine. Hence anything which will cause prolonged distention of the pelvis of the kidney, retention of urine, blood, entozoa, false membrane, etc., blocking up a ureter, is able to occasion pyelitis. Pressure of the pregnant uterus in the female probably acts in the same way, in inducing that fatal form of pyelitis attending lying-in women, even where there is no pya?mia. (3) Besides the above causes, a host of others, may be enumerated as more rare. Thus, the irritating action upon the kidneys of turpen- tine, of constantly over-concentrated, over-acid urine ; the existence of chronic forms of Bright's disease ; the deposit of cancerous or tu- PYELITIS— SYMPTOMS. 335 bercular matter in the walls of the kidney-pelvis ; foreign bodies other than stone ; worms, hydatids, clots, etc. Pyelitis also attends certain diseases as a complication at times, the eruptive fevers, typhus, cliolera, etc., and is found not infrequently with pytemia and carbuncle. Symptom!^. — Pyelitis is usually attended by pain in the back, of the same character as that described in the section on nepliralgia. This pain is made worse by pressure, and is usually confined to the affected side, although there may be pain over both kidneys when only one is diseased. When the affection depends on kidney-stone, usually there have been some attacks of nephritic colic more or less marked. Occasionally, however, the disease comes on in an insidi- ous manner, with little or no pain in the back, what symptoms there are being referred to the bladder. Sometimes paroxysms of pain, re- sembling nephritic colic, are experienced where there is and has been no stone. Early in the disease the urine will usually be found to con- tain blood-disks, a little excess of mucus, with many small, round, oval, spindle-shaped, and irregular epithelial cells, such as abound in the pelvis of the kidney. There is a trace of albumen depending on the blood, and the urine reacts acid. As the disease advances the epithelial scales are replaced by pus-cells, not in clusters, but evenly distributed through the urine, giving it a uniform, turbid appearance when voided. The amount of pus steadily increases in quantity, the urine usually remaining strongly acid ; on standing, this pus settles down into a dense, greenish, oily-looking deposit. Violent exercise increases the nephralgia and the amount of pus in the urine. Often the pus diminishes greatly in quantity for some days, and suddenly reappears in excess. This phenomenon is especially noticeable when the kidney has become sacculated. The pus retained in a sacculus accumulates there, until finally it bursts its barriers and reappears in quantity for a day or two, when it will again cease to flow abundantly, until the sacculus has had time to refill. The pain in the flank is often greater when the pus is not flowing, and any swelling existing there is apt to become more prominent. These variations in the amount of pus are less marked when both kidneys are affected. In rare cases there may be no discharge of pus whatever, as when the ureter is absolutely occluded. Chills of varying duration and intensity are often present, espe- cially if the kidney is sacculated and contains large amounts of pus. These rigors may assume the quotidian or tertian type, and recur with great regularity, especially in the evening. One symptom of pyelitis is very liable to lead to error of diagnosis, especially if the pain in the back has not been prominent and no tumor exists in the flank. This symptom is frequent micturition. This irritability is due to reflex action, and by it the bladder is stimu- lated to repeated contractions, and many a case of pyelitis has been 336 DISEASES OF THE KIDNEY. treated as chronic cystitis, powerful injections being thrown into the bhidder in the vain hope of controlling the formation of \n\s, which is supposed to have its origin there. The bowels usually act irregu- larly, diarrhani and constipation alternating with eacli other, due to inflammatory adhesions between the dilated kidney and tlie colon, or to the more mechanical jiressure of a distended pyone])hrotic kidney upon the large intestine passing over it. "When the kidney becomes dilated and sacculated by the pressure of accumulated pus, a tumor is formed, wliich is tender on pressure, sometimes affording a feel of deep fluctuation, more or less perceptible to sight and touch, accord- ing to its size, sometimes becoming ap]u-eciably smaller after a free discharge of pus in the urine. The position usually occupied by such a tumor is in the flank between the last ribs and crest of the ilium. On the right side the transverse colon may separate the tumor from the liver, but this diagnostic sign may be absent, from inflammatory ad- hesions having taken place between the coverings of the two glands. The tumor formed by a pyonephrotic kidney is occasionally large enough to extend across the middle line of the abdomen. As the disease advances the patient becomes cachectic, pale, and de- bilitated. Hectic fever may set in and close the scene, the patient being worn out by constant suppuration, or poisoned by the urea, which can not lind an exit through his altered kidneys. Ulceration of the pelris of the kidney may occur, especially if it contain stone, and, through an opening thus made, pus and urine may infiltrate the tissues, forming pcrincphritic abscess. This points in the back or under Poupart's ligament (simulating psoas abscess), or opens into the bladder or pleural cavity, into the lung, or, more commonly, into the intestine — rarely into the peritoneal cavity. A distended, sacculated, jiyonephrotic kidney in the same way may contract inflammatory adhesions to all the surrounding tissues, and finally break and burrow in any of the above directions. The tumor subsides rapidly Avhen the jient-up matter has found an outlet, but, unless the calculus or other offending body escapes, or is extracted through the opening, a permanent fistula is pretty sure to remain. When such an abscess breaks into the bladder, bowel, or lungs, the subsidence of the tumor is attended by a copious discharge of pus at the anus, urethra, or mouth. After the abscess has discharged itself and remained fistulous for a time, in some favorable cases, it may gradually shrivel and dry up, owing to total atrophy of the kidney, and in such cases, if the other kidney be healthy, the patient recovers completely. Perinepliritic abscess does not necessarily depend for its origin upon antecedent kidney-disease. It may come on as the result of fatigue and a straining exertion of the muscles about the kidney-re- gion, from cold or other cause. Three exceedingly interesting exam- ples of perinephritic abscess, not caused by or attended with any PYELITIS— SYMPTOMS. 337 kidney-disease, are reported by Dr. H. J. Bowditch^ in a paper read before the Boston Society for Medical Observations, May 4, 1808. Tn each of these there was a distinct tumor in the right loin, witii the usual train of symptoms, chills, hectic, etc. ; in each there was pul- monary and pleuritic complication, with discharge of pus by the mouth, the matter having made its way up along the sheath of the psoas muscle into the pleural cavity ; and in each there was marked relief of all symptoms and ultimate recovery after a timely opening into the tumor, which was made in two of the cases before fluctuation could be distinctly felt. In two of the cases the kidney was recog- nized by the exploring finger free in the cavity of the abscess, but neither microscopic nor chemical test applied to the urine revealed the presence of kidney-disease. These cases demonstrate the advan- tage of early opening for perinephritic abscess. Generally perinephritic abscess is due to kidney-disease primarily. This may be calculous pyelitis with obstruction, or, perhaps more often, the suppuration of a tubercular kidney. The collection of pus may be enormous. Heustis,* of Mobile, drew from a suppurating kidney by an incision in the back three pints of pus, and his patient made a good recovery. I have operated several times, the relief being instantaneous and more or less complete. G. Nieden's f paper is a valuable one, tabulating one hundred and sixty-six cases. V. P. Gib- ney J has contributed to our knowledge of the affection as occurring in children. Instead of breaking externally, a pyonephrotic kidney, after its secreting substance has become atrophied, may consolidate into a hard, cheesy mass, and cease to give trouble. One perfectly good kidney is sufficient for life. Unfortunately, the disease is most often double. Prognosis. — The prognosis of pyelitis depends upon its cause. The milder cases, occurring with stricture or prostatic disease, cease to be troublesome after successful treatment of the latter. The forms occurring with fevers, pleurisy, and zymotic diseases often get well quickly if the primary disease spares the patient. In pyeemia and carbuncle the complication aggravates the prognosis. Depending upon local cancer or tubercle, the affection does not get well. With hydatids or calculus it is severe, but not necessarily fatal. Double pyelitis is always grave. Where there is pyonephrosis the chances of recovery are not great, but with one sound kidney there is always hope. Autopsies have revealed wasted, withered sacs, perhaps clasp- ing a stone, or a mass of hard, concrete pus, whose existence had never been suspected during life. Discharge of the pus by other than * "Am. Journ. Med. Sci.," Oct., 18Y5, p. 457. t "Deutsch. Archiv f. klin. Med.," Nov., 18'78, p. 451. X "Am. Journ. of Obstetrics," vol. ix. No. 1, April, ISTG, and "Chicago Medical Jo'.irnal and Examiner," June, 1880. 22 338 DISEASES OF THE KIDNEY. the natural channel is often speedily fatal, excej^t in favorable cases where the opening occurs tlirough the loins. Treatment. — When pyelitis depends upon bladder, prostatic, or urethral disease, its treatment is identical with that of its cause. The same is true of cancer, tubercle, etc. In fever, zymotic, or scorbutic disease, the main malady must be treated, care being exercised to pre- vent the urine from becoming too acid and concentrated. Where it is attended with considerable hcemorrhage, tannin, gallic acid, acetate of lead, opium, ergot, or other styptics, may be advantageously tried, and borncic acid, the bcnzoates, or nai)htharine, if tlie urine is offen- sive and the stomach will tolerate the drugs. During an acute attack of pyelitis, with great pain, high fever, frequent urination of bloody purulent matter, wet cups over the kid- ney, hot baths, hot local fomentations, warm diluent drinks, and opium to allay pain and spasms, are the main features of treatment. In chronic cases, however, such as are not infrequently met with in practice, where there is reason to suspect kidney-stone, and where con- stant suppuration is wearing out the patient, the surgeon's duty lies in puttiug him into the best possible hygienic conditions, giving him the advantage of rest, country air, and a sustaining diet, with sucli tonics as iron, quinine, and cod-liver oil. Roberts speaks highly of large doses of muriated tincture of iron. Alkaline diluents will some- times diminish the amount of pus, by making the urine less concen- trated. Wine is often serviceable, and in some cases the mineral acids improve the digestion, increase the strength, and better the condition of the urine. Tlie vegetable astringents, alum, and the terebinthinates, are occasionally useful as stimulants to the mucous membrane in chronic cases. If there is reason to suspect kidney-stone, palliation must be de- pended upon unless the patient will submit to nephrolithotomy, an operation growing in favor and especially suitable for this class of cases. The solvent treatment can not be relied upon. At best it may do some good in cases of acid kidney-stone where there is no pyelitis. But, when the pelvis of the kidney is in a catarrhal sta<"e from sui^puration, the stone becomes covered externally with a layer of phosphates which at once protects it from any possible solvent action of an alkaline diuretic. When there is pyonephrosis, with sacculation of the kidney and a tumor which can be felt in the flank, two courses of treatment are open : 1. The general treatment by tonics, astringents, and hygiene, keeping up the patient's strength in every way, and encouraging him to wait for final atrophy of the kidney and desiccation of the pus, using all the means suggested above for chronic pyelitis with contin- ued suppuration. HYDRONEPHROSIS. 339 2. The operation of opening, or even removing the kidney. The former course is hardly justifiable at the present day. Unless the general condition of the patient is such as wholly to forbid any operation, an incision in the loin is the proper treatment for pus re- tained in the kidney or lying about it. The risk of the operation is moderate, far less than that of leaving the pus to burrow its own way toward the surface. Nephrotomy is the treatment after the aspirat- ing needle finds pus. There is no fear of wounding the peritoneum if the back or flank be perforated, as the kidney is an extra-peritoneal organ. After the matter has been evacuated, search may be made in the cavity with the cannula for any calculus which may occupy it. If none be found it is not possible to state that the disease is not of calculous origin ; nor, if calculous matter be found, can the converse of this proposition be affirmed with absolute certainty. In Dr. Pe- ters's case * the abscess was punctured with the aspirator, pus evacu- ated, and finally, on withdrawing the instrument, a fragment of stone was found impacted in its extremity ; yet, after the kidney had been extracted, the case proved to be one not of calculous pyelitis, but of inflammatory (cheesy) pyelonephritis. The patient had pseudo- tubercular epididymitis, with fistula, and pseudo-tubercle of both vasa deferentia and vesiculse seminales. As a rule, however, if stony matter can be felt, calculous pyelitis may be safely diagnosticated, and an operation rationally undertaken for its relief. If no stone be discov- ered, the abscess cavity should be thoroughly drained and the patient allowed to rally. Subsequently nephrectomy may be easily performed if thought desirable by shelling out the shriveled remains of the kid- ney. This double operation is considered safer by modern surgeons than primary nephrectomy for (strumous, as it is sometimes called) suppurating kidney. Extra-renal abscess should always be opened early, even if no at- tempt be made to perforate the pelvis of the kidney. HYDROITEPHROSIS. When there exists an obstruction of any sort in the ureter, urine may accumulate and gradually distend the pelvis of the kidney, and lead to more or less atrophy of kidney-substance. This is hydrone- phrosis. It may be caused by obstruction to the free outflow of urine in the bladder or urethra, but obstruction in the ureter is greatly the more common and the more efficient cause. George A. Staples, of Dubuque, Iowa, has recently made an excellent study of this condi- tion, and compiled tables of operations upon hydroneiDhrotic kidneys, with their results. The hydronephrotic kidney sometimes reaches an * "New York Medical Journal," November, 1872. 340 DISEASES OF THE KIDNEY. enormous size, simulating ascites or ovarian cyst, with wliicli maladies the affection has boon confounded by good observers. Koborts * quotes a case reported by (J lass, in which thirty gallons of light coffee-colored limpid fluid were taken after death from the hydronei^hrotic kidney of a young woman. The motlier stated that her child had been born dropsical. Congenital hydrono})hrosis has been often observed, and has been reported as the occasion of dystocia, one of the causes being imperforate urethra. Sometimes the cyst is smaller than tlie healthy kidney (atrophy). Absorption of the secreting structure is usually partial, but may be complete. One or both kidneys may be affected, and, what is remark- able, both kidneys may be largely dilated, and display, on autopsy, not a trace of true renal structure, and yet the urine jn-esent nothing abnormal, and the patient live in this condition for a variable length of time. In such cases the urine is usually of low specific gravity and very abundant, and death may occur at any time with urajmic symptoms. Infants with congenital double hydronephrosis do not live (Kayer), but, where the affection comes on gradually, life is possi- ble to a far greater limit than would seem probable a priori. It is pre- sumed that the skin and bowels do the work vicariously in these cases for the kidneys. The fluid of hydronephrosis is generally pale, odor- less, limpid, showing no albumen on the application of heat and acid, and leaving very little residue on evaporation. The specific gravity is generally very low, as is usually the case in urine secreted under pressure. The amount of urea is diminished. A careful examination will in most cases detect the ordinary ingredients of normal very dilute urine. Sometimes the cysts contain a colloidal substance. Cholesterine has been found (Coghill). Causes. — Hydronephrosis is often congenital, depending upon an impervious ureter, or some valvular obstruction of the same. Imper- vious (congenital) urethra may be the cause ; later in life, calculus impacted in the ureter, stricture of the ureter from previous ulcera- tion, pelvic tumors, ovarian cysts, or other body (gravid uterus) com- pressing the ureter. Sometimes no mechanical cause can be assigned, except a valvular fold of mucous membrane, or great obliquity of en- trance oi ureter into pelvis of kidney, acting like a valve. Morbid growths within the bladdei* may lead to hydronephrosis, or cancer of the pelvic organs, uterus, vagina, and rectum. In short, any obstruc- tive cause may lead to it. Morris narrates a number of cases where an unusual cause of ol)struction existed — such as local injury and the contraction resulting therefrom, abscess of the fundus of the bladder (Ebstein), a fibrous band across the ureter (Simpson), enlarged lym- phatic glands (Rayer), frequency of urination due to tight prepuce (James), compression of the ureter by retained menstrual blood in one * "Journal of the American Medical Association," April 12 and 19, 1884. HYDRONEPHROSIS— SYMPTOMS. 341 half of a bifid uterus (Lagrave), division of renal artery, one branch of which compressed the ureter (Boogard). (hurse. — The obstacle (possibly calculus) perhaps becomes dis- lodged in time, and the cyst evacuated. The latter may not refill ; its sac may shrivel up. Finally, ursemic symptoms may carry off the patient, but many die of intercurrent disorders. Spontaneous rupture of the cyst very rarely occurs. Spencer Wells* punctured a dis- tended hydronephrotic kidney and employed drainage. After a time two calculi passed into the bladder, and the hydronephrosis got well. John W. Taylor* reports a case of acute hydronephrosis of the left kidney in which rupture of the sac took place, the urine extravasating into the peritoneal cavity. The abdomen was opened, the perito- naeum sponged out and cleaned, the margins of the sac sewed into the abdominal wound, and the patient recovered. Symptoms. — The symptoms of hydronephrosis depend mainly upon the size acquired by the cyst, and the compression exerted by it upon the surrounding organs. If the tumor be small and the other kidney healthy, no symptom during life may lead to the suspicion of disease, and old age may be attained. When the tumor reaches con- siderable size, it usually presents itself in the flank, extending back- ward into the lumbar region, and forward, upward, and downward, to a greater or less extent, into the abdomen. The colon usually lies in front, the small intestines being pushed to the opposite side. The tumor is flat on percussion, feels soft, perhaps lobulated, and is evi- dently fluctuating. Sometimes the tumor suddenly disappears coinci- dently with a free discharge of urine. This syipiptom, when present, is of the highest diagnostic value. Pain is usually absent, unless there be at the same time impacted calculus in the ureter. The action of the bowels may be irregular, dysenteric or diarrhoeal, from compression of the large intestine. The urine presents no characters pathognomonic of the disease. It may be absolutely normal, and is not necessarily increased in quantity. The affection occurs about twice as frequently in the female as in the male (Morris). There may be pain in the back, thirst, irritable bladder, partial anuria, per- hai^s intermittent, abdominal pain, all symptoms due to obstruction and occurring sometimes without obvious tumor. Uraemia may occur if the affection is bilateral — constipation, vomiting, fever, even coma. Pain is sometimes excruciating ; sometimes there is no pain. The diagnosis in man is with ascites, hydatid cysts, and pyone- phrosis. In hydi-onephrosis the colon lies in front of the tumor ; there is no resonant percussion in the lumbar region of the affected side, but it exists on the other side, unless the disease be double. No change in the patient's position affects the sounds. In ascites, * " British Medical Journal," April 29, 1876. f " Lancet," October 4, ISS-i, p. 589. 342 DISEASES OF THE KIDNEY. tlie Innibar dullness is double, but the sounds change with the posi- tion of the patient. In hydatid cyst there is escape of hydatid vesi- cles with the urine, or the presence of hydatid fremitus. Hydatid cyst is less often double than hydroncphro;;is. In pyonephrosis there is or has been pus in the urine ; the symptoms are more severe, pain is prominent, rigors are common. A ditlorcutial diagnosis with ovarian cysts seems sometimes to be impossible without exploratory incision. Treat nun f. — The disease, not being as a rule very dangerous to life, does not call for officious surgery. If it be presumed that there is a calculus impacted in the ureter, precautions should be taken to prevent a similar accident on the opposite side. Koberts believes that be was successful in one case in overcoming the obstruction jicrmanently by manipulation. A little girl of eight, iinder his care, had a soft, fluctu- ating tumor on the left side of the abdomen, about the size of a child's head, which was believed to be hydronephrosis. This was carefully manipulated in every direction by the aid of a lubricating ointment on alternate mornings. After the third manipulation a large quantity of urine Avas suddenly discharged through the natural channels, the tumor disappeared, and did not return while the patient was under ob- servation. Broadbent had a similar case and Thurman another (Mor- ris). But manipulation may be impossible on account of pain and dangerous, for a thin- walled cyst might be ruptured. If the tumor becomes troublesome by its size, interferes with the intestinal func- tions, or shows signs of inflaming, aspiration is a proper treatment. The needle should be entered in front of the eleventh intercostal space on the left side, unless there is some thin or bulging point elsewhere, which manifestly invites puncture. On the right side the point of election is ''half way between the last rib and the crest of the jlium, between two inches and two inches and a half behind the anterior su- perior spine of the ilium " (Morris). Aspiration sometimes efifects cure by relieving pressure or letting a bent ureter unfold. Croft tapped a case (occurring after a traumatism) eight times in three months, getting several pints each time, and a cure followed, Morris thinks the obstruction in this case was due to clot. liecovery after single puncture is not common, but has been noted. Injection of irritating substances has been resorted to when simple puncture has failed. Morris condemns the method, and says that he knows of no case m which the practice has been successful ; yet Woelfler* has re- corded one case where Billroth punc':ured an immense hydronephrotic tumor in a boy of thirteen, drawing off 1,900 c. c, and tapping through the abdomen as for ascites. Urinary constituents were dis- covered in the fluid. The tumor recurred, and seven weeks afterward was again punctured, and twenty-four grammes of Austrian tincture * "Wiener med. Wochcnscbrift," No. 10, 1876, p. 366. CYSTS. 343 of iodine injected with an equal quantity of water and allowed to re- main in five minutes, then partly withdrawn. The injection was re- peated in three months, and the patient is recorded as dismissed cured four months later. The sac may inflame and suppurate after tapping. In such case, or should aspiration fail to cure, the next ai:)propriate expedient is nephrotomy, stitching the edges of the incised cyst-wall into the loin. The lumbar incision for nephrotomy is made high and carried well forward, the cyst exposed and punctured, the puncture enlarged with a bistoury, and the edges of the incision sewed into the edges of the wound in the loin. A large rubber tube is to be retained in the cyst, and daily antiseptic irrigation practiced. Staples, in his excellent monograph, records seventeen cases successfully treated by this meth- od, although permanent fistula remained in more than half the cases. When fistula remains, its annoyance may be moderated by-wearing a large rubber tube in the fistula, which expands below into a light rub- ber bag, attached to the abdomen by a belt. After nephrotomy, an attempt should be made to find and remove impacted calculus. Nephrectomy is only called for when the sac after drainage suppu- rates offensively. The operation in such case should be lumbar. KIDNEY-CYSTS. Several forms of cysts are found in the kidneys. Simple cysts by occlusion in the healthy, or more often the granular kidney, rarely large enough to occasion aj)preciable symptoms during life. Complete cystic degeneration of the kidneys, congenital, and oc- curring very rarely in adult life, almost invariably affecting both kid- neys, and necessarily fatal.* Of the entozoa found in the kidney, hydatid cysts only come under the surgeon's notice. They are not as common as hydatids of the liver or lungs, but are more frequent than hydatids of other parts of the body. Space will not allow a description here of the history and hab- its of this interesting entozoon. Both kidneys are rarely involved in hydatid disease ; the left seems to suffer more frequently than the right. The cyst may be primarily lodged in any portion of the kidney-substance, which it gradually de- stroys by pressure as it grows. It forms a rounded, elastic tumor, and may reach the size of an adult head. The cyst tends to point inward, and burst into the pelvis of the kidney, but may grow to a large size * In a practical work covering as mnch ground as does the present, it is impossible to more than indicate the existence of this rare form of disease, although it naturally falls within the domain of surgery. It is very rarely encountered, and totally unamena- ble to treatment. For its study the reader is referred to text-books on renal disease and pathological works, in which it forms interesting chapters. 344 DISEASES OF THE KIDNEY. without so doing, and eventually discharge into the intestines or the lungs. Kidney hydatid cysts have not been known to discharge into the peritoneal cavity, or externally through the integument. The cyst may inilame, or excite abscess in its vicinity ; the echinococci may die, and the cyst shrink and be transformed into a calcareous mass, either before or after bursting. The cyst may be ruptured by external violence. Sytnpfom-'i. — Until the C3'st grows large enough to be felt or seen in the flank, there are usually no symptoms. Febrile attacks, with rigors and pain, are occasioned, if the cyst or its neighborhood inilame or suppurate. The only pathognomonic symptoms are the hydatid fremitus on palpation, and the appearance of the characteristic vesicles, laminated shreds, or booklets, in the urine. The hydatid fremitus is rarely perceived. It may sometimes be obtained by grasping the tu- mor with one hand and tapping the fingers sharply with the other hand ; or by applying a stethoscope over the tumor while the latter is tapped smartly with the fingers. The sensation is a sort of a creaking vibration or thrill communicated to the fingers, and has been com- pared to the vibrations of a repeater watch held in the hand. The discharge of characteristic vesicles by the urethra, when a cyst has burst, is usually spread over a considerable length of time, the dis- charges occurring in paroxysms, occasionally with an interval of years ; if there is only one small cyst, it may empty itself in one paroxysm. These paroxysms usually begin with pain in the back, followed by nephritic colic as the vesicles pass into the bladder, and perhaps retention of urine and considerable pain as the larger vesi- cles traverse the urethra. The urine usually, at such times, contains blood and pus, and there are symptoms of mild cystitis of the neck of the bladder. The tumor in the flank may become smaller after such an attack, from a discharge of some of its contents, or increase in size by distention with urine, if a vesicle be retained for a time in the ure- ter. The disease is most liable to be confounded with hydronephro- sis, in case no vesicles appear in the urine. Prognosis. — The natural tendency of the disease is to get well by a discharge of the echinococci through tlie ureter. The mortality is lower than for hydatids of any other internal organ except the uterus. Where the cysts discharge by other routes, or become inflamed and suppurate, a fatal result is to be feared, although even in such cases recovery is possible. Treatment. — Medicines are of no avail before the cyst has opened into the pelvis of the kidney. Niter, coffee, white wine, spirits, and, in general, diuretics, have sometimes been found to increase the quan- tity of hydatids appearing in the urine after the opening of a cyst. If the cyst attain a large size, and do not burst into the pelvis of the kidney, the proper surgical treatment is lumbar nephrotomy, the sides TUBERCLE. 345 of the cyst being stitched into the incision. If the tumor jirojects prominently in front, or is adherent there, an abdominal incision may be preferable. TUBERCLE OP THE KIDNEY. This disease occurs in two forms — (1) miliary tubercle and (2) tubercular pyelonephritis. 1. Miliary tubercle occurs as small granulations of true tubercle deposited rapidly in acute general tuberculosis and occupying the secreting structure and pyramids. The little nodules are deposited mainly along the course of the smaller vessels. This species is only a part of acute miliary tuberculosis. It rarely furnishes local symp- toms, and is usually discovered after death. As a kidney disease it is unimportant. It is generally bilateral, and occurs chiefly in chil- dren under ten years of age. The testicle, seminal vesicle, and pros- tate may be involved. 2. Tuhercular Pyelonephritis. — This is the scrofulous kidney, the form of kidney tuberculosis which may be diagnosticated during life. When involving only one kidney it may remain localized for years, finally resulting in atrophy of the kidney, which remains as a larger or smaller encapsulated cheesy or fibrous mass, or it may go on to make the large, cheesy, tubercular kidney full of inspissated pus, pos- sibly attended by perinephritic abscess, opening spontaneously (if al- lowed) in the flank, groin, or intestine. Scrofulous kidney generally commences by a deposit of gray tuber- cular matter upon the papillae, thence passing to the mucous mem- brane of the calices. The gray nodules first infiltrate a portion of tissue, then undergo a cheesy degeneration, and break down into tu- bercular ulcers, which advance inwardly, destroying everything in their course. The pelvis and ureter participate in the disease, perhaps pri- marily, but certainly in the course of time. The disease is compara- tively rare, and not infrequently coincides with the deposit of tubercle elsewhere, especially in some other portion of the genito-urinary appa- ratus (prostate, epididymes, seminal vesicles). All ages are liable to it, but it is most common in early manhood. It comes on usually in an insidious manner. The little tubercular masses unite to form large patches. Kidney-substance is absorbed, to be replaced by the lowly vitalized tubercular matter. After- a while the masses soften centrally, break down into a puriform matter, and leave ragged ulcers in the kidney-substance, or in the walls of the pelvis. Earely these ulcers or abscesses heal, leaving a depressed cicatrix. Some ulcerations may cicatrize, while others progress. The fibrous structures of the ureters and pelves of the kidneys become greatly thickened and indurated by chronic inflammation, so that the caliber of the ureter may be nearly or, quite obliterated. The ureter so constricted mav become blocked 346 DISEASES OF THE KIDNEY. up by some softened tubercular matter or tissue debris, coming down fi'om above, in which case pyonephrosis would in all probability result, with symptoms of nephritic colic at the beginning. A stone formed in the kidney may be unable to pass the contracted ureter, or, from decomposition of the urine retained in the kidney in contact with the tubercular ulcerations, phosphatic stone may be formed there. Under any of these contingencies the symptoms would resemble those of chronic calculous pyelitis. The disease is more frequently double than single. Sometimes, however, it is found on one side only, and then it not unusually happens that the testicle or epididymis of the same side also suffers. There is an undoubted connection in the male sex between tuberculization of the genital organs and that of the kidney. The attack of the former usually precedes that of the latter, and seems to hold a certain causal relation to it. Instead of remaining local, the malady may involve other organs. General tuberculosis may exist with it. Symptoms. — The symjitoms are identical with, and in fact are, those of chronic pyelitis, witii or without severe nephralgia or nephritic colic. It is rare that much or any pain is felt at first, the disease most often coming on insidiously. There are exceptions to this rule, when, for instance, a large, acute deposit is attended by great local pain, fever, bloody urine, etc. If pyonephrosis comes on, the tumor or sacculated abscesses may be felt in the flank. As the disease progresses the nephralgia be- comes more marked, as do also the accompanying symptoms of cystitis. Great emaciation, with rigors and hectic fever, supervenes, and the patient dies exhausted, or, from the bursting of kidne3'-abscess, possi- bly with ursemic symptoms, or, from tubercular disease elsewhere, wasted by hectic. There is rarely any profuse hEematuria with kidney tuberculosis. The urine is almost uniformly over-acid. The disease may prove rapidly fatal in a few months, or may drag along many years. Diagnosis. — The most reliable diagnostic marks of this affection are chronic pyelitis coming on in a tubercular subject, or one of tuber- cular antecedents, or living in bad hygienic surroundings, where no other cause (stone, etc.) for the pyelitis is evident. Where the epididy- mis is the seat of cheesy degeneration, or, the seminal vesicles knotty with chronic, cheesy deposit, or the prostate affected by similar dis- ease, and symptoms of chronic pyelitis come on, a diagnosis of tuber- cular pyelitis may be safely ventured. The urine usually contains a large amount of debris besides its pus, but, taken by itself without the evidence furnished by other symptoms, this sign is absolutely value- less. The bacillus is sometimes found by careful staining of tiie clumps of pus. Treatment. — Tubercular disease of the kidney is very rarely recov- CANCER. 347 ered from ; it is even more fatal than tubercle of other vital organs. Its treatment is that of chronic pyelitis, and that of chronic tubercu- losis — fatty medicines and food, proper hygiene in air, clothing, and diet, witli quinine, iron, astringents, and, if the pain be great, a small amount of anodyne. Eenal and extra-renal accumulations of pus may require external incision. Extirpation is not to be thought of, unless thGre is pretty positive evidence that one kidney is sound, in which case nephrotomy is the proper operation, followed later, if necessary, by nephrectomy. A question of the first importance to decide in these cases is whether or not the other kidney is involved. The various ingenious means suggested, such as Fenwick's* suction catheter, Silberman's f com- pression bag, for closing one ureter within the bladder by filling the bag with mercury, Lewer's J method in women, by using one half of Bryant's rectal speculum passed through a dilated urethra, thus com- pressing one ureter while the other acts, other means of pressure within the bladder upon one ureter, several of which have been suggested, Simon's and Winckel's catheterism of the ureter in the female — none of these means seem practically applicable. A negative rough diag- nosis may be made by the absence of tumor upon the side supposed to be sound, the absence of pain upon this side subjective or called out by manipulation, the secretion of a normal amount of urine contain- ing a full daily quantity of urea. Both kidneys are implicated as often as one alone, perhaps more often ; therefore it is safer first to resort to nephrotomy, leaving nephrectomy for subsequent performance, if called for after further study of the case. CANCER OF THE KIDNEY. Cancer of the kidney is not a common disease. It occurs primarily in the kidney or in general cancerous cachexia as a secondary deposit, especially secondary to cancerous disease of other parts of the genito- urinary apparatus, in which case it often fails to furnish any symptoms, and is to be detected only by autopsy. Again, secondary cancer of the kidney may assume primary rank, and lead to the fatal issue by its rapid growth. Secondary deposits occurring in connection with cancer, other than of the genito-urinary organs, usually afi;ect both kidneys in the shape of numerous nodules, from the smallest imaginable size up to that of a nut or larger. These nodules as a rule occasion no renal or vesical symptom, there being enough tissue left to perform the function of the kidney. Their softening and ulceration may not have time to take place, on account of the more advanced condition of the * "Lancet," September IS, 1SS6, p. 529. f "Berliner klin. Wochensehrift," 1S84. i "Lancet," November 13, 1886, p. 914. 348 DISEASES OF THE KIDNEY. primary cancerous deposit, Avliich carries ofT the patient by cachexia or otherwise. Cancer of the kidney is ahnost always encephaloid (soft); scirrhous, colloid, and other forms being mentioned as curiosities in surgery. No time of life is exempt from an attack of primary cancer of the kid- ney. Children under four years seem especially liable, and old age the next most frequent epoch for its appearance. As a rule only one kidney is affected. The disease may advance until the mass has reached a size large enough to fill the whole abdomen, and a weight of twenty to thirty pounds. It always seems to begin in the cortical substance, extending thence to the pyramids. The kidney-substance as such becomes absolutely obliterated, no trace of it being left in the large cancerous mass, which, like other sjiecimens of soft cancer, is usually lobulated, harder in some parts than in others, of different consistence in different specimens, giving obscure or real fluctuation in parts, often containing large cavities filled with clots, fluid blood, or cancer debris, possibly pus, "a strange, distempered mass" (Ilcy). Cancer of the kidney, like that of the liver and testis, is commonly filled with numerous large, thin-walled vessels which readily break, form- ing blood cysts and clots of large size. Kidney-cancer sometimes grows out through the renal vein and advances into the ascending cava. Here portions of it may be broken off and be carried along in the general circulation to form infarctions in the lungs. When the cancerous mass sprouts out into the pelvis of the kidney, its large, thin-walled vessels are apt to give way and occasion that symptom so characteristic of cancer — profuse, spontaneously recurring hemor- rhage, often filling the bladder to distention with clots. The disease may commence as a single cancerous nodule, or as an infiltration. When the tumor reaches large size, it usually forms in- flammatory adhesions with all the surrounding viscera. The colon lies in front of it, the other viscera are crowded aside. The pressure of the cancerous mass may cause caries of the vertebra. The ureter is often occluded. When the disease in the kidney is primary, second- ary deposits are apt to occur in the rest of the body. The lymphatic glands in the hilum of the kidney and the vertebral and mesenteric glands are often involved, sometimes forming a considerable tumor of themselves. Sometimes the primary seat of the cancerous growth is in the lymphatic glands or other tissues about the hilum, whence, spreading, the kidney becomes implicated. Maxon thinks that this is the commonest method of onset of primary renal cancer. Symptoms. — The most constant symptom of primary renal cancer is a tumor, which sometimes in adults, more often in children, attains enormous proportions before death. This tumor is first noticed in the flank above the crest of the ilium, growing forward and upward. It usually feels irregular but smooth (lobulated), and sometimes gives the CANCER. 349 sensation of clcop fluctuation at points. It may be entirely painless to pressure. The resonance of the colon passing in front of it may often be made out. Pain in the back and hypocliondrium, in the re- gion of the Icidney, of the nephralgic character, is usually complained of before the tumor appears, perhaps not till later. The pain is usu- ally intermittent in character, and not often very intense. It may be wholly absent. Hajmaturia is a sign of great value when present, but its absence has not the signification which has been given to it. It may be absent throughout the disease, or appear for a time only at the beginning or at the end. It is rarely continuous through- out, tending, as it does, to be irregularly intermittent without appreciable cause. Often during the paroxysms it is very profuse, perhaps clot- ting in the ureter or bladder, aiid causing considerable incon- venience and pain. If distressing feelings have been present, some alleviation of them is apt to fol- low profuse bleeding. When h^ematuria is abundant and parox- ysmal without provo- cation, in the case of renal tumor, cancer should be suspected. Vesical irritability may be the only pro- nounced symptom, leading the careless observer to overlook the kidney and to search for the seat of the disease in the bladder. Among other symptoms there may be ascites, anasarca, and great development of the cutaneous abdominal veins, from pressure of the tumor upon the large venous trunks within the abdomen. The size of the tumor may cause functional derangements of the stomach and bowels. Vomiting sometimes appears early. The urine presents no characteristic diagnostic features. It is idle to place any reliance Fig. 104 (Roberts). 350 DISEASES OF THE KIDNEY. Tipon the appearance of so-called cancer-cells in the urine, or upon tlie hope of finding a shred of cancer-tissue, since such a shred, start- ing at the kidney, already softened and partly decomposed by iho. ulcerative process which loosened it, would become wholly indistin- guishable asa portion of cancer after traversing the ureter and remain- iucr soaked in urine in the bladder for even a short time. In children the disease is more rapidly fatal than in tiie adult. It rarely lasts over a year. The tumor grows to an immense size, not infrequently lining the whole abdomen. The patient emaciates rapidly and dies. Fig. 104 is an excellent representation of a child with advanced cancer of the kidney. It is rather too extreme to be typical. Adults with cancerous kidney usually die in two or three years, but many drag out more than double that length of time (Roberts). Cancerous cachexia is more liable to be marked in the adult than in the child. TJie diagnosis in the male is with ascites, hepatic or splenic tumor, or renal tumor of other nature (hydronephrosis, pyonephrosis, hyda- tid). In ascites fluctuation is distinct, both loins are flat, the dull- ness may be made to change by position. A kidney-tumor is im- movable, feels solid in parts, only one flank is flat on percussion. A tumor in connection with the liver does not have the colon in front of it. A kidney-tumor can usually be separated from the liver unless adhesions have formed ; perhaps a line of resonance will exist between them. A splenic tumor does not have the colon in front ; it grows more upward than downward ; resonance may be heard in the flank behind it ; its border may be felt stiff and thinnish ; deep percussion will elicit the bowel-sound beneath (for the spleen is not a very thick organ) ; the history will show previous malarial poisoning. For diagnosis with other renal tumors, the previous history, pres- ence or absence of cachexia, existence of pus or hydatids in the urine, sudden decrease of the tumor after free urination, etc., form the dis- tinguishing points. Treatment. — The hasmaturia, if excessive, calls for treatment, as may also the nephralgia. As the disease is so often confined to one kidney for a length of time, without infecting neighboring glands or other parts, if the case is recognized early, nephrectomy is the proper treatment. OTHER TUMORS IN THE KIDNEY. Many other forms of tnmor occur in the kidney, such as myo- sarcoma, adenoma, cavernous angeioma, lymphadenoma, villous papil- loma, syphilitic gummata. The villous growth yields hasmorrhage ; some of the others do the same, others not. A diagnosis is difficult even when a tumor can be felt. Treatment is palliative, with extir- pation reserved for the cases which seem to justify it. NEPEKOTOMY— NEPHRECTOMY. 351 NEPHROTOMY. A slightly oblique inciyion, three and a half to four inches long, i., made from behind forward ici the ilio-costal space, commencing over the outer edge of the erector spinas muscle. The incision is about tlic same as the oblique incision for lumbar colotomy. After dividing the deep fascia and all the muscular structures in the line of the in- cision, keeping the posterior part of the wound the deepest, the edge of the quadratus lumborum will be seen, and may be divided if broad and in the way. The deep lumbar aponeurosis is cut through, and then the deep fat around the kidney is come upon, perhaps consider- ably condensed and modified by inflammatory changes. The abscess of the kidney or cyst for which nephrotomy is being performed is reached by cutting or tearing through the condensed fat, is then punctured and freely opened with the knife or Paquelin cautery, the finger introduced into the pelvis of the kidney to break down parti- tions and search for stone. Then the cyst or abscess wall may be sewed into the abdominal wound with silk, small drainage-tubes be- ing left outside between the cyst- wall and the fresh wound if required, or a large drainage-tube may be inserted into the kidney and the wound partially sutured, especially the front part of the superficial incision. The operation is not a serious one. I have performed it several times upon the more damaged of two suppurating kidneys when both were diseased, and have always seen the patient rally well and find re- lief. If the ureter is obliterated and enough kidney substance left to secrete urine, permanent fistula remains. A flat rubber bag fitted to the loin and connected with a drainage-tube inserted into the fistula makes this condition bearable by the patient. If the abscess does not get well, and pus continues to be abundantly secreted, nephrectomy may be subsequently called for to save the patient from exhaustion. NEPHRECTOMY. Nephrectomy is the entire removal of the kidney by a cutting oper- ation. There are two recognized operations, the lumbar and the ab- dominal. Lumbar nephrectomy is usually preferred. The perito- ngeum is not opened, and natural drainage is easily effected on account of the posterior and therefore dependent position of the wound. It is the only operation usually allowable after previous nephrotomy when the latter operation has not effected a cure, but has left a disor- ganized suppurating kidney which fails to get well under drainage. For stone in the kidney when nephrolithotomy is not applicable, lumbar nephrectomy is the projDcr operation, as it is also for rupture or wounds of the kidney or ureter when the case is sufficiently severe 352 DISEASES OF THE KIDNEY. to demand more than palliaiivo nioasuros or draiiiaqo. For cysts and small tumors, tlie lumbar operation is also preferable, and for very l)ainful iloating kidney when neplirorraphy will not answer. Abdominal nephrectomy is called for when the diseased kidney is very large or nuicli displaced downward, and in most cases of cancer when any operation is allowable. Nephrectomy should not be performed until all other means of relief are exhausted, and when life is seriously threatened either imme- diately or remotely. A patient with only one kidney to rely upon is always in more serious danger from the occuri-enco of any kidney dis- ease than if he had two organs, although one of them nniy be structur- ally unsound. Lumbar Xcpltrcrtomij. — A transverse incision, running in a slightly oblique direction downward and forward, is made in the ilio-costal space, about four inches long, and never nearer than half an inch to the twelfth rib, for fear of opening the pleura, which sometimes de- scends below the rib. A second liberating incision may be made if necessary vertically downward, starting near the posterior extremity of the first incision. This second incision may not be needed, and may be left until after the kidney has been exposed and employed if re- quired to make more room for getting at the pedicle. When the capsule of the kidney is reached, by tearing through its fatty envelope, if there has been little or no previous inflammation around the kidney, the organ may be separated with its capsule from the surrounding parts by a careful use of the finger. If there has been much perirenal inflammation — notably in cases of the so-called scrofulous kidney, and after previous nephrotomy — the kidney proj^er must be shelled out from its own thickened capsule, which latter is usually firmly attached to the surrounding parts. The pedicle is secured by passing a strong double-silk ligature with a long aneurism needle between the ureter and the vessels. The lat- ter are ligated in mass, the other half of the double ligature being em- plo3'ed to secure the ureter. The ligatures should be placed as deeply as possible. The kidney may now be drawn out of the wound by forcibly elevating the twelfth rib, another ligature is thrown around the entire pedicle close to the kidney, including the ureter, and between this and the other two ligatures the pedicle is carefully snipped away with blunt curved scissors. All bleeding points in the wound must now be carefully secured with ligature, all the ligatures cut sliort, and the pedicle dropped into the wound. xVntiseptic irrigation should be employed and a large drainage-tube used, the wound being brought together with deep and superficial sutures and treated antiscptically as to its dressings. The drainage-tube should be kept in a short week, and then be removed by being gradually shortened from day to day and made smaller. The SYPUILTTIC KIDNEY. 353 wound requires about a month to close, and meantime the patient should bo kept very quiet, being fed sparingly both as to food and drink. If the lumbar space is too small to allow removal of the kidney, ex- cision of the last rib has been advised. This is of very doubtful pro- priety. It is better in such cases to have recourse to the abdominal operation. If the colon or peritonaeum be opened, they should be sutured at once. If the pedicle bleeds and can not be successfully ligated, a clamp should be placed upon the bleeding points and allowed to remain in the wound. Abdominal Nephrectomy. — The incision generally adopted is along the outer border of the rectus muscle on the side of the kidney to be removed. Before the peritonaeum is opened, all bleeding must be arrested. When the abdomen is open, the clean and disinfected hand is passed into the peritoneal cavity to explore the other kidney. If this is found to be sound, the operation is continued, otherwise it should be given up. The intestines are kept out of the way as usual with large, flat, clean, disinfected abdominal sponges. The outer layer of the meso-colon should now be opened sufficiently to allow three fingers to be introduced. With the fingers the fat should be separated and the renal vessels sought. They are to be tied in mass with strong disinfected silk. The ureter should then be seized with two pinch forceps and tied between with silk. It may be stitched into the wound if it contains pus. Another ligature may now be thrown about the vessels nearer the kidney, if there is room, and the pedicle divided between the ligatures. The kidney is now to be enu- cleated and carefully removed. The wound should be carefully irri- gated and sponged with hot water or Thiersch solution, the peritoneum sewed up with catgut, if thought necessary, a hard rubber or glass drainage-tube passed to the bottom of the wound, and the abdominal incision sewed up as after ovariotomy with deep and superficial sutures. Antiseptic dressings are applied. The bottom of the drain- age-tube is to be sucked out hourly at first, then at longer intervals, by a trained nurse or skilled assistant, with any form of suction-tube or long-nozzled syringe. After twenty-four or forty-eight hours, the tube may usually be removed. If thought better, it may remain longer. The patient must get up slowly and wear an abdominal bandage for many months. SYPHILIS OF THE KIDNEY. Syphilitic disease of the kidney is not common. Lancereaux,* in 24 autopsies of patients affected with visceral syphilis, found the kidney involved in 8. Moxon f was more fortunate, finding changes j^ost * "Gaz. Hebd.," i, 1864, p. 502. t " Guy's Hospital Reports," 1868, p. 329. 23 354 DISEASES OF THE KIDNEY. mortem in 14 out of 25. Vircliow* believes that am3'loid degenera- tion of the kidneys may depend directly upon sy])hilitic cachexia. E. Wagner.f in 0,000 autoi)sies, found G3 cases of kidney trouble in syphilitics, of which 35 were amyloid, 3 only were syphiloma, the rest inllammatory changes. Speiss, J in 320 syphilitic autopsies, found 7 cases of gummatous nephritis and 140 damaged kidneys, not obviously syphilitic. Bamberger,* in 1,460 cases of Bright's disease, acute and chronic, found syphilis in 49 cases. The syi)hilitie nature of larda- ceous degeneration was first described by Kaycr || in 1840. lie also notes other forms of syphilis of the kidney. Hans Ilebra-^ reports an excellent case of syphilitic paraj^legia cured by treatment. About a month after recovery the patient returned with swollen legs and in- tense albuminuria, which disappeared promptly undrr large doses of the iodide of potassium. Syphilitic disease of the kidney is relatively more common in the infant who dies of inherited disease than in the adult with acquired syphilis. Albuminuria has been quite often noticed in the early exantliema- tous stage of syphilis. Lancercaux thinks that prolonged mercurial treatment may have something to do with this in an etiological way. Hardy believes it due to the debilitating influence of the virus directly. Certain it is that the albumen sometimes appears in cases which have taken no mercury, and equally certain is it that it often disappears under the continued use of mercury. This I have verified more than once. In many instances, again, albumen wmII disappear totally, to- gether with the symptoms which accompany it, if iodide of potassium i? freely given. This, also, I have more than once observed in a man- ner so definite and striking that I do not hesitate to make a general statement of the fact. My note-books possess the cases. But, on the other hand, it will occasionally happen that patients with visceral syphilis, under protracted treatment by large doses of iodide of potas- sium, will gradually show morning nausea, and upon examination their urine will be found light, slightly albuminous, and containing pale casts. In such cases the kidney-trouble is probably due to the irritation produced by the large amount of iodide of potassium passing through them, and the albumen and casts may be made to disappear, together with the morning nausea, by reducing the activity of the treatment. Several such cases have fallen under the author's observa- tion. Hutchinson ^ confirms this view, as do also Wood J and At- * "Die krankhaften Geschwulste," vol. ii, p. 4Y1. f "Deutsches Arcliiv f. klin. Med.," Bd. xxviii, 1880, p. 94. X "Virchow und Hirsch Jaliresb.," xi, p. 539. * Tolkmann's "Saniml. klin. Yortrii-.," 1879, No. 173, p. 10. II " Maladies des Reins," t. ii, pp. 489, 493, 498. ^ " Vitljahresschrif t. f. Derm. u. Syph.," II, i, p. 3.5. "Lancet," i, 1876, p. 204. X "Therapeutics," p. 379. SYnriLITIC KIDNEY. 355 kinson.* Symptoms may be entirely absent, or there may be only lack of appetite, with sense of weakness and morning nausea, or there may be any and all the symptoms usually encountered in Bright's disease, The pathological appearances of syphilitic kidney, besides amyloid defeneration, which may be found, perhaps due to the disease, are those of interstitial chronic inflammation (usually circumscribed), local cirrhosis (rarely general), thickening of the parenchyma and cap- sule, perhaps local fatty degeneration, with atrophy, the tough adhe- rent capsule being depressed in deep seams, the kidney stroma com- pressed, atrophied, and degenerated between portions of contracted connective tissue. These appearances may be found alone or combined with one or more yellow gummy nodules, of varying size, solid, or more or less softened. Such nodules are usually connected to white bands of hypertrophied connective tissue, running through the kidney. The gummy nodule is pathognomonic ; the chronic interstitial nephri- tis is distinguished from the usual form by being generally confined to circumscribed portions of the gland. Gummata are usually found near the surface of the cortex, and when the kidney contains gummata the same are generally found in the liver. Greenfield and Wagner have found the walls of the arteries, in the kidneys affected with syphilitic disease, thickened, with the lumen nearly obliterated. Trmtmmit is mercurial in early syphilis, mixed in late syphilis, the iodides being freely used, sometimes pushed to excess ; but the fact should be constantly borne in mind that iodides alone may cause albu- minuria, a knowledge of the fact suggesting the remedy. CHAPTER XXI. DISEASES OF TEE SCROTUM. Anatomy.— Injuries.— OSdema.— Emphysema.— Eczema.— Intertrigo.— Pityriasi?.— Eczema Margina- turn. — Pruritus Genitalium. — Pediculi Pubis. — Plilegmonous Erysipelas. — Elephantiasis.— Tumors and Cancer of Scrotum. ^Epithelioma. The scrotum is a pouch formed of skin, muscular and connective tissue. Its function is to contain and support the testicles. It is developed from two lateral halves which unite centrally in the raphe (paTTTO), / sew), a raised line continuous with the raphe of the penis and that of the perinseum. The lateral halves sometimes remain separated and resemble labia majora, giving rise to an appearance sug- gestive of hermaphrodism. The healthy scrotum in the young man is * "American Journal of the Medical Sciences," July, 1S81, p. 17 et seq. 356 DISEASES OF THE SCROTUM. thrown into raga3 at right angles to the raphe on either side by the contractions of the dartos. The integument of tlie scrotum is delicate in structure, covered with a few hairs, and a])t to become pigmented at puberty. The sebaceous glands are very large. The dartos is a layer of unstriped muscle. It lies beneath and tirmly attached to the integument, and is reflected on either side inward from the raphe, to form the septum scroti. Each testicle has thus a dartos of its own. On exposing the scrotum to the air, the vermicular contractions of this muscle can be readily seen. They occur under the influence of cold or fright, and during the venereal orgasm. In youth, especially in winter, the dartos is habitually contracted and holds the testicles well up under the pubes. The ancient sculptors did not fail to notice that contraction of the scrotum was a mark of general as well as of sexual vigor. In the aged and inflrm, on the other hand, especially during summer, the muscle relaxes, allowing the testicles to hang low, supported mainly by the cord. The connective tissue of the scrotum is peculiarly loose, and con- tains no appreciable amount of fat. The septum scroti is pervious to fluids, so that serum or infiltrated urine can find its way readily from one side to the other. The lymphatics of the scrotum are large and numerous, and lead to the inguinal glands. The scrotum develops independently of the testicles, but, if the latter fail to descend, it is always rudimentary. INJURIES OF THE SCROTUM. In contusions, extensive ecchymosis is liable to occur, on account of the laxity of the connective tissue. This should not be incised. The parts should be supported and covered with cool lead-water, to which a little spirit has been added, or laudanum, if there is pain. Absorp- tion may be pretty confidently expected. In wounds of the scrotum there is usually a great deal of bleeding. In uniting such wouuds, many sutures are required, to overcome the tendency of the dartos to pull the edges apart. Abscess of the scrotum after injury requires no comment. An early opening is advisable. CUTANEOUS AFFECTIONS OF TEE SCROTUM. Nearly all of the numerous diseases, syphilitic or otherwise, of the general integument, may occur also upon the scrotum. Certain of them are modified by their position, and require a passing notice. Extensive (edema is liable to complicate any inflammatory affection of the scrotum, on account of the laxity of its tissue and its dependent position. Scrotal oedema may also be due to any obstruction to the return of its blood, as occasionally to the hard inflammatory induration EMPHYSEMA— ECZEMA MARGINATUM. 357 around inflamed lymphatic glands in the groin, or it may come on in connection with general prostration and anasarca. Where oedema is excessive, and the tension is so great that injury t.o the skin seems imminent from pressure, a few punctures may he made on either side of the raphe, at the most depending point of the scrotum. These punctures, however, should be practiced with caution, as there is danger of their being followed by gangrenous erysipelas. Em'pliysema of the scrotum is occasionally met with. It is easily distinguished by the crackling under the lingers, and resonance on percussion. It occurs with general subcutaneous emphysema, and with scrotal gangrene. Eczema. — Eczema attacking the scrotum, perinaeum, and thighs around the root of the scrotum, is apt to be excessively obstinate, and prone to relapse. (For treatment, see text-books on dermatology.) Intertrigo occurs in children, and often in fat men of rheumatic habit who perspire a good deal. This affection is apt to be trouble- some. Much can be done to prevent it, by scrupulous cleanliness, and the use of a suspensory bandage, to keep the cutaneous surfaces apart. To overcome the hyperasmia when it exists, rest, cleanliness, and ex- posure of the parts to the air are speedily effective in mild cases. If the surface is moist and excoriated, it should be dusted with equal parts of finely powdered oxide of zinc, camphor, and starch, or it may be dressed with the oxide-of-zinc ointment or with a solution of sul- phate of zinc. A strip of old thin linen should be used to sling up the scrotum and keep the cutaneous surfaces apart. Later, when the parts are dry, tincture of iodine, locally, will hasten the cure. Avoid- ance of stimulating food and drink, to render the secretions less irri- tating, is advisable. Pityriasis. — In men with a delicate skin, especially in summer, there is often a slightly brown discoloration of the thigh and of the scrotum, where the two surfaces lie habitually in contact, caused by a vegetable parasite in the upper layers of the epidermis. It is, in fact, a pityriasis versicolor, and sometimes gives rise to a mild local erythema and considerable itching. A few applications of the com- pound tincture of iodine diluted to half strength, and painted on after the affected skin has been washed with soap and dried (to remove the fat from the scales and spores), will cure the discoloration and the itching. Sulphurous acid does well. Eczema Marginatum. — This is another parasitic disease, affecting the scrotum, thighs, mons veneris, and buttocks. It is not an eczema, but a herpes tonsurans vesiculosus — a combination of herpes tonsurans and intertrigo, as proved by Pick,* in a written discussion with Hebra. The eruption commences in one or more small, round patches, red, * " Zur Verstandigung iiber das sogenannte Ekzema Marginatum," " Archiv f . Derm und Syph.," 1, iii, p. 443. 35S DISEASES OF THE SCROTUM. elevated, and itchy, just where the scrotum lies habitually in contact with the thigh. It spreads circumfcrentially, healing in the center. The border of the eruption is sharply defined, and forms the distinct- ive feature of the disease. It is composed of papules, vesicles, excoria- tions, and crusts. The parts within this festooned border over which the disease has passed are left of a brown color. Often, little hea]is of dried-up scales lie here and there upon this surface. Patches of eruption break out in the neighborhood or within the border, and behave exactly like the patches first constituting the disease. The affection is slow in getting well, and tends strongly to relapse. Fric- tion and moisture of the parts, together with the parasite, are neces- sary for its production. Among the scales scrajied from the margin, the microscope may detect the moniliform filaments and spores of the tricophyton of Malmster, the parasite of ordinary ringworm. In cer- tain stages of the disease, the parasite is difficult to find. Treatment. — Dilute lead-water or oxide-of-zinc ointment may be used locally at first if there be much inflammation of the skin, to be followed by parasiticide lotions, or the latter may be commenced with at once. The best of these is a mild solution of corrosive sublimate in water, gr. j-jss to the 3 j, which should be kept constantly applied. Sulphurous acid, pure, is an excellent parasiticide ; tincture of iodine may be used, or an ointment of turpeth mineral (hydrarg. sulph. flav.) gr. x-xx to the 3 j. Treatment should be kept up for some time after apparent cure, as relapses are the rule, and can only be averted in this way. Pruritus Genitalium. — This, like other purely pruriginous skin- affections without eruption, is excessively obstinate. Rheumatic and gouty subjects most often are the sufferers, and with such, any dietetic or hygienic errors seem liable to induce or aggravate the disorder. After the exclusion of animal or vegetable parasites from the role of causality, the treatment consists in hygienic and dietetic precautions, with the internal exhibition of alkalies, and, if need be, tonics. Turk- ish and Eussian baths are often very serviceable. The following are among the most generally useful local measures, what is suitable for one case often having no effect upon another. Hy- giene and change of air are sometimes the only really curative agents. Hot water, tar, pure or in combination, yellow wash, chloral, camphor ; or, V/, Cliloroform, 3 j. Adipis, I j. M. Keep corked in a vride-mouthcd bottle. Or, 5 Acid, hydrocyanic, dil., 3 ss- 3 iv. Glycerini, 3 j- Aqute, q. s. ad § j. M. Ft. lotio. PEDICULI PUBIS— PHLEGMONOUS ERYSIPELAS. 350 Finally, local electricity, either tlie induced or the continued current, has moderate curative power over some cases. Pediculi Pubis. — These parasites may be found upon the scrotum, as they may, in fact, upon any part of the body from which the hairs of puberty grow. They exist in greatest abundance, however, about the genitals, and particularly on the mons veneris. They are plainly visible to the naked eye, as are their eggs attached to the hairs (Fig. 105, a). They may be de- stroyed by sprinkling the parts with calo- mel, or by applying a lotion of gr. j-iij corrosive sublimate to | j of Cologne- water, or a wash made of equal parts of tincture delphinii and water, or by the free local use of kerosene-oil. When they p^^ ^q- infest the whole body, some few usually escape the ordinary application of lotions, and these soon breed a new crop. Care and patience, however, will always finally dislodge them. No treatment is better than the old-fashioned blue mercurial oint- ment, half an ounce of which may be rubbed into the hairy parts about the pubis and perinseum and somewhat down the thighs, the patient going to bed in drawers and sleeping in the ointment all night. Two such applications, at a few days' mterval, generally destroy the colony. The treatment is a very dirty one, and much soap and hot water form essential parts of it. Moursou, a French naval surgeon, first pointed out the relation between certain blue spots on the skin and pediculi pubis,* and Douguet confirmed the relationship by in- serting a bruised pediculus under the skin and producing a spot. Mallet proved that the coloring matter resides in the salivary glands of the pediculus. In the early spring the spots are more abundant than in other months. TJeikaet Infiltration" has been already described. Phlegmonous Erysipelas. — Upon the scrotum this is an exceed- ingly dangerous disease. It is most frequently observed in the aged or debilitated. Injuries and operations may also be occasionally at- tended by it. The so-called metastatic inflammations occurring in typhus, variola, scarlet fever, mumps, etc., are in reality phlegmonous erysipelas, described by some English authors as acute oedema. Symptoms. — A sharp chill announces the disease. The scrotum becomes at once the seat of increased heat and redness, with pain, and rapidly enlarges. Blood escapes into the subcutaneous connective tis- sue, so that the whole scrotum may be black and shining, or its color may be mottled. The scrotum may reach the size of a child's head, the integument is put upon the stretch, the epidermis may crack or * "Lancet" (editorial), September 16, 1SS2, p. 454. 360 DISEASES OF THE SCROTUM. may be raised into vesicles or bii]la\ The general tendency of the disease is always toward gangrene. Pain is not very great, but the prostration is excessive. The pulse runs up to 120-100, is small, feeble, and irregular. The appetite fails, the tongue gets brown and dry, the patient breathes hurriedly, is depressed and overcome. The skin is hot and dry at first, but becomes subsc(piently moist from de- jiression. The diagnosis is between infiltration of urine and lifematocele. From the former it may be distinguished by the greater severity of the attack, the rapid change of color of the parts, the fact that one side of the scrotum is more seriously involved than the other in phlegmonous erysipelas, and that the oedema does not so certainly ex- tend to the penis and abdomen. The patient is more depressed, and no pre-existing cause for infiltration is present. In true ha?matocele one side only of the scrotum is enlarged, and there is not much thick- ening of the skin. The swelling may be often made out as involving the testicle. The general symptoms in ha?matocele are not formidable. The dangers in phlegmonous erysipelas of the scrotum are twofold : the life of the jiatient is in danger ; the integrity of the scrotum is at stake ; any portion or the whole of it may slough, leaving the testi- cles uncovered. Treatment. — The treatment should be energetic and supportive. Repeated small doses of brandy, whisky, or -wine, must be given, with milk, cream, and beef-tea. The quantity of stimulant varies in every case. Eight or ten ounces of brandy or whisky in twenty-four hours, in small portions at a time, is a fair average quantity. A good effect of the stimulant will be noticed in the pulse, which will decrease in frequency and become more strong and regular. The tongue will get moist, and the patient rally from his depression. The local treatment is equally important. Hope of aborting the disease need not be entertained. One long, free incision parallel to tlie rajohe, on either side, should be made well down into the sub- cutaneous tissue of the oedematous discolored mass. Persulphate of iron may be used, if necessary, to check bleeding, and water-dressings, with one per cent carbolic acid, applied. If gangrene has already commenced, and sloughs begun to separate, or if the latter form in spite of the incision, they should be detached and removed as soon as possible. The testicles hang out uninjured in these cases, suspended by the cord, and if left to themselves and kept moist, or, perhaps bet- ter, mildly stimulated, granulations will sprout out upon them, and a cicatrix will form, binding them up under the pubis in a manner not unsightly nor inconvenient. The patient is always agreeably disap- pointed in the final result. If the process of repair does not form a good scrotum, recourse may be had to oscheolasty {ocrxeov, scrotum ; irXdora-w, to form), as performed by Delpech, Dieffenbach, Diirger, and ELEPHANTIASIS— CANCER— EPITHELIOMA. 301 others, by transplanting from neighboring parts flaps of skin large enough to cover in the testicles. Elephantiasis Sceoti. — This disease, not uncommon in some portions of the globe, is rare in the United States. Hypertrophic overgrowth may attack the scrotum or penis alone, but usually botJi are involved, the scrotum to the greater extent. The scrotum may enlarge until it touches the ground. It has been known to reach the weight of one hundred and sixty-five pounds ! A scrotum of this weight was removed by Wilkes.* Tlie only remedy for the disease is the knife. Curling advises a disregard of the penis and testicles in operating, if the tumor be very large. Patients are apt to die on the table, from hemorrhage, which is always excessive. If the mass is not excessively large, the penis, testicles, and cords may be dissected out, enough of the healthiest tissue being left to cover them. Many cases of successful operation are recorded, among others, one by The- baud, of New York, the mass weighing, when removed, sixty-three pounds. Lymph Scrotum (pachydermia lymphangiectatica — Rindlleisch) is analogous to and suggestive of elephantiasis scroti. The names of Carter, Manson, Eoberts, and Wiedel are best known in connection with it. Numerous vesicles and tubercles, discharging lymph when punctured, are found upon an hypertrophied scrotum, and the malady tends to prolong itself indefi.nitely. The disease is doubtless due to filaria Bancroftii. Busey f considers the subject. In one of Carter's J cases, chylous urine alternated more or less regularly with a flow of lymph from the tubercles on the scrotum. A punctured tubercle would sometimes yield a pound of chylous fluid a day. Cystic, fatty, and fibrous tumors of the scrotum are found occa- sionally. Small steatomatous cysts are common. They may reach a large size. Can^cer of the Scrotum, in this country, is a rare disease. When it occurs, it is almost invariably epithelial. Scirrhous and medullary cancer, recurrent fibroid, and melanotic sarcoma, are encountered at long intervals, but not as differing in any way from the same growths elsewhere. Epithelioma of the Scrotum has been denominated chimney- sweeps' cancer, since it is somewhat common in England upon chim- ney-sweepers. Soot seems to be the exciting cause in England, although in other countries those whose occupation brings them into contact with this substance do not seem to suffer. On the contrary, our countryman, Warren,* states that he has seen it a few times in * Titley, "Diseases of the Genitals," p. 317. f " Congenital Occlusion of Lymph-channels," New York, 1S7S, p. 98. X "Med.-Chir. Trans.," 1862, vol. slv, p. 189. * "Surgical Observations on Tumors," p. 329. ~ 362 DISEASES OF THE TESTICLE. the Uuited States, but never in chimney-sweepers. Coalrdust is en- tirely inoperative. The disease begins as one or more small, soft warts, or tubercles, usually at the lower fore-part of the scrotum. These remain un- changed for a time, but finally indurate slightly, become excoriated, scab over, and ulcerate, the ulcer extending backward, and destroy- ing, with more or less rapidity, the whole scrotum. Sometimes the testicles are involved, sometimes they escape. The ulcer resembles an epithelial, cancerous ulceration, wherever seen. It has the same hardened, irregular, purplish, everted, knotty borders ; the same hard, uneven, unhealthy-looking base ; the same ichorous discharge, now sanguinolent, now purulent. Death occurs by exhaustion, or by haemorrhage, if a large vessel be severed by the advancing ulceration. The disease continues local for some time. It is only tardily that the inguinal glands become in- volved. Treatment. — Thorough removal with the knife offers the only chance for safety. If the inguinal glands have not become infected, the operation is a simple one. If either testicle should be found in- volved, or even adherent to the diseased mass, it should be removed. If the glands in the groin are greatly enlarged and indurated, opera- tion is unadvisable. If they are only slightly enlarged, they may be left ; but, if they are at all indurated, they too must be removed. The earlier the operation is undertaken the less the chance of relapse, which is always to be feared. A second and third operation may be advisable, if the patient's general condition be not seriously impaired. (For mucous patches of the scrotum, see Syphilis.) CHAPTEK XXII. DISEASES OF THE TESTICLE. Anatomy.— Anomalies.— Cryptorchidism.— Lnxation.—ITypertrophy.— Atrophy.— Injuries.— ITiEmatocele.— Ha;matocele of tlie Cord.— Free Bodies in the Tunica Vaginalis. The testicles, suspended each by its spermatic cord, lie loosely in the scrotum, surrounded by connective tissue. The left is usually slightly larger than the right and hangs lower, evidently for the pur- pose of allowing these important organs the more readily to elude violence. It has been observed, in transposition of the viscera and blood-vessels, that the right testicle hangs the lower. The mean di- mensions of the testicle, according to Curling, are one and three fourths inch long, one and a fourth inch antero-posteriorly, and one EPIDIDYMIS. 363 inch laterally. The average weight in the adult is about six drachms. The dimensions, weight, and consistence vary considerably, according as the organ is in action or not. During venereal excitement it is turgesccnt, firm, and elastic ; otherwise soft and yielding. Two of the envelopes of the cord also cover the testicle, the cromaster mu.scle and the tunica vaginalis communis, while the remains of the guber- naculum testis attach it to the bottom of the scrotum. The proper coverings of the testicle are two — the tunica vaginalis testis and the tunica albuginea. The former is a shut serous sac, in- vesting all the secreting portion of the testicle, except where the epi- didymis is attached behind, and the remains of the gubernaculum be- low. It dips down in the middle posteriorly, between the epididymis and the testicle, forming a cul-de-sac, at the bottom of which the sac on the two sides comes into close contact, and sometimes there is a communication at this point. On the outer side the tunica vaginalis covers and closely invests the epididymis. The reflected layer forms a shut sac, and this extends up the cord to a greater or less extent. This tunica vaginalis represents a portion of the peritonaeum which was brought down by the testicle in its descent from the abdomen. Ordinarily, at birth, all connection between its cavity and that of the peritonaeum is closed, a white, fibrous line (habenula) alone marking the original continuity of membrane. Sometimes, however, the open- ing remains permanent, in which case congenital hernia is likely to occur. The communication may be a narrow canal, open only to the passage of fl.uid. Again, partial obliteration may exist, isolated serous sacs being left along the cord. Finally, as more often happens, the upper aperture is closed, and a considerable portion below remains unobliterated, so that the tunica vaginalis extends for some distance upward in front of the cord. The cavity of the tunica vaginalis is lined by pavement epithelium, and normally contains only enough fluid to lubricate the surfaces. The function of the sac is to allow the testicle to slip easily away when in danger of being pinched. The tunica albuginea is the proper investing membrane of the se- creting portion of the testicle. In its substance the branches of the spermatic artery ramify, and break up to be distributed to the seminal tubules within. It is composed of dense, white, fibrous tissue, is only slightly extensible (whence the pain in orchitis), and sends trabecul^e into the substance of the testicle to break it up into compartments (about four hundred for each testicle) for the lodgment of the ulti- mate tubuli seminiferi. It forms the rete testis (corpus Highmori) above and behind, where blood-vessels and absorbents pass to and from the testicle, and where the straight tubes come out to form the coni vasculosi — together, the head of the epididymis. The glandular substance of the testicle consists of innumerable little tubes (tubuli seminiferi) closely packed in conical segments be- 364 DISEASES or THE TESTICLE. tween the fine, fibrous septa thrown out by tlic tunicu albuginoa. The number of these cones is coni})uted to bo from 2b0 to about 5C0, and their combined length from 1,UU0 to 5,500 feet. The diameter of tlie tubules has been yariously estimated at from ^ of a line (Miil- ler) to -^^ of a line (Lauth). Their mean length is estimated by Lauth at 25 inches. The tubes are all of the same size throughout, and anastomose fre- quently with their fellows of the same cone, and with those of neigh- boring cones. They are lined with mucous membrane furnished with polygonal cells, containing spherical nuclei. These cells are the act- ive agents in forming the spermatozoa, the ciliated cells (so-called animalcula?) always found in health after puberty, free in the tubes in greater or less number, according to circumstances. The ej)i(Iidiji)u\^ [iirc, upon; ScSv/aos, testicle) caps the testicle proper, and skirts its posterior border. It is large and spread out above, be- ing composed of the coni yasculosi or convoluted vasa efferentia. This portion is known as the globus major, or head of the epididymis. The coni vasculosi finally all empty into one canal — the canal of the epididymis, which forms by its convolutions the central pari or body of the epididymis. This body is separated from the testicle proper by the cid-de-sac of the tunica vaginalis already alluded to. Below, the canal of the epididymis exhibits further convolutions. At this point it is known as the globus minor, or the tail of the epididymis. Con- nective tissue unites it to the testicle at this point, and from here on the canal becomes more dense, and is known as the vas deferens. The little supernumerary diverticulum (or there may be several), known as the vasculum aberrans of Haller, when present, usually empties into the canal of the epididymis at this point. The canal of the epididymis is furnished with ciliated epithelium, whose cilia sweep its contents along toward the vas deferens. The two constituent parts of the testicle, which have been briefly described above, are developed separately in the foetus. Each re- ceives its blood in the main from a separate artery, although these arteries anastomose pretty freely at their extremities. This peculiar- ity of Tascular supply may account for the fact that one portion of the organ is often diseased, the other part remaining sound. The epi- didymis is formed from the lower part of the Wolffian body, and its duct is a continuation of the Woltlian duct to the lower and back part of the bladder. The deferential artefy, a branch of the hypo- gastric, supplies it. The secreting portion of the testicle, on the other hand, is formed from fetal tissue lying in front of, but seem- ingly independent of, the Wolffian body, and its artery, the spermatic, comes from the aorta just below the renal artery (Kolliker).* * "Entwickelungs-Geschichtc des Menschen und der boheren Thiere." CRYPTORCHIDISM. 305 ANOMALIES OF THE TESTIS. Instances of supemumcrury testicles have been reported, but in all tlie cases where dissection has been resorted to, to clear up the doubt, the extra organ has proved to bo some cystic, fatty, fibrous, or otlier tumor, so that it is doubtful if the anomaly exists at all. Even in the observed cases of double penis there was no abnormality of the testi- cles. The opposite condition, however — absence of the testicle — does exist (Paget).* One or both testicles may be absent ; the vas deferens and seminal vesicle in these cases being sometimes fully developed, and ti-aceable into the inguinal canal, or even to the bottom of the scrotum (Curling). CHYPTORCHIDISM-MONORCHIDISM.t A CRYPTORCHiD (KpuVretv, to concectl ; opxi% testicle) is an individ- ual whose scrotum contains no testicles. A MONORCHID (/xoVo?, oloQie ; opxi.^, testicle) has only one testicle in the scrotum. When a testicle is absent from the scrotum, the presumption is that it has been arrested somewhere in its descent. The testicle is formed high up in the abdominal cavity, behind the peritonaeum, in about the position occupied by the lower end of the kidney at birth. Dur- ing fetal life, guided by the gubernaculum testis, it descends, carry- ing with it a portion of peritongeum, which is to become the tunica vaginalis. It passes through the inguinal canal, and by the end of the ninth month is usually in the scrotum. It may, however, be ar- rested at any point in its descent, or may follow an abnormal direc- tion, finding its way into the thigh through the femoral ring, or even into the perinseum, where it may become inflamed, and has been mis- taken for an abscess. One very common point of detention is in the inguinal canal. In all of these situations it can be felt, and should be searched for in case the scrotum is empty. In about one case in five (or ten — Wrisberg) the testicle is not in the scrotum at birth. It de- scends, usually, during the first week, but is often retained for mouths, sometimes longer, and not very infrequently until puberty, or even later ; it has been known to descend as late as thirty years after birth. * "Medical Gazette," vol. xxix, p. 817. f The literature on this subject is rich. The following papers may be consulted with profit : FoUin, "Mem. sur les Anomalies de Position du Testicule," "Archiv. de Med.," 18.51. Le Comte, "These sur les Ectopics congenitales des Testicules," 1851. Roubaud, " Traite de I'lmpuissance," Paris, 1872, p. 607. Godard, " Etudes sur 1' Absence congenitale du Testicule," " Mem. de la Societe de Biologic," 1856-'o9. Godard, "6tude sur la Monorchidie et la Cryptorchidie chez I'Homme," Paris, 1857. Godard, "Etudes sur 1' Absence congenitale du Testicule," 1S58. 3GG DISEASES OF THE TESTICLE. When it descends after birth there is great probability that a portion of intestine will follow it, constituting congenital hernia. It is esti- mated that in about one case in a thousand the testicle is permanently retained in the abdomen, or inguinal canal. The right testicle is a little more liable to this accident than the left (Petreqnin Quctclet). "When the testicle is retained in an abnormal position, it is almost universally found undeveloiicd, or in a state of fatty or fibrous degen- eration. Under these circumstances no spermatozoa arc discovered in it, or in the seminal vesicle of the atlectcd side. Excci)tionally, how- ever, it has been found of full size. When one testicle only is re- tained, the other undergoes conservative hypertrophy, and the deform- ity is a matter of no consequence, as one large, healthy testicle is all- sufficient. But, where both testicles are retained, it may become a very nice matter in a medico-legal sense, or in regard to prospective matrimony, to decide whether the cryptorchid is sterile or not. Ac- cording to Godard, the cryptorchid is necessarily sterile, yet he may be, and usually is, thoroughly potent, and possessed of the full amount of sexual desire. An opinion of his ability to beget children can only be founded upon microscopic examination of the spermatic fluid. The secretion may be natural in consistence, quantity, and odor (it is liable to be brownish), but, if it does not contain spermatozoa, im- pregnation can not be effected. The least offensive way of obtaining a specimen for examination is to request the patient, immediately after sexual congress, to cause the woman with whom he has cohabited to urinate, and then to bring the urine for examination. When al- lowed to settle for a short time, spermatozoa can always be recovered, Avith a pipette, from such a specimen, provided the seminal fluid con- tained any. Several cases are recorded where cryptorchids have mar- ried, whose wives have had children, but doubt has always been raised as to the paternity of the offspring. Authors are not of accord as to the sterility or virility of cryptorchids. The majority take the former ground, but, as these individuals are apparently never impotent, the test of their sterility can be easily applied, if desirable. The retained testicle is apt to become diseased. When retained in the inguinal canal, it is often the seat of severe pain, especially at about the age of puberty, from pressure by the tendons of the abdomi- nal muscles. It may be painful enough to impede motion, in which case an operation should be undertaken for its removal. A testicle in this situation is liable to become the scat of malignant disease, due partly, according to Virchow, to the injuries inflicted upon it by the contractions of the abdominal muscles, and partly to a predisposition from its incomplete development. A testicle in this situation, which becomes inflamed, as it may in connection with gonorrhoea, is not able to swell, and consequently is doubly painful. Testicles retained in the inguinal canal may be mistaken for hernia. CRYPTORCHIDISM. 3f;7 Operations to replace a testicle when found in uu abnormal posi- tion have been executed with measurable success. When the organ in early life, as is often the case, can be manipulated outside of tlie external ring, and retained there by a truss having a water or a gly- cerine jiad, if it is so retained for a long series of months, it may eventually become lodged outside the ring, and develop normally in this situation Just over the pubic bone. I have succeeded in this en- deavor several times. Truly, the testicle in this position is exposed to injury more than it would have been if left in the inguinal canal, yet its integrity is preserved, it develo^DS normally, and the ring may be closed by the pressure of the pad, and the risk of hernia greatly lessened. This risk patients with a testicle retained in the canal always run. I have had to operate for strangulated hernia under these circumstances. When such an operation is called for, it is probably always better to castrate and sew up the abdominal ring with catgut, thus curing the immediate trouble, ridding the patient of an incessant annoyance, and effecting a radical cure of the hernia. Thomas Annandale,* July 5, 1877, replaced in the scrotum a testi- cle which was abnormally situated in the perineum of a boy three years old. The scrotum was opened, the testicle liberated by incis- ions, replaced in the scrotum, and retained there by a suture of cat- gut. The operation succeeded fully. Curling relates a similar case, except that he did not suture the testicle to the bottom of the scro- tum, and the operation failed. James Adams f has operated success- fully. John Wood J replaced a testicle which he found in the ingui- nal canal. He everted the scrotum and sutured the testicle to it. The patient recovered and was discharged wearing a truss having a water-pad. Wood * is also credited, in a case where he found the cord too short, with having stretched the cord, dissected the vas def- erens from the globus major, and inverted the testicle, thus placing it safely within the scrotum. Max Schliller || replaced from the ingui- nal canal the testicle of a youth of twenty, closing the external ring by suture. Schliller refers to unsuccessful operations by Eosenmerkel and Chelius. The best present conclusion, therefore, is : If the testi- cle is in the inguinal canal and can be brought out by manipulation, retain it there by a suitable truss. If it is in the canal and can not be brought out, a truss can not be worn with any advantage, unless it have a cup-shaped pad, and the choice lies between letting it alone until something happens — which is hardly surgical — or cutting down upon it and attempting to replace it in the scrotum. This can be * "Edin. Med. Journ.," January, 1878. f "Lancet," 1871, May 27th, Part I, p. 710. X "Lancet," May 1, 1880, p. 681. * " St. Louis Med. and Surg. Journ.," June, 188-t, citing " Australian Medical Gazette." II "Ann. of Anat. and Surg.," Sept., ISSl, p. 89. 3GS DISEASES OF THE TESTICLE. done if the cord is long enough. If the cord is too short, the oper- ator must be prepared to castrate and close the ring and canal wi£li catgut sutures, operating antiscptically. LUXATION OF THE TESTICLE. Occasionally the testicle is dislocated. In one case reported,* the right testicle was suddenly and violently drawn up into the inguinal canal during masturbation, and did not come down again. Later in life, when the patient died, this testicle was found soft, atrophied, pulpy, about one fifth the size of its fellow. P. Bruns f records the case of a man run over while lying on his back. The right testicle was dislocated over the pubis at the root of the penis. It remained there and did not atrophy. He refers to other traumatic dislocations, one under the skin of the thigh (the testicle atrophied), and a num- ber where the luxation was into the inguinal canal. HYPERTROPHY AND ATROPHY. The testicle becomes hypertrophied conservatively when its fellow is defective or wanting, and in certain lusty individuals the testicles are abnormally large. Atrophy of the organ may result from a variety of conditions. The retained testicle in a monorchid does not develop fully, and may atrophy. In hot climates the organ is said to atrophy (Larrey), as it does normally in old age. Atrophy may come on, usually attended by neuralgia, after prolonged sexual excesses, or may succeed sudden pain after fatigue. Probably some inflammatory element is at the bottom of this cause. Lemmonier J records the case of a man of nineteen, who after a severe injury to the skull suffered rapid atrophy of the right testicle (with hemiplegia, etc.). Kelaton and others have spoken of atrophy of the testicle resulting from causes acting at a distance. Lereboullet * saw a case in tlie Val-de-Grace where double atrophy of the testicles from mumps was accompanied by a simultaneous development of the mammae in a man of twenty-two. True orchitis (inflammatory) or the form complicating mumps may be attended by atrophy. Mumps usually spares the testicle before puberty, and even after puberty, when the testicle is implicated, only partial atrophy or no atrophy at all may follow. I have thought that the rather free internal use of jaborandi lessens the probability of atrophy when the testicle is at- tacked in mumps. * " Med. Times and Gazette," vol. xviii, p. 67. f " Mittheilungen aus der chir. Klinik zu Tubingen," Heft 3, p. 483, 1884, X "France Medicale," December 25, 1884. * Quoted in "Hays's Monthly Abstract," October, 1877, p. 462. nYPERTROPHY— WOUXDS. 369 True orchitis, or the form comjtlicating mumps, is liable to be followed by atrophy. Any tumor or morbid growth pressing on the testicle, or obstructing its vascular supply, may cause atrophy, e. g., ligation of spermatic artery, aneurism of aorta involving the spermatic arteries (Wardrop's case) ; in certain rare cases, hydrocele, large con- genital hernise, varicocele, may act in this way. A section of the nerves of the testicle will cause atrophy, as may also certain injuries of the head, back, or spinal cord. Ligation of all the veins of the cord produces atrophy. Atrophy sometimes attends severe neuralgia, especially the form accompanying large varicocele. Non-use of the testicle for any length of time does not cause it to atrophy. The somewhat common belief that the long-continued use of iodine will occasion atrophy of the healthy testicle is incorrect. Occasionally in children the testicles will cease to develop, or even atrophy, without any apparent cause. Syphilis may occasion atrophy, without any gummy deposit. Treatment. — For atrophy of the testicle there can be but little done. The causes are usually beyond the surgeon's control. In cer- tain cases the cause (neighboring tumor, syphilis) may be removed. CONTUSIONS OF THE TESTICLE. Contusions of the testicle are rare, owing to the peculiar anatomi- cal surroundings of the organ, notwithstanding its exposed position. In severe contusions there is usually more or less ecchymosis, and per- haps hrematocele or orchitis, and subsequent atrophy may result. One of the modes formerly adopted in the East for emasculating the attendants of the harem was that of squeezing the testis, and a simi- lar plan has been resorted to upon animals, instead of castration, in England and France (Curling). The inflammation after injury may be sufficiently severe to lead to the formation of abscess or to gan- grene. Treatment. — The patient must be placed at once upon his back, if the contusion be severe, with the testicle elevated and covered with a cooling application ; if subsequent inflammation occur, it must be met appropriately (orchitis). WOUNDS OF TESTICLE. Punctured wounds, if small, are of no importance. They give rise to no inconvenience and heal without trouble. Penetrating wounds of any size, however, allow some of the tubular structure of the testis to escape. This, projecting outside and covered with pus, is very apt to be mistaken for a core of pus, and to be pulled out as such. Malgaigne mentions a case where he saw the whole pulp of the 24 370 DISEASES OF THE TESTICLE. organ pulled oxit in tliis way. Incised wounds are followed by suppu- ration, partial exulceration, and recovery, with more or less atrophy. Injuries to the testicle (contusions or wounds) are usually very pain- ful in sensitive subjects, and are liable to be conii)licated at the time with faintness, nausea, vomiting, convulsions, or tonic s]iasnis. Treatment. — In wounds of the testicle, if there be any true hernia of the secreting substance, it should be reduced if possible, and re- tained by pressure, or by a suture through the tunica albuginea. If it can not be reduced, it may be snipped off with the scissors, or al- lowed to separate by the natural inflammatory process, but should in no case be pulled upon. Large incisions should be cleaned, united by suture, and the parts carefully supi)orted. Even if a large part of the testicle has been destro^'cd by the accident, an effort should be made to preserve what is left. Dorsal decubitus must be preserved, and the testicle properly supported. Cool water-dressing is as good as any that can be emjiloyed, perhaps mingled with a little alcohol or carbolic acid. HEMATOCELE. The term ha^matocele is applied to a tumor caused by the effusion of blood into the sheath of the testicle and cord (sometimes into the cellular tissue of the scrotum as well), into the tunica vaginalis, or into a pre-existing cyst of the cord. It is usually of traumatic origin, or is a secondary affection occurring where hydrocele has preceded it by a mingling of blood with the serous contents of the tuiiior. The most common cause is violence, associated with crushing of tissue and injury of blood-vessels. An operation u})on a hydrocele may wound a vessel or the testicle itself, and, if the haemorrhage takes i^lace internally, a hrematocele results. The disease may ex- ceptionally have a spontaneous origin from active or passive hypere- mia ; varicose scrotal or seminal veins connected with great laxity of the scrotum ; or, rarely, from a luTmorrhagic secretion in scorbutic individuals. Sir Benjamin Brodie * mentions as a cause a diseased (calcareous) condition of the arteries distributed upon the tunica albu- ginea, similar to the degeneration of the arteries of the brain which often precedes apoplexy. One of them may rupture into the tunica vaginalis. There are, consequently, two varieties. The one coming on rap- idly, usually after injury, and attended by effusion of blood into the scrotum, where the latter suddenly swells, becomes blue, black, or vio- let-colored, with a more or less evident feeling of fluctuation, or where a pre-existing cyst or hydrocele, after violence, becomes suddenly larger, more tense, and painful. There is more or less high sympto- matic fever, and the inflammation may possibly go on to suppuration. * " London Medical Gazette," vol. ix, p. 927. n^JIATOCELE— CAUSES. 371 In the other, or spontaneous variety, the tumor increases slowly in size and simulates hydrocele, except in regard to transluccncy. This latter form is difficult to diagnose from hydrocele in proportion as the blood is thin and confined to the tunica vaginalis propria. The blood in hsematocele may be found red and fluid, but it is usu- ally black or brown, and may be mixed with pus, if severe inflamma- tion has followed its effusion. Its fibrinous portions may be more or less stratified, as in aneurism. The walls of the tunica vaginalis, or of a cyst in contact wrih blood (unlike what occurs when their contents are serous), tend to thicken and become adherent to the surrounding connective tissue, while the inner surface becomes rough and uneven, resembling anything more than a serous surface (Fig. 106). The walls of hasmatocele have been found an inch thick. The diagnosis of h?ematocele of the second or spontaneous variety presents many difficulties. Here there is no guide in any discoloration of the scro- tum, or any suddenness of growth of the tumor. The records of surgery pos- sess many cases where perfectly healthy testes, surrounded by a hsematocele in- side of a thickened tunica vaginalis, have been extirpated, under the idea that they were cancerous. Often there exists no positive means of diagnosis short of an exploratory operation with the knife, which is the proper course to follow in such cases. There are, however, characteristics of hsematocele which may serve to distinguish it from hydrocele and malignant growths. The pyriform shape of hydrocele exists, but there is no translu- ccncy of the tumor. This, however, would also be the case in an old hydrocele with thickened walls. The mass feels unusually heavy when balanced in the hand. If it has been attentively watched, it will be found to have decreased a little in size at some period of its growth, which does not occur in malignant disease. The peculiar sensibility produced by pressure on the testicle can often be called out by pressing upon the mass behind, at about the middle portion. Ex- ploration with the aspirator and a good-sized exploring-needle will clear up the diagnosis. The amount of pain is variable. The general health does not, as a rule, suffer much. In a doubtful case an ex- ploratory incision is demanded. In the traumatic variety, when the blood has been effused into the connective tissue of the scrotum, the diagnosis is made at once by the Fig. 106 {Curling). 372 DISEASES OF THE TESTICLE. history, size, heat, and color of the tumor. Tliis is more strictly con- tusion with effusion of blood, and not true lutMnatocele ; but it may accompany the latter condition when due to violence. 2'rcatinent. — In acute cases all that can be done is to keep the patient upon his back, with the testicle sujiportcd and covered with cold lotions, administering j)eriiaps an occasional laxative and an ano- dyne if the pain be severe. If the quantity of blood effused is not too great, the pain will soon begin to subside, and the ]iatient may be al- lowed to go about with a suspensory bandage. The blood will gradu- ally be absorbed. If, in spite of these means, which will rarely be found to fail, blood continues to be poured out into the cavity so that the pain becomes excessive, and the tension of the parts very great, a trocar may be in- troduced to draw off the blood, and cold and pressure applied to pre- Tent refining of the sac. If it fills again, a second tapping, delayed as long as possible, will probably afford a more serous fluid than the first, and a third, a fluid still less tinged, after which radical treat- ment by injection may be attempted. When, however, the blood is in clots, it will not flow through a trocar, and then an incision may be required, as it is also when the inflammation is imminent from tension. All the clots should be turned out, the cavity thoroughly washed with a mild, warm solu- tion of carbolic acid, or other antise])tic lotion ; bleeding-points should be looked for and secured by ligature. Damaged and redun- dant portions of the tunica vaginalis may be cut away, and, after thor- ough antiseptic irrigation, the sides of the tunica vaginalis may be attached by suture to the sides of the scrotal incision (Volkmann's method), the cavity drained and dressed antiseptically. In incising the tunica vaginalis an opening should fii'st be made above and in front, and this should be continued on a director, or be- tween two fingers, fairly to the bottom of \hQ sac, to secure good drainage. If the incision be made at one stroke, the testicle, which is sometimes misplaced and lies in front, may be laid open, an accident which has happened in the most experienced hands. If the tunica vaginalis in an old case be found much thickened, it is better to cut it away — invariably if its walls contain calcareous plates. The reaction following operation is rapid and severe, and, in the case of old patients, it may sometimes be preferable to perform castra- tion, as the milder alternative. With the young and middle-aged, however, this course is not to be thought of, as the testicle is seldom injured, although in long-standing cases it is occasionally atrophied. Erysipelas or gangrene may follow the laying open of hematocele. A haematocele produced by the effusion of blood into a pre-existing hydrocele may usually be treated like uncomplicated hydrocele. Any systemic state predisposing to haemorrhage requires special manage- HEMATOCELE— TREATMENT. o < o ment, and all operative interference should be delayed until such blood-dyscrasiae have been removed. H.^MATOCEIiE OF THE CORD. Pott has described a diffused haematocele of the cord coming on during straining at lifting or at stool, and confined within the tunica vaginalis communis. This form is exceedingly rare. It may occur, also, in connection with general ecchymosis of the scrotum from injury, and calls for the same treatment. The blood will be reabsorbed in time. It has been confounded with hernia, and operated on as such. If the tumor continue to enlarge in spite of position, rest, and cool- ing applications, a free incision should be made, the clots turned out, the wound washed, and the bleeding vessel sought for and secured. When an encysted hydrocele of the cord, by accident or dyscrasial disease, becomes a htematocele, the same changes take place in the walls of the sac and surrounding tissue as have been described in haematocele of the tunica vaginalis. The treatment is also the same, care being always taken to treat the dyscrasial causative condition. FREE BODIES IN" THE TUNICA VAGINALIS. Occasionally little excrescences spring up from the surface of the testicle within the cavity of the tunica vaginalis. They may grow any- where within the tunica vaginalis, but are more common on the epididy- mis or around the so-called hydatid of Morgagni. These excrescences have an inherent tendency to grow large at the summit by a deposition of concentric layers of very dense connective tissue, and thus become pediculated. New excrescences may form upon an old one, constituting a sort of dendritic vegetation. There is a tendency to a central deposit of calcareous salts early in the formation of these little pedunculated balls, which causes an arrest in their growth. After this the pedicle becomes more and more thin, and finally breaks and disappears in some motion given to the testicle. In this way are the free bodies formed. They are found of all sizes, from the head of a pin to a large hazel-nut. They are not encountered in connection with very large hydroceles, although some fluid in the tunica vaginalis usually accompanies them. They may often be felt from the outside, and be liberated at once by an incision if they cause pain or inconvenience ; which, however, they sel- dom do. Occasionally after tapping a hydrocele great pain has been complained of, which has been found to be connected with the existence of a loose body in the sac. In structure these bodies consist of con- centric layers of very dense fibrous tissue, cartilaginous to the feel, sur- rounding a central nucleus of calcareous matter. An attentive inspec- tion of the surface of the testicle will often show prominences or de- pressions corresponding to the points where the free bodies had been attached by their pedicles. 374 DISEASES OF THE TESTICLE. CHAPTER xxin. DISEASES OF THE TESTICLE. Hydrocele, acnte, chronic.— Dinrrnostic Table of Chronic Hydrocele with Incarcerated Ilcmia.— Pal- liative Treatment. — Itjulical Treatment.— C(>nj;enital Hydrocele.— Dia-iiiostic Table of t'ongeni- tal Hydrocele and Hernial Tumor.— Trne and Spurious Hydrocele of Hernial Sac— Encysted Hydrocele of Testis.— Spermatocele.— Spermatic Congestion.— Origin of Spermatocele.— Hydro- cele of Cord, diffuse, encysted. Hydrocele, or dropsy of the testicle, consists in an accnniultitioii of serous tluid within the cavity of the tunica vaginalis (simple hydro- cele), or Avithin a cyst connected with the testicle (encysted hydrocele). This fluid is usually highly albuminous and of a pale-yellow color, hut it may vary through shades of red, brown, green, and black, by the admixture of more or less blood, or blood-pigment, and in old cases the fluid may contain fatty matter and plates of cholesterine, granular bodies, pus, epithelium, and occasionally spermatozoa (spermatic hydrocele). The fluid differs, both in its nature and mode of pro- duction, from that of general anasarca. In anasarca the scrotum may be full and the tunica vaginalis empty. The liquid of hydrocele often contains a substance similar to fibrin. On exposure to the air under these circumstances, it will generally deposit in one or several layers. Buchanan, of Glasgow, found that if blood were mingled with the fluid it coagulated, when by contact of air alone it would not do so. Alexander Schmidt produced the same coagulation by adding blood-globules or hgemato-crystallin. The fluid sometimes contains salts and albuminates in a proportion analogous to that of lytn])h — which never obtains in the fluids of simple dropsies (Virchow). Chy- locele* is the name given to the hydrocele in certain cases. Vidal de Cassis first described this affection, calling it galactoccle.f Buscy calls it chylous hydrocele, and Claudius Mastin, chylocele. William Mastin cites the cases of Vidal, Euthnum, Ferguson, and C. H. Mastin, and adds his own, a fifth case, in which, and in 0. H. Mastin's case, incis- ion effected a cure. In both, a projecting point, believed to be the offending lymph-vessels, which leaked, was ligated and cut awtiy. Ty- son, of Philadelphia, examined the fluid in both instances, and found it to resemble chyle ; alkaline, 1015-1018, albuminous, full of mole- cules and small granular cells. Ether dissolved the fat, which after- ward on evaporation offered a cream-like mass. In one of the cases there were a few spermatozoa. * W. H Mastin, "Ann. of Anat. anl Surg.," May, 1882, p. 223. f "Traite de Pathologic et do Med. operatoirc," 5tb edition, vol. v, 18G1, p. 180. nYDROCELE. y/ib Another form is that of multilocnlur hydrocele, christened lymph angioma by Steinthal,* and consists of a main sac, a': the botUnn (jf which are many small ones, the largest as big as a cherry, containing clear, white fluid. Steinthal thinks the cysts are developed out of dilated lymph-vessels. They are lined with endothelium. Cause of Hydrocele. — In the aged, anaemic, weak, and badly nourished, there may be a chronic dropsy of the tunica vaginalis, the cause of which is simply general hydrasmia ; there are usually other serous effusions existing at tlie same time. Thin condition is a general one, and no special attention need be paid to the hydro- cele, except the wearing of a suspensory bandage, until the general health is restored, after which it would be proper to undertake a radi- cal cure, if the hydrocele did not spontaneously subside. In excep- tional cases, when the collection of fluid becomes excessive, palliative puncture may be resorted to. A slight amount of hydrocele exists, as a rule, in conjunction with all diseases of the testicle, especially of the inflammatory sort (orchitis, epididymitis), and not infrequently with syphilitic and tubercular disease of the organ. But in these cases again the hydrocele is only a symptom, and a radical cure should not be attempted. When the disease of the testicle subsides, the hydrocele will get well. True hydrocele is the result of a secretory irritation of the tunica vaginalis testis, produced usually by mechanical violence, or in sym- pathy with some irritation of the testicle, cord, or urethra. The mechanical violence most apt to produce it is such as is slight, irrita- tive, and long continued ; rubbing, jolting, crushing. In warm cli- mates it is very frequent, on account of the relaxed condition of the scrotum, which exposes the testicle to injury. In Brazil one man in every ten is said to suffer from hydrocele (Hyrtl). Hydrocele may be left behind after an acute inflammation of the testis, and, in those exceptional cases where the communication of the tunica vaginalis with the peritoneal cavity has not been closed after birth, a hydro- cele is known as conoeuital. ACUTE HYDROCELE. This is an acute peripheral orchitis, coming on in connection with acute epididymitis or orchitis, and needs no detailed account. The condition is analogous to pleurisy. The effusion is rapid, sero-plastic, or sero-hcemorrhagic. The fluid is absorbed, as a rule, while the inflammation of the testicle is subsiding, and no treatment is of any service before that time, unless, possibly, puncture, if the effusion be very large. * "CntiToltt. f. Chirurgic," October 10, 1SS5, and Hays's, "International Journal," January, 18S6, p. 283. 376 DISEASES OF THE TESTICLE. It is always caused in a mild degree by the stimulating injections, or other treatment used for the cure of chronic hydrocele, and may occur idio})athically Avithout necessary connection with other inflam- matory disease of the testicle, but this is exceedingly rare. Rest with cooling lotions, and acupuncture, if necessary, constitute the treat- ment. CHRONIC HYDROCELE. In chronic hydrocele, the effusion takes place slowly, and without pain. The swelling is often only discovered by accident. It com- mences in the lower part of the testicle in front. It has no tendency to spontaneous subsidence. The accumulation of fluid tends to go on indetinitely, with occasional periods of quiet, until, in some cases, an enormous size is reached. The amount of fluid may be only a few drachms. It seldom exceeds a pint. Curling met witli one case which contained forty-eight ounces. Sixty-four ounces were taken from one (personal) case. Mr. Cline is said to have removed as much as six quarts from the historian Gibbon (Sir Astley Cooper). Out of a thousand cases reported by Dr. Dujat, from the Hospital of Cal- cutta, in eighteen the quantity drawn off varied from fifty to one hundred and twenty ounces for each case. The mechanical incon- venience of such a tumor in such a position is at once apparent. When a hydrocele has lasted for a length of time, its walls arc liable to a fibrous thickening, which greatly obscures the diagnosis, or they may undergo cartilaginous or, more rarely, calcareous degenera- tion. If subjected to irritation or repeated injury, which can hardly be avoided, these changes are all the more apt to occur. The con- tents of hydrocele may be mixed with blood, or even become puru- lent. Secondary cysts may form in or upon the surface of the testicle, surrounded by the fluid of the hydrocele, but this is rare. Long- continued pressure of the fluid, especially when the tunic is thickened and covered with lymph, occasional!}', but very rarely, leads to atrophy of the testicle. Points of adherence may exist between the two sur- faces of the tunica vaginalis, dividing the cavity into compartments. Si/m/>ioms. —Hydrocele is usually pear-shaped, larger below than above ; or it may be oval, and, if very large, almost spherical. It can not be reduced by pressure. Fluctuation can usually be made out. The tumor is generally very tense, the scrotum often stretched and shining. The cord, of natural size and feel, can be grasped above the tumor. The weight is slight compared with the size of the mass. The testicle is usually situated behind, a little below the center (Fig. 107), and pressure on this point gives rise to the peculiar sensation experienced when the testicle is squeezed. Occasionally the testicle is found below and in front, more rarely in the center, in front, from plastic adhesion. Its position should always be ascertained before HYDROCELE. 377 operating on a hydrocele. Dupuytren mentions several cases where this precaution was overlooked, the testicle was wounded and the diagnosis unconfirmed. If the testicle be punctured, as a rule no serious inflammation results. Pressure on a hydrocele does not pro- duce pain ; there is no heat or redness of the skin, unless the tumor be large enough to keep it constantly on the stretch. There is flatness on percus- sion, differing from hernia, and there is no subjective symptom except a little dragging sensation in the groin and lower part of the abdomen, run- ning up to the back, caused by the weight of the tumor. Diagnosis. — The infallible diag- nostic sign is translucency. This is obtained by making the skin tense over the tumor, and viewing a lighted candle, held as near the tumor as pos- sible, through the upper part of the swelling, shading the eye with the hand, or, better still, looking through a cylindrical roll of paper, or a stetho- Fig. 107 {Potf). scope. If the room be darkened, translucency may be detected where otherwise the test might fail. Often translucency may be made out by simply making the tumor tense with one hand, shading the eye with the other, and holding the hydrocele between the eye and the window, in the daytime. Trans- lucency is greater in proportion to the slowness of the accumulation, the thinness and whiteness of the walls, and the limpidity of the fluid. If the contents of the tumor are dark-colored, or its walls very dense and thick, there will be no translucency. In such a case exploratory puncture will decide on the nature of the tumor. A fine exploring trocar should be used with an aspirator. Few diseases are easier of detection than simple, uncomplicated hydro- cele ; few more difficult where many complications exist. Varicocele may compliccite hydrocele. To recapitulate : the symptoms of simple hydrocele aie pyriform shape, slow growth, commencing at the bottom of the scrotum, fluc- tuation, translucency — all with absence of pain. DIAGNOSTIC TABLE-HYDROCELE-INCARCEIIATED HERNIA. Hijdrocde. 1. Largest below. 2. Commences gradually. Incarcerated Hernia. 1. Largest above. 2. Comes on suddenly. 378 DISEASES OF THE TESTICLE. ffi/droeelc. 8. Commences at the bottom of tlie scrotum, anil grows up. 4. Is tense or fluctuating. 5. Cord can be maile out (normal) above tumor. 0. Testicle can not be founJ. 1. Dullness on percussion. 8. Tumor heavy, but movable. 9. KeJuction impossible. 10. Size usually constant. 11. Test by aspiration completes the diagnosis. Incarcerated Hernia. 8. Commences at the external ring and grows down. 4. Usually doughy. 5. Cord can not be distinguished, or is felt as distinct from tumor. 6. Testicle can usually be separated from tumor posteriorly. 7. Resonance on percussion (unless her- nia be omental). 8. Tumor unwieldy. 9. Ilcduction impossible. 10. Size varies at short intervals. Simple hydrocele may be complicated with incarcerated or simple heruia (Fig, 108). True and false hydrocele of a hernial sac and con- genital hernia in connection with hydrocele will be considered later. Absence of pain makes diagnosis easy Avith all inflammatory acute maladies. Smoothness of surface distinguishes hydrocele from cancer, cystic and tubercular disease. Treatment of Hydrocele. — Hydrocele is cured by causing the fluid to 'be reabsorbed, by arresting the secreting activity of the tunica vaginalis, or by excising the walls of the tunic by a cutting operation. Absorption occurs oc- casionally in the young, and, as a rule, in acute hydrocele spontaneousl}'. The treatment is pal- liative and radical. Tapping. — This is best performed with the aspirator (using needle No. 2, Dieulafoy). The skin is made tense, and the needle plunged into the anterior ]iarfc of the tumor, a little above the middle. The testicle should be carefully avoided. This simple operation will always efface the tumor at once, but in the majority of instances the sac will begin to refill in a few days, and after some weeks, or at most months, will have regained its i)rcvious size. Sometimes the tumor never refills, and the palliative o])eration thus becomes radical This rarely occurs except with children and very recent hydroceles. The chances of obtaining this fortunate re- sult are greatly increased if the inside of the sac be roughly scratched with the point of the exploring trocar, after the fluid has been drawn off. If the patient is old or greatly debilitated, he should always rest for a few days after tapping. The constant stretching of the skin by a large hydrocele renders it prone to take on gangrenous inflamma- FiG. 108 (.Vaclise). HYDROCELE— TREATMENT. 370 tion. Sir Astley Cooper mentions two cases of inflammation witii slouo-hing, followed by death, in old men who took a long walk imme- diately after the operation. It is well also, if the collection of fluid is very large, especially if the patient is old, not to draw it all off at one sitting. If the testicle has been wounded, the patient will complain of some pain, and blood will flow after the serum has been evacuated. Under these circumstances it is advisable to strap the testicle with adhesive plaster immediately after the operation, to prevent the further effu- sion of blood into the sac, as this is favored by the removal of press- ure. Collodion is recommended by some authors to compress the testicle in this and other conditions, but it will not do for all cases, as its application to the thin and sensitive integument of the scrotum sometimes gives rise to exquisite and prolonged torture. Acupuncture. — This consists in making the skin tense over the tumor, and penetrating the sac rapidly a number of times with a needle, which should be rotated as it is being withdrawn. The serum, in cases so operated upon, gradually escapes into the scrotum (in twenty-four to forty-eight hours), where it does no harm, and whence it is absorbed. The adult hydrocele will usually fill up after this operation, as it will after tapping, but the hydroceles of children often remain radi- cally cured, especially if the internal surface of the sac be scratched. If the cyst-wall be thick, and the tumor not translucent, neither tap- ping nor acupuncture will ever effect a cure. Healthy young patients can put on a suspensory bandage and resume work at once after tapping or acupuncture. Radical Treatment. — External irritation or stimulation of the skin will often suffice to cure a simple hydrocele in a young child. Tincture of iodine, at about half strength, may be used, or a lotion, recommended by Curling, of hydrochlorate of ammonia 3], distilled vinegar 3 iv, water 3 vj ; in fact, any mildly stimulating ointment or lotion will do. It is a waste of time to try this treatment upon the adult. Although chronic hydrocele has been known to subside spon- taneously in the adult, yet this termination is of so rare occurrence that practically it may be said never to happen. Sometimes the sac becomes ruptured by accident, inflammation follows, and the cure is permanent. That this is not an inevitable result is proved by a ease reported by M. Serres,* of a Spaniard, who was accustomed to ride horseback, or perform some other violent exercise, when his hydrocele became uncomfortably large. In this way he had ruptured it thirty times, remaining well for a considerable period after each application of this rather severe treatment. Of the many methods of treating * Cited bv Curling. 380 DISEASES OF THE TESTICLE. simple hydrocele, only two need be detailed, as they are applicable to all cases, nanielv, injection and incision, inclnding excision of the tunica vaginalis. Galvano-puncture failed in my hands. Injection. — All simple hydroceles which are translucent, no matter what tiieir age or how great their size, are amenable to treatment and cure by injection. Injection is not applicable to cases where the con- tents of the tumor are scro-purulent or sero-sanguinolent, or where tlie tunica vaginalis is extensively thickened, with or without calcareous deposit. In such cases incision cr excision should be resorted to. Ilvdrocele complicating syphilitic testis should generally be left alone or treated by palliative tapping — but in one such case I succeeded in effecting a cure by the injection of carbolic acid. Generally the hydro- cele accompanying syphilitic disease of the testicle disappears spon- taneously as the testicle grows better under internal medication. Celsus alluded to injections as a method of treating hydrocele, but Munro, of Scotland, Sir James Earle, and Sir James Ranald Martin, of England, are the names most prominently connected with it. In- flation with air has been employed, and the most varied substances have been used in injections, from distilled water to the strongest acids, hot and cold. Many substances have been employed success- fully, such as spirits of wine, port wine, solutions of alum or sulphate of zinc, air, chlorine gas, lime-water (Curling), chloride of zinc, bi- chloride of mercury, tincture of iodine (Martin), and last and best carbolic acid. A hydrocele should not be injected when first seen. Tapping should be tried first, and perhaps the fluid may not rcaccu- mulate. I have seen extensive inflammation follow simple tapping on two occasions in the cases of old men. Both resulted in cure. When the tumor is very large, it is best first to reduce its size by one or more tappings, and finally to inject when the surface has become con- tracted by being relieved from prolonged tension. If the hydrocele is found to contain more or less blood, injection should be postponed until some future tapping yields a comparatively limpid fluid. If syphilitic or tubercular disease be found, injection is inadmissible, generally. I have used many substances in injection for the radical cure of hydrocele, and have finally come to rely totally upon pure carbolic acid. It is more certain, more speedy, less pain- ful, and less dangerous than any substance I have ever used. To R. J. Levis, of Philadelphia,* belongs the credit of having introduced this substance to the profession as a proper injection in cases of simple hvdrocele. I have adopted the suggestion with thanks, but think I have improved the method. I have applied it with entire success to hydrocele simple (and in one case complicating syphilitic testis), to encysted hydrocele of the cord, and to spermatocele— all with success in each and every instance save one, a case of small spermatocele. No * " Trans. Med. Soc. of State of Pennsylvania," 1881. HYDROCELE— TREATMENT. ggl complication and no serious reaction in any case lias ever occurred in my hands. Pain is uniformly moderate. No carbolic-acid poisoning or any symptoms of it have occurred. I have injected at the same sit- ting two and a half drachms into three separate cysts, in the cords of an old gentleman past sixty, with entire success and confinement of only a few days. I have operated on the table at the hosjjital clinic, and had the patient get up from the table and Avalk down smiling to the wards — an impossibility if iodine had been used. I have operated in my office in New York and sent the patient home in a carriage to Brooklyn. How many times I have operated I do not know, but they count by scores. I look upon the injection as entirely innocent and harm- less, but, of course, I usually take precautions, and ask my patient to remain in bed one day. If, at the end of that time, he can get up and go about, he may do so ; if pain and swelling prevent, as they some- times do, he must remain in bed until motion is possible, using a poul- tice and taking an anodyne if necessary. I have even aspirated on the third day, in certain cases in which the reaction has run high. When the patient goes about, he should wear a suspensory bandage. The tunica vaginalis always refills after the operation, and the testicle is generally quite tense and hot for a few days after the first twenty- four hours. Sometimes it remains cool and flabby, but refills partly with fluid, and the patient is as nearly as possible devoid of pain from one end of the treatment to the other. The reaccumulation of fluid is slow to absorb, especially in the flabby cases where there is lit- tle or no inflammatory reaction, but it always, in my experience, dis- appears totally within the period of one year, and the patient remains perfectly cured. I have operated upon a child two months old and an old man past eighty, always successfully thus far, and in many in- stances I have effected a cure after the previous use of iodine at the hands of another had failed. To Dr. Levis belongs great credit for having introduced so valuable a substance. My operative method is very simple. The instruments are a glass syringe, holding one hundred minims, having an ordinary hypodermic point (rather large and about two inches long)— this, and an aspirator. I fill the one-hundred-minim syringe with pure carbolic acid deli- quesced with a few drops of glycerin. I plunge into the hydrocele the needle of this syringe detached, and watch for the oozing out of a drop of clear serum to announce the fact that the tip of this needle is well within the cavity of the tunica vaginalis. I now insert the as- pirating-needle and rapidly exhaust the hydrocele, if possible to its last drop, an important measure, that the carbolic acid may not be diluted. Meantime the hypodermic needle first introduced has not been disturbed at all. When all the serum has been removed by the aspirator, I screw upon the hypodermic needle, first introduced, the one- hundred-minim syringe, and rapidly inject from forty minims to one 3S2 DISEASES OF THE TESTICLE. drachm and a half of the pure acid, according to the size of the hydro- cele, immediately witiidrawing: the needle, and leaving the acid within the cavity of the tunica vaginalis. This little oi)eration is clean, almost ]iainless, absolutely bloodless. No anaesthetic is required. The tes- ticle is maniinihited a moment to insure the diffusion of the acid, an anodyne is left to be taken if required, and next day, if there is only moderate pain with swelling, the patient gets up and continues about. If the reaction has been considerable, he remains in bed for a few days with the testicle sui)ported. and using such anodyne or local soothing measures as his surgeon thinks it proper to order. Second- ary aspiration gives relief if the tension is great. Incision must be employed where there exists the least doubt as to whether or not tlie tumor be hernia, where the walls of the tumor are very thick or calcareous, where its contents are sero-purulent or sero- sanguinolent, and where injection has failed. Unless the position of the testicle has been positively made out beforehand, the sac should be opened upon a director, otherwise a clean incision may be made from top to bottom anteriorly. If the walls of the sac are very thick, and especially if they contain calcareous plates, they should be cut away. After incision, the best treatment of the wound is that suggested by Volkmann,* namely, after antiseptic irrigation the serous membrane or its remains, if parts have been snipped away, are joined all around by many points of fine suture to the edges of the incision in the scro- tum, the cavity drained and dressed antiseptically. Incision is a harsh method, and entirely unnecessary in simple hydrocele, whatever its size. I have cured a hydrocele holding a quart by the carbolic-acid-injection treatment. CONGENITAL HYDROCELE, In congenital hydrocele there has been only a partial obliteration of the peritoneal prolongation at its neck, and, instead of the usual solid, thin, fibro-cellular cord (Scarpa's habenula), we have an open canal making the cavity of the tunica vaginalis continuous "with that of the peritonaeum. The abdominal serum gravitates into this cavity, and hydrocele is the result. The diagnosis is usually easy, but in certain cases there is some chance of confusion with hernia. Coiir/cnihxl Hifdroccle. Hernial Tumor. 1. Appears soon after birth. 1. May appear at any time. 2. Tumor continues into inguinal canal. 2. Same. 3. Receives impulse on coughing. 3. Same, 4. Flatness on percussion. 4, Resonance on percussion. * " Bcrl, klin. Wchnschrft.," January 17, 1876, p. 29. CONGENITAL HYDROCELE— TREATMENT. 383 Congenital Ihjdrocclc. Hernial Tumor . 6. Always reducible at an even rate, 5. If reducible, goes back suddenly, more or leas rapidly according to size of with a {gurgling sound, opening ; no jerk. 6. Testicle, entirely obscured by the 6. Testicle can usually be made out as tumor, reappears on the reduction of the a distinct lump. latter. 7. Feel soft, not doughy. 7. Doughy feel — perhaps gurgling, on manipulation. 8. Always translucent. 8. Never translucent. A simple liydrocele may coexist with hernia at any time of life, and it is not uncommon for congenital hydrocele to be complicated by congenital hernia (Fig. 109). Congenital hy- drocele may be found in adults, but is rare. Treatment of Congenital Hydrocele. — The fluid need not be reduced, but a well-fitting truss must be applied. This will usually ob- literate the neck of the sac, and is Nature's method of accomplishing cure. The fluid will be absorbed in from two to eight months after closure of the neck of the sac. If not absorbed, the case, after the neck is closed, may be treated as simple hydrocele. Complication with hernia does not call for any modification of treatment. Congenital hydrocele should never be injected. Desault and Dupuytren did inject congenital hydrocele with a stimu- lating fluid, making, at the same time, firm pressure at the ring. This treatment, sometimes successful, has also been followed by fatal peritonitis. If the neck of the sac can not be closed, the case may be left for radical operation by the knife in adult life by laying open the neck of the sac and suturing the sides of the ring with catgut, as for the radical cure of hernia. Fig. 109 {Madise). HYDROCELE OF HERNIAL SAC. An old hernial sac may become obliterated at its neck by wearing a truss, or by becoming plugged up by a portion of small intestine or a piece of omentum. This old sac may fill with fluid, and thus become hydrocele of the hernial sac. The diagnosis is made mainly by a study of the history of the case. Treatment. — Injection is not allowable. A careful incision is to be made, the fluid evacuated, the intestine returned, the omentum cut off, the ring sewed up with catgut, the wound drained and man- aged antiseptically, as in the radical cure of hernia. 384 DISEASES OF THE TESTICLE. SPURIOUS HYDROCELE OF HERNIAL SAC. This is a considorable aeciimiilatioii of lluid around an incarcerated hernia. Treatment. — Incision and operation for reduction of licrnia. The iluid in true and in spurious hydrocele of the hernial sac is usually dark-colored. ENCYSTED HYDROCELE OP THE TESTICLE. Simple cysts, developed out of the ]KHliculatcd or non-pediculatcd hydatids (so called), sometimes containing spermatozoa, are found about the head of the testicle. They may be found within simple hydrocele, and it is by the bursting of one of these cysts into the cav- ity of an already distended tunica vaginalis (or its puncture during operation) that the contents of the hydrocele contain spermatozoa (spermatic hydrocele). On this point Virchow and Gosselin are in accord. Such cysts may be treated by incision or injection with carbolic acid. SPERMATOCELE. Spermatocele is a collection of serous fluid, containing spermatic elements, either in the tunica vaginalis or in a cyst situated near the head of the testicle. The title has been inappropriately bestowed upon another condi- tion, which may be briefly disposed of. When the sexual appetite has been kindled and kept excited for some time without being grati- fied, seminal fluid, which has been j^roduced and is collected in the testicle, vas deferens, and seminal vesicles, will usually be discharged in an involuntary emission at night, and no inconvenience Avill be felt beyond slight aching, and increase of size of the testicle. Sometimes, however, Nature fails to relieve herself, and then the testicle becomes large, hot, and excessively tender, the epididymis is distended and knotty, the whole cord tender and tense, the scrotum red, the suffering very considerable, and the testicle, apparently, about to become acutely inflamed. The origin of the mischief can always be ascertained. A cure follows a natural discharge of the excess of semen, or may be brought about by rest, elevation of the testicle, and cooling lotions. This derangement does not deserve the name of spermatocele. It might be called spermatic congestion. Listen (1843) and Lloyd (1849) first found spermatozoa in the fluid of hydrocele. Spermatic hydrocele does not exist, except in an encysted form, or secondary to it. Although a tumor may resemble hydrocele in all respects, yet it may yield, on puncture, a milky fluid SPERMATOCELE. 335 containing spermatozoa. In such cases one of two accidents has oc- curred : 1. An encysted spermatocele, jutting out within tlic tunica vagi- nalis, and obscured by its fluid, has been punctured during tapping of the latter, and thus allowed a mingling of spermatic elements with the other contents of the hydrocele. 3. The cystic spermatocele has ruptured early in its formation, discharged its contents into the tunica vaginalis, and continued on furnishing spermatozoa mixed with the fluid of the hydrocele (Vir- chow, Gosselin). There exist normally upon the head of the epididymis several little prominences,* solid and cystic, known as the hydatid of Morgagni or pediculated hydatid, corpus innominatum of Giraldes, and non-pedicu- lated hydatids. They are the remains of the Wolffian body, and of the duct of Miiller. From one of the non-pediculated hydatids, un- doubtedly, spermatocele is formed, f * Rosenmiiller, " Qusedara de ovariis Embryonum et Foetuum humanorum," Lipsise, 1802. Kobelt, "Der Neben-Eierstock des Weibes," Heidelberg, 1847. Miiller's "Physi- ology," by Baly. Virchow, " Die krankhaften Gesehwiilste." Strieker, " Manual of Histology," American edition ; and " Todd's Cyclopaedia," vol. v, Supplement, Art. " Parovarium." ■)■ The testicle is developed in the foetus, near the Wolffian body, but independent of it. This Wolffian body consists of a set of tubes, all of which open into the duct of the Wolffian body. The duct terminates in the uro-genital canal. This duct becomes finally the vas deferens in the male (in the female it atrophies). Of the tubes forming the Wolffian body the central ones unite by open ends (vasa recta) with the testicle. They become the coni vasculosi, and connect the testicle with the canal of the epididymis. Of the lower caecal tubes of the Wolffian body, not connecting with the testicle, some atrophy, and others (one or more) become developed into the vasa aberrantia of Haller, while the upper tubes atrophy, or become converted into non-pediculated hydatids (so called) ; in other words, simple little cysts at the head of the epididymis. The corpus innominatum of Giraldes, a convolution of small tubes, shut at both ends, is another remnant of the Wolffian body. In the female, all the tubes of the Wolffian body continue ctecal. They constitute the parovarium of Rosenmiiller, and furnish the little cysts so often existing normally in the broad ligament, near the outer border of the ovary. Besides the duct of the Wolffian body, there is found in the foetus another tube, be- ginning in a blind extremity running over the tubes of the Wolffian body, but not con- nected with them or with their duct, to which it runs parallel, and emptying by a sepa- rate orifice into the uro-genital canal. This is the duct of Miiller. In the female it forms the Fallopian tube. Its extremity becomes fimbriated, and its blind end atrophies or remains as a small, pediculated hydatid. In the male it atrophies, its blind extremity often persisting as the hydatid of Morgagni (so called), a pediculated cyst at the head of the epididymis. Its length lies along the border of the epididymis, as an atrophied thread, sometimes showing hydatidiform swellings, while its other extremity is repre- sented by the prostatic utricle. This insight into the origin of the little cysts found normally at the head of the epi- didymis explains why we sometimes have developed there a simple cyst, and sometimes a spermatic cyst. If the hydatid of Morgagui or one of the hydatidiform swellings of the atrophied duct of Miiller should become enlarged into a cyst, we should have a simple cyst, for the duct of Miiller never possessed any connection either with the testicle or with 25 386 DISEASES OF THE TESTICLE. It tends to increase in size indctinitely. It may coexist with hydro- cele, and be masked by it. It may be broken early by accident, and, continuinfj to secrete, form spermatic hydrocele, or it may be punctured with the trocar when a supposed sinii)le hydrocele is tapped. Symptoms of Spermatocele. — When complicating simple hydrocele and jutting into the cavity of the latter, there are no symptoms by wiiich si)ermatocele can be distinguished. Uncomplicated, it has peculiar features. Usually a slight uneasy sensation is experienced near the head of the epididymis, not amounting to pain, often en- tirely unnoticed, or at least forgotten by a patient who may afterward find the little tumor by accident. If seen early, an uiulofined sense of thickening with extra resistance is distinguishable by the finger, in the region of the top of the testicle. This goes on increasing, usually, at so slow a rate that the patient soothes himself with the idea that it will become no larger. It grows, however, constantly, and may at- tain a large size.* There is no pain, except a slight dragging on the cord. The cyst keeps its position at the upper end of the testicle, and becomes gradually heart-shaped, the testicle lying below at the point, the cyst sometimes notched above. The walls are usually thin and tense, so that fluctuation can not be always distinguished, but trans- lucency is usually present. The fluid may be dark-colored or very milky, somewhat masking translucency. The patient is very apt to become hypochondriacal, and to imagine that his sexual appetite and power are failing. On tapping such a cyst, the fluid will usually be found milky or dark-colored, and the microscope readily detects spermatic elements, often exhibiting lively movements, with others more or less decom- posed, many oval heads without the tails, blood, granular and fatty matter, and some granular pigment and epithelial cells. The diagno- sis can never be pronounced with absolute certainty until the micro- scope has detected spermatic elements in the fluid. Treatment. — After tapping, a spermatocele will invariable refill. The proper mode of treatment is by injection or by incision, as in hydrocele. the Wolffian body. If, on the other hand, one of the far more numerous cysts, the re- mains of the upper blind tubes of the Wolffian body, should enlarge, it is easy to see how the connection which originally existed between this blind pouch and the duct of the Wolffian body (now canal of the epididymis and vas deferns) might be re-established (or never have been closed), and seminal elements find their way into the cyst, especially if there were some stricture of the canal of the epididymis or of the vas deferens. In the same way, if one of the vasa aberrantia should enlarge, we might readily have spermato- cele. It has been supposed that some of the tubuli of the testis itself may become en- larged into a spermatocele, but this has never been demonstrated. * Frost records a case forty years old yielding fifty-two ounces on tapping. " Lancet," December 14, 1878, p. 483. HYDROCELE OF THE CORD. 387 HYDROCELE OF THE SPERMATIC CORD. Hydrocele of the cord is either diffuse (infiltrated) or encysted. The spermatic cord is enveloped in a loose layer of connective tissue, which is continuous with the external and internal connective-tissue envelope (perimysium) of the abdominal muscles, starts at the external abdominal ring and surrounds the whole cord, the epididymis, and the testicle, being firmly attached to the latter at its lower end, and in- separable from the reflected tunica vaginalis propria. The cremaster muscle is spread out upon its external surface. This loose connective tissue is described by anatomists as a sei^arate fascia, and is called tunica vaginalis communis. The meshes of this tunic sometimes become the seat of a diffuse serous infiltration (first described by Pott) constituting infiltrated hydrocele. Scarpa has described it as a simple oedema. Boyers rec- ognizes it as a special form of hydrocele. Vidal doubts its existence, and Pitha never saw it. It is very rare. Curling believes it may oc- cur in general anasarca, and saw it once complicating acute orchitis. It is mainly interesting from its liability to be confounded with omen- tal hernia. The symptoms readily differentiate it from ordinary hydrocele. Symptoms. — The swelling is uniform, round, and smooth, the in- filtration occupying the meshes of the connective tissue ; toward the base there may be one large cavity. There is no communication with the cavity of the tunica vaginalis propria. Enlarged inguinal glands, or any obstruction to the return of blood from the testis, may act as causes. The swelling ceases, according to Pott, just where the vessels enter the testicle, the latter organ being isolated from the general swellihg. The tumor becomes more cylindrical in shape in the supine position, but it does not disappear. Pressure makes it recede upward slightly, but it returns in any position of the patient. The penis never appears so much retracted as in simple hydrocele of equal size. Diagnosis is with omental hernia. The latter, however, when re- duced, will remain in the abdomen until the jDatient stands up, while the hydrocele will return in any position (Pott). The surface is firmer in epiplocele, and the swelling larger above than below. Hydrocele is not so entirely reducible, and receives no impulse on coughing. In irreducible epiplocele the diagnosis is difficult, at times impossible. Fluctuation can be felt at the bottom, but not at the top, of diffuse hydrocele. The enlargement extends to the ring. The shape is rather pyramidal, but can be somewhat altered by pressure. Treatment. — Palliative punctures may be made at the bottom of the swelling. Large incisions are dangerous. Pott lost a case in this way. When a diagnosis with omental hernia is impossible, and an operation seems advisable, an exploratory incision may be practiced. 388 DISEASES OF THE TESTICLE. ENCYSTED HYDROCELE OF THE CORD. Cysts may form along the cord in the habenula (remains of peri- tonea! process from the abdomen to the tunica vaginalis) when its oc- clusion has been imperfect at certain points. Tiie " hydrocele en chapclet '' of Cloquet is so formed. Again, cysts may be developed at any point along the cord^in its connective tissue, or in the meshes of the tunica vaginalis communis. They vary in size from a jiea to a hen's Qgg, or larger. They are usually tense, smooth, oval, the long diameter parallel to the axis of the cord, translucent, sometimes fluc- tuating, although the tension of the cyst usually makes this sign val- ueless. Pain is absent or insignificant. The cysts usually occur be- tween the external abdominal ring and the testicle, but may also be found in the inguinal canal. In the latter situation it is sometimes impossible to distinguish such a tumor from incomplete inguinal her- nia without an exploratory herniotomy. When the cyst occupies this position, whether in the male on the cord, or in the female on the round ligament, unnecessary fear and anxiety are often excited in regard to hernia, and a truss or some other retaining bandage is usu- ally applied. This always gives rise to jDain, and considerably aggra- vates the trouble. Treatment. — For large encysted hydrocele of the cord, injection, as in simple hydrocele, is the best treatment. Injection is inadmissible when the cysts are strung out and communicate, as the result would be necessarily imperfect. For small cysts, whether single or multijile, incision is the best treatment, care being taken to avoid wounding the constituents of the cord. Incision is indispensable for cysts situated within the inguinal canal, or where there is any doubt as to hernia. HiEiiATOCELE of the cord is rare, but may occur in the same way as haematocele of the tunica vaginalis, usually after injury. Indica- tions for treatment are the same. CHAPTER XXIV. DISEASES OF TUE TESTICLE. Inflammation.— Orchitis.— Causes.— Symptorna.— Pathological Changes.— Prognosis.— Treatment.— Epididymitis.— Frequency and Date of Appearance in Gonorrlia'a.— Causes.— Symptoms. —Ster- ility as a Result of Epididymitis. — Diagnostic Table oi Orchitis and Epididymitis.— Treatment of Epididymitis. Ikflammatiox of the testicle may be limited to the epididymis (epididymitis), or may attack the secreting structure alone (orchitis). This has been explained by the fact that the arterial supply is differ- ent for the different constituents of the testicle. Sometimes both ORCHITIS— CAUSES. 3S9 parts inflame simultaneously — as after injury. Tlie secreting struct- ure may become secondarily involved by a simple inflammation com- mencing in the epididymis, but the latter rarely suffers in connection with primary, true orchitis. The subserous connective tissue of the tunica vaginalis, being in direct continuation with the connective tis- sue of the epididymis, in the vast majority of cases of epididymitis also becomes inflamed, constituting periorojiitis, or acute hydrocele. Periorchitis, on the other hand, is rarer with inflammatory orchitis, since the dense structure of the tunica albuginea keeps an inflammation originating on one side of it from being rapidly transmitted to the other. ORCHITIS. Causes. — True orchitis is very uncommon. As complicating mumps (so-called metastatic orchitis), no rational theory has been ad- vanced to account for it. Observation abundantly proves that it oc- curs in at least five per cent, as a complication of mumps in young adults, and the fact must be accepted without explanation. It has been noticed, indeed, during the prevalence of an epidemic of mumps, that cases of orchitis occur spontaneously in some patients whose parotids escape.* Orchitis due to mumps is most often observed at about the age of puberty. It comes on near the end of the first week of the mumps, and is usually confined to a single testicle. The ejH- didymis is perhaps also involved, but may escape. The affection runs a quick course of about a week or ten days, very rarely terminates in suppuration, usually subsides without leaving any impairment of the organ behind, but is sometimes followed by atrophy, f The right tes- ticle seems to suffer more often than the left (Rilliet). Isham J refers to several reported cases of alleged success in the treatment of the metastatic orchitis of mumps with jaborandi. I have used the drug and think well of it. Orchitis after severe injury to the testis is not uncommon. It tends to terminate in abscess or gangrene, and to be followed by atrophy, with loss of function of the organ. Orchitis as a result of cold is possible. Hanot* records a case of spontaneous orchitis which came on during typhoid fever and was followed by partial atrophy. Terrillon || gives the case of a healthy man who, during an effort at * " Medical Times and Gazette," vol. xix, p. 512. •f Laveran, "Medical Times and Gazette," July 20, 1878. Among four hundred and thirty-two cases of mumps in soldiers, there were one hundred and fifty-six cases of orchitis — not metastatic, as the parotid swelling did not subside when the testicle swelled. Out of one hundred and eleven cases atrophy occurred in seventy-three. With double atrophy virility is lost. X " Amer. Jour. Med. Sci.," October, 1878, p. 369. * Referred to in " London Med. Record," December 15, 1878. II " Ann. des Mai. des Org. Genito-urinaires," April 1, 1885, p. 230. 390 DISEASES OF THE TESTICLE. lifting, felt a suddou pain in llic left testicle, which mounted into the groin, remained there, inllauicd and atrophied into a librous nodule, which, becoming neuralgic, required ablation, lie refers to another case.* Sometimes orchitis comes on in children, and even in adults, where no sufficient cause can be assigned. Excessive sexual excite- ment has been adduced as a cause. Very rarely orchitis complicates variola or typhoid fever. A low grade of true orchitis, located in the fibrous covering of the organ, is liable to attack gouty individuals. Orchitis may come on secondarily during ci)ididymitis. Occasionally, especially in the old or enfeebled, true orchitis originates spontane- ously in patients having chronic inflammatory urethral or prostatic disease. Symptoms. — In true orchitis the increase in size of the testis gen- erally advances rather slowly, and seldom becomes considerable until the affection has lasted a length of time. This is accounted for by the unyielding nature of the albuginea, and the fact that there is usu- ally no effusion into the tunica vaginalis. The pain is exphiincd in the same manner. It is often excruciating, and always out of propor- tion to the amount of swelling. It has been compared to that of ne- phritic or hepatic colic. No position gives rest, and any handling of the organ is liable to induce syncope. The irritated cremaster con- tracts upon the sensitive testis, and draws it up toward the groin. The pain continues high for several days, and then gradually becomes more bearable, or it may suddenly cease altogether. This last circum- stance is gratifying only to the patient. The surgeon learns it with regret, for he knows that it may mean mortification of the organ. The shape of the testicle is rarely altered in orchitis ; it is smoothly, regularly ovoid. The epididymis is not distinguishable from the rest of the tumor. The organ feels peculiarly indurated, the natural elas- tic feel having entirely disappeared. The scrotal tissues are often red, swollen, cedematous, inflamed. There is a strong tendency to suppu- ration or mortification, the latter marked by a sudden cessation of pain. The former is often announced by the occurrence of chill. After the chill the testicle commences to enlarge more rapidly, the scrotal tissues adhere to its surface, and, after a period longer or shorter, according to the depth at which the matter forms, a soft, fluctuating spot, surrounded by indurated borders, indicates clearly the position of the purulent collection. After the pus has escaped, all the severity of the symptoms abates, unless a second purulent collec- tion exists in some other part of the gland. The flow of pus gradu- ally diminishes. As it decreases, the swelling subsides, and partial or total atrophy of the testicle ensues, Avith perhaps a fistula remaining open for years. Sometimes exuberant granulations grow up out of * Kocher's article, Pitha and Billroth, p. 3C6. ORCHITIS— CAUSES, 391 the opening, forming a cauliflower excrescence (hernia testis), wliicli may reach considerable size, and, growing as it does out of an en- larged, hardened testicle, perhaps at this stage irregularly lumpy, and containing some softer spots, while at the same time the glands in the o-roin may become enlarged, hardened, and tender, and the general health decline — all this array of symptoms is very liable to give rise to a suspicion of cancer, a suspicion which the result does not justify. Sometimes an abscess forms centrally in true orchitis, and never comes to the surface. . In such a case the symptoms run a despair- ingly slow course, but the hard and tender organ gradually reduces in size, undergoes chronic inflammatory induration, Avhilc the purulent collection gradually becomes solidified, surrounded by a tough cap- sule ; perhaps cretiiSes and so remains indefinitely, the function of the testicle being destroyed, unless the j)urulent collections have been very small. A somewhat similar state of affairs may succeed deep abscess, which has discharged and remained fistulous for a considerable time. These testicles remain long the seat of chronic pain, and are liable to repeated outbreaks of inflammation. Pathological Changes. — On section, it is usual to find a con- crete mass of more or less solidified pus in some jjortion of the organ, surrounded by a distinct fibrous capsule, while the contiguous struct- ure of the testicle is modified by chronic inflammation, perhaps de- generated into a fibrous mass. Concrete pus is distinguishable from cheesy tubercle in that the latter usually lies not encapsulated in di- rect contact with the seminal tubules, which, though atrophied by pressure, are in other respects sound. The yellowish, gummy (syph- ilitic) tumor is distinguishable from concrete jdus in not being (strict- ly) encapsulated, being usually homogeneous, consistent, tough (not friable, like concrete pus), and being infiltrated through the convo- luted tubes. Teemin'Atiois'S. — When orchitis terminates in gangrene,* after adhesion of the scrotum, the slough makes its way through the skin, and is found to be not black, or brown and fetid, like an ordinary slough, but yellowish, dry, and soft. It is a sort of dry gangrene, a necrosis, as Kicord calls it, and the slough may be pulled away in long filaments, constituted by the dead seminal tubules. Finally, two other termi- nations of orchitis are encountered : 1. Eesolution, with a return of the organ to its full functional power. 2. Atrophy, without either necrosis or suppuration. The general symj^toms in true orchitis are marked, often severe ; slight chills, pretty high fever, anorexia, nausea, vomiting, hiccough, * Gangrene is very uncommon. Consult an article by Tolkmann, " Archiv f. klin. Chir.," xxiv, 3, p. 399. Gerster reports an excellent case, " Xew York Med. Jour.," June, 1880, p. 576. 392 DISEASES OF THE TESTICLE. coustipation, sleeplessness, anxiety, great nervous irritation. The general symptoms have been comjiared to those of strangulated hernia, and, indeed, there is strangulation of the testicle Avithin its tight, fibrous sheath. Prof/)iosis is always grave ; the most energetic treatment is called for, to keep oil impending destruction of the organ. Treatment. — Rest on the back in bed, with the testicle supported in a sling, is essential to even moderate comfort. The patient needs no urging to keep him lying down. If the case is seen early, some of the large scrotal veins should be opened, and the bleeding encouraged by causing the patient to sit in a hot bath, or ten to fifteen leeches may be ajiplicd in the neighborhood of the abdominal ring. If seen at the very commencement, it might be allowable to try the constant application of ice-water in bladders, but this expedient has little or no influence over inflammation once under way in the testicle. ^Clie con- stipation which always exists should be combated. The testicle may be enveloped in strong belladonna-ointment, or a paste composed of powdered opium and glycerin, or, if the pain be not too excruciating, in a light tobacco poultice. In short, the organ must be narcotized and held suspended by an appropriate sling, so that the venous blood may be assisted in draining out of it. The diet should be low, non- stimulating, easily digestible. The early employment of these means gives the testicle its best chance. If in spite of them the symptoms fail to abate, in short, on the slightest suspicion of impending gan- grene, or in any case where the symptoms run very high, it is wise to resort without delay to subcutaneous section of the tunica albuginea, to take off tension from the strangulated parts within. This simple operation is readily performed with a sharp tenotomy-knife introduced through the skin, and then made to cut the tense fibrous capsule, while the testicle is steady in the other hand. The incisions should be carried fairly through the tunica albuginea, several short cuts being made at different points on the surface of the testicle (three to six), not over two or four lines long. In this way the tension being re- lieved, the pain will usually cease, and a continuance of the means above enumerated will probably lead to resolution. If abscess form, puncture should be made on the first appearance of fluctuation. In sphacelus, carbolized water-dressings are advisable. Nature and time alone are able in many cases to close a fistitla of the testicle left behind by the opening of an abscess. All that art can do is to make the opening a depending one, slit up sinuses, keep the j)arts clean, apply some stimulating lotion or injection to the sinus, and build up and maintain the patient's general health. In benign fungus (hernia testis), besides the above means aj^plied to the opening from which it grows, the mass itself may be cauterized, cut or tied off, subjected to pressure by adhesive straps, or, preferably, EPIDIDYMITIS. 393 after other diseased conditions have been subdued, the edges of the wound may be incised, freshened, and united by suture after the fungus has been replaced (Syme). Fungus should never be pulled upon, for fear of drawing out the entire contents of the testicle. In severe, long-standing cases, where a testicle is the seat of chronic induration full of fistula?, or with large, obstinate fungus, cas- tration is advisable, sometimes necessary, in order to remove from the patient a source of physical irritation, and to save him from serious injury to the general health. EPIDIDYMITIS. Epididymitis is the most common of all the diseases of the testicle. It occurs at all ages, most frequently during early adult life and mid- dle age, since its chief cause — urethral inflammation or irritation — most commonly exists during these periods of life. It has an acute form, but is very prone to run into the chronic state, and may be sub- acute from the first. It habitually terminates in resolution, rarely in abscess. One attack predisposes to another. It is often double, but the two testicles are very rarely simultaneously involved ; one usually precedes the other by a number of days or weeks, after which the disease sometimes returns to the testicle first invaded, chiefly in badly- managed cases. Fournier * has never seen double simultaneous epididy- mitis. It is uncommon but does occur. I have encountered it twice. Although the epididymis bears the brunt of the disease, it rarely suffers alone, except in very mild or chronic cases. In all acute attacks the tunica vaginalis is more or less involved, giving rise to acute hydro- cele, and sometimes the secreting structure of the testis takes fire as well. One particularly interesting feature of the disease is the fact, mainly brought out of late years by Oosseliu, that the chronic indura- tion so often left behind in the epididymis by inflammation sometimes blocks up the tubes sufficiently to prevent the passage of the spermatic elements, thus entailing temporary and sometimes permanent sterility, without an accompanying loss of sexual power. Feequeintct of Epididymitis and Date of its Appeaeaxce lif Go]sroEEH(EA. — Fournier states that epididymitis occurs about once for every eight or nine cases of gonorrhoea ; Sigmuud puts it at six or eight per cent. The left testicle suffers more often than the right. In some individuals there seems to be a predisposition, so that every attack of gonorrhoea, notwithstanding the utmost care, is invariably attended by swelled testicles ; while others, regardless of all hygienic precautions, go around with a raging gonorrhoea, employing perhaps no treatment, continuing sexual intercourse and the abuse of alcohol, not even supporting the testicle with a suspender, and yet they escape. * Art. " BlcnuoiThagie," "Diet, de Med. et de Chir. prat.," p. 211. 394 DISEASES OF THE TESTICLE. Foamier saw it develop, on the other hand, in a gonorrhoeal patient with typhoid fever, who had not ])nt his foot to the ground for six weeks. Here the generally shattered condition of the patient, brought about by typhoid fever, probably acted as a ]iredisposing cause. It may, however, be stated dogmatically, that while a gonorrhoea of itself will sometimes, in spite of all precautions, occasion swelled testicle, yet this complication is not apt to ensue if the patient wear a suspen- sory bandage, abstain from violent or jolting exercise (horseback, danc- ing), and avoid bodily fatigue and efforts at lifting. Above all, sexual excitement or indulgence, and the use of alcohol in any shape, must be interdicted. The passage of instruments through a canal subject at the time to gonorrhoea is a sufficient cause for epididymitis. The power of the suppressive treatment of gonorrhoea by strong injections early in the disease, although somewhat active, has been overrated. It should, however, be borne in mind. Balsams and terebinthinates internally can not give rise to the affection. The remarks already made concerning the liability to epididymitis in gonorrha?a apply with about equal force to cases of stricture. Some patients suffer from the worst of the inflammatory sequences of strict- ure, but the testis escapes ; while in other cases, perhaps of mild type, one or the other epididymis will be constantly falling into trouble on the slightest provocation, until the normal condition of the urethra has been restored. The treatment of stricture by instrument may itself originate epididymitis. As to the date of occurrence of gonorrhoeal epididymitis, Fournier has a personal tabulation of 232 cases, of which there occurred — In the first week. " second " " third " " fourth " " fifth " sixth " " seventh " " eighth " Mali ing in the first mo second third fourth fifth sixth seventh eighth ninth nth 86 22 34 SO 11 ... . 18 22 6 oq (1 6 19 It 4 9 a 3 01 11 3 11 4 Later 10, of which in the seventh year 1 ; most of the latter cases de- pend evidently upon stricture. De Castelnau's exhibit,* derived from the statistics of four surgeons, shows a total of 239 cases, of which there occurred — In the first week. " second " " third " In the fourth week 39 " fifth " 54 " sixth " and later 12 Unfortunately, this "and later" is deceptive, since it includes all cases of epididymitis due to stricture. * Quoted by Bumstead. EPIDIDYMITIS— CAUSES. 395 It is probable that, as a rule, the time for tlic occurrence of epididy- mitis in gonorrha3a has been set down a little too late. In every-day practice it is perhaps nearly as common to find tliis complication before as after the sixth week. In a general way it may be laid down that epididymitis is to be looked for mainly from the^third to the eighth week of gonorrhoea. A number of cases ai'c on record in which it is alleged that epididymitis has preceded the gonorrhocal outbreak (Pourneaux-Jordan, Sturgis, Stansbury, Castelnau, Vidal). In my opinion these are not true cases of gonorrhoea, but instances of bastard gonorrhoea, in which a deep urethra already damaged is kindled by sexual exercise into acute irritation, which promptly shows itself by producing swelled testicle, and only later manifests itself as a discharge at the urethral orifice. Causes. — Nearly all the causes enumerated as capable of producing orchitis may also exceptionally give rise to epididymitis : traumatic violence, cold. Prolonged, sexual excitement may cause it, and gout, but urethral infiammation or irritation is by far the most active cause. The most common form of this irritation is gonorrhoea, or urethritis, then stricture, finally any prostatic or urethral irritation, the passage of instruments, especially through a urethra already affected by mild chronic inflammation or stricture, but occasionally where no appreci- able disease exists, the use of the lithotrite, cutting operations for stone, retention of a small calculus or stone fragment in the prostatic urethra ; in short, any inflammatory affection of the prostatic sinus around the orifices of the ejaculatory ducts. It is probable, with all this last series of causes, that the mechanism of the cause is identical ; namely, that the prostatic sinus in the neigh- borhood of the orifices of the ejaculatory ducts first becomes inflamed, if only slightly, and that the inflammation, starting there, travels rapidly down the continuous mucous membrane of the vas deferens to the epididymis, where it locates itself. That this is sometimes the method of propagation is demonstrable by the course of the symptoms, and by the traces of inflammation occasionally found in the vas deferens after death ; but in the vast majority of instances the inflammation, pass- ing rapidly through the vas deferens, announces its course by no symptoms, and leaves no vestige of its presence behind. This has induced Brown-Sequard to deny that epididymitis is a transmitted inflammation, and to claim that it is a reflected irritation. He draws a comparison between the passing of a sound through a seemingly healthy urethra, or an inflammation existing in the canal, and the subsequent epididymal swelling, and ulceration of the small intestine after extensive peripheral burns. Pournier has cautiously emitted the theory that epididymitis may be a specific gonorrho?al affection of the rheumatic type, like the gonorrhoeal (rheumatic) affections of the eye ; still this would fail to account for epididymitis from the passage 396 DISEASES OF THE TESTICLE. of an instrument or the lodgment of a stone fragment. To sum up briefly, the theory most plausible and best borne out by observed facts is, that epididymitis from urethral inflammation or irritation is a direct but sudden transmission of inflammation over a continuous membrane,- from the orifice of an ejaculatory duct to the epididymis. This is further supported by the following facts : E})idi(lymitis from gonorrho?a rarely comes on early in tiie disease, unless instruments or irritating injections have been used, but occurs toward the end of the causing malady, just when the latter occupies the lower end of the urethra. The mucous meml)rane behind a tight stricture is always more or less inflamed, and this inflammation is liable at times, in bad cases, to run backward and affect the neck of the bladder. Under these circumstances, mild, continuous forms of epididymitis are not uncommon. The deeper down the urethra the stricture lies, the more apt is epididymitis to complicate it. Instrumental interference, or the retention of a stone fragment in the forward parts of the urethra, is very rarely attended by epididymitis, while this complication is not uncommon when the same irritation is applied to the prostatic portion of the canal. Symptoms. — Epididymitis may come on in an acute or a subacute form, the latter where the epididymis has previously suffered from a similar attack. First attacks, like first attacks of gonorrooha, are usually the most severe. Epididymitis is ushered in by premonitory symptoms which j)recede the swelling by some hours. Gonorrhoeal or gleety discharge is usually not visibly modified until after the testicle begins to swell. Then it becomes lessened, perhajos stops, to return again as soon as the inflammation of the epididymis is fairly on the decline. A vague uneasiness is felt in the testicle, and along the cord up into the back, as if the cord were being pulled upon. Attentive pa- tients will frequently aver that the pain was noticeable in the groin for some hours before any uneasiness was experienced in the testicle. This forerunning inguinal pain is rarely absent where the epididymitis is of urethral origin — except in hospital patients, who are unintelli- gent observers. There is usually only a slight painful tension in the groin, but sometimes it is very severe, extending around to the lum- bar region, and up the back. Sometimes there is a sense of weight in the perinaeum, frequent desire to urinate, with perhaps pain and diffi- culty in the act. Occasionally a chill, with febrile action, will usher in the affection, but these symptoms are far more constant with orchitis. Whether any of the foregoing symptoms have attracted attention or not, within a few hours decided pain is felt in the testicle, attended by a rapid increase in size. The amount of pain and swelling varies in different cases. In the subacute form of patients Avith stricture. EPIDIDYMITIS— SYMPTOMS. 397 the swelling is moderate, comes on rather slowly, palpation at once distinguishes the heat, sensibility, and hardness of the epididymis, and that the testicle itself is less affected. Periorchitis is absent, or not marked. There is but little, if any, fluid in the tunica vaginalis, or it may be felt loosely in the sac, not causing any considerable dis- tention. With such mild cases there are no general constitutional symptoms, and the pain is not excruciating. It is aggravated by the erect posture, but wholly disappears after the patient has been on his back, with the testicle elevated, for a few moments. The scrotal structures escape implication. But the picture changes vastly for the onset of an acute attack. The swelling commences promptly, and increases with rapidity. First it is localized posteriorly, but soon the subserous connective tissue of the tunica vaginalis carries the inflammation to the latter structure, which rapidly inflames, pouring out a plastic material upon its sur- face, and a sero-sanguinolent fluid into its cavity, which becomes rap- idly tense and distended, greatly adding to the pain. The secreting structure of the testicle is often distended fully with blood, but is not the seat of any pathological changes. The scrotal tissues inflame and become oedematous, large veins sometimes appearing on its surface. Yet, even under all these disadvantageous surroundings, with an oedem- atous scrotum and a tensely-filled tunica vaginalis, careful examina- tion will rarely fail to localize all the hardness and most of the pain in the epididymis. The inflamed mass rapidly reaches the size of the fist, but its shape is not so evenly oval as in orchitis. The cord becomes swollen, and painful on pressure. Occasionally so much inflammatory swelling exists here that the cord becomes partly strangulated in the inguinal canal, since it is impossible for it to swell much there, sur- rounded as it is by firm fibrous structures. This gives rise to all the well-known symptoms of inflammatory strangulation — excessive local pain, great prostration, anxiety, vomiting, perhaps hiccough. Pain in acute epididymitis is great, increasing from the first pro- portionally with the rapidity of growth of the swelling. The pain, however, is not so severe as in true orchitis. It is of the sickening variety, making patients feel faint. Locomotion is almost (sometimes quite) impossible, the motions of the patient are very deliberate as he changes his position, and, if necessitated to stand, he carefully sup- ports and shields his swollen scrotum with his hand. Eest on the back, with the testicle raised, while it modifies, does not allay the pain, but in this position the torture is more bearable. If strangula- tion of the cord at the ring occurs, the pain is greatly intensified, re- sembling that described for acute inflammatory true orchitis, being, in fact, dependent on the same cause — inflamed tissues strangulated within unyielding fibrous coverings. If some inflammation of the body of the testis exist, the pain will be proportionally heightened. 398 DISEASES OF THE TESTICLE. As tlie disease advances, pain increases in intensity for several days (three to six), remains stationary for several days after the organ has reached its full size, and finally begins to decrease, and, even in desperate cases, by the end of the second week has usually disap- peared, or become reduced to the slight dragging uneasiness which constitutes the only pain of mild cases. This relief from pain is often experienced while the organ is yet large, the epididymis thickened, the scrotum oedcmatous; and some fluid still left in the tunica vagi- nalis. For several days after the pain has ceased, a few moments in the erect posture, with the testicle hanging, will recall it. The form and size of the swelling vary greatly. In the mildest cases the tail of the epididymis alone suffers. All the inflammation local- izes itself there, forming a hard, sensitive lump, giving a little uneasi- ness unless supported, everything else being normal. The head, to- gether with the tail of the epididymis, may suffer, nothing else be- ing involved, or tlic whole of the epididymis, while the gland proper may be felt normal in every respect in front of the inflamed mass. The vas deferens may be also involved in mild chronic cases, as in the tuberculoid varieties. It may, however, in any inflammation of the epididymis, be increased in size (perhaps greatly so), and painful on pressure. In very acute attacks the whole cord is sensitive and hypercTinic. The seminal vesicles are also occasionally inflamed at the same time. Very rarely peritonitis has been seen to come on, provoked by the last-named complications (Hunter, Velpeau, Eicord). If the disease be at all acute, the tunica vaginalis is sure to be in- volved, the degree of its inflammation usually, but not invariably, co- inciding with the intensity of the epididymitis. This periorchitis varies greatly. Fluid may be rapidly poured out, filling the sac to its utmost, giving rise to a tense swelling of considerable size, in which case it becomes impossible to distinguish the constituent parts of the testicle. This form is often attended by excruciating pain, relieved, as if by magic, by puncture of the tunica vaginalis. Again, but little fluid may be effused. This, lying loosely in the sac, fluctuates freely, and does not in the least obscure the fact that the main disease is in the epididymis. The fluid may be absorbed speedily, allowing the plastic material effused with it to glue together the two surfaces of the vaginal tunic, or perhaps only to form numerous bridled adhe- sions. Some fluid may remain throughout — the nucleus of future hydrocele. In acute cases the scrotum may be so inflamed and oedema- tous as to give a very exaggerated idea of the size of the tumor. Tlie constitutional symptoms, fever, loss of appetite, etc., are mild with epididymitis, do not occur at all in chronic and subacute cases, and in acute cases, like the pain, vary with the intensity of the inflam- mation. What fever there is disappears before the pain, and long be- fore the swelling. EPIDIDYMITIS— SYMPTOMS. 399 Epididymitis may be said to have a natural limit for its acute symp- toms of about two weeks, but relapses are very common, and careless- ness may prolong the trouble to as many months. Hardness of tlio epididymis may remain behind for months, or even years ; such indura- tions retain their sensitiveness on pressure for a long time. Relapses are always milder than first attacks. If the other testicle inflame be- fore the first is well, the latter runs through its course more quickly. The gradual disaj)pearauce of the hardness from the epididymis may extend over many years, and in some cases is never accomplished entirely. The body first attains its natural feel, then the head, and, last of all, the tail. The absorption starts rapidly, but progresses more and more slowly, until in some cases it seems to rest stationary. In such cases the little hard lump at the bottom of the epididymis occasions the patient no uneasiness, is not sensitive to pressure, and is ignored. Suppuration is very rare in true epididymitis, not tuberculoid in character ; atrophy never occurs unless the substance of the testi- cle has been involved. Sterility. — In connection with the sterility often following double epididymitis, the pathological changes seen on section are instructive, and fully explanatory. In the early stages, hyperemia, plastic, se- rous, and sanguinolent effusions occur. These plastic deposits take place in the cavity of the epididymal tubules as well as around them, gluing them firmly together, so that after a certain time, especially in the tail of the epididymis, nothmg can be distinguished on section but a homogeneous mass, in which the eye seeks in vain to trace out the convolutions of the epididymis or the course of its canal. In the case of a patient of Velpeau,* an examination of the specimen by Eobin disclosed the fact that the hard lump occupying the epididymis was homogeneous, resembling cheesy tubercle on section. The con- voluted tubes inclosed in this mass were dilated to several times their ordinary size, but filled with the products of inflammation — jDus-cor- puscles, fatty debris, granulation bodies — all of this being within and none without the tube, looking as if all the inflammatory action had expended itself in producing secretion in and upon the free mucous surface, not extensively involving the peritubular tissue. Gosselin f found in his interesting dissections that the canal in the lower part of the epididymis was often impermeable, the tubes beyond the obstruc- tion being sometimes dilated, sometimes normal Testicles in these cases of obstruction do not atrophy, nor do the seminal vesicles of the same side undergo any change. For purposes of prognosis it is well to recall the anatomical fact that the head of the epididymis is formed of many tubes (coni vasculosi), all going to unite with and pour their secretion into the canal of the epididymis. * Reported in the " Gazette des Hopitaux," December, 1854. f " Archives Generales," Fourth Series, xiv, xv. 400 DISE.iSES OF THE TESTICLE. Hence chronic induration hero may have allowed one or more tubes to escape, and sterility is not so inevitable. The tail of the epididy- mis, on the other hand, as Gosselin sagely pointed out, is composed of the convolutions of one tube. This tail of the epididymis, too, is just the spot Avl'ioro the chronic induration left behind by epididymitis is apt to become localized. The tube obliterated here cuts ofT communi- cation with the testicle, and, if both sides arc affected, no spermato- zoon can reach the urethra. Yet it is well to know that even in these cases affairs arc not always desperate. The patient is by no means impotent, his sexual power and appetite are unimpaired. He ejaculates semen resembling the healthy fluid in quantity, smell, and color, only it contains no siiermatozoa, and consequently he is sterile. The same holds good usually of a monor- chid who has epididymitis on the sound side, for the retained tes- ticle seldom furnishes spermatozoa. This sterility is in my opinion generally permanent, and I have studied a great number of cases at all ages after tlie disease, and failed to accomplish cure by a great va- riety of treatment. Yet I can not assert that it does not sometimes get well. Certain it is that some patients who allege that they have had double epididymitis in their youth, are yet perfectly fertile. A curious fact in connection with tiiis subject (showing the bound- less kindness of Nature in doing everything to preserve the genital functions uninjured) is, that the testicle does not atrophy, no matter how long its duct may be occluded, and, if the latter finally become pervious, the testicle is ready for use. Animals have been experi- mented upon by having their vasa deferentia cut, but the testicle does not atrophy. Healthy spermatozoa are found in it months afterward (Curling). Another curious fact is, that in man sexual intercourse may be practiced without (as might have been expected) causing pain- ful, or inducing any, swelling of the testicle or upper portions of the epididymis from the accumulation of spermatic elements. In the vast majority of cases time alone will remove the indurations, and with them the sterility ; and even this can not be counted on. Diagnosis. — The following table may be of service-as bringing into contrast the most marked diagnostic differences between true orchitis and epididymitis. Of course, when orchitis comiDlicates epididymitis the symptoms will be mixed. Orchitis. Epididymitis. 1. Comparatively rare. 1. A very common affection. 2. Causes usually, injury, mumps, gout, 2. Cause almost invariably urethral in- cold, etc. flammation or irritation. 3. Pain usually excruciating, and not 3. Pain usually bearable except with relieved by position, while enlargement is extreme enlargement, always modified by still moderate. position, except in cases of strangulations of the cord. EPIDIDYMITIS— TREATMENT. 401 Orchitis. ' 4. Shape of tumor oval. 5. Epididymis not distinguishable from the rest of the tumor. 6. Testicle of peculiar hardness, very sensitive. I. Rarely any fluid in tunica vaginalis. 8. Constitutional symptoms usually present. 9. Termination in resolution, abscess, gangrene, chronic induration, or atrophy. 10. Never followed by sterility except as result of destruction of tissue, and then, if both sides have suffered, by impotence as well. II, Course often slow. Epididymitis. 4. Shape oval, roundiah, oblong, often irregular — especially from scrotal (f;doma. 5. Epididymis distinguishable from the rest of the tumor, enlarged, indurated, and particularly tender; testicle often percep- tible, of natural feel in front of it. These symptoms, perhaps obscure for a few days, at the height of the affection, always hold good during the period of decline. 6. Testicle often normal in front of epididymis ; perhaps hard from inflamma- tion of its tunics, but not as sensitive as in orchitis. V. Always fluid in tunica vaginalis in acute cases. 8. Constitutional symptoms absent or unimportant. 9. Termination habitually in resolution, leaving slight chronic thickening of tail of the epididymis behind. 10. Often followed by temporary, some- times indefinite, sterility if both sides have suffered : never by impotence. 11. Course generally rapid. Treatment. — The prophylactic treatment of epididymitis is the use of a suspensory bandage during the existence of urethral disease, to- gether with a strict observance of the hygiene of the urethra (p. 43). When, late in gonorrhoea, or during treatment of stricture, complaint is made of a dragging, uneasy sensation in the groin or testicle, the patient should be immediately placed upon his back, with the testicle elevated, and the threatened attack may thus be often averted. In mild cases, where rest on the back with elevation of the testicle is sufficient to quiet pain, these means alone are required to effect a cure, perhaps aided by a light, hot flaxseed-poultice and a laxative. In a few days the patient can stand, and, by supporting his testicle, walk without pain. In acute cases the treatment must be more active. Eest on the back and elevation of the testicle over the abdomen are indispensable. The latter can not be secured by a suspensory bandage, since that supporter allows the testicle to hang down ; nor is it well to trust to pillows and compresses under the testicle, since they allow the patient no motion. No improvement on Curling's method has yet been sug- gested. It consists simply in a handkerchief or piece of bandage around the waist, and a large (preferably silk) handkerchief, folded in triangle. The base of the triangle is placed under the scrotum ; one (acute) angle on each side is tied to the waistband, the other (right) 26 402 DISEASES OF THE TESTICLE. angle is brought up ovor the testicles and penis, serving to retain dressings, and is pinned or tied to the "waistband. If the testicle be not Yer\' large, or the patient move much, the sling tends to slip up in some cases. This may be easily obviated by sewing a tape to that })or- tion of the sling immediately under the scrotum, carrying it between the nates and attaching it at the back to the Avaistband. In all inflammatory diseases of the testicle this bandage is of the first importance. Having arranged it, the patient is put to bed with the testicle enveloped from the start in a tobacco-iioultice. In cases that require any active treatment at all, and where pain and swelling are already present, any cold or astringent application is harmful. The object is to narcotize the testicle at once, and quiet pain, and this, in the vast majority of instances, tobacco, heat, and position will do.* The poultice is made by mixing a paper of any line-cut tobacco ( | j) in about 3 x of hot water, bringing the whole to a boil while stirring it briskly, and then adding ground flaxseed, with or without ground elm-bark, until the proper consistence of a poultice is obtained, stir- ring the tobacco well in with the meal. A poultice of this mass is made about a quarter of an inch thick, and large enough to envelop the whole testicle. A piece of fine muslin is put on the surface of the poultice, which is perhaps sprinkled with laudanum, and placed upon the testicle as hot as it can be borne, the whole covered with a piece of oil-silk — for cleanliness' sake as well as to retain the heat — and sup- ported in the handkerchief-sling above described. Ordinarily, the tes- ticle will be narcotized and nearly painless in a few hours, unless the patient attempt to stand upright. The poultice is to be renewed every eight hours, and these applications continued steadily until the indu- rated epididymis has quite or nearly lost its sensitiveness to i)rcssure, ■when the patient may commence gradually going around, wearing a suspensory bandage containing some woolen batting. A cleaner and equally effective method of narcotization is to rub up into a paste dialyzed opium with oleate-of-zinc powder, spread tliis thinly upon a light poultice made of powdered elm-bark, and apply ; or powdered opium mixed with stramonium ointment may be used, 3 j or 3 ij in the 1 j ; or hot opiate or belladonna fomentations. I have tried ice, and abandoned it ; bismuth paste is, I believe, useless ; Fourneaux Jordan's 3 ij of nitrate of silver in the 3 j of water, painted once over the entire scrotum, has a value in most cases, but it is quite painful for a time, and often fails to relieve. The hot narcoti- zation, I think, is a better plan. Ordinarily, the acute stage of the disease requires not a whit more of treatment than this to effect speedy resolution. A laxative, with a " The tobacco-poultice was subjected to the test of a thorough trial through many years at the New York Hospital. It proved itself more serviceable than any other agent. EPIDIDYMITIS— TREATMENT. 403 tempered regimen, is always appropriate where a healthy man is sud- denly confined to his back. In conditions, however, of extreme pain, where the disease is ex- ceptionally acute, we have at our command powerful means of relief. When the cord has become strangulated, and position does not bring relief, from ten to fifteen leeches above the groin, along the course of the cord, will often calm the pain as by magic. The bleeding should be encouraged by the use of hot water. This is much more efficient than the extraction of blood from the scrotum. Another cause of ex- cessive pain, in some cases, is extreme distention of the tunica vagi- nalis with fluid. A puncture to let this out is followed by strik- ing and immediate relief. Some authors advocate puncture of the tunica vaginalis in all cases, whether it be tensely distended or not, stating that it moderates the pain and shortens the attack. It is often unnecessary, and need not be resorted to where position and local nar- cotism suffice to quiet pain, as they usually will. Patients with swelled testicle are sometimes unruly, and refuse to go to bed, taking narcotics and wearing a poultice while they continue at their work. Such a course is certain greatly to prolong the dura- tion of the attack, and to be followed by chronic induration of the epididymis, which is very apt to be obstinate and to entail sterility, as far at least as one testicle is concerned. Then, again, the imj)atience of restraint, felt by a man lying on his back and suffering no pain, often induces him to leave his bed too soon, and thus sometimes a re- lapse is provoked. Patients anxious about business or concealment should be advised from the start that they will save time and trouble, and perhaps avoid destroying the functional activity of the testicle, by yielding to the necessities of the case at once and going to bed. They may be assured that often four or five days are enough, and that not more than a week, or, in the worst cases, ten or twelve days in bed will be required, if they will observe the horizontal position absolutely for that period. In such a case leeches to the cord, puncture of the tunica vaginalis, and diligent poulticing will bring the testicle in a week to a condition of comparative repose, not paining when let alone, but still, perhaps, several times larger than its fellow, painful on ma- nipulation and in the erect posture. Under these circumstances the patient may employ his time as he chooses, and go about at will if the testicle be strapped. Strapping a testicle to reduce swelling, first proposed by Fricke,* of Hamburg, has not met with the favor it deserres, for two reasons : 1. It takes time, trouble, and some experience to apply it so as to give comfort and be of service. * Fricke's proposition was to strap a commencing swelling, and thus prevent it. This is impossible. 404 DISEASES OF THE TESTICLE. 2. If unskillfullj applied, it either docs no good, or causes pain, and actually does harm. It has been known to occasion gangrene. In declining epididymitis, however, this agent, properly em- ployed, is most valuable in abridging the duration of treatment. When the organ is still quite sensitive to pressure, some days before the patient can walk with comfort, even with his testicle suspended, if adhesive straps be carefully and snugly applied, locomotion with- out pain is at once possible (with a suspender), and there is no fear of a relapse. Strapping is performed as follows : The hairs are cut from the scrotum and strips of adhesive plaster * prepared, from one half to three quarters of an inch broad (according to size of testicle) and six to eight inches long. The patient now sits on the edge of a chair in front of the surgeon, with his knees widely separated. The testicle is caught in the hand, gently rolled and manipulated until the scrotum relaxes and the thumb and finger can encircle the cord easily above it. The position of the encircling finger upon the scrotum is accu- rately noted with the eye ; the patient is instructed to seize the testicle lightly, and hold it in position ; a piece of bandage long enough to encircle the testicle, and about two inches wide, is rapidly placed around it, its center corresponding to that portion of integument previously encircled by the thumb and finger, and a strip of warmed adhesive plaster is placed at once over the center of the bandage be- hind and one end brought round to the front and secured. The sur- geon now seizes the top of the testicle, draws lightly upon it, at the same time producing constriction with his thumb and finger above, and with the other hand pulls upon the free end of jilaster, brings it rapidly around to the front, following the central line of the bandage, and attaches it under tension to the back surface of the other end of the same strip. Now the testicle may be dropped. It will be seen to be covered by a tense, shining, perhaps purplish-looking integument, pretty tightly constricted above by a strip of plaster, the latter mar- gined all around on both sides by about three quarters of an inch of bandage. The object of the bandage (prepared lint is perhaps better) is to keep the sharp edge of the adhesive strip from cutting into the tender scrotum, an accident which always happens to a patient strapped without this precaution who walks about, and sometimes even in spite of it. The first strap is put on tightly enough to cause a little uneasiness. It has to be snug, or the straps subsequently applied would push the testicle through it. The remaining straps are adjusted in circles, each one covering about half of its predecessor, and all applied with a cer- * Bumstead's puegcstion of two parts of adhesive plaster with one of extract of bella- donna, spread on thin leather, is a good one. It does away with the necessity of any lint or bandage under the top strap. EriDIDYMITIS— TREATMENT. 405 tain degree of tension which can only be learned by personal experi- ence. After a number of straps have been applied, it will be found that they will no longer adhere (in a circular direction) to the purple, tense, bulging extremity of the scrotum. This portion is conse- quently covered in from the sides, and from before backward, by attaching a strip of plaster at a given point, high up over the circu- lar strips, bringing it down and tightly across the bulging end of the testicle, and attaching it high up over the circular straps at a point exactly opposite that from which it started. In this way, by start- ing at successive points, the whole of the exposed skin at the end of the testicle is covered tightly in. One or two more circular straps may now be applied to keep the lateral ones from slipping. The whole looks something like a large cartridge. A certain amount of soreness follows this apparently rough hand- ling, and it is well for the patient to lie down again for half an hour, to find out whether the strapping feels comfortable or not. If prop- erly applied, comfort will have returned by that time, and the patient may now place his testicle in a suspensory bandage to keep it from dragging upon the cord, and go around at will without fear of pain or a relapse. By the mechanical action of the evenly-adjusted pressure, the blood is kept as thoroughly out of his testicle as it was by his posi- tion in bed. If the straps cause pain after half an hour, they should be removed. Straps need to be reapplied every twenty-four or forty- eight hours, whenever they become loose. If they have been care- lessly put on, any point where the pressure is uneven will become cedematous. There is habitually some oedema about the bottom of the scrotum on removing the straps, but it is of no importance. The straps may be detached by cutting each one separately, or they may be conveniently removed all at once in a hot bath. After removal, new straps should be applied immediately. Ordinarily, after four or five strappings, extending over as many days, or perhaps a week, the testicle will be found to be reduced nearly to its natural size, a certain amount of hardness still remaining in the epididymis, perhaps con- fined to its tail. This hardness, as a rule, subsides spontaneously in a few weeks, in cases which have been judiciously managed ; some- times, however, it remains for years. Its departure may be hastened by keeping the testicle constantly in a suspender, covered by oil-silk, so as to keep up slight constant heat and moisture, of course treating any urethral disease which may exist. Sometimes it seems as if the continued use of mild mercurial ointment under the oil-silk hastened the absorption. No known medicine is of any proved service, iodine and iodide of potassium included. Tonics and cod-liver oil do good by improving the quality of the blood. To obtain the advantage and avoid the mechanical inconveniences of strapping, several contrivances have been devised to compress the tes- 406 DISEASES OF TEE TESTICLE. tide ; that of Alfred L. Carroll,* a woven bag to be laced up in front, and that of 0. A. Wiiite, f a thin sheet of molded hard ruliber to be similarly laced np. are examples. The simplest method of strapping is to roll lip the testicle in an ordinary thin rubber bandage, pinning it with a safety-pin. This does not cover in the tail of the testicle, but it admirably answers all the necessities of ordinary cases, is clean, quickly applied, safe, and can be removed at will by the patient, if re- quired. Jesse Hawes, J of Greeley, Colorado, has devised a rubber compressor to be laced in front, the walls of which are double and capable of being distended with hot or cold water, thus increasing the pressure and applying heat or cold as desired. The plan is a good one, the only objection being the perishable character of rubber goods. Nothing has been said of internal medication in the treatment of epididymitis. No medicine has any sjiccific power over it. Gonor- rhccal treatment may be continued, as it does no harm. Injections into the urethra are best intermitted, except in cases of relapsing epi- didymitis due to deep urethral inflammation, in which case deep ure- thral instillations of minute quantities of the nitrate of silver in solu- tion are often capable of effecting cure.* CHAPTEE XXY. DISEASES OF TEE TESTICLE. Psendo-tubercularEpididymitis.— Tubercular Testis. —Symptoms. —Pathology.— Treatment.— Syphi- litic Epididymitis. —Syphilitic Orchitis ; Interstitial ; Gummy.— Cancer.— Sarcoma.— Diagnostic Table of Syphilitic Testis, Tubercular Testis, Cancer, Sarcoma, including Diagnostic Features of Different Fungi.— Castration.— Dermoid Cyst.— Irritable Testis.- Neuralgia Testis. Pseudo-tubercular Epididymitis is very rare. It is simple, slow, chronic inflammation. Desormaux and Fournier | seem alone to have called esjiecial attention to it. It is peculiar in being observed, as a rule, only in the course of chronic urethral discharges, and because it simulates tubercularization with the most absolute accuracy, so as to be usually mistaken for it. It comes on during chronic urethral discharge, often without ap- preciable, immediate exciting cause, either as a subacute epidid3'mitis, very indolent and not yielding to ordinary treatment, or, even more insidiously, it commences in an absolutely indolent chronic form, * "Medical Record," March 19, 1881, p. 332. f "Boston Medical and Surgical Journal," January 29, 1880. X "Medical Record," Xovember 8, 1884, p. 529. * Keyes, " Xew York Medical Record," May 28, 1887. I Art. " Diet, de Med. et de Cliir. pratiques." ' TUBERCULAR TESTIS. 40 7 simply characterized by knobbed, irregular points of induration in the epididymis, slightly sensitive to pressure. The swelling increases slowly, but the pain ceases, until after a time we may have a large, knobbed, irregular epididymis, a healthy testicle, more or less fluid in the tunica vaginalis, and, perhaps, the vas deferens, which not infre- quently participates in the disease, swollen to the size of a pipe-stem, hard, slightly sensitive to pressure, smooth, or knotty and irregular. There is now a strong tendency to suppuration, and one or more abscesses may form in the epididymis, or possibly in the vas deferens, and discharge externally. Such abscesses long remain fistulous, and closing leave a nodosity which is slow to disappear. Sometimes matter forms near the tail of the epididymis, but the abscess finally dries up without discharging. This may leave a hard, insensitive shot or mar- ble-like lump, freely movable in the scrotum, and connected with the tail of the epididymis by a pedicle. Such curiosities are occasionally encountered. Sometimes resolution is effected after many weeks, per- haps months, without suppuration. The treatment is hygienic and tonic, in fact exactly the same as for tubercular epididymitis, but with more hope of ultimate success. TUBERCUIiAE, TESTIS. Tubercular disease of the testis is usually described as occurring in two forms — one as a continuation and degeneration of chronic inflam- matory thickening, left behind by previous disease ; the other spon- taneous, tuberculization coming on without apparent local cause, and unconnected with any urethral disease. The first of these forms has been described above as pseudo-tubercle. It always affects the epididy- mis primarily, may extend thence to the vas deferens and seminal vesicles, and finally involve the testis proper as well. It is distin- guished under a different head from tubercle proper. Its prognosis is much better. If not arrested, however, its advanced stages may be identical with those of true tubercular testis, and its terminations the same. The pathology of the affection is cheesy degeneration of in- flammatory products effused inside of, as well as outside of, the seminal passages. Tubercular testis ]oroper has certain peculiarities of its own. Its pathology is cell-proliferation, totally outside of the tubes and ducts (Rindfleisch).* Malassez gives the endothelium a share in the forma- tion of tubercle. His views are well set forth in an exhaustive mono- graph, containing bibliography to date, by P. Eeclus.f Tubercle of the testis is less common in the miliary form, but it does occur (Vir- chow). Tubercular disease of the testicle, in cases where it does not * " Histological Pathology," 2d edition. t "Du Tubercule du Testicule," Paris, 1876. 408 DISEASES OF THE TESTICLE. follow gonorrlioeal or other epididymitis as a sequence of chronic or of pseudo-tubercular disease, comes on without ai)preciable pro- Tokiug cause in lymphatic, strumous, or tubercular subjects, some- times in young men apparently perfectly healthy. It is most liable to appear during early manhood just after puberty, when the phy- siological activity of the gland is most marked. It may apjiear in childhood. Si/mpfoms. — The deposit takes place by preference in the epididy- mis, but the secreting structure usually also suffers later (Rindfleisch). There is no jjain, so that it is usual for the disease to pass unnoticed until by accident the patient's attention is attracted by the fact that one testicle is larger than the other. Sometimes, where the deposit is rapid, slight pain is experienced. On examining such a testicle, it is usually found large, hard, and lumpy behind ; but the Avhole organ is often also hard, irregular, unevenly nodular. There is perhaps some fluid in the tunica vaginalis, obscuring the outline of the testis. The vas deferens is often knotty, enlarged, and hard as far as it can be felt, and a finger in the rectum may detect the seminal vesicle similarly affected. There may also be (more rarely) tubercular prostatitis or evidences of tubercular kidney. The testicle feels heavy, the skin over it is unaltered, pressure does not cause pain (unless abscess be forming), nor does it occasion the sensation felt when the healthy testis is squeezed. It is not uncommon for both testicles to be affected, the one in a more advanced stage than the other. If botli are involved, the sexual ajipetite is usually reduced or absent. The malady advances slowly, sometimes remaining stationary for many months ; finally the nodules soften into abscess ; the skin becomes oedematous, adheres over the epididymis, the patient has a little pain for a few days, when the abscess bursts and discharges a thick, cheesy material, containing, if the body of the testicle has ulcerated, portions of necrosed seminal tubules from time to time. These abscesses remain fistulous for a long time, sometimes indefi- nitely, the fistulous tract being marked by great induration from chronic inflammation. New abscesses tend to form, pointing by old or new routes. After abscess of the substance of the testis, hernia testis may come on, and, when the disease mounts the cord, the in- guinal glands are not infrequently enlarged. These cases are often mistaken for cancer, and as such extirpated and recorded as fortunate cases of removal of cancer with no return of the disease. A patient may have both testicles indurated, knobbed, full of fistulas for years, and still seem to be enjoying excellent health, witli the exception of more or less loss of sexual desire and power, but usually he is pale, thin, anaemic, weak, perhaps with tubercular deposits in his lungs or elsewhere. For differential diagnosis, see table after Sarcoma. As to prog- TUBERCULAR TESTIS— TREATMENT. 400 nosis, a tubercular testicle is not necessarily lost. Pseudo-tubercular disease also is often indistinguishable from it. Pathology. — Tubercular nodules arc developed in the connective tissue (or lymph canals) around the seminal tubes and ducts. These partly organize into fibrous tubercles. The tubercles coalesce into large masses, dirty yellow on section, in direct connection with healthy tissue, not encysted ; and then, their vitality being low, cheesy de- generation of the center takes place. After a variable period the mass breaks down, and is partly eliminated by abscess. Kindfleisch, following Langhans and Klebs, believes tubercle to be the result of endothelial proliferation in the lymphatic spaces sur- rounding the seminal tubules. Terrillon and Lebreton* have collected from various Frencli sources cases of primary tubercle of the testicle, where the patients were followed until death and autopsies made, 33 in all, of which there died : 26 by consecutive tubercular disease of bladder and kid- neys ; 1 by consecutive tubercular disease of lung and peritongeum ; 3 by consecutive tubercular disease of peritonaeum ; 3 from accidental cause ; and 1 not accounted for. Thompson's statistics of 18 cases give 8 by general genito-urinary tuberculosis, 7 by renal and pulmonary tuberculosis, and 3 by pulmo- nary tuberculosis alone. The conclusions of Reclus are indorsed that primary tuberculosis of the testis is a grave source of danger and a focus of general infec- tion, and consequently that castration ought to be performed early. Lancereaux, f on the contrary, disagrees with Eeclus, and states that tubercle is never primary in the testicle, that it always begins in the prostate and goes from thence to the seminal vesicle, then to the tes- ticle, that it is consequently always a general disease from the first, and that it is not proper to remove the testicle. Treatment. — In tubercular disease of the testis the treatment ap- plied may save not the patient's life, for that is rarely implicated, but his sexual power, his peace of mind, and may give life to his children. It is hard to convince such patients that medicine is not the best thing for them, and they suffer so little pain that they are slow to see the necessity of giving up their business and living an easy out-door life in the country, or, better still, of transplanting themselves to one of the high inland resorts where the climate and surroundings are hostile to tubercle. Some patients, unfortunately, can not follow this course, and their case is sad indeed. Others can, but will not recognize the necessity of it. The chances are not encouraging or the hope very great, but in all cases where there is a hope that the disease may be pseudo-tubercular, * "Ann. des Mai. des Org. Genito-urinaires," Jan. and Feb., 1883, pp. 142-162. t "Ann. des Mai. des Org. Genito-urinaires," Jan., 1883, p. 153. 410 DISEASES OF THE TESTICLE. Tvhere only the epididymis is inyolvcd, tlie testicle being healthy, where onlv one organ is affected or even where both sutler, but the disease has not advanced far, the surgeon's duty is pUiinly to throw the whole wejo-ht of his influence into the scale, to induce the patient to flee into the country, to change his air and his surroundings, and to observe all the conditions of johysical liygicnc suitable to tubercular cases. A sus- pensory bandage is useful, with the testicle enveloped in oil-silk. Tliese means exhaust our best resources. Local dressings to the testicle are of no avail, except to amuse and satisfy the patient. If abscess form, it should be poulticed, and induced to point quickly, the other treatment being followed unremittingly. Old abscesses, tuber- cular cavities, and cheesy foci, with all fistular communications, should be laid freely open and very thoroughly scraped. Castration in my opinion should not be performed until the testicle is absolutely disor- ganized. The danger of general infection is not very great. This advice applies more positively to cases in Avhich both testicles are in- volved. When the disease is unilateral, castration is allowable for less serious local disease than when both organs are tubercular. The rea- sons for this are obvious. Cod-liver oil, the hypophosphites, phos- phate of lime, iron — especially the iodide — quinine, cinchona, and to the end of the chapter, are of service as general tonics. Arsenic has value, and possibly iodide of potassium a little. The latter has been greatly overrated. Mercury is of no service. Both mercury and iodine have undoubtedly derived their reputation from curing cases where a syphilitic testicle has been believed to be tubercular, a mistake some- times not easy to avoid in obscure cases. The rule of treatment in tubercular testis is imperative. Do not lose time by trying drugs. Let the patient get a change of air at any sacrifice to himself, and let him take his medicine while he is using the stronger agents, intelligent hygiene and dietetics. SYPHTLITIC TESTIS. Syphilitic disease of the testicle * has become of late years a well- recognized affection, and has, indeed, absorbed into itself, according to agreement by most modern authors, most of the cases which were formerly described as chronic inflammation of the secreting portion of the testicle. It is not, indeed, too much to say that perhaps all cases of chronic enlargement of the testicle of a seemingly inflammatory origin, excepting such as are left behind by previous acute inflammation, when not due to cancer or tubercle, are syphilitic, although there may be at the time no other evidence of syphilis upon the patient, and may not have been for years. For distinguishing marks of these forms of en- * Rcclus has an admirable article on the testicle, in which the syphilitic affections are clearly explained, in the " Diet. Encyc. des Sciences Medicales." SYPIIILITIG ORCHITIS. 411 largement, see diagnostic table. There are two forms of syphilitic testis : 1. Syphilitic epididymitis. 2. Syphilitic orchitis, diffuse and gummy. 1. Syphilitic Epididymitis. — An exhaustive description of this affection was first furnished to the profession by Dron,* who gives a number of cases. Other authors have since described the disease. No autopsy has yet revealed its exact pathology, but an identity of lesion with other syphilitic affections of the testicle is probable. It is of rare occurrence. It comes on usually in the early months, at a mean of about three or four months after chancre, during the period of the early eruptions. Bassereau and Eollet have seen it coincide with roseola. The disease is confined to the epididymis, mainly to the globus major. The epididymis may suffer with the testicle in the later forms of syphilitic orchitis, but in this earlier form the testicle is only involved in a small minority of cases. Lancereaux states, as a general rule, that the earlier syphilis attacks the testicle the more liable is the epididymis to suffer. This syphilitic epididymitis has been observed (very rarely) as late as several years after chancre. The disease usually involves both sides at the same time. I have en- countered it a number of times, but always confined to one side. In one such case, Dron examined the semen of a patient and found sper- matozoa. This test might be of service in doubtful cases to differen- tiate the disease from ordinary chronic epididymitis, although in the latter it is the tail and not the head of the epididymis which is gener- ally involved, and there has been almost invariably some urethral dis- charge preceding the attack. Furthermore, this syphilitic induration of the globus major stands out clearly defined as a hard tumor, en- tirely distinct from the testicle, and not capped over it as is usually the case in chronic epididymitis. The swelling is indolent, accom- panied by an insignificant amount of pain. All reported cases have ended in resolution ; it never suppurates, but declines rapidly under the appropriate treatment of early syphilitic lesions (mercurial). Eol- let puts the limits of treatment necessary at from fifteen days to two months. Local means are not necessary. No functional alteration or organic lesion is left behind. Dron saw the malady once in the globus minor. 2. Syphilitic Oechitis. — This affection appears under two forms : a. Diffuse, chronic, interstitial inflammation of the organ, of a peculiar sort. I. Gummy nodules ; the latter being an intensification of the former process, often accompanied by it, but of the two forms the more rare. * "De rEpididymite syphilitique," Archives Gen., Sixth Series, vol. ii, Xovember and December, 1863, pp. 513 and '724. 412 DISEASES OF THE TESTICLE. a. The diffuse form, like interstitial lie]):ititis, or nephritis, is an interstitial orchitis, a peculiar sort of chronic inliammation attack- ing the fibrous envelope and the septa of the organ. Kicord named it albuginitis. The process begins by hyperemia ; young cells appear in the coiinectiye tissue of the organ, many of tliem develo])ing into fibers which go on to contract. These young cells press upon, and gradually cause atrophy of, the tubular structure. The tunica albu- ffinea becomes thickened, as does also the tunica vasinalis. More or less lluid occupies the cavity of tlic latter, wliile many adhesions com- monly take place between the free surfaces. In this way the organ reaches double its natural size, perhaps more, but rarely becomes very large, unless from a considerable collection of fluid in the tunica vagi- nalis. Often only a portion of the gland is involved in these changes. Both testicles may be affected simultaneously, but usually consecu- tively. After a time the newly-formed connective tissue contracts, the septa between the lobes of seminal tubules become greatly thick- ened, composed of dense, fibrous tissue, showing white on section, while the clusters of tubules intervening between them, after first undergoing a brown pigmentation, become atrophied by pressure, and finally may disappear, lost in the general fibrous metamorphosis of the gland. The contraction may continue, much of the newly-formed material being absorbed, and the process going on to wasting of the organ, until only a stump is left behind. If the gland has only been l^artially invaded, a depression may be left marking the site of the dis- ease. In this form there is no tendency to suppuration, ulceration, or formation of fungus. This is the slower variety of disease. b. TJie (jummy form, which is believed to be an intensification of the foregoing process, sometimes coexists with it. It is marked by the formation of nodules, usually multiple, which seem often to take their origin in the external tunic of a vessel, or the wall of a sper- matic tubule (Lancereaux). They may be found of all sizes, from a mere point to that of an egg, and consist of an agglomeration of cells, with more or less fatty, granular matter, toughly united by fibrous elements into a lump, presenting, on section, a grayish-yellow or dis- tinct dark-yellow color. As they get larger these nodules tend to soften at the center. They are surrounded by a grayish areola, trav- ersed by vessels, and later are often enveloped by a condensation of tissue somewhat resembling a capsule. These tumors may form near the surface, or deep in the gland. They may occur in the epididymis. The latter, however, usually escapes, while the vas deferens is very rarely involved. The tunica vaginalis is usually more or less distended with fluid. In gummy orchitis the testicle may acquire a very large size. I have seen, in connection with syphilitic testis, the gummatous form, an implication of the entire epididymis with the development of thickened plates of induration in the tunica vaginalis. I have seen SYPHILITIC ORCHITIS— SYMPTOMS. 413 these plates nearly a quarter of an inch thick, and half as large as the palm of the hand, in a case of enormously enlarged testicle, gumma- tous and diffuse, complicated also by hydrocele. The latter got well under carbolic-acid injection, the testicle recovered, and the plates dis- appeared under internal mixed treatment with iodides in excess. I have seen many other examples of the implication of the epididymis in combination with these indurated plates in the tunica vaginalis, and have come to look upon them as characteristic of syphilis, as they always disappear under mixed treatment. The gummy tumors once formed may cease to grow, soften, degenerate, and calcify, or be en- tirely absorbed, leading to atrophy, perhaps, of the whole organ, or only of a portion. Again, the integument over them may ulcerate after adhesion has taken place, and syphilitic fungus result. The mechanism of the formation of fungus is as follows : The gammy matter infiltrates the tunica albuginea, and undergoes degen- eration, causing softening of that structure, with bulging of the con- tents of the testicle. The suprajacent skin and intervening tissues now inflame and adhere, finally ulcerating and allowing the continu- ous growth of gummy matter within the testis to extrude through the opening, together with the tubular structure, which may be found lying in little clusters amid the yellow material. The fungus contin- ues to grow, the dartos and skin contract about its pedicle, and the extruded mass becomes covered with some granulation tissue, and bathed in pus. These syphilitic fungi are rather firm to the feel, painless, and do not bleed very easily. If cut off they continue to grow, or, if the disease be not arrested, the sprouting may continue until the whole tubular structure of the testis has been pushed out from the inside, after which it may wither and dry up, the testicle going into complete atrophy. The seminal tubes in the fungus retain some of their activity, as shown by the fact that spermatozoa may be found in the discharge. The fungus differs from other fungi of the testis. After injury some of the tubules may protrude as a slough, but whatever fungus there is is simple granulation, soft, bright, pink, bleeding easily. (For differential diagnosis of fungi of testicle, see DiAG]srosTic Table.) Syfnptoms. — True syphilitic orchitis, affecting the body of the testis, rarely appears until after at least a year, rarely before the third year has elapsed from the date of chancre. It may be occasionally more precocious. Eicord and Bumstead have seen it as early as the fourth or fifth month. It may coincide with iritis, with groups of tubercles, with ulcers, or deeper lesions of bone or cartilage. ISTot in- frequently, however, it comes on long after the patient has ceased to show any evidence of specific disease. The enlargement of the testis takes place gradually and without pain. It is usually first discovered by accident, already quite large, so that the patient affirms that the 414 DISEASES OF THE TESTICLE. swelling came on very rapidly, in a day or more. There may be, however, some sligiit pain at tirst, especially along the cord, and in the groin, with an uneasy feeling in the testicle itself. When first seen, the size of the testicle is usually not more than twice or three times as large as natural. It may be perfectly smooth, and hard as wood, the epididymis not distinguishable. Sometimes the body of the testis is irregular and nodular, very hai'd, or there may be one or more prominent lumps of gummy exudation. Only a portion of the testi- cle may be involved, the rest feeling natural. In such a case the healthy portion may be normally sensitive, giving, when pressed, the natural sensation of squeezing the testicle. Often, however, the swell- ing is wholly insensitive, and may be squeezed at will, without evoking the least uneasy feeling. The outlines of the testicles may be obscured by a considerable col- lection of fluid in the tunica vaginalis. After drawing this off, the hard, nodular, uneven outline of the insensitive syphilitic testis be- comes api^arent. The vas deferens is nearly always healthy, and the scrotal tissues rarely involved, so that the hard mass can be freely moved and examined under the thin skin of the scrotum. I have seen a case in which the cord was also involved, the vas deferens be- ing thickened to the size of a lead-pencil, smooth, hard, painless. Fournier * also records a case, and Desprcs \ another. The general health may appear excellent, but, if both testicles are involved, sexual appetite and power are almost invariably absent. There are no erections, and function is temporarily abolished. The same impairment of sexual funcftion exists in a less degree where one gland only is involved. There may be, very rarely, a syphilitic fun- gus, as described above. The glands in the groin are not affected. (For differential diagnosis, see Diagxostic Table.) The duration of the disease may extend over several years. The ter- minations are resolution, degeneration (fibrous, fatty, calcific), atrophy. Prognosis. — The prognosis is good. The seminal tubules do not become occluded. They only perish by degeneration and atrophy, from pressure, and some of the canaliculi have usually escaped. The sooner treatment is commenced, the better the prognosis. The gum- my material melts away under appropriate measures, liberating from pressure such of the tubules as have escaped atrophy, and, with a re- turn of the organ to its natural size, erections and sexual appetite re- appear. Gosselin has found spermatozoa in the semen of patients who had had double syphilitic orchitis after the same had been cured by treatment. Eclapse is always to be feared, especially if the treat- ment be not persisted in long enough, or if the testicle be subjected to mechanical violence when nearly cured. * " Sarcoc^le syphilitique," Paris, 1875. t " Bull- dc la "Soc. de Chir.," 1875, 1, 2, p. 140. SYPHILITIC ORCHITIS— TREATMENT. 415 Treatment. — All three forms of syphilitic testis arc amenable to treatment. Early syphilitic epididymitis gets well promptly under mercury, employed as for the earlier syphilidcs. Of the other two forms, the purely gummy may be more promptly relieved ; but, in any case, the earlier an intelligent treatment is instituted the more speedily does the disease respond. The mixed treatment is most com- monly applicable — mercury and iodide of potassium ; but, as a gen- eral rule, the later the attack after the chancre the more reliance is to be placed upon the iodide, and the less upon mercury. With dis- tinct, large-knobbed, gummy tumors, and always with syphilitic fun- gus, and in connection with other marked evidences of tertiary dis- ease, the iodide should be used alone, carried rapidly to a high dose. (See Treatment of Syphilis.) A suspensory bandage should be worn, and all hygienic means employed. Local treatment is unneces- sary. Fungus may be touched with nitrate of silver, and strapped after any constriction at its neck by the scrotal tissues has been divided ; but reliance can only be placed on internal treatment, which will cause it to shrink back into its place. It is unwise to cut away any portion of it, for healthy seminal tubules may thus be sacrificed. It is needless to add that no attempt need be made to cure the accom- panying hydrocele. The fluid will disappear as the testicle reduces in ordinary cases in size, and no injections or other local measures need be called into play. As often as the tunica vaginalis become distended a palliative puncture may be resorted to. If occasionally the hydro- cele persist after the testicle has returned to a state of health, it may then be treated successfully by the ordinary methods. Sometimes a syphilitic testicle is first suspected, after the evacuation of a hydro- cele, by the characteristic feel of the gland. Extirpation is not to be thought of. Before syphilitic disease of the testicle was understood, the older surgeons were in the habit of extirpating many large, chron- ic, indolent swellings of the organ (called sarcocele, or hydro-sarco- cele), which an appropriate treatment might have restored. Sir Ast- ley Cooper at one time gave it as a general rule that no testicle should be removed for chronic enlargement and induration until '^the gums had been touched by mercury." Modern progress has altered the rule. We no longer " touch the gums," but it may now be safely laid down as a proper rule to follow, in all cases of douht, with en- largement of the testicle, never to operate until a thorough antisyphi- litic treatment has heen tried faithfully, including large doses of the iodide of potassium. A final caution must be given, namely, not to remit treatment too soon. It should be kept up for many months after the testicle has resumed its natural size, and only given up grad- ually, for fear of relapse. 416 DISEASES OF THE TESTICLE. CANCER OF THE TESTICLE. Soft carciuomii is the only variety of cancer occurring primarily in the testis. Scirrhus lacks the "strict requirements of anatomical proof." * XcpveUjf however, details tliree personal cases of undoubted scirrhus, and cites six other cases from various sources. The course of the malady is slow, averaging six years ; the testicle may be increased or diminished in size. Pigmented cancers are said to have been seen as metastases. But even soft cancer is very rare. It does occur, how- ever, and is found at all ages from the cradle to the grave. Pitha saw it in a new-born infant. After sixty it is very uncommon. It is met with mainly in early manhood, when the function of the testicle is most active. It rarely occurs on both sides. An injury seems sometimes to be the immediate exciting cause. Sarcomatous tumors of the testis are very liable to degenerate after a time, and become car- cinomatous. Symptoms. — Gradually, sometimes rapidly, induration and enlarge- ment come on. The oval shape is preserved, there is only slight pain (worse on pressure throughout the disease), and there is effusion into the tunica vaginalis. As the testis grows, it becomes uneven on its surface, elastic in portions, perhaps so soft as to give the idea of true fluctuation. The pain now increases in the testicle and cord, the lat- ter becomes engorged, the pelvic and abdominal glands, as also often the inguinal, swell, and become cancerous. The tumor formed by these glands may usually be felt in the loins. There is generally constant pain in this region. Venous circulation is impeded by i^ress- ure of the cancerous masses upon the great abdominal veins, the veins of the scrotum stand out varicose and prominent, the leg be- comes (edematous. The pains become intense, sharp, shooting, often burning in paroxysms, between which a constant ache is felt in the testicle and cord. The testicle during this period has been constantly growing, it has burst the bounds of the tunica albuginea, involved the epididymis and cord, but the scrotum expands and the tumor may reach the size of a child's head. Boyer removed a cancerous testis weighing nine pounds. During its growth it may experience periods of rest when there seems to be little or no advance made, or when it may become smaller for a time, by the absorption of some fluid por- tions, as of fluid in the tunica vaginalis. The pain is aggravated by pressure, and the normal feeling on pressure is absent. After a time, if death or an operation do not remove the tumor, the scrotum will adhere to it at some one or more prominent portions, the skin will ulcer- ate, and the cancerous mass will spread to the outside, forming fun- * Rindfleisch, loc. cit., p. 351. Curling, Pitha, Focrster, Verneuil, and others, admit scirrhus. t "Archives Gen.," February, 1879, p. 129. CANCER. 417 giis hematodes, the true cancerous fungus. This is bathed in a thin bloody ichor, grows rapidly, portions of it slough away, and it often bleeds profusely. Meantime the general healtii, perfect at first, suffers proportionately with the advance of the disease, until finally well- marked cancerous cachexia is reached, attended by its usual sallow- ness and tendency to waste away. The pain so characteristic of this disease is sometimes very slight in the testicle, but particularly so in connection with the cancerous growths from the pelvic and lumbar glands, where there may be no pain at all with advanced disease (Brodie). Pathology. — The disease commences at different points, which co- alesce. It is rarely a general infiltration. On section it is impossible with the naked eye to distinguish between soft carcinoma and soft sarcoma, but the soft ''medullary" sarcoma is also malignant, affects the retro-peritoneal glands, and is finally fatal. They both exhibit the same soft spots, perhaps filled with pultaceous matter, the same white or pink-white colors. The microscope shows the cancer to be a stroma, richly permeated by young cells, inclosing " epitheloid cell-aggrega- tions" which owe their origin (Birch — Hirschfeld) to the proliferation of epithelial cells of the glandular tubuli ; the medullary sarcoma, also malignant, shows a broad trabecular work of sj)indle-shaped cells, with often nests of epithelial cells, showing that it is partly carcino- matous, or a round-celled stroma, with elements of other histoid for- mations (mucous cartilaginous tissue, Eindfleisch). The large soft spaces yield a plentiful juice when pressed, and if water be run over them the softer parts may be washed away, leaving a delicate stroma behind. The stroma, again, may be thickened and fibrous. Cysts are not infrequently found, sometimes blood-cysts, or large blood-clots, as in kidney-cancer. Cancerous degeneration may have attacked a testicle already sar- comatous, when we should find, besides the conditions above described, perhaps cartilage more or less calcified, or mucous tissue, or unstriped muscle. The enlarged abdominal glands press upon the vena cava. The cavity of the latter has been found obliterated, filled with cancer- growth ; the bones of the spine become involved, while secondary can- cer may be found in the kidneys, liver, and lungs. A few instances have been cited of cancer of the testicle beginning in the tunica vagi- nalis. One or two cases of colloid and melanotic cancer are recorded, as well as a few of scirrhus. Diagnosis. — In the early stages of the disease, especially if its course be slow, diagnosis is often exceedingly difficult. The diagnosis IS with sarcoma, syphilis, tubercle (for which see Diagxostic Table), hydrocele, and haematocele, with dense walls. Hydrocele or ha?mato- cele may be diagnosed, if all other symptoms fail, by exploratory punct- 27 418 DISEASES OF THE TESTICLE. ure with trocar. If a trocar be used and thrust into a soft part of a carciuomatous testicle, enough blood may escape to encourage the idea of hfematocele, but it will be noticed that the volume of the tumor docs not decrease proportionally to the amount of blood which has escaped. Pro(/nosis is even worse than for cancer elsewhere. Two years is a fair average duration for the disease, and the liability for second- ary cancer to appear in the loins or elsewhere after operation is very great. But few cases are reported of a continuance of health a num- ber of years after extirpation, and in these cases the operation was always done very early.* Treatment. — ]\Iedicine is of no service. Puncture of tunica vagi- nalis will often relieve pain immediately, A very early operation offers the only chance, but ho2)e departs when the cord and glands become involved. LYMPHADENOMA OF THE TESTICLE. This malady has been carefully described by Monod and Terrillon. Malassez first recognized the affection in a specimen sent by Pean to the laboratory of tlie College of France in 1874. There is a develop- ment of tissue similar to that of normal lymphatic glandular tissue as a reticulated stroma occupying the tissue between the tubes in the testis and destroying them. The whole extent of the testicle seems to be involved from the beginning, and the disease may simultaneously attack both glands, a peculiarity not noticed with other neoplasms in this region. Generalization is rapid and early in the bones, viscera, and even in the skin and subcutaneous tissue, at a distance from the primary seat of disease. General cachexia is slow to come on. There is no leucocythemia. Prognosis is fatal. Eemoval of the testicle does no good. SAHCOMA. Cystic Sarcoma, Enchoxdroma, Myoma, Myxoma. — This affec- tion is even more rare than cancer. Its cause is unknown. It occurs most frequently between eighteen and twenty-five. It is rarely bilat- eral. The body of the testis is involved, the epididymis sometimes secondarily. When the morbid mass is made up largely of cysts, it is called cystic sarcoma ; when there are but few cysts and much solid matter, it has been customary to call it fibro-cystic sarcoma. SymptomH. — The growth of sarcoma is slow and usually painless, so that considerable size may be attained before the disease is noticed. There may exceptionally be some pain or dragging in loin, groin, or testicle, especially after the mass has become bulky. The tumor may * Poinsot cites some interesting cases of apparent cure after castration. " Bull, de la Soc. de Chir.," 1878, iv, No. 3, p. 169. SARCOMA. 41 9 fittain a weight of several pounds. The shape is oval, and the surface smooth, unless some large-sized cysts happen to he superficial. A healthy epididymis can be felt at first distinct from the testicle ; finally it is lost in the general swelling. The tumor may remain many years of a certain size, and then take on malignant degeneration, after which symptoms of cancer supervene. Sarcoma is liable to be confounded with cancer, tubercle, syphilis (see Diagnostic Table), hydrocele, or haematocle, but the tumor is elastic, not fluctuating, and a trocar distinguishes it from the latter affections. Severe pressure often produces a sensation of faint- ness. Patliology. — On section the tunica vaginalis and tunica albuginea are found thickened. There may be but a few cysts, or vast numbers constituting nearly the entire tumor, varying in size from a point to a pigeon's Qgg. The smaller cysts contain a gelatinous fluid which gets thinner afterward, and may contain cholesterin, fatty debris, etc. The fluid is often colored with blood. A pure watery serum is rare. Sometimes the fluid is synovial-like, sticky, stringy. The cyst-walls, especially the smaller, are lined by cylindrical epithelium. Papillary excrescences, covered also by cylindrical epithelium, are found growing into the larger cysts, which often become entirely filled up by them, as in cystic sarcoma of the breast, and as in the latter disease, so also in this, it is not uncommon to find in the cysts little yellow, hard spherules of condensed epithelium.* As to the mass of the tumor, fibrous tissue is found in greater or less proportion, and as the tumor is nearly always a complicated one, it is not unusual to discover por- tions of muscular tissue (of both kinds, Senftleben, Billroth, Nepveu), masses of mucous and even of adipose tissue, and hyaline cartilage, perhaps partly calcified. This cartilage, which may be found in all sorts of curious, branched shapes, has been made out by Paget and Billroth to occupy the lymph- vessels. In Paget's case the cartilage extended up the lymphatics of the cord into the abdomen, and a mass was found growing from one of them into the vena cava. Cartilag- inous nodules were found in the lungs. Where there is much carti- lage there are seldom many cysts. Indeed, the tumor may consist solely of hyaline cartilage at first. This grows slowly, painlessly, and may attain the size of a hen's egg, when, possibly after several years, a sudden, rapid enlargement of the testis sets in, and we find that the cartilage has become surrounded by recently formed masses of sarcom- atous character. Cretification may be found in the testicle and its coverings, in connection with enchondroma or sarcoma (Eindfleisch). A pure myoma may occur in the testicle as a solid, painless lump. Rokitansky describes one as large as a goose-egg, of striped muscular * These little pearl-like clusters of epithelium are encountered in various pathological conditions of the testis. 420 DISEASES OF THE TESTICLE. tissue ; Rindfleiscli auothor, of unstripcd fibers. Sarcomu miiy occupy only a portion of the testis or the whole gland ; the tubular structure is then either found spread out upon the new de})osit or scattered through it. It eventually atrophies. The e])ididyinis becomes flat- tened and wasted, or finally involved in the disease. According to Billroth, sarcoma commences in the sub-epitlielial tissues of the semi- nal tubuli as a round-celled degeneration of the tunica propria, leading to occlusion of the tubule and subsequent dilatation behind the oc- cluded point. Commencing cancerous transformation may often be detected. Treatment. — The only treatment is extirpation. The disease may be indeed purely benign at first, and remain so jierhaps indefinitely, but it may become cancerous, and, if the individual have one good testicle left, it is unwise to put off the operation. If the patient be a monorchid, strict justice would allow delay so long as any of the se- creting structure of the testis had been spared by the disease and con- tinued its functions. Lipoma of the testicle has also been recorded by Roswell Park,* of Buffalo, who removed such a tumor growing from the testis and filling the tunica vaginalis. The tumor weighed six pounds. DIAGNOSTIC TABLE. Since it is so diiScult often to decide upon the nature of a given chronic enlargement of the testicle, it seems advisable to display the main diagnostic features of the four affections, tubercular testis, syjihi- litic testis, cancer, and sarcoma, side by side in tabular form, so as to bring out as clearly as possible, and emphasize, their most striking differences : Tubercular Tcxds. 1. Most common in early youth and manhood. 2. No change in scrotal veins. 3. Docs not grow to great size. 4. Holds second place of frequency. Sjipldlitic Tcstvi. 1. ^fost common in middle and later life. 2. Same. 3. Is usually com- paratively small. 4. Most common of the four. Cancer. Sarcoma. 1. Most common 1. Most common in youth. in early manhood. 2. Scrotal veins en- larged and varicose after the disease has lasted some time ; due to the pressure of cancerous glands above. 3. May reach an immense size. 4. Holds third place. 2. No change. 3. May become very large. 4. Least common. * "Medical Record," May 8, 1886, p. 542. DIAGNOSTIC TABLE. 421 Tubercular Testis. Si/philitic TchHs. Cancer. Sarcoma, 5. Primarily affects 5. Primarily afTects 5. Same. 5. Same. epididymis. body of testiy. 6. Form knotty, ir- 6. May be perfect- 6. Uneven ; prom- 6. Slightly uneven, regular, hard, espe- ly smooth and oval, or inent hard and soft oval, perhaps with cially the epididymis. more or less lumpy. spots ; indefinite fluc- tuation. points of fluctuation. 1. Development v. Same. 7. Development 7. Very slow, of- slow. rapid. ten suddenly becom- ing rapid. 8. Pain absent or 8. Often absolute- 8. Pain liable to 8. No pain. 9. Often discov- ered by accident. 9. Same. 10. Usually no sen- 10. Same, sation on pressure, neither pain nor the normal sensation. 11. Fluid in tunica vaginalis sometimes. 12. Tendency to suppurate, discharge, and leave fistula. 13. Both testes of- ten consecutively at- tacked. 14. Loss or impair- ment of sexual de- sire and power when both glands are in- volved. 15. Fungus not very common. If found, it is pale and soft, bleeding rather easily, composed mainly of granula- tions. Pus thin, si- nuses leading into testicle, growth slow, usually painless. 16. No glandular enlars-ement. 11. Fluid in tunica vaginalis nearly al- ways. 12. Tendency to atrophy without ex- ternal opening, some- times there are a dis- charge and fungus. 13. Same. 14. Same, and more marked ; some- times exists when one gland only is dis- eased. 1 5. Fungus very rare. If found, it is hard, yellow, mainly composed of tubes and yellow syphilitic matter, does not bleed very easily, no sinuses, growth slow, painless. 16. Same. be severe soon af- ter commencement, sometimes excruciat- ing. 9. Recognized by pains from the start. 10. Darting, sharp, burning paroxysms and constant pains, aggravated by han- dling. 11. Fluid in tuni- ca vaginalis usually slight. 12. Tendency to open and form fun- gus hsematodes. 13. Usually only one testicle suffers. 14. Both glands not involved simul- taneously. 15. Fungus con- stant if testis remains long enough, grows rapidly, bleeds pro- fusely, sloughs read- ily, is covered with sanious, badly smell- ing ichor, is formed mainly of cancer-tis- sue, is very painful. 16. Inguinal and pelvic glands in- volved. 9. Tumor grows slowly, and is usually discovered small. 10. No pain; squeezing testicle of- ten produces feehng of faintness. 11. Fluid in tunica vaginalis rarely. 1 2. No tendency to open or to form fungus. 13. Same. 14. Same. 15. No fungus. 16. Glands some- times involved. 422 DISEASES OF THE TESTICLE. Thibercular Testis. 17. Very rebellious to medical treatment. 18. Cord always affected eventually. 19. Vcsicuhe sem- inales liable to be- come involved. 20. Foci lumpy. 21. Duration, eral years. sev- 22. Prognosis not favorable. Progress always indolent, en- tire cure rare. Si/philitic Testis. 1 7. If taken early, quickly amenable to treatment. lu any case always reduci- ble in size, by intelli- gent medication, to which all doubtful cases should be sub- jected, to give them a chance. 18. Cord never in- volved in a pure case. 19. Nothing of the sort. Cancer. 17. Treatment in- effective. If cut out, returns elsewhere. 18. Cord affected in advanced disease. 19. Nothing. Sarcoma. 17. Medical treat- ment ineffective. If cut out, disease does not necessarily reap- pear ; if left, can- cerous degenerations may occur. 18. Cord never af- fected. 19. Nothing. Excessively 20. Hard and soft. 20. Elastic. 20 hard. 21. Duration, sev- eral years — usually less than tubercle. 22. Prognosis good ; gets well, with functions restored if treated ; atrophies if not treated. 21. Duration, av- 21. Duration, many erage two years. years. 22. Prognosis bad ; kills by bleeding or cachexia if not re- moved ; by return of the disease if extir- pated. 22. Prognosis good. Does not re- turn if removed. If left, liable to become cancerous. CASTRATION. This is an operation not very often required since sarcoeele (as any chronic fleshy enlargement of tlie testis used to be called) has been more closely studied and better understood. Still, there are occasions when it is proper to remove the testicle. The operation is a simple one, and is best performed as follows : The pubes, perinaeum, and scrotum are first shaved, and any complication in the way of hernia is excluded if possible. An anaBsthetic should always be administered. An incision is made, commencing a little below the external abdom- inal ring, and carried to the bottom of the scrotum along its anterior aspect. Even if such a length of incision were not required by the size of the gland to be removed, 5'et it is better to make it long, so that the lower angle may be depending, and thus to allow a free exit for the discharges. The spermatic cord is next exposed, and, if it must be ligated very high up, it is better at once to put a ligature of silkworm-gut or stout catgut around it, and to tie the whole cord quickly and firmly. If enough of the cord is left to be seized, it may be held by the fingers of an assistant, but care must be taken not to let it slip, or it will disappear within the inguinal canal and a great deal of haemorrhage may occur before it can be recovered by dissection. CASTRATION— DERMOID CYSTS. 423 The cord being cut, the testicle is to be turnefj out more by tearing tliiin by cutting. An oval piece of skin may be removed with it if it is very large, and, if it adheres pretty tightly, care may ne required to prevent wounding the urethra or the other testicle during the dissec- tion. After the testicle is removed, the arteries of the cord (the sper- matic, deferential, and the cremasteric) may be tied separately with catgut, and all the bleeding points in the scrotum secured. If a single ligature has been used for the whole cord tied high up, the individual vessels need not be ligated. Pain, however (and even tetanus), has been said to be produced by the single ligature from including the nerves of the cord and the vas deferens. The wound should not be united until all the bleeding points have been secured. There are few operations in surgery which are so liable to be complicated by trouble- some bleeding after the wound is closed. This is due to the laxity of scrotal tissue. Drainage and antiseptic dressings insure a good result. Healing by first intention along the whole line is not uncommonly attained. If hernia complicates the disease of the testis, it is better to take advantage of the opportunity, slit up the sac, and operate for radical cure by suturing the pillars of the ring with catgut or silkworm-gut. If the cord should slip into the inguinal canal after being divided, and before its arteries have been secured, and if it can not be hooked down, the tendon of the external oblique must be cut at the external pillar of the ring, and the dissection continued up the canal until the cut end is reached and all its bleeding points secured. Several instances of death are recorded from neglect of this precaution. If hsemorrhage comes on after the wound has been closed, it should be reopened and the bleeding vessels searched for. A few points of suture are neces- sary, otherwise the edges of the wound will be kept gaping by the contractions of the dartos. Self-castration has often been resorted to by lunatics, or by individuals, usually young men, laboring under some depression brought on by masturbation or other abuse of the organs. The bleeding is always excessive, but, in the cases reported, has usually been successfully arrested, or ceased spontaneously. DERMOID CYSTS OF THE TESTIS. The testicle, next to the ovary, is the most favorite site for the development of dermoid cysts. These cysts are cavities lined by integument, furnished with stunted papillae, sebaceous and hair glands. Their contents are a sebaceous matter mixed with epithelium and rolls of long hair, usually reddish. Besides these there are often found fully-formed teeth, sometimes in great numbers, often imbedded in portions of bone, bones with smaller bones articulated to them, car- tilage, muscle, nerve. In a personal case a portion of the inferior 424, DISEASES OF THE TESTICLE. maxillary bone with some molars and a bicuspid were found. The dermoid cyst may be within or outside the testis, as in Velpeau's * cusc. These are the cysts sometimes known as fetal inclusions. The cysts are jn-obably always congenital. They usually grow very slowly at first, but. may reach an inconvenient size in time. Generally they become very large, then suddenly begin to grow rapidly and are re- moved, or. becoming injured by a blow, they inliame, suppurate, and discharge their contents, remaining listulous. The only treatment is removal with the knife. It should be re- membered that the cyst sometimes lies outside the testicle, the latter adhering to it. The gland should be dissected otf, and spared if pos- sible. D'Arcy Power * says that only ten cases have been \n\t on record during the past two hundred years. He showed a specimen at the London Pathological Society. Ue is evidently wrong. IRRITABLiE TESTIS. This is a name given to a species of neuralgia of the gland. The whole organ, or usually a particular spot, is extraordinarily sensitive to the lightest touch ; contact of the clothing alone is sometimes exqui- sitely painful. In the recumbent posture, with nothing in contact with the testicle, the pain usually disappears. Sometimes the organ is tense and engorged ; but it is of full size, and seemingly normal. Again, it may be decidedly flabby, the scrotal tissues being soft and lax. Irritable testis occurs at all times, from early puberty to late middle life. It is met with chiefly in old bachelors and widowers. The patient otherwise may possess robust health, sometimes (especially with flabby testis) he is ancemic, nervous, hypochondriacal, and dys- peptic. The causes of irritable testis are lack of use, or abuse, of the sex- ual powers — perhaps most often ungratified sexual desire. Curling says, "In a person of chaste habits, thus affected, I was informed that the morbid sensibility disappeared on marriage." Temporary irritable testis may be produced in a healthy person, at any time, by prolonged sexual excitement ungratified. Masturbators who have suddenly reformed, and recent widowers, and those who have abused their sexual powers by over-use, are all liable to the affection under consideration. These patients are usually hypochondriacal, look upon their own * "Gaz. Med. de Paris," February 15, 1840. Andrd, "M6m. de I'Acad. Royale de Med.," vol. iii. Ollivder (d'An^er.^), " M6m. sur la Monstrositd par Inclusion," " Archiv. Gen.," vol. xv. Vcmeuil, " Archiv. Gen.," June, 1855, who has collated nine cases besides one of his own. f " Lancet," October 23, 1886, p. 775. NEURALGIA OF THE TESTICLE. 425 condition as a pitiable one, and ascribe it to loss of seminal fluid — per- haps to nocturnal emissions — to neither of wliich does it stand in any relation of effect. They often demand castration — a demand which should be acceded to on no account. Curling quotes from Romberg an interesting case bearing on this point : A young man acquired irri- table testis after becoming engaged to be married. It distressed him so seriously that he demanded extirpation of the organ, and would not yield until at last the operation was reluctantly performed. Eight days afterward the old pain returned in the other testicle. This being all he had left, the patient preferred to keep it. He married, and "very soon recovered completely." Treatment. — Hygiene, physical, moral, and sexual, is the proper treatment for irritable testis. As local means, a suspensory bandage and the cold douche are adjuncts. Drugs exert no specific power and can not be relied upon. Marriage, with a proper sexual hygiene, is the natural antidote to any irritability of the sexual apparatus. NEURALGIA OF THE TESTICLE. An extreme degree of the condition just detailed constitutes neu- ralgia of the testicle, a disease which sometimes attains horrible inten- sity, and assumes the tic-douloureux type in paroxysms at irregular (occasionally regular) intervals. The pain in some cases is constant, and perhaps quite mild, but increased by walking and standing so as to occasion great discomfort. The character of the pain is acute, darting, stabbing, sometimes dragging, heavy. The cremaster some- times contracts spasmodically during the paroxysm, forcibly retract- ing the testicle, and a cold sweat, with nausea and vomiting, is not a rare accompaniment. Between the paroxysms the testicle is often entirely free from pain. Handling the organ is liable to induce a paroxysm. The testis, sometimes swollen and tense, is usually unal- tered. There is no febrile action. Neuralgia is usually confined to one testicle, unlike irritability, which is frequently double. Neu- ralgia must not be confounded with the sympathetic pain in the tes- tis, and its retraction from spasm of the cremaster, accompanying cer- tain morbid states of the bladder, ureter, and kidneys, and so often seen in kidney-colic. The cause of neuralgia of the testis is sometimes difficult of appre- ciation. It is often due to the same general influences which lead to the development of neuralgia elsewhere (gout, syphilis, malaria, etc.). It sometimes follows an attack of orchitis. It has been vaguely re- ferred to the spinal cord, deranged digestion, etc. It has been seen to follow injury and to attend a small, deep-seated, purulent collec- tion. B. Brodie * found it in one case always preceded by clay-col- * "Medical Gazette," vol. xiii, p. 621, 42G DISEASES OF THE TESTICLE. orcd evacuations and i)ain in the back of the lu'ad. Tie believed the cause in this case was situated in the liver. In another case, he found a small projection on the epididymis, which, on pressure, gave the sensation of touching an exposed nerve in a tooth. This latter condi- tion I have encountered a number of times. Keuralgia of the testicle not infrequently is due to irritative iuUammatory or other disease of the deep urethra, and may be cured by removing its cause — by deep urethral nitrate-of-silver instillations, use of the sound, or other means. In neuralgia of the testis no nerve-lesion has been found. Sexual hygiene will be often found at fault. The affection may last for years and (possibly) then disappear spontaneously. Treatment. — Neuralgia depending on bladder, urethral, or kidney disease, disappears with its cause. In true neuralgia, a strict h3'giene is all-important ; this involves marriage. Among drugs, arsenic, qui- nine, and iron bear the best reputation internally ; belladonna, opium, and aconite externally. But little reliance can be placed on them, however ; sexual and general hygiene outrank all remedies. If the testicle be extirpated, there is always danger of a return of the pain in the cord, or in the other gland. Diday * recently very strongly advocates the continued application of cold in all pure cases of neu- ralgia, and claims remarkable success with this agent. His method consists in filling two bladders with large pieces of ice. One of these he places upon towels, so arranged as to underlie and support the testis, the patient being supine. The other bag is now placed upon the testis, so that the whole organ is surrounded by ice, or, rather, iced-water. This application is kept up night and day for two to four days, after which (Diday states) the neuralgia does not return. William A. Hammond f claims to have cured this malady by tightly squeezing the entire cord between the blades of an instrument like a lemon-squeezer for five minutes, then letting up the pressure (to allow circulation to be resumed) and reapplying it. I have not tested this method. * " Annales de Derm, et de Syph.," 1869, No. 3, p. 182. f " St. Louis Courier of Mcdiciue," May, 1880. IMPOTENCE. 427 CHAPTEE XXVI. MALADIES INVOLVING THE GENITAL FUNCTION. Impotence.— True Impotence, its Causes and Treatment.— False Impotence, its Causes and Treat- ment.— Sterility.— Masturbation.— Pollution, Nocturnal and Diurnal.— Spermatorrhcea. — ^Eroto- mania.— Satyriasis.— Priapism.— Aspermatism. Impotence is a symptom, usually, of some physical morbid condi- tion entailing inability to accomplish the sexual act. Its causes are very numerous. Most of them have been already considered ; the others will receive a few words of detail in this chapter. Impotence will only be considered as affecting the male. Impotence, from whatever cause, is a complaint not unfrequently submitted to the surgeon ; not always frankly and openly as such, but often by implication, as though it should be recognized and inquired about, in answer to remote indications which the patient has scantily furnished. Indeed, the surgeon who would meet the daily wants of his fellow-men, in reference to troubles of this sort, must possess an accu- rate knowledge of the physiology of the sexual function, and of its vari- ous derangements, and be ready to anticipate the reticence of patients ; otherwise he will fail to sound many of the depths of human nature, where suffering lurks — which suffering is for the most part prevent- able or relievable. Impotence signifies that an individual can not beget children be- cause he can not perform the sexual act properly, no matter what the obstacle may be, whether he have spermatozoa or not. The term must be carefully distinguished from sterility, which signifies inability to beget offspring on account of defect in the semen, whether the indi- vidual can have sexual intercourse properly or not. The two are undoubtedly often associated in the same individual, but they may be totally distinct, as the following examples will illustrate. Thus there are two methods of making eunuchs in the East : by one the j^enis is removed as well as the testicles, and such a eunuch is necessarily both impotent and sterile. By the other method the testicles alone are re- moved ; and a eunuch of this description, though sterile (having no spermatozoa), may be still partly potent, and does not bring so high a price as another eunuch who has no penis. It is a well-known fact that both animals and men, from whom the testicles have been re- moved after puberty, still retain sexual desires, *and may have inter- course, with venereal orgasm and ejaculation of prostatic mucus, occasionally during a period of several years. A cryptorchid is rarely at all impotent, but is very apt to be sterile, and so of a patient with 428 MALADIES INVOLVING THE GENITAL FUNCTION. double gonorrhceal epididymitis ; while, as instances of impotence with- ont any sterility, may be mentioned, deformities preventing sexual intercourse, where the spermatic lluid is normal (exstrophy of the bladder), extreme incurvation of the penis, with or without hypospa- dias, asperniatism. The distinction between impotence and sterility being now plain, a few words regarding each of these complaints will perhaps serve to clear them of the mists of uncertainty which often surround them. Impotence may be considered as true and false. TRUE IMPOTENCE. This is exceedingly rare in the male. Any one who can perform the sexual act is potent. This act imperatively involves two conditions, namely, sufficient erection to make intromission possible, and a mucous fluid leaving the body by ejaculation. Roubaud * has added two other factors as essential to the act of copulation ; namely, the existence of venereal desire and pleasure in the act ; and, although both of these undoubtedly exist in a state of health, nevertheless the absence of either of them by no means necessitates impotence, while the absence of either of the first-named conditions is impotence. An illustration of these points will bring out all that can be said practically concerning true impotence. That lack of desire before the act and j^leasure during its accom- plishment are not absolute essentials to sexual intercourse is shown by the two conditions, priapism from cantharides, in which there is no desire, and yet intercourse is possible with perfect intromission and ejaculation, and certain diseases of the cord attended by more or less paraplegia, where intercourse may take place, followed by conception, and yet there be no pleasure in the act of ejaculation, the patient being unconscious at what moment it occurs. CoxDiTiONS iNVOLYixG True Impotexce : 1. Absence of penis, as in the cases already referred to Q). 5).f In these cases, if there are healthy testicles, the patient can not be called sterile. 2. Minute size of penis may involve impotence, as in Roubaud's case of a student whose penis was so small that, although he could practice masturbation, he was not able to reach the stage of ejaculation during sexual intercourse, on account of the minute size of his penis, between which and the vaginal walls there was little or no friction. Roubaud J rendered this man potent, and, he says, greatly increased the size of his i)enis by fitting him with an artificial one, into a depres- * "De rimpuissance et dc la Sterility," Paris, 1872, second edition, f A ca?e has been encountered by the author. X Op. cit., p. 160. TRUE IMPOTENCE. 429 sion in which his own would fit, and directing a series of copulative acts, anointing the penis, etc. That small size is only relatively a cause of impotence is evident, and that it by no means involves sterility is shown by Orfila,* in a case where an action for rape was brouglit against a man with only the stump of a glans in place of the full penis, by a woman who was im- pregnated by him. Orfila decides that impregnation may take place under these circumstances, but only through the consent of the woman, and that rape is consequently impossible. The numerous cases on record where impregnation has taken place without rupture of the hy- men shows that a deposit of semen within the ostium vaginae may fer- tilize an ovum, and such a deposit of semen might be accomplished by the smallest possible penis. Intromission and ejaculation might take place, and impotence, though possible (as in Eoubaud's case), is not necessary. The patient is not sterile. 3. Extreme size of the penis is a (relative) cause of impotence. 4. Extreme ejjispadias and hypospadias, with or without extreme incurvation, involve impotence, without sterility. Exstrophy of the bladder the same ; and, although as in Huguier's f case, copulation might be possible with exstrophy, yet intromission of semen would not take place, and impotence would be inevitable. The female with ex- strophy is neither impotent nor sterile. Slight hypospadias may, but does not necessarily, involve impotence. The semen is not properly ejaculated into the upper part of the vagina, and impregnation some- times fails to take place — through the fault of the male. A very short frenum may act in the same way as slight hypospadias. 5. Large size of the prepuce, excessively tight and narrow orifice of the same, may involve impotence, as may also any tumors or growths upon or about the penis, elephantiasis, fatty tumor, hydrocele — or neighboring deformity, as faulty position of the thigh from anchylosis of hip, excess of abdominal fat, etc., all of which may mechanically interfere with copulation without in the least implying sterility. 6. Very tight stricture of the urethra, esj)ecially if there be large and multiple fistulse behind it, may involve impotence. The semen does not escape by ejaculation, but dribbles away after erection sub- sides. A similar cause of impotence exists in a vicious direction of the orifices of the ejaculatory ducts, by which the semen, during ejacu- lation, is turned backward into the bladder, and escapes afterward with the urine, as in Peyronie's case, J or from prostatic disease. Ac- cording to Grimaud de Caux,* such a condition of things may be caused by the action of a certain class of Parisian prostitutes, who, * "Medecine legale," vol. i, pp. ITV, ITS. t "Gaz. des Hop.," 1840, p. 467. X Quoted by Orfila, " Traite de Med. legale," fourth edition, vol. i, p. 186. * " Physiologie de I'Espece," Paris, 1847, p. 337. 430 MALADIES INVOLVING THE GENITAL FUNCTION. fearing pregnancy, watch for the moment of ejaculation, and then press forcibly upon the urethra of their })artncr just in front of tiie prostate, by inserting a linger into liis rectum. By this means tlie veru montanum, the natural dam to prevent reflux of semen into the bladder, is' forcibly turned backAvard, and finally, by a rojietition of the act, the faulty direction of the senien becomes permanent, and the individual remains impotent, ejaculating his semen into his own bladder. 7. The peculiar affection called aspermatism is impotence. The patient is not sterile ; his copulation is jicrfect, except ejaculation. 8. Imperfect, irregular, bent erections, due to intlammution of or deposits of various kinds in the sheaths or substance of one of the erectile cylinders of the penis, may sometimes be extreme enough to prevent intromission, and entail imi)otence. 9. Eunuchs, and patients having atrophy of both testicles, are usu- ally impotent, always sterile. 10. Planque mentions a case where a blow on the head was followed by permanent loss of erection. The same may follow jirolonged sper- matorrhoea, or excessive and continued masturbation. 11. Impotence may be symptomatic — not to speak of the physio- logical impotence of childhood and old age — and then is only condi- tional or temi3orar3% and disappears usually with the removal of the cause. Impotence depending upon most of the conditions already enu- merated is, critically speaking, symj3tomatic, such as impotence from local deformity or overgi'owth, or obesity, or stricture ; but the term " symptomatic " is used to make a class apart from idiopathic impo- tence, in both of which the entire sexual tract and the penis are seem- ingly in good condition. A single example will illustrate the point : A has double syphilitic orchitis ; has no desire, no erections — has, in short, impotence symptomatic of syphilis. Prompt treatment is em- ployed ; his testicles return to a normal state, his erections reappear, and he is well. B has the same condition of the testicles, the same impotence, but he employs no treatment ; both testicles go on to atro- phy, and he passes from a condition of symptomatic into one of true impotence, with sterility as well. In symptomatic impotence there is always lack of erection, and often also temporary sterility. Under the head of impotence symp- tomatic of intoxication, Roubaud mentions, as causes, hashish, cam- phor, iodine, antimony, arsenic, lead ; and, although some of these have some influence over the sexual function, it is well not to overestimate their power. The supposed efficiency of iodine in producing atrophy of the testicle is largely hypothetical, and evidently based, to a great extent, upon the influence of Iodine over syphilitic enlargement of the testicle, and the coincidence of atrophy of the same after an inefficient course of iodine. FALSE IMPOTENCE. 431 Symptomatic imiootence, broadly considered, is found in connection with all acute (general) febrile diseases, more or less marked with all cachexioG, in connection witli any advanced condition of disease of the testicle, especially with syphilitic testis, often depending on syphilis, without any appreciable affection of the testicle. It is encountered with severe varicocele and neuralgia of the testis, with bad cases of spermatorrhoea, and as a result of the lack of tone of the genitals pro- duced by long-continued excess — especially by masturbation — with severe diabetes and other advanced devitalizing diseases. Roubaud relates an exceedingly interesting case of symptomatic impotence, where a patient ap]3lied to him with large double hydrocele, and was entirely impotent. Eoubaud supposed that the continued pressure of the hy- droceles had caused atrophy of the testes. He punctured on both sides. The patient recovered his potence, and impregnated his wife. He lost power again when the sacs refilled. The testicles were not atrophied. 13. Finally, impotence may come on without assignable cause ; but there are certain well-recognized causes which, acting upon certain subjects, are capable of producing impotence, more or less prolonged. Partial erection, attended by rapid ejaculation, is a not uncommon variety of impotence, due usually to continence, overexcitement, etc., and observed in animals as well as in men. In such cases also there will be found, not infrequently, a neuralgic condition of the prostatic sinus, and the treatment usually most effective is that of neuralgia of the vesical neck, with instillations of nitrate of silver, the cold sound, local external applications of cold water, and general hygienic measures. These means, aided by the confidence with which a phy- sician should inspire his patient, and the counsel to be deliberate in the sexual act, and to practice it in the early morning rather than the evening ; or even to trust to a second effort, rather than place all hope upon the first, will often overcome this variety of impotence in time. Circumcision may sometimes be necessary to diminish the sensitive- ness of the glans penis, which is often overacute. FALSE IMPOTENCE. False impotence is an affection which the practical physician is often called upon to treat. True impotence involves the treatment of the physical irregularity, deformity, disease, cachexia, etc., giving rise to it. False impotence requires a treatment of the individual, and not of any disease. In false impotence the cause is always nerv- ous, or, it may be, a moral one ; and there is often no impotence at all, except in the mind of the individual. Here the surgeon requires all his delicacy, all his sympathy, in order to obtain the confidence of his patient, overcome his suspicions, and gently lead him to a cure, which is always possible if only the patient have faith. 432 MALADIES I.WOLVING THE GEXITAL FUNCTION. Among the causes of false impotence may be mentioned sexual in- difference, either temporary and spontaneous or more or less prolonged, as a result of sudden shock, grief, excessive joy, fright, repugnance, lack of affection for the individual with wliom copulation is attempted. Under the two latter circumstances, the patient will sometimes think of another i)er.>on tlian the one with whom he is lying, and thus main- tain erection and effect ejaculation. The sudden flooding of the vagina with warm mucus will sometimes cause erection to cease at once. Drunkenness Avhicli is not habitual may induce temjiorary impotence. Koubaud mentions a curious case where impotence came on with an indigestion, and remained long after its cause had disap- peared. He speaks * of anotlier man who became imjDotent on draw- ing a ])rize of thirty thousand francs in a lottery. Another curious case of false impotence is related by the same author : f A young man brought up in the country was, at the age of fourteen, initiated into the mysteries of Venus by a young friend of the family, twenty-one years old. Her hair was liglit, and worn in curls, and, for precaution's sake, she never had intercourse with the boy except when dressed — that is, wearing a corset, high boots, and a silk dress. The boy yielded for the sake of pleasure, but had no affec- tion for the ]ii(\y. She was passionate, and drev/ largely upon his young powers during four years, after which he went to the military school. On entering garrison, he found that he had full sexual powers, but that they were aroused only by certain women, and under certain circumstances. A dark beauty had no power over him, and a night-dress extinguished all his fire. In short, he found himself utterly impotent except in the comjoany of a light-haired woman, wearing curls, with high boots, a corset, and a silk dress. This false impotence had a powerful hold over him. Twenty-five years after having left his seducer it was still upon him, and that, too, in spite of his having meantime fallen desperately in love with a bru- nette, to whom he was afraid to offer himself on account of his inca- pacity ''d'exercer le coit dans le neglige de la couche conjugale." In this case, the exercise of tact, aided by an aphrodisiac potion of cantharides and phosphorus in time effected a complete cure. An equally instructive case, illustrative of false impotence, occur- ring in the practice of Peirilhe, is related by Grimaud de Caux,;]: of a celebrated mathematician, who married a young and beautiful woman, whom he loved tenderly. He felt the power of her charms, and could commence the sexual act creditably, but, althougii they both ardently desired a child, before the moment of ejaculation arrived, the thoughts of the philosopher would unconsciously stray toward some favorite and engrossing mathematical problem, and erection would fail. A cure — at least to the extent of making Mr. father to several fine cliil- Op. cit., p. 186. t Op. cit., p. 439. t Op. ciL, p. 341. FALSE IMPOTENCE— TREATMENT. 433 drcn — was effected by instructing his wife to get her husband partially intoxicated before accepting his approaches — the success of the expe- dient establishing the truth of the old adage : " Sine Ccrere et Baccho friget Venus.'' Treatment. — This form of moral impotence requires special atten- tion to all the agencies which may be active as causes, and the exer- cise of patient tact, and often of sympathy to acquire and retain the patient's confidence, a point of treatment most essential to success. The surrounding hygienic conditions must be made favorable, the advantages derived from change employed, all indications of deviation from health in any respect appropriately met. It is necessary to arouse the moral sentiment of carnal desire, as well as the power of the organs, locally, to respond. The first is attained by favorable relations to the sex — opera, theatre, etc. The second, by general dry frictions of the whole body, by massage and flesh-brush ; cold-bath ; sea-bathing ; generous diet, and the internal use of tonic medication ; the mineral acids, strychnine, ergot, and esjoecially phosphorus and cantharides, or the two combined, commencing at a fair dose, one-fortieth of a grain of the former to ten drops of the tincture of the latter, three or four hours before the desired erection, and increasing the dose care- fully. Cantharides produces erection without desire ; phosphorus and damiana increase desire directly. Cold and heat, by the douche, elec- tricity, and local applications of mustard, are sometimes serviceable in recalling erection. In one case of syphilitic impotence, decided ad- vantage was derived from the use of a quack-treatment, by an instru- ment called the equalizer, a large cell, in which the patient sits with his head out, and from which the air is exhausted. (A modification of the ventouse enorme of the French.) Nervous impotence, the most common form of false impotence, encountered frequently in young men, remains yet to be described. The patient is young and usually healthy. He has generally mastur- bated more or less, and has nocturnal pollutions. He has usually plentiful evidences of virile power. He has desires which are some- times excessive. He awakes with erections. He can provoke erection, or even emission, at will ; but, in presence of a woman, and when he desires to have sexual intercourse, his organs will not respond ; or, if erection comes on, it lacks full energy, and is liable to fail at any moment during the act. In short, the patient can do anything he wishes, except that he can not rely upon an erection at the critical moment. This form of impotence is the result of unnatural excitement of the sexual functions. It may come from protracted chastity, ungratified desii'e, or excessive erotic excitement at the moment. It is not infre- quently accompanied by involuntary emissions during sleep, and by the 28 434 MALADIES INVOLVING THE GENITAL FUNCTION. occasional escape from the urethra at any time of a semi-transparent, viscid fluid furuislied by the uretlira and prostatic follicles. The most persistent and obstinate mental dejection usually accompanies this form of impotence. Under the pressure of imperious desire, and after prolonged chastity, the sufferer has ])robably approached some incon- gruous female, and at the portals of success his erection has failed him. The mental depression following an experience of this sort is of the most exaggerated nature, the existence of impotence is considered as demonstrated beyond cavil, and hope is obstinately banished from the liorizon. The seminal fluid, it is assumed, is escaping in the urethral discharges, and with it manhood and vitality. These ideas are inten- sified by the cunningly conceived advertisements of charlatans, with which the swarming newspapers abound, and the patient is still further enveloped by them in despair. False promises of cure often tempt him to a trial, and their failure relegates him to the surgeon sooner or later, more than ever deeply despondent. Such cases, which are unhappily not rare, require for their management all the ability and tact that can be brought to bear upon them. Treatment. — The best treatment for a man with nervous impotence (who invariably awakes sooner or later with an erection) is to patiently instruct him in sexual physiology and hygiene, acquire his confidence by sympathy, and get him married, with the advice to attempt no in- tercourse, to be entirely frank and honest with his wife (who will more than equal him in timidity and ignorance), and, awaiting some morn- ing when awaking with a vigorous erection, to accomplish coitus promptly, without delay or dalliance, as a matter of imperious duty. The act once accomplished, the charm is broken. The use of the steel sound and of local applications of tannin, with the cupped sound, or of instillations of the nitrate of silver, often of decided service where ejaculation is too rapid, are also sometimes useful here. STERILITY. The consideration of sterility is so interwoven with that of impo- tence that but little remains to be said. Sterility is an inability to beget children on account of absence or imperfection of the semen, and in many such cases there is impotence as well. All eunuchs are sterile ; when both testicles are degenerated or destroyed by disease or atrophy, or retained as in cryptorchids (usually), sterility results. In two special conditions there is sterility without impotence, namely, obliteration of the canal of the epididymis, after double gonorrhceal epididymis, and obliteration of the orifices of the ejaculatory ducts, after stone or operations, from cauterization of the prostatic urethra with solid nitrate of silver, after the process of Lallemand. Of the latter we see and hear little in this country at the present day, but, SELF- ABUSE. 435 according to Grimaud de Caux, in his time the instrument of Lalle- mand made more eunuchs than did the demands of the harems of the East. AVhenever the seminal duct is occluded on both sides at any part of its course, sterility is the natural result, since the sjiermatozoa can not reach the urethra, but, under these circumstances, if the testi- cles are healthy, the patient is fully potent, his desire, his erection, his ejaculation, his pleasure, are normal ; his ejaculated fluid resembles semen in every respect except that it contains no seminal clement. The relief of sterility depends uj)on its cause, which often can not be directly reached by treatment. SELF-ABUSE. Self-abuse is the production of the venereal orgasm upon one's self. The term masturbation signifies that an orgasm is produced by means of friction with the hand, as it most commonly is. Masturbation is not a malady. It does not necessarily produce disease, unless it is carried to excess. The practice of it is not confined to man. Monkeys are often masturbators, bears have the same habit, goats, making use of the mouth, indulge in it, turkeys sometimes practice it upon a round object, like a smooth stone. In the human being it is practiced by both sexes at all ages. Females are much less given to it than males. The majority of women have very little passion, and suffer the approaches of a lover or husband largely as a matter of complaisance. There are undoubtedly numerous exceptions to this rule, but still a rule it is that the female, naturally modest, retiring, refined, learns what passion is only as the result of education after marriage. With the male it is different. His passion is natural. He often has erections while yet a child, and sexual yearnings long before puberty. Planque * mentions two children four years old whose sexual organs were so developed that they could perform sexual intercourse. Karely does a boy escape an initiation into forbidden pleasures by his school-fellows or his elders, and, when he escapes these, he is still very apt, when handling himself during erection, to find the sensation agreeable, and go on, really ignorant of what he is doing, until he becomes a confirmed masturba- tor. Male babies are sometimes handled by their nurses to keep them quiet, a practice which is certain to beget the habit, even in the earliest years of life. Stone in the bladder, irritation of the prepuce from retained smegma, traumatic stricture and bladder-disease, ascarides, etc., lead a child to handle himself, and inevitably end in masturba- tion, if long enough continued ; indeed, there are so many causes, natural and unnatural, why a boy should masturbate, that probably few escape. The most common incentive, however, is undoubtedly instruc- tion, and this is usually received by children from other boys at school. " Op. ciL, art. " Accroisement." 436 MALADIES IXVOLVING THE GENITAL FUNCTION. It may be safely assumed that a large proportion of mankind have at some period of life masturbated more or less, a^ul it is equally safe to assert that at least ninety per cent of such masturbators are not physictilly injured by the habit. Sexual indulgence in the natural way will produce evil effects if carried to excess, yet it is probable that sex- ual intercourse is not only harmless, but even bcncticial in moderation, when carried on naturally — as it can be only in the married state. It is not the loss of seminal fluid which is of the first importance in pro- ducing disease from sexual excess, but the nervous shock of the oft- repeated orgasm. Babies and young children lose no seminal fluid, women have none to lose, yet, in all of these, evil results follow excess, as certainly as they do in the male after puberty. It is probable that any succession of nervous shocks as sharp and decisive as the sexual orgasm, even although they were purely intellectual, such as joy or fear, would shatter the vitality and nervous tone of an individual, per- haps as much as masturbation. Such writers as Lallcmand, Acton, Belliol, certainly make too much of the solitary vice, wliile quacks find here the largest and most lucrative field for their nostrums. The latter scatter their books and circulars broadcast over the land, and often, under alluring titles, thrust them within the eager grasp of the young, the inexperienced, the hypochondriacal, of the nervous, overworked, un- married youth, whose sexual needs, stimulated by his impure thoughts, do not find adequate relief. Here their tenets find ample faith and ready acceptance, and errors are implanted in the ingenuous mind which years of sober after-thought and experience, aided by the sur- geon's careful and conscientious advice, are scarcely able to eradicate. Self-abuse is not confined to youth ; middle and old age are not free from it. The numerous foreign bodies found in the urethra and blad- der attest the tendency that men of all ages have to meddle with their genitals. Dr. J. E. Wood, of K'ew York, had a long, thick, leather thong which he was called upon to remove from a patient, who had introduced it through his urethra into his bladder, and amused him- self by Avorking it backward and forward until the free end in the bladder became knotted, and Dr. Wood was called upon to extract it, finding the patient with several inches of the thong projecting from his meatus. The use of tobacco, alcohol, and, it might be added, tea, is as wide- spread as is the habit of masturbation ; and each of these habits, or certainly the first two, inflict as much injury upon the human race as, in all probability, does the secret vice ; yet who would affirm that every man who smoked would have headache, dyspepsia, heartburn, neuralgia, intermission of the heart-beat, etc. ; would become thin, depressed, nervous, sleepless — effects all of which may be produced by an excess of tobacco ; or that another who drank liquor would neces- sarily have delirium tremens, cirrhosis of the liver, fatty kidney, and SELF-ABUSE. 407 die with ascites and Bright's disease ? As it is with whisky and to- bacco, so it is with masturbation carried to excess. It is capable of producing, it must be recognized, the most serious results, among which idiocy, insanity, epilepsy, dementia, physical prostration, hypo- chondria, impotence, and sterility, are prominent, but these are prac- tically very rare — so rare, indeed, that they arc encountered, as a rule, only by the specialist, and very rarely by him ; and, finally, even when these serious results can be traced to masturbation as a first cause, it will often be found that some other cause has acted in conjunction with the masturbation, such as a blow on the head, hereditary tend- ency to the disease in question, natural feebleness of nervous tone, ir- regular and self-indulgent habits, abuse of stimulants, syphilis. Hence it becomes plain that, while the intelligent physician must recognize the possible physical evils produced by masturbation, he should oppose himself boldly to tliat sickly sentimentality which shrouds in mystery one of the failings of our physical nature, because it involves the sexual function, and should try to look the subject honestly in the face, and handle it as if it were a problem in mathematics. Looking at masturbation in this way, the truth is that the majority of mankind who indulge in it do so just before and after puberty. Most of them are ignorant at first that they are harming themselves, but they soon find it out by one means or another, and then sooner or later give it up. The longer and the more frequently they yield to the vicious habit the stronger does its hold become, so that in case they escape the mental and physical disorders to which excessive venery in extreme cases may give rise, still they may jDay the penalty of excess by some diminution of vigor in after-life, by throwing confusion into their sexual hygiene, and establishing sexual necessities which they find it difficult to meet suitably ; and, finally, they may continue on through life victims to a perverted sexual sense, shunning women, from whom they aver that they derive no pleasure, totally wrecked as to their morale, often hypochondriacs, and suffering from all sorts of functional distress, phj^sical and intellectual, real and fancied. The chief reason why so much is said of venereal excess by mastur- bation, and so little of sexual excess in the natural way, is, that the former is so much more common, and not that the act itself is johysic- ally more harmful. The solitary vice, as it is aptly styled, may be practiced on all occasions, even in company, by the hand in the pocket, or by friction against some prominent object. In schools, not infrequently, boys practice it upon each other ; but, generally, mas- turbation is performed in bed, and in solitary places, where there is no possibility of disturbance. Hence the frequency of its perform- ance is, in some cases, very great, and the effects of often-repeated nervous shock more pronounced. Sexual intercourse, on the other hand, requires the consent of two individuals, and opportunities which. 43S M.\XADIES INYOLVIXG THE GENITAL FUXCTION. relatively, are hard to find. Moreover, a man's moral sense will often keep him from committing excess with a woman, wiien nothing will restrain him while alone. In married life, excess is the exception ; sexnal hygiene is more apt to be correct, man is in his natnral condi- tion, other emotions enter largely into his daily life, and it is rare that the snrgeou encounters in his practice a man happily married com- plaining of any disorder of the genito-urinary system, except those of a purely jihysical nature. Sy?npfonit< of Masturbation. — A young child who has been taught to masturbate will be seen constantly at work at his genitals, and ob- served to have erections with unnatural frequency. Ko further signs are needed. Such children become fretful, peevish, thin, nervous, ex- citable. They sleep badly, have a haggard look, seem to be prone to convulsions, and, it is said, are apt to have epilepsy. Boys who masturbate to excess usually have a long prepuce (they may have none, for Jews masturbate) ; they get a sallow look, have a sheepish, hang-dog expression ; their eyes are deep-set, they incline to melancholy broodings, to sitting by themselves, and reading over a fire rather than to joining their companions at play. They become absent- minded, and their memory seems defective. The hand is apt to be cold and moist in the palm. The skin is often pallid ; the innocent frank- ness of youth is absent. The young man is over-shj', unambitious, he shrinks from a steady gaze, blushes readil}^ and seems to be conscious of having done some- thing unmanly and little. Men who masturbate often show no sign of the habit. They are apt to be cowardly, mean-spirited, poor specimens of humanity ; but it is rare for adults to practice masturbation to great excess, and, if they suffer from any of the supposed evil consequences of the habit, it is either on account of excess in earlier life, on account of imperfect sexual hygiene, or irregularly gratified sexual desire, their symptoms assuming a multiplicity of expression, and generally being such as are arranged under the term hypochondria, and manifestly not dependent entirely upon masturbation, since the same symptoms are very com- mon in patients who do not masturbate, who, indeed, are perfectly continent, and since they are not infrequently relieved by marriage. As to atrophy of the genitals, varicocele, chorea, epilepsy, idiocy, in- sanity, it is quite doubtful if these are often due to masturbation act- ing alone ; and although this vicious habit may be the most impor- tant cause in a given case, and should always be sought for, and if possible corrected, yet undoubtedly usually some other obscure cause of disease is in action, and is, perhaps, to l)lame for the masturbation as well as the idiocy or epilepsy. Dr. Van Buren cut out a piece of the vas deferens on each side in one case, without success in ward- ing off impending idiocy in connection with excessive masturbation. SELF-ABUSE. 439 W. L. FoLsom * is the authority for the statement that Dr. Josiah Crosby, of 'Now Hampshire, In 1843, castrated a young man for ap- proaching dementia due to masturbation, and completely cured the patient. Sometimes, after a severe blow on the head, the intellect fails, epile2)sy comes on, the boy approaches nearer to the brute and is found to masturbate in excess, and this result of his injury frequently is blamed as the cause of all his troubles. The foregoing remarks are not intended to palliate in the least de- gree the baseness of the practice of self-abuse, or to deny that lack of l^hysical and sexual vigor, spermatorrhcBa, neuralgia of the urethra, etc., may be frequently caused by its excessive indulgence, but they are intended to oppose the idea, seemingly so prevalent, that very few men indulge in the secret vice, and that all who do so S'uffer ; and they are also intended to advance the proposition that in the vast majority of instances masturbation does little harm to the individual, except in regard to his morale. It unmans him, makes him untrue to himself, and cowardly ; and most sensible boys find this out before a great while, and give up the practice, which they feel to be sapping their manhood and self-esteem. Treatment. — It is infinitely better that a boy should never mastur- bate, if he can be saved from it. Prophylactic treatment may save him. In the case of babies who do not do well, nurses should be watched, and discharged as soon as there is any evidence that they are handling the child. If the infant have already acquired the habit, his hands must be tied when he sleeps, and at all other times he must be watched until he grows out of the habit. Boys should always be made to sleep alone, never allowed to consort habitually with any other boy, especially if the latter be the older ; all close intimacies between boys of different ages should be broken up, and, on the ap- pearance of any of the signs of masturbation, a close watch should be kept up. It is not good policy in most cases to ask a boy if he fingers his privates. He will be pretty sure to say no, and then to tell other lies to substantiate the first. It is the safest course to assume the fact after a careful study of the case, and the boy, thrown off his guard by the statement that he does masturbate, will rarely deny it, or will do so in such a feeble manner — occasionally with such overpositiveness — that he will convict himself. Finally, when the patient has confessed his folly, it is not wise, in most cases, to try to terrify him out of his habit by brilliant and exaggerated statements of the possible misery he may bring upon himself if he does not stop. This is appealing to a base motive, fear of an indefinite evil in the future, and, although sometimes successful, it is often inadequate to the proposed end, for a healthy boy can not realize what it means to be sick ; he can not * "New York Medical Record," July 16, ISSl, p. 84. 440 MALADIES IXVOLVIXG THE GEXITAL FUNCTION'. understand it, and consequently is not afraid of it. Tlie method of treatment which is most etleetive, but at the same time the one which requires the most force to carry out, is to elevate the boy out of his bad habit, to shame him, to make a man out of him, to reason with him, and talk to him honestly and openly, without reserve or mysti- cism ; to sympathize with him, not to wound him ; to study him and treat him morally. This course will succeed with the greatest num- ber, provided only sufficient time and attention be given to it. When a man comes complaining of the results of masturbation, an attentive study of his symptoms will not infrequently disclose his dis- ease to be hypochondria, and his malady ungratilled sexual desire, with often some neuralgia of the vesical neck. His training should consist in encouragement and continence, with absolute purity of thought, and subsequently marriage, to regulate his sexual hygiene. After marriage it is rare to hear any further complaint from these cases — always provided there is really nothing more than functional derange- ment at the bottom of the patient's complaint, as is the case in the vast majority of instances. As for medicines, they are of little or no value ; camphor, bromide of potassium, or lupulin might be given as placebos, but it is doubt- ful if they are of any efficacy. Cold sponge-baths, out-door sports, physical fatigue, sleeping in a cool room on a hard bed, with a light covering, are all useful ; eating lightly at night, not retiring until very sleepy, and rising immediately on waking in the morning, are powerful assistants in breaking up the habit, but all will be of no avail unless the morale of the patient be elevated, unless he keep his thoughts pure, and desire, for the manliness of it alone, to bo rid of his bad habits. POLLUTION. Pollution is a term applied to involuntary emissions of semen in ejaculation, attended by a venereal orgasm, more or less marked. Pol- lutions are nocturnal or diurnal. Nocturnal pollutions are exceedingly common. They usually ac- company an erotic dream, and the jDatient wakes just as the ejaculation is occurring. Sometimes, when sleep is profound, the patient does not wake, or, if he does, he forgets his dream. The sensation of pleasure undoubtedly accompanies ejaculation in these cases, but is faint and forgotten. Nocturnal emissions in moderation are entirely natural, and by no means a sign of disease. Their frequency compatible with health varies with the purity of mind and the sexual vigor of the patient. A man who is happily married rarely has nocturnal emissions while living with his wife, but, if he leaves her for several weeks, it is natural, and entirely the rule, that there should be a formation and collection of semen which, distending the seminal vesicles, excites POLLUTION. 441 erotic fancies, and, in the relaxed condition between sleeping and waking, escapes at the conclusion of a dream. Any man suffering from ungratificd sexual desire is normally in a condition demanding relief for his overdistended seminal vesicles, and, if that relief be not aiforded in some way by the patient, it will come spasmodically during sleep. This is all the more certain to be the case if the patient has established a habit of rapid "formation of semen by frequent calls for a supply of the same in excessive sexual intercourse, or masturbation practiced as a habit for a considerable length of time : and especially if, when natural or unnatural gratification is given up, lascivious thoughts are indulged in, and impure associations continued. Occa- sionally nocturnal emissions may be overfrequent, and indicate a con- dition of irritation in the deep urethra — some modification of neural- gia of the vesical neck which requires treatment. Treatment. — When emissions do not exceed three times weekly they should be disregarded, and attempts made only to purify the thoughts of the patient, elevate his tone, and get him, if possible, happily mar- ried. Where they become very frequent, as nightly or several times a night for a considerable time, besides the employment of all known tonic and hygienic means and the measures detailed above, certain special attempts to correct the habit are advisable. The patient should exercise and develop his muscular system. He should endeavor to sleep soundly, by tiring himself out through the day by physical work. Dry frictions, cold bath, cold douche, locally, are useful. He should sleep on a hard bed, lightly covered. The stomach should not be full on retiring. Most patients have involuntary emissions toward morn- ing, and, waking, find themselves lying on their back. This position, with the bladder somewhat distended, tends to beget erection, and, by avoiding it, pollution may be escaped. This is accomplished by causing the patient to tie a towel round his waist on retiring, with a hard knot in the back over the spine. When he lies upon this knot it will wake him. Besides these means, among all of which purity of thought comes first, bromide of potassium, camphor, and luj)ulin may be given internally, with strychnine and a mineral acid, or sucli tonic as the physical conditions seem to call for, and locally decided advantage may be derived from the gentle use of the steel sound, as in neuralgia of the vesical neck, and finally the cujDped sound with tannin, as in spermatorrhoea, or prostatic injection with nitrate of silver, which I have found of great value in some cases. Different mechanical devices appear from time to time for treating pollution, their object being either to prevent the patient from handling himself during sleep or to awaken him before emission when he gets an erection. I believe them usually to be without value, and as liable to do harm as good by keeping the patient's mind concentrated upon his malady, and lead- ing him to attach too much importance to the physical act of emis- 442 MALADIES INVOLVING THE GENITAL FUNCTION. sioii. I liavo used one upon a patient wliich started a battery and gave an electric shock in the back wlien erection came on. Verneuil used a similar instrument, which caused a bell to ring when erection came on, and he reports a successful case,* as does also Tillaux.f There is another machine, a ring, which lightly encircles the penis, but when distended by erection causes pain and awakens the sleeper. I think these mechanical means bad, and unsatisfactory in their result. It is attacking only one symptom and letting tlie real malady go. Diin'fial poUiifioH is rare. In some impressionable patients, espe- cially if suffering from prostatic irritability due to venereal excess, the sight or thought of certain women will produce ejaculation, as may a touch upon the glans penis. Ejaculation of semen may be produced by a variety of causes. Lallemaud speaks of a man who could produce it by striking his head with his knuckles. Sudden injuries to the spine sometimes produce the same effect. Lallemand quotes from Hedel- hofer that a man fell upon the sacrum, and immediately had an ejacu- lation. In decapitation by the guillotine, unless the neck is severed too low, ejaculation is quite common. The treatment of diurnal pollution is by steel sounds and local astringents to the prostate, together with most of the means detailed for nocturnal emissions. Circumcision should be performed if the glans penis is sensitive. SPERMATOIlB,H(EA. Few terms are more abused and distorted in their significance than spermatorrhoea. The young man into whose hands some pamphlet on "Manhood Restored" has fallen, imagines himself hopelessly doomed to impotence, paralysis, and idiocy, because he has spermatorrhoea, which spermatorrhoea consists in nocturnal pollution, escape of mucus during prolonged erection, appearance of amorphous phosphates in his urine — often in a gleety discharge, due to stricture or a damaged patch of mucous membrane in the urethra, and sometimes, where the diseased mind of a youth suffering from ungratified sexual desire can find nothing else to confirm its suspicions, the natural, healthy, floc- culent cloud of mucus collecting normally in all urine, after it has stood a while, is pointed to, in dejected triumph, as a demonstration of the never-ending loss of seminal fluid. Occasionally a patient will even bottle his urine and keep it a week, until it has decomposed, and then bring it to the surgeon in its murky condition to prove that he has "spermatorrhoea." Most of the symptoms whicli a patient usually mistakes for sperma- torrhoea have been already disposed of in other portions of this work, * " Bull, dc la Soc. de Chir.," May 5, 1877, p. 298. t Ibid., Nov. 7, 1877, p. 535. SPERMATORRHCEA. 44.3 and need not be again alluded to (gleet, phosphatic urine, vesical mu- cus, decomposing urine, etc.). It falls to the lot even of the special- ist to see but very few cases of true spermatorrhcea. Spermatorrhoea is an escape of seminal fluid containing sperma- tozoa, without ejaculation and without pleasurable orgasm — usually at stool, with the urine, or, to a slight extent, at all times. During prolonged erection under intense sexual excitement, a small amount of true seminal fluid is apt to escape into the prostatic sinus, and to be passed at the next urination. This may happen to any one occa- sionally, and does not amount to disease. Causes. — Spermatorrhcea sometimes follows excessive masturbation ; occasionally it appears as a sequence of acute general prostration — as after typhoid fever ; it may come on in connection with imperfect digestion and general nervous distress from overwork or other cause, or follow chronic disease, of the inflammatory type, of the floor of the prostatic sinus and seminal vesicles. Symptoms. — In true spermatorrhoea it is usual for spermatic fluid in small quantity to pass from the meatus during defecation, esjiecially if the patient is constipated, and for a certain amount of the same fluid to be voided during urination, particularly in the morning ; while, occasionally, jolting, riding, etc., cause a little oozing of a blu- ish fluid from the meatus, which, on examination, is found to contain spermatozoa. These symptoms alone constitute spermatorrhoea, or indeed. the disease may be said to exist where the urine habitually con- tains spermatozoa, although no semen, as such, is involuntarily passed through the urethra. The subjective symptoms of spermatorrhoea are most varied — very often the patient does not know lie has the disease. He complains of some feeling of weight in the prostatic region, of dys- pepsia or some nervous derangement, has little care for his sexual functions, and is not disturbed on the subject of impotence ; presents, indeed, a most strongly marked contrast, as far as expressions of dis- tress go, with the hypochondriacal patient imagining himself impotent from spermatorrhcea, and taxing the capacity of his language to ex- press his woe. Patients with true sj)ermatorrhoea are not by any means necessarily impotent, but their sexual appetite is usually mor- bid, excessive, or feeble, perhaps unnatural and perverted, while sexual power is generally diminished. In many cases the general symptoms are those of great lack of nervous tone, dyspepsia, headache, melan- choly, neuralgia, loss of spirits, pains in the back, groins, testicles, vesical irritability. Such patients tend to grow thin, to lose their ambition and their zest for all ordinary pursuits, to run down, be- come fanciful, indeed hypochondriacal, and often to fret seriously and unceasingly about their malady, of which they entertain only faint hopes of a cure, which they urgently demand. Finally, in the most severe cases, all the above symptoms are aggravated ; the penis shrivels. 444 M.VLADIES INVOLVING THE GENITAL FUNCTION. the testicles become small, flabb)% very sensitive, not infrequently nen- raJgic, the veins of the cord largo and full ; the loss of somen contin- ues for a long time, finally becomes thinner, more like simple mucus, and at last ceases to contain spermatozoa, being made up of the fluids of the seminal vesicles, the prostate, and Cowper's glands. At last the patient becomes truly impotent, incapable of erection. This malady does not kill. I know several patients who have had it during most of my professional life-time — and one old gentleman who was on Dr. Van Buren's books long before my day, who enjo3's excellent health and has nevertheless true spermatorrluea, and has had it more than fifty years. Many cases are positively incurable, some get well — medicine is of little or no value. Precisely the same symptoms as those found in spermatorrhopa may exist in connection with oxaluria, azoturia, lithiasis, and be found with various jn-ostatic and deep urethral neu- roses when there is absolutely no seminal loss whatever, and on the other hand I have several times found true spermatorrhoea when not one of the usual symptoms of the malady was present except the habitual loss of seminal fluid in the urine. The absolute lack of symp- toms in true spermatorrhoea, however, is very rare. It is unfortunate that so many text-books ascribe value to the use of drugs in this mal- ady. It leads to despondency on the part of the jiatient, and places his physician in a false light before his eyes. A few cases can be cured, and something can be done for others, but some cases remain uncured, and the less they potter with themselves the better. If a positive local treatment, with perhaps some tonics when required, fails to cure, the patient will be wise to accept his malady as he would some deformity which others can not see, and think as little of it as possi- ble, keeping his mind pure, and his thoughts away from the subject. Treatment. — All the hygienic, general, and local measures advised for cases of pollution and sexual weakness, already given, become im- peratively necessary in treating true spermatorrhoea, with the hope of success in mild cases, and without entire despair in severe ones. The use of the steel sound helps to give tone to the parts. Eoubaud thinks well of ergot — two to eight grains daily — in atonic cases. The use of a local astringent to the prostatic sinus is often of marked ad- vantage. The best agent for effecting this is nitrate of silver in solution, used as a deep urethral instillation in the manner detailed when describing my deep urethral syringe. Formerly Pig. 110. I employed tannin with the cupped sound (Fig. 110), filling in the cups with a paste of glycerin and tannin, but of late 3'ears I seldom EROTOMANIA— BLUE SPERM. 445 use it. The nitrate of silver gives far better results. I never use a solution stronger than sixty grains to the ounce, and place only three to five drops of this in the deep urethra. Often as much good can be effected with a solution of ten grains to the ounce. Lallemand's in- strument for actual cauterization with solid nitrate of silver should never bo used. It destroys tissue, and may substitute a worse disease (sterility) for the comparatively trivial one of spermatorrhoea, by ob- literating in the cicatrix the orifices of the ejaculatory ducts. EROTOMANIA. Erotomania is a species of insanity. It is a disease of the central nervous system, characterized by the existence of erotic desires with- out the power of accomplishing them, sometimes apparently without the wish to do so, as in a case, which is on record, of a patient so affected, who, when asked what he would do if put to bed with a woman, remarked that he " would go to sleep.'* The malady is not a disease of the genitals, and does not call for any more lengthy descrip- tion here. SEXUAL PEHVERSION. This is a disease of the mind rather than the body, and no lengthy description here is proper. Westphal * and Kraf t-Ebing f have writ- ten learnedly about the matter. Casper gave the name "Lesbian love" to that perverted instinct which inclines a woman sexually toward another woman rather than toward a man. Sometimes the dis- ease takes the form of sexual excitement being produced in a man by wearing articles of female attire. This has been called " gynomania." X Intercourse between women is also called tribadism. Between man and man, or unnatural intercourse between man and woman, is called sodomy. If the victim is a boy it is called paederasty. Ulrichs has given the name " Timings " to those whose sexual sense is only stimu- lated by consorting with one of their own sex. Such individuals in their dress, acts, habits, walk, etc., desire to act the part of one of the opposite sex. They abhor natural sexual intercourse. The subject is a disgusting one, and the very contemplation of it is degrading. BLTJE SPERM. Guelliot * reports a case of '^ spermatorrhee et cyauospermie." Ultzmann has called attention to the same phenomenon, which he ascribes to the presence of indigo, * "Archiv f. Psychiatric und NerYcnkrankheiten," vol. vi, p. 620. f Ibid., vol. vii, p. 305, and " Irrenfreund," vol. xxiv, No. 1, 1884. X "New York Medical Eecord," March 19, 1881, p. 336. * "Ann. des Mai. des Org. Genito-Urinaires," May, 1886, p. 294. 446 MALADIES INVOLVIXC THE GENITAL FUNCTION. SATYRIASIS. Satyriasis is constant desire with erection ; erotic delirium. It is also a brain-disease. An illustrative case is quoted by Acton * of an old man who was eminently satyriasic, so much so that he would masturbate in the presence of ladies. Dying, a tumor of the size of a split pea was found in the pons Varolii. PRIAPISM. Priapism is more or less continuous erection without desire. With some forms of priapism intercourse with ejaculation may take place. The connection between injuries of the cerebellum and spinal cord and erection has long been observed. Koubaud f quotes Serres in stating that out of eleven cases of cerebellar hasmorrhage erection of the penis was noted six times. Death by hanging is often accompanied by par- tial erection. After injuries to the spine, and in some diseases of the cord, producing paraplegia, erections are often absent, returning as the paralysis improves. On the other hand, certain diseases and injuries of the cord are notably attended by priajjism, disappearing as the para- plegia gets well. Lallemand J quotes a case from Fages of an officer who was thrown from his horse, and became at once paraplegic, and simultaneously had priapism. The latter annoyed him excessively, as it produced retention, relievable only by local and general refriger- ants, which reduced the erection. As his paraplegia gradually got well his priapism ceased. Lallemand gives another very interesting case * of a soldier, who, climbing out of garrison to see his mistress, fell upon his sacrum and became partially paraplegic with priapism. He had no venereal desire, yet, because the priapism interfered with his making water, he at- tempted frequently to free himself of it by masturbation, but without success — there was no ejaculation. On one occasion, with the mistress, on attempting to see whom he had acquired his malady, he indulged in copulation almost continuously for several hours, until he had ex- hausted his partner— but all to no effect. He had no pleasure or ejaculation, yet when asleep he had lascivious dreams, with ejaculation and slight sensation. This was a mixed case, since some of its charac- teristics are those of aspermatism. The effect of large doses of cantharides in producing erection with- out desire is well known. Prolonged mental exertion, overanxiety, and other causes capable of reducing the tone of the nervous system are sometimes attended by priapism, due perhaps (immediately) to some local injury such as * " On the Reproductive Organs," fifth edition. t Op. cit., vol. ii, p. 62. + Op. cit., p. 280. * Op. ciL, vol. ii, p. 64. ASPERMATISM. 447 gonorrhoea, the j)assagc of a stone, the introduction of a sound. Pria- pism not very infrequently attends some of the neurotic prostatic affections, especially in patients whose nerve-force is defective. Leu- cocythasmia as a cause of persistent priapism has heen noted by many writers. Peabody * in two papers summarized our knowledge on the subject and gave some cases of his own. Salzer f discusses the various theories of immediate cause — extravasation of blood in the corpora cavernosa, impeded circulation in the smaller vessels, formation of thrombi due to the altered condition of the blood, and irritation of the nervi corigentes — and decides in favor of the last, in some cases at least. Wetherell, J Ketli, Longuet, and other names are known in connection with this subject. Mackie * notes a case of persistent pria- pism lasting twenty-one days in an old man of seventy. After nine- teen days the right corpus cavernosum swelled, incontinence came on with paraphimosis, all relieved by incising the swelling, which dis- charged much black, half-decomposed blood. A chill preceded all these phenomena. Mackie thinks a small extravasation in the corpus cavernosum was the immediate cause of the priapism. Schwerin | has a case of cantharidal strangury without erotic symptoms. He agrees with Palle in dropping cantharides from the list of aphrodisiacs, but the cases of A. Pare, Chauvel, and others quoted by Sonnenschein,^ go to show that the erotic may be roused to the fullest extent by poisonous doses of cantharides. Priapism in children is often due to stone in the bladder, tight pre- puce, worms in the rectum, etc. Extreme cases are on record where priapism has terminated in gangrene of the penis. Treatment. — Priapism usually gets well under hygienic and symp- tomatic treatment, beyond which no special measures can be suggested, except irritating the lower part of the spine, blistering the peringeum, an India-rubber seton at the nucha, possibly the use of electricity, and strychnine, ergot, bromide of potassium tentatively, notably in can- tharidal priapism. Iodide of potassium has been successfully used. J ASPERMATISM. Aspermatism is a peculiar condition of very rare occurrence, in which there is competent erection, sometimes moderate sexual desire, sometimes none at all, no ejaculation of semen possible during sexual * "New York Medical Journal," May, 1880, p. 463, and September, 1880, p. 272. f "Med.-chir. Rundschau," June, 1879, and "Bcrl. klin. Wochensclirift," 1879, Na 46. X " New York Medical Record," August 14, 1880, p. 192. * "Edinburgh Medical Journal," November, 1872. II "Berl. klin. Wochenschrift," November, 1873. ^ " Handbuch der gerichtlichcr Chemie," p. 266 et seq. I " Lancet," May 14, 1887. 448 -MALADIES IXVOLVIXG THE GEXITAL FrXCTIOX. intercourse. A uumber of observers have noted this i)ecnliar condi- tion. Ult/mann * lias a typical case. In the cases observed by the authors the i)atients have been physically vigorous, capable of pro- longed sexual exercise, but utterly unable in any voluntary way, in sexual intercourse or otherwise, to excite an orgasm or have a seminal emission. Every case has confessed to having lascivious dreams, and to have aAvakened with a pleasurable sensation and found seminal lluid upon the night-di'css. A full-sized sound passed into the urethra produces the ordinary sensations in the fore part of the canal, but the prostatic urethra is absolutely insensitive. The theory advanced to account for this strange malady is that, by reason of spasm about the ejaculatory ducts, the semen is prevented from getting into the prostatic sinus. This, however, is untenable ; for, were there desire and pleasure, prostatic mucus would be secreted in excess, and would be thrown out by ejaculation, while the semen proper would collect and distend the seminal vesicles and ducts below the ejaculatory orifices, and would escape and flow away from the meatus, after the relaxation of spasm, brought about by the fatigue following prolonged sexual intercourse. But this is not the case. The fault is evidently in the nerves. There is no pleasurable sensation, no call for secretion of prostatic mucus, or for a supjily of spermatic fluid. There is anaesthesia of the prostatic sinus, and, although the power of having an orgasm and an ejaculation remains, as proved by dreams, yet there is some connecting link missing in the chain which transforms friction of the glans into pleasure at the prostate, and finally into secretion in the testicle. Treatment. — Eoubaud advises antispasmodics, on the theory that muscular contraction is the essence of the disease. He speaks of suc- cess in one case by blistering the perineum and powdering for several days with morphine. No rational or effective treatment has yet been devised. AZOOSPERMATISM. This is a condition in which there is spermatic fluid, but no sper- matic elements. It exists in many cases after double gonorrhoeal epididymitis, in atrophy of the testicle when the fluid is watery and may contain Boettscher's crystals, and in suppuration of both seminal vesicles. * "Ueber maunliche Sterilitat," " Wicn. med. Prcssc," Nos. 1-3, 187S. SPASM OF THE CllEMASTER. 449 CHAPTEE XXYII. DISFASES OF TUB CORD. Anatomy.— Spasm of Crcmastcr.— Varicocele, mild, severe. The cord is made up of the vas deferens, the habenula or remains of the peritoneal process going from the tunica vaginalis to the abdo- men, vessels and nerves, all held together by meshes of connective tis- sue containing unstriped muscular fiber (internal cremaster of Henle). Outside of these there is a continuous layer of connective tissue, ad- herent to the tunica vaginalis below, and continuous with the fascia transversalis above, called tunica vaginalis communis. Outside of this the cremaster muscle lies in loops, some embracing the testicle in a fan shape, others extending only a short distance down the cord. The arteries are the sjDermatic from the aorta, the deferential from the superior vesical, the cremasteric from the epigastric. The veins from the testicle and epididymis unite in the pampiniform plexus, and. constitute the bulk of the cord. The larger veins have valves ; they unite usually to form one large trunk, which empties, on the left side, into the renal vein, on the right side into the ascending cava. The spermatic plexus of nerves is derived from the renal, aortic, superior mesenteric, hypogastric, and lumbar (genital branch of gen i to-crural nerve supplying the cremaster). The cremaster muscle varies in size and power in different sub- jects ; it is a voluntary muscle ; most persons can exercise it simul- taneously on both sides, drawing up and holding the testicles against the abdomen ; occasionally the muscles can be exercised separately, one testicle being elevated while the other is lowered. The function of the muscle is to assist in sustaining the testicle by its tonic contrac- tion, and to compress the organ during the sexual orgasm. The mus- cle is subject to painful spasmodic contraction in kidney-colic, in neu- ralgia of the testicle, and sometimes in connection with prostatic or urethral irritation. A large portion of the cremaster muscle was ex- cised by the late Valentine Mott for obstinate spasm. Cure of the prostatic irritation causing it relieves the spasm. The spermatic cord is rarely diseased. There is more or less tur- gescence of the veins, with sensibility to pressure, in the different in- flammatory conditions of the testicle and vas deferens, and injury may lead to local inflammation, to be assuaged by rest, hot fomentations, etc. Diffuse and encysted hydrocele and h£ematocele of the cord have been considered in connection with similar conditions of the testicle. 29 450 DISEASES OF THE CORD. Fatty tumors are occasionally found. They can not bo diagnosed from encysted hydrocele without an exploratory tapping, and are liable to be mistaken for hernia when located within the inguinal canal. They generally occur later in life ; if large, they have a dougliy feel, and tiro lobular in character ; treatment is rarely required. In cases of doubt, when the tumor might be an omental hernia, the utmost care is necessary in operating for removal. Calcareous de- posits have been encountered in the cord. Vernouil found a large, gummy (syphilitic) tumor in the cord ; Lancereaux and Fournier have recorded cases. VARICOCELE. Varicocele is constituted by a varicose enlargement of the pampini- form plexus and veins of the cord. In a mild form, it is perhaps the commonest affection of the genital organs. It has been estimated that about ten per cent of males have slight varicocele. It occurs almost invariably on the left side ; when very marked on this side, it may exist slightly on the right, but varicocele of the right side alone is almost unknown. Pott met with it on both sides only once. Breschet, in one hundred and twenty operations, operated only once on the right side. Slight turgescence of the veins of the cord does not deserve to be called a disease. The chief factor in its production is ungratitied sexual desire, frequent erotic fancies not finding relief, or, less often, the oj^posite condition, abuse of the sexual powers, by which the veins are kept constantly engorged. The largest proportion of slight vari- coceles which are encountered are found in young unmarried men or old bachelors ; the affection rarely commences after twenty-five ; it is unusual to find it in' a married man whose sexual relations are satis- factory. The slight turgescence of the veins constituting the varico- cele of the young bachelor, and often causing him incessant and need- less alarm, usually disappears after marriage, together with the uneasy sensations which accompanied it. Old men whose testicles are inactive rarely have varicocele, though their legs show many tortuous veins, and their tissues be degenerating. This fact is of the utmost importance, and is dwelt upon thus early in the consideration of the disease, in order that attention may be spe- cially directed to it. The idea that slight varicocele is often a sexual derangement, a functional disorder depending upon bad sexual hy- giene, is not brought out by text-books, and is rarely appreciated by practitioners. Young men in many cases distress themselves unceas- ingly, and importune their surgeon for an operation to cure a disorder which would be more speedily and effectually removed by marriage. The degree of varicocele alluded to above may be dismissed briefly. It is found upon the left side ; the vessels are a little full, the cord VARICOCELE. 45 1 loose, feeling like a small bundle of earth-worms, no one vessel being exceptionally large, the testicle is perhaps oversensitive (irritable), and- there is usually a slight dragging sensation in the groin, but be- yond this nothing except the fancied ills and the hypochondriacal complainings of the young man who is cheating Nature or abusing her gifts. The proper treatment of such cases is found in the employ- ment of all hygienic and tonic measures. The patient's mind must be diverted, he must be dissuaded from an operation, told to wear a snugly-fitting suspensory bandage, and if possible to forget his sex until an opportunity of marriage affords him a chance to get well. As a local measure, the free application of cold water to the parts daily is a very useful adjuvant. Varicocele serious enough to constitute a disease and demand act- ive surgical measures for its relief does, however, occur. It is an ex- aggeration of the milder form ; it comes on in early manhood, and has no connection with varices of the legs or anus (haemorrhoids). It is found on the left side, rarely on the right. The cause of this is believed to lie in the following facts : The left testis hangs habitually lower than the right ; only the larger veins of the cord have valves ; the left vein empties at a right angle into the left renal vein, the right at an acute angle into the ascending cava ; the position habitually as- sumed by men, of standing on the left foot, has been supposed to add to other predisposing tendencies. The veins of the cord, in any case, would seem to be in a position ready to become overdistended, as they lie loose and dependent in the scrotum, and then pass through the comparatively narrow inguinal canal. The position of the sigmoid flexure of the colon, on the left side, so often distended by fecal ac- cumulation, is also believed greatly to assist in the formation of left varicocele, which is always worse during obstinate constipation. In the female, the ovarian veins are rarely found varicose, except in the left side. Sir Astley Cooper never saw it on the right ; the sigmoid flexure seems at fault. Pressure upon the veins at the groin, abdomi- nal tumors, etc., assist in causing varicocele. Sometimes, during sud- den effort, varicocele appears at once, and .increases rapidly ; occa- sionally it occurs acutely shortly after orchitis. Pott * has recorded three cases where, after fatigue, local injury, and cold, sudden pain in the back set in, followed, in a few days, by relief from the pain, and an acute varicocele, which in its turn was succeeded after some days by complete wasting of the affected testis, in one case of both. Prob- ably, in these cases, there was some inflammatory condition obliterating the veins above. * I have seen a number of cases of acute varicocele following an effort — straining of some sort — or coming on spontaneously. I have never seen it terminate otherwise than in recovery, under a suspensory bandage, a * Quoted by Curling. 452 DISEASES OF TUE CORD. mild anodyne and a laxative. I have seen it last a nnmber of weeks, and occasionally leave slight permanent enlargement of the veins of the cord behind. Si/nijjtom/<. — Excoi)t in acute cases, such as tliose just detailed, vari- cocele comes on gradually, and is discovered by accident. The amount of pain complained of is very variable ; a very large varicocele is often attended by absolutely no pain, while a very slight enlargement of the veins may give rise to considerable uneasiness, extending up the back and down the thigh, perhai).s amounting to neuralgia of the testis. Landouzy has noticed that the symptoms are markedly relieved during and immediately after coition, but become worse on the following day. In a full-formed varicocele the vessels are elongated, their valves broken down, their Avails alfected by fatty atrophy, and thickened, as is also the surrounding connective tissue. The mass fills up one side of the scrotum, perhaps encroaches on the other ; its shajje is some- what pyriform ; the loops of A^eius often hang below the testicle. The mass feels soft, like a bunch of earth-worms ; there may be j^hlebolites in the veins. The veins of the testicle, also between the tunica vaginalis and the tunica albuginea, are in bad cases varicose. The scrotal veins may be similarly affected. The scrotum is thin and relaxed, the dartos powerless ; sometimes the integument is so thin that the blue color of the blood in the veins of the cord is visible. In long-standing cases of severe varicocele the circulation of the testis is liable to be interfered with to such an extent as to cause the gradual atrophy of the organ, a result in no way due, as has been intimated, to the weight of the mass of veins. The only general symptoms in varicocele besides pain are those of hypochondria and defective morale, so common in all affections of the genital organs. Diagnosis. — There is perhaps no disease less liable to be mistaken than varicocele ; the wormy feel and i^eculiar look of a cord surrounded by large tortuous veins are h.ardly to be confounded with anything else, unless, possibly, omental hernia. A simple test, however, removes all doubt. If the patient lie down, the whole swelling may be readily reduced. The fingers are now placed at the abdominal ring, and the patient is told to rise ; hernia will be retained, the swelling of varico- cele will return, the vessels filling from below upward. If the pressure at the ring be strong enough to compress the arteries as well as the veins, the tumor will not reappear. Varicocele complicated by large hydrocele, or by hernia, is more difficult of diagnosis. Treatment. — If varicocele be small and the symptoms to which it gives rise inconsiderable, the palliative treatment already recommended for simple cases will suffice. Varicocele never compromises life, rarely deteriorates health, and, when it is sinijily mechanically incouA^onient, to a moderate extent it should be overcome by mechanical means. All the operations proposed for varicocele up to a very recent date have VARICOCELE— TREATMENT. 453 been more or less formidable, and have entailed possible fatal conse- quences. To offer such an alternative to a patient moderately afflicted was a serious matter. Dr. Van Buren during his lifetime was opposed to any operation for varicocele except in extreme cases. During my twenty years of association with him I can only recall three cases of varicocele operated on, one by curtailing the scrotum, one by silver wire, one by the antiseptic open operation. Each of these operations confined the patient to bed several weeks. Since perfecting the new operation which I have recently advo- cated,* namely, the subcutaneous use of silk, I have operated upon a great number of cases. No patient has been detained in bed more than ten days, many not more than five, one only forty-eight hours. No accident has happened. The first (catgut) cases did not get well. Catgut does not answer. The last (silk) cases all got permanently well. I have had no abscess, only the escape of a little serum in two cases, possibly a little sero-pus in one which I did not personally at- tend. I now look upon the operation as one of the smallest impor- tance, and one capable of yielding such marked benefit that I do not hesitate to recommend it in any case of any material varicocele which yields discomforting symptoms. I once saw atrophy of the testicle follow ligature of the veins at the hands of an excellent surgeon. I have never seen any approach to this catastrophe when all the veins on both sides of the vas deferens were ligated by the method I am about to detail. That atrophy may not come on if all the veins are tied up I am not able to affirm ; but, if all the large veins are selected out and ligated in two masses, one on each side of the vas deferens, atrophy does not, in my experience, come on. I generally apply only one ligature high up ; I have frequently also applied another on the other side of the vas deferens or posteriorly ; sometimes I apply two on the same, the outer, side of the vas deferens, one high up, the other near the globus major. I think it, therefore, only necessary to describe two operations for varicocele : (1) the simple subcutaneous ligature ; (2) the curtailment of the scrotum, applicable to cases in which the scrotal tissues are very long and loose, and in which the scrotal veins are also varicose. Subcutaneous ligature of the vessels for varicocele has been prac- ticed for many years, silver wire, silk over an outside spring or button, or rubber ring being commonly used, or the elastic ligature. Finally, catgut came to be employed, being cut short and left in. This served admirably so far as suppuration was concerned, but the catgut did not remain long enough in place, and the vessels resumed their patulency generally, making the operation a failure. Who first used silk in subcutaneous ligature I know not. Ogston f used it in 1878. E. * " New York Medical Kecord," Feb. 20, 1886, Sept. 18, 1886, and Nov. 26, ISSY. + " Annals of Surgery," August, 1886. 454 DISEASES OF THE CORD. Barker* reports two cases in which he used silk, passing it by means of a puncture made with a knife. I eni])loYod silk for te first timeh in April, 1880, not knowing at that time that it had been used before. Since that date I have used nothing else, and I have nothing to regret, nothing to desire. I liave prepared the silk — the common twisted silk, of good size, so strong that it can not be broken by the power of my hands — in various ways. Recently I simply boil it for a few minutes to purify it and get the kinks out, and put it into a bottle containing pure alcohol. It keeps indefinitely, and is always ready for use with- out further preparation. I have devised and used no less than six dilierent needles for facili- tating the operation, but of late have come to use a modification of Eeverdin's needle. The needle, as modified (Fig. Ill), is simply a straight needle in a handle. By a mechanism in the handle the eye Fig. 111. of the needle is opened and shut, and by a spiral spring which I have applied the eye is kept permanently closed, so that, while manipulating the handle, the eye can not be opened, as may and occasionally does happen in the original Eeverdin needle, during careless handling. Tlie Operation. — The scrotum is washed in a bichloride solution of 1 in 1,000. The patient stands beside the bed, so that, if he becomes faint, as he often does after the puncture, he may be at once placed upon his back in bed and the operation continued in that position. The distended veins are separated by manipulation fi'om the vas def- erens, which can be easily felt among the elements of the cord, and are moved toward the outer side of the scrotum. The needle, taken from the bichloride solution and armed with one strand of silk, is made to transfix the scrotum between the veins and the vas deferens. "When the eye of the needle emerges, the silk is drawn through with a tenaculum and disengaged from the eye of the needle. Now the punctured scrotum is traversed independently by the needle and the one strand of silk. The scrotum is again washed in the bichloride solution, and the needle withdrawn partly until it clears the veins, but it is not withdrawn out of the point of anterior puncture in the scrotum. The veins are now allowed to rejoin the vas deferens, and the point of the needle is again advanced upon the outer side under the dartos, and made to emerge posteriorly at the exact point out of which the silk is protruding. The eye of the needle is now opened, the silk placed in it, and the instrument entirely withdrawn, carrying the silk with it. The scrotum is again washed. A few hairs are plucked away from the posterior point of puncture in the scrotum, * "Lancet," September 30, 1882, p. 521. VARICOCELE— TREATMENT. 455 and, the anterior ends being firmly held, the scrotum, is pulled away so that the shred of dartos included in tlie loop at the posterior punct- ure may be pulled free from the integument. Now a few more hairs are plucked out at the anterior point of puncture, that they may not be tied in, and the silk is forcibly tied. I make a triple knot for security, cut the ends short, and let the knot sink into the scrotum. No bleeding occurs. Any drop of oozing may be covered at the punctured points with iodoform or iodol. The dressing is simply a little cotton and a suspending sling. If other veins are to be ligated on the other side of the vas deferens, the punctures should be made during the erect position of the patient. The washing and final ligation may all be done after the patient lies down. An anodyne is usually unnecessary. I rarely give any medicine except a laxative on the third day. Some pain and swelling follow. As soon as the patient can stand erect without considerable pain, he is allowed to go about. The swelling gradually subsides. The hard spot at the ligated point remains, certainly for a year, possibly longer. If all the affected veins are ligated, cure is certain. I have as yet seen no complication. If pus should form, which I hardly think possible if proper care has been used, it must be let out by incision and treated according to its necessity. Ablation of the scrotum, when called for, may be performed by cut- ting away the redundant portion with curved scissors, or upon one of the numerous clamps which have been devised for the purpose.* Anaesthesia is necessary. The excess of scrotum is to be taken up in the line of the raphe, and parallel to it. All bleeding points should be carefully ligated with catgut. If this operation is performed, it is better to dissect out the enlarged veins, to ligate them at each end, and cut away the middle portion. Finally, the edges of the wound are to be accurately coapted and closely sutured, the wound drained and dressed antiseptically. CHAPTER XXYIII. DISEASE OF TEE VAS DEFERENS AND SEMINAL VESICLES. Anatomy.— Inflammation, acute and chronic. The excretory duct of the testicle commences at the tail of the epididymis, forms one of the principal constituents of the cord, passes through the inguinal canal, curves down into the cavity of the pelvis, * The clamp of Henry, of New York, is an admirable one. 456 DISEASE OF THE YAS DEFEREXS AND SEMINAL VESICLES. skirts the base of tlie bladder, and, joining with the duct from the seminal vesicle, terminates as tlie ejaculatorj duct on one side of the summit of tlie veru montanum in the prostatic sinus. The canal is nearly two feet long, from a line to a line and a half in diameter. Four fifths of its structure is muscular. It is very dense and hard, and feels like a whip-cord when rolled between the fingers. Its outer coat contains condensed connective tissue, elastic libers, vessels, nerves, and a little longitudinal unstriped muscle. The middle tunic is mus- cular, its external and a few internal fibers run longitudinally, the middle fibers are circular. The internal tunic is mucous, provided at its commencement with ciliated epithelium. This membrane lies in longitudinal folds, more or less reticulated, particularly in that part of the canal lying within the brim of the true pelvis. Here the cavity of the canal usually enlarges into a sort of reservoir, while the sides are furnished with pouches and diverticula, recalling the appearance of the seminal vesicles. The dilated portion of the canal is well supplied with simple sacculated glands. They are filled with numerous yellow- ish-brown granulations which give a jDCCuliar color to the mucus of the part. The vas deferens may end in a blind extremity or be deficient when there is no testis. It is not often diseased. It may become inflamed in connection with gonorrhoea leading to abscess. It participates in tubercular and pseudo-tubercular disease of the epididymis. Portions of its structure so diseased may soften and form abscesses, which break externally, or perhaps internally, followed by a slight discharge of bloody pus from the urethra, and perhaps leading to occlusion of the canal during cicatrization. DISEASES OF THE SEMINAL VESICLE. The seminal vesicle is a reservoir connected with the vas deferens. Its function is to collect seminal fluid, dilute it by an admixture with its own secretion, and hold it ready for use. The vesicle, from one to two and a half inches long by half an inch broad, lies at the outer side of its own vas deferens, its apex imbedded in the prostate, its fundus diverging from its fellow of the other side, so as to skirt that portion of the bladder which usually lies in contact with the rectum, and corresponds to the trigone within. The vesicle is simply a tube so rolled up and doubled upon itself that its blind extremity nearly corresponds in position to its neck. When unrolled, the tube meas- ures from four to eight inches. It is plentifully supplied with diver- ticula and branched pouches, so as to present on section the appearance of a cellular cavity. At the neck a short constricted canal joins the vas deferens at an acute angle, to form the ejaculatory duct. The minute structure of the walls of the seminal vesicles is identical with THE SEMINAL VESICLE. 457 that of the vas deferens. The convolutions of the tube arc united by connective tissue, containing a large amount of unstriped muscle. After surrounding the vesicle, this tissue crosses over and envelops the vesicle of the other side. The whole is known as the posterior aponeurosis of the prostate. The arteries of the seminal vesicles come from the inferior vesical and middle hsemorrhoidal. The veins join the plexus on the sides of the bladder. The lymphatics go to the j)elvic ganglia. The fluid of the vesicles is albuminous, and contains many yellowish bodies and masses of spermatozoa. The vesicle discharges by contraction of its own wall, of the muscular membrane surrounding it, and of the leva- tor-ani muscle. An acquaintance with the position of the seminal vesicles is essential to the performance of puncture of the bladder by the rectum, or of the retro-vesical operation for stone. When the bladder is full, the vesicles are pressed apart, and it would be difficult to wound them. Cruveilhier,* however, speaks of a specimen, pre- sented to the Anatomical Society by Deville, where the two vesicles were confounded in a single median pouch with two difEerential canals. This anomaly is very rare. Ateophy of the seminal vesicle follows atrophy of the correspond- ing testicle or its ablation. The vesicle is also absent or defective where there is no testicle of the same side. The vesicles are jiartly imbedded in prostatic hypertrophy, and become involved in prostatic cancer. The only morbid conditions of these organs, however, commonly met with in practice, are inflammatory and tubercular disease. Con- gestion of the prostatic sinus, in individuals given to venereal excess, especially if they be weakly, leads to a lack of tone in the ejaculatory ducts, so that they remain more or less patulous. Under these cir- cumstances involuntary emissions are frequent, and a flow of semen may occur on urination, or during efforts at straining, particularly at stool, if there be constipation. The pressure of the levator ani and of the fecal mass upon the seminal vesicles forces their contents through the relaxed ducts. Reliquet f has recorded a case of impaction of the left ejaculatory canal by sympexions (the little, soft, yellowish, striated bodies, breaking with a peculiar fracture, and always found in the semi- nal vesicles. Sometimes large sympexions entrap in their structure the true spermatic elements). Eeliquet is inclined to ascribe to these sympexions the pain which some people feel at certain times during the venereal orgasm. Eeliquet calls his case spermatic colic. A man of thirty-five, who had had pain on urinating a year before without obvious cause, and who during straining at stool had often voided a thick white fluid by the urethra, complained for two months of pain during the venereal act, followed by pain on urination, with spasm, * Op. cit., p. 375. f Reprint from "Gaz. des Hop.," 1874. 458 DISEASE OF THE VAS DEFERENS AND SEMINAL VESICLES. pain on standing and walking, great pain during an action of the bowels, and excessive distress on erection. The urine contained blood. The left seminal vesicle was hard, swollen, painful upon rectal touch. Eeliquet made an exploration with a lithotrite. During Avithdrawal .of the instrument there was violent spasm, after which the patient voided some water which had been previously injected into the bladder, and ])assed forty soft, dead-white bodies, varying from the size of the head of a pin to that of a small bean. These bodies were declared by Robin to be sympexions. The patient's symp- toms immediately improved, and an examination of the seminal vesi- cle showed that it was no longer distended. Keliquet * later pub- lished a somewhat similar case, cured by milking out the seminal vesi- cle several times with the finger. Inflammatiox of the Seminal Vesicles. — This affection is rare. It is usually unilateral, and is due to extension of inflammation from the prostatic sinus, gonorrhojal or otherwise. Symjitoms. — Digital examination by the rectum reveals a hot, sen- sitive, oval swelling behind the prostate, in the position of the seminal vesicle, perhaps on both sides. The size is double, or more, that of the normal vesicle. The surface is hard and uneven, or fluctuating. There is complaint of a continued, heavy pressing (perhaps pricking) pain in the rectum, low down, shooting toward the sacrum. The pain often involves the testicle, which is sensitive and turgcscent. Urina- tion may be difficult on account of the pain, which is increased by rectal examination, and greatly aggravated during defecation. I have seen retention of urine from this cause, and many cases in which more or less persistent spasm of the deep urethral cut-off group of muscles was due to it. Verneuil f reports an excellent example of this compli- cation. There may be frequent painful erection, perhaps priapism. Any attempts at sexual intercourse greatly aggravate the pain. There may be involuntary painful nocturnal emissions of semen mixed with pus and streaked with blood, and a constant viscid purulent discharge from the urethra, also colored or streaked with blood, and containing spermatozoa. These symptoms may subside after a few days or persist in a chronic form indefinitely, there being a gleety discharge containing seminal elements, and more or less sexual irritability. This may wear the patient out, leading to serious melancholy or hypochondria. The symptoms, however, may gradually improve with the general health up to complete recovery. If the inflammation reach a high grade, the duct of the vesicle becomes obliterated, abscess forms and discharges into the urethra or rectum, leaving fistula behind. After such abscess and fistula, the vesicle sometimes gradually atrophies, and with it the * "Gaz. dea Hop.," 1879, p. 891. f Referred to by Sebeaux, " Contractures du Col de la Vessie," Paris, 18Y6, p. 40. TUBERCULAR DISEASE OF THE SEMINAL VESICLES, 459 vas deferens and epididymis of the same side are very apt to dwindle away. Finally, the chronic inflammation, under the influence of gen- eral impaired vitality, may lead to thickening of the walls of the vesicle, cheesy degeneration with softening, abscess, fistula, calcification, etc. Inflammation of the vesicle may lead to peritonitis (Peter, Godard, Faucon).* Treatment. — The treatment of acute inflammation of the seminal vesicles is absolute rest in bed, with opiate suppositories, and perhaps camphor and lupulin, to modify erection. This, with local application of heat, warm enemata, and an early ojDcning through the rectum of any abscess that may form, constitutes the treatment. Any chronic inflammation, with gleety discharge, which may be left behind, must be combated with general hygiene and tonics. Hydrocele of the seminal vesicle yielding an enormous amount of fluid on tapping is reported by N. R. Smith, f of Baltimore. It was cured by a second tapping. Heinemann J showed to the New York Society of German Physicians a specimen of double cystic disease of the seminal vesicles. The vesicles were about three times the normal size. He had found records of four similar cases, Pitha and Billroth, Eng- lisch. Mason, and Peabody. Tubercular Disease of the Seminal Vesicles. — This affection may occur without any antecedent local inflammation, or may follow chronic inflammatory disease. Cheesy, yellow masses of deposit occur, which tend to soften centrally. It rarely is seen, except in connection with more advanced disease of a similar character in the prostate, epididymis, kidney, or bladder. The vesicle is often involved syn- chronously with the vas deferens, and may be felt through the rectum, hard, knobbed, irregular, perhaps insensitive to pressure, perhaps tender, more or less inflamed, and with softened spots. If abscess form, it discharges into the rectum, or perhaps into the prostatic sinus, leaving a cavity in connection with the latter, which furnishes a constant supply of gleety material such as escapes from the urethra in tubercular prostatitis. Treat7nent. — Local treatment is symptomatic. The general meas- ures, which may be curative if conscientiously followed out, have been given in the sections upon treatment of the same morbid condition of the prostate, bladder, and epididymis. * "Archiv. Gen.," October, 1877, p. 385. f London "Lancet," October, 1872. t "New York Medical Journal," March, 1880, PAET II. CHANCROID AND SYPHILIS. CHAPTER I. CHANCROID. Definition.— Transmissibility to Animals.— Cause of Chancroid.— Indefinite Inoculahility.— Relative Frequency.- Methods of Contagion. — Explanation of Apparent Long Period of Incubation.— Situation of Chancroid. — Symptoms.— Course. — Character of Scar. — Variation of Cluincroid from Type, in Initial Form, in Shape, in Number, in Size, in Duration, in Pain, in Condition of Base, in Course (Relapse).— Complication by Vegetations, by Syphilitic Chancre, by Inflamma- tion, by Gangrene and Gangrenous Phagedena, by Pultaceous Phagedena, by Bubo, by Lyni- phitis.— Diagnosis of Chancroid.— Prognosis. Custom in America has adopted the name '* chancroid " (originated by Clerc) to express that form of contagious venereal ulcer which is not accompanied by any constitutional syphilitic infection. It is "widely known also as soft chancre, or simple chancre ; but, of the many terms, perhaps chancroid is the least liable to lead to ambiguity, and it is essentially appropriate, as signifying a disease which, while it is like a (syphilitic) chancre, is still, in fact, widely different from it. For true chancre, the initial lesion of syphilis, the term syphilitic chancre will be adopted. Chancroid is a local virulent ulcer, never the starting-point of syphilis, always due to inoculation of pus derived from a similar ulcer. Its own secretions are freely auto-inoculablc. Of the three distinct venereal di.seases — gonorrho?a, chancroid, syi^hi- lis — gonorrhoea is, strictly speaking, the most venereal, being practi- cally never acquired except in sexual intercourse. Chancroid, equally virulent, is less venereal, and recognizes many methods of propagation besides sexual congress ; while syphilis is of all the least virulent (in the sense of the facility with which it may be acquired), and the least venereal, as will be shown when treating that subject. CAUSE. 4f;l Chancroid is an affection only perpetuated by contagion, but for this sexual intercourse is not essential. Wherever upon the human body a chancroid is found, there, it may be positively affirmed, pus from some other chancroid has been deposited under conditions favor- able for its absorption. No amount of sexual excess, no degree of uncleanliness, no irritation, traumatic or chemical, however prolonged, no simple or poisonous ulceration from other specific source (syphilis, cancer, glanders, etc.), nothing, in short, can produce chancroid ex- cept chancroid (chancroidal bubo of course included). The appar- ent exceptions adduced by Pick, Lee, Wigglesworth, Kraus, Eeder, L. Vidal, Kaposi, Bidenkap, and others, showing auto-inoculable pus derived from sources not chancroidal, do not negative the above proposition.* Of syphilis this much can not be said ; its methods of propagation are far more numerous than simple local contagion. Chancroid, furthermore, is transmissible to animals. Some experi- menters have obtained only negative results ; others have been success- ful, showing that, although animals may receive the disease, they do so imperfectly and often not at all. Chancroid developed on animals heals quickly. Auzias Turenne, in 1844, first successfully inoculated monkeys, rabbits, cats, and dogs with chancroid. Eobert de Weltz, in 1850, inoculated his own arm four times with pus taken from chancroid artificially developed ujDon a cat and a monkey : all four inoculations took and produced the characteristic ulcer. Diday, in 1851, from a chanci-oid which had been produced by inoculation upon the ear of a cat, inoculated himself successfully on the jjenis. The ulcer became phagedenic and was attended by supjiurating bubo. Eicordi brought about a chancroidal bubo m a rabbit, which he had inoculated with pus from the chancroid of another rabbit. It was in connection with experiments of this order that Auzias Turenne invented the term "syphilization," since he found that rein- oculation of chancroid pus upon animals resulted in a less and less perfect ulcer each time, until no effect was produced at all. f As Auzias Turenne recognized no difference between chancroid and syphi- lis, he supposed that this immunity of the skin of animals to chan- croid pus indicated that they were saturated with syphilis, '' syphi- lized," and exempt from all further trouble from that disease. Hence the term syphilization, which, starting in a misconception, has been perpetuated even to our day, and has still some conscientious advocates. Cause. — As already stated, the cause of chancroid is unique. It can be produced only by the contact of pus from a similar ulcer upon some portion of the skin or mucous membrane under conditions favor- * I have considered this subject with some care and at some length in my work on "Venereal Diseases," New York, William "Wood & Co., 1880, p. 11 et seq. f Letter to the Academy of Sciences, 1850, quoted by RoUet. 462 CHANCROID. able for ab?or]>tioii. No one is exempt. The bearer of a chancroid is just as liable to be poisoned by the pus of his own sore as is a per- fectly healthy person. Other diseases do not furnish any immunity.* Positive results are obtained by inoculation upon patients with cancer, with syphilis, witli scrofula, with elephantiasis, and a previous attack of the disease does not insure in any manner against succeeding at- tacks. Eollet,f following Von Roosbroeck's lead, has demonstrated by ex- periment that the contagious principle resides in the pus-corpuscles, and, if these be filtered out, all inoculations witli the remaining fluid prove negative. What this contagious principle or virus is, has not yet been discovered. Assertions have appeared from time to time (Donne, Didicr, Salisbury) that a peculiar parasite has been discov- ered, now animal, now vegetable, which was the essential poisonous agent, but the authors of all such theories thus far have failed to sub- stantiate their claims, and it still remains for the chemist or the micro- scopist to demonstrate in exactly w'hat the poison of chancroid con- sists. Thus far the pus of chancroid is identical, under all tests, with pus from any other ulcer. By its poisonous effects alone it is distin- guishable. These effects may be studied by inoculation. Chancroidal pus preserves its poisonous i^roperties if kept cool in tightly-corked bottles. Boeck states (oral communication) that they are in the habit of sending it from the hospitals of Christiania into the surrounding country for purposes of "syi)hilization." It may be frozen, and still inoculable when thawed. Boeck believes that it loses its virulence after having been dried. Dried pus certainly sometimes fails to give positive results when remoistened, but this can not be re- lied upon, as Sperino J used a lancet which had been laid aside for ■* It has been stated that chancroid will not take upon a patient suffering at the time from acute febrile disease. Dr. Morrison-Fiset, at the Charity Hospital, at my suggestion undertook some experiments. They were, unfortunately, interrupted after the doctor had inoculated one patient three times upon the thigh — the gentleman in charge of the fever wards being fearful lest syphilis should be introduced among his patients. The one case inoculated was, however, carefully studied by Dr. 5Iorrison-Fiset. The inoculations were made at the end of the second week after chill, the patient's temperature ranging at 103-104° Fahr. Boeck's method was used, and three punctures made, one quarter of an inch apart. Two of the punctures took perfectly, although the process of ulceration was very slow. On the thirteenth day pus from one of these ulcers was inoculated upon a healthy patient, with the effect of producing a characteristic chancroid. The ulcers on the leg of the typhoid patient finally became confounded in a single ulceration two inches in diameter, which was dressed with iodoform, and on the patient's discharge from the hospital, convalescing, after a sojourn of fifty-three days, the ulcer was reduced to a diameter of one inch, and was healing. The ulcers were under observation after inocula- tion forty-six days. The evening temperature remained near 104° for several days after inoculation. — Keyes. \ "Trait6 des Maladies v6ndriennes," Paris, 1866. X "Studi clinici sul Virus sifilitico," Turin, 1863. INDEFINITE INOCULATIBILITY. 4fj3 seven months, upon the point of which was some dried chancroidal pus. Three punctures were made with this lancet, all of which took. Heat, however, at the boiling-point, destroys the activity of the virus ; acids, alkalies, alcohol, all destroy its virulence at once, and decompo- sition is fatal to it. When gangrene attacks a chancroid, the sore is no longer poisonous. With the above and kindred exceptions, a mix- ture of chancroidal pus with any indifferent menstruum does not injure its virulence ; such as water, urine, saliva, sweat, mucus, muco-pus, spermatic fluid. As to the amount of pus required to effect contagion, probably one microscopic pus-corpuscle is sufficient. The smallest possible prick of the skin to which the pus is applied will produce just as characteristic a chancroid as will the bountiful smearing of a raw surface of any size. Puche * got positive results by inoculation from a drop of pus diluted with half a glass of water, Boeck after diluting with 1,100 parts of other pus. The poisonous effect of chancroidal pus is evinced by its power of rapidly begetting a chancroid whenever it is brought within the reach of absorption, by a removal of the cuticle or external layers of epithelium from any surface. Inoculation or hetero-inoculation signi- fies the contact of this pus with an abraded surface of any individual other than the one who furnishes the pus. Auto-inoculation signifies such contact upon the body of the bearer of the chancroid. Evidently such inoculation may be the result of accident or design. Chancroidal poison is indefinitely auto-inoculable. Lindmann in- oculated himself 2,700 times, and was still making successful auto- inoculations when last reported by Fournier. The body of Auzias Turenne is said to have been found covered with chancroid scars at his death, showing that he did not shrink from practicing his pet theory, "syphilization," f upon himself. By the process of syphiiization, immunity of the skin to the poison is obtained. A certain pus is employed, and reinoculated until it will no longer produce a pustule ; then fresher pus from some other younger chancroid, until it also fails ; and until, finally, no inoculation gives a positive result. This much syphilizers have taught us, and they have also taught us that the different regions of the body are susceptible in a different degree to the action of a chancroidal j)us of given virulence ; for, after the chest fails to take, the arms may still be inoculated suc- cessfully ; and, finally, when the arms have acquired immunity, the thighs will still furnish characteristic results upon inoculation. This * Kicord, " Le9ons sur le Chancre," Fournier. f The term syphiiization is here used in the sense first given to it by Auzias Turenne, but it must be understood tliat, in accordance with the views advanced in this treatise, the term is essentially incorrect, as the virus of true syphilis is entirely distinct from that of the chancroid ulcer. 464 CDANCROID. immunity, however, obtained by frequent and continuous irritation of the skin with numerous chancroid ulcers, is more apparent than real, since it is only temporary ; for after the skin lias had a rest for some months, inoculations often again give a positive result (Bocck, oral communication). Hence the rule, practically true : an individual may have chancroid as often as he is exi)osed ; there is no limit to the number of jiossible attacks. Frequency of Chaxcroid. — Statistics, which vary greatly at the hands of different collectors, only show in a general way that in dispensaries and hospitals, among the poor and dirty, the frequency of chancroid far outranks that of true syphilitic chancre, while private statistics taken from otiice practice in the better classes demonstrate clearly that in this set of patients the true syphilitic chancre is more common than the chancroid. Puche's ancient figures gave eighty per cent to chancroid in the Midi Hospital, but that this varies greatly is shown byMauriar* and Ilorteloui^f Fournier J first clearly called attention to the general relative difference between the cases com- monly encountered in hosjoital and in private practice. The reasons for this singular difference of figures are obvious. The lower classes of society who enter hospitals are given to intemperance, and careless in their habits. Furthermore, they are poor, and consort with the lower orders of prostitutes, those who are unable to care for themselves when diseased, but must continue at their profession to gain their daily bread. Most of these also are old, have had syphilitic chancre and contagious secondary lesions in their youth, and are therefore incapable of giving syphilitic chancre, while many of them possess old chronic chancroid, which is kept from getting well by constant local irritation, and which forms a hot-bed of infection for all who approach. Old prostitutes get used to the idea of having a chancroid, and con- sider it a small matter. The more refined and wealthy males of the upper classes, on the contrary, are careful in their selection of females. They seek the young and those apparently sound. Young prostitutes are often unaware of having syphilitic chancre or secondary lesions of the vagina, while they can scarcely be ignorant of the presence of the more formidable-looking chancroid with its possibly accompanying inflammatory bubo, and fear prompts them to seek medical aid, and give up their profession temporarily in the latter case, while they might innocently continue it in the former. Furthermore, none of the upper classes appear at hospitals, and few>of the lower who have syphilitic chancre (often an insignificant-looking painless lesion), while they run in all haste for relief for the painful, angry-looking chan- * " Raret6 actuelle du chancre simple," Paris, ISYC. f "Ann. de Dermat. et de Syph.," January, 1880, p. 64. X Art. " Chancre," " Diet de Med. et de Cliir. prat." METHODS OF CONTAGION". 465 croid. Finally, syphilitic chancre occurs but once in a lifetime, and rarely lasts long ; while chancroid may be acquired an indefinite num- ber of times, and may possibly in certain forms last a number of years. Hence the rule : in hospitals, chancroid far outnumbers syphilitic chancre. The same holds for the practice of the young surgeon, or for those who attend the poorer classes ; while, in the higher walks of life, ulcerations about the penis will be mainly herpes, or abrasions, or balanitis, syphilitic chancre next in frequency, chancroid least common. Methods of Coktagion. — Contagion is immediate, i. e., by direct contact, as in sexual intercourse, or manipulation of chancroids with fissures or abrasions on the hand ; or mediate, i. e., through some intervening agency, as by carrying the poison upon the fingers in scratching, and thus inoculating some abraded surface. The "virus is fixed and not volatile, and actual contact with the pus is essential to infection. Contagion takes place in the vast majority of instances during the sexual act, but, as any abraded surface upon any part of the body is capable of absorbing the virus, cases of accidental, mediate, or immediate contagion occasionally occur, as on the finger of the accoucheur. Spontaneous auto-inoculation is common, especially where the virulent pus is retained between two tegumentary surfaces lying in contact, as beneath the prepuce. Mediate contagion in sexual intercourse is possible. Thus, a man with a long prepuce, but no abrasions, may carry the virus from one woman and deposit it in another, with whom he cohabits at a short interval. Then washing himself, he may escape infection, after having none the less occasioned chancroid in the last-mentioned woman. The same intermediate part may be played by the sound vagina — a woman receiving the poison from one man, transferring it shortly to another in sexual intercourse, and herself escaping. This is mediate contagion. Cullerier's * two famous experiments on women establish beyond dis- pute the fact that chancroidal pus may lie for some length of time in contact with a vagina, presenting no abrasions, without being absorbed. In these experiments chancroidal pus from the groin was deposited in the vagina, the latter showing no abrasions, and its secretions being inoculated with negative result. In one case the pus was left in the vagina 'thirty-five minutes, in the other nearly an hour ; the patients, ignorant that they were the subject of experiment, were made to walk about, closely watched. Finally, some of the vaginal secretion was again collected, and successfully auto-inoculated in both cases. The vagina was thoroughly washed out with an astringent solution, and did not become ulcerated in either case, although the poisonous pus had remained for some time in contact with its walls. These two cases at once raise the question, Can chancroidal pus be * " Quelques Points dc la Contagion mediate," Mem. de la Sec. de Chir. 30 466 CHANCROID. absorbed except through an abrasion ? Evidently not at once, as the two cases prove, nor probably in any length of time through the hard epithelium of the skin, for hospital patients, little careful as to clean- liuess, handle with impunity their chancroids from day to day, and do not inoculate their lingers, except through ])re-existing abrasions ; but that the poison may enter through a mucous surface not visibly abraded is certain, whether by direct absorption, or by corroding for itself a way, has not as yet been demonstrated ; but in all i)roba- biiity by the latter means. In this way may be explained chancroid with a comparatively long period of incubation. A man lies with a woman having chancroid. lie inspects himself after the act and finds no abrasion, but, neglecting to wash himself, pulls forward the pre- puce and goes on his way. A small quantity of virulent ])us remains in the little pocket alongside of the frajnum, Avhere the mucous mem- brane is very thin and always moist. The pus, by its acridity, destroys the superficial layers of epithelium in a few days, and then, finding a loop-hole for absorption, poisons the spot at once, and the patient appears, perhaps a week after his suspicious intercourse, with a chan- croid only just commencing, the long period of incubation here being more apparent than real. In like manner a few pus-corpuscles rubbed into the mouth of a minute follicle during the friction which accom- panied the sexual act could not be washed away, and by the same pro- cess of corrosion give rise to a characteristic ulcer, after a period of apparent but not real incubation (follicular chancroid). Situation of Chaxcroid. — Chancroid is rarely found far from the genitals, for the obvious reason that it is usually too consjiicuous to be lightly handled, except by the accoucheur or the surgeon who has it under treatment. It was at one time supposed that chancroid could not occur upon the head or face, but now medical literature con- tains several cases of undoubted chancroid of the face, giving positive result by auto-inoculation, and not followed by syphilis (Bassereau, Boeck, Puche, Eofeta, and others) ; while syi^hilizers have abundantly proved that the head and face, as well as any other portion of the tegumentary exi^ansion, may be successfully inoculated wath chan- croid. Boeck, however, in studying the susceptibility of the different portions of the body to the action of chancroid poison, found that in- oculation produced upon the cheeks or head only small, shallow ulcera- tions of comparatively short duration ; * the chest and abdomen come next, then the arms, and, finally, the thighs, which would furnish positive results to inoculation after the latter had become impossible upon the upper portions of the body. Chancroids upon the male genitals appear by preference in the * But that chancroid may be occasionally severe on the head is proved by a case re- ported by R. W. Taylor, in Brown-S^quard's "Archives," No. 5, 1873, and three by Pro- feta, "Ann. de Derm, ct de Syph ," 1873-74, No. 3. SYMPTOMS. 4fj7 sulcus on either side of the fraenum, but may occupy any position even to the inside of the urethra, where they are occasionally found, usually occupying the meatus, and thence extending inward, or wholly concealed inside the canal. Duncan inoculated his own urethra by transporting into it some chancroidal pus. He got urethral chan- croid with double bubo.* liicord figures a case of deep urethral chan- croid, with chancroidal-looking ulcerations of the bladder, but tuber- cular ulceration has been suggested to explain this unusual case. Intra-uterine chancroids in the female have been reported (Delmas and Combal). Scrotal chancroids mainly result from auto-inocula- tion of abrasions by discharges from some chancroid of the penis or under the prepuce. Chancroid of the anus is rare in the male. In the female, where the poisonous discharges trickle from the posterior vaginal fourchette over the anus whenever the patient lies upon the back, they are not uncommon. In the male, when not resulting from pederasty, they are rare. That chancroid may develop upon patho- logical as well as normal tissues is proved by the successful inoculation by Boeck and others upon elephantiasis, and by a case reported by Breslau f of chancroid found upon an epithelial cancer of the uterine neck giving positive results by inoculation. Symptoms. — The symptoms of chancroid may be best observed by studying the course of the artificial ulcer produced by inoculation. The smaller the inoculation the more perfect the result. It has been noticed in the large chancroids produced by inoculation of scarified surfaces that the lesion often develops from many initial centers, numerous points on the scarified surface " taking," the whole consti- tuting a multiple chancroid, which soon unites into one. To inocu- late properly, a lancet or pin should be used ; the latter can always be obtained new, clean, and sharp. If a lancet be employed in any doubt- ful case to inoculate as a test, it should always be scrupulously cleaned before use. With the lancet, Boeck's method is the best. Scrape a little pus on the point of the instrument, hold the point at right angles to the surface of the skin, and cause it to penetrate just barely below the epidermis ; then rotate the instrument, held in the same direction, half round and back ; withdraw it, and smear over the little red point with whatever pus remains upon the end of the lancet. Within twenty-four hours after such an inoculation, a reddish blush will envelop the puncture ; on the second day the little dark speck of dried blood is surrounded by a faint, inflamed areola. Occasionally there is already commencing pustulation on the second day, usually on the third day, sometimes later. The red areola enlarges, and sur- rounds a vesico-pustule. Break this, and beneath will invariably be found an ulcer, a perfect, fully-formed chancroid in miniature. If * "Cours des Maladies syphilitiques," Petit-Eadel, 1S12. f " Archiv der Heilkunde," 1861. 4G8 CHANCROID. left alone, the vesico-pustule beeomcs an ecthymatous jnistule, which usually breaks in a few Jays after it has reached the size of a s})lit pea. The circular ulcer which results, continuing circular, enlarges and deepens. It usually becomes stationary before it reaches the size of a half-dime, but mtiy become as large as a silver quarter of a dollar, or occasionally far exceed it. This ulcer is a true chancroid, resembling in every minute particular the ulcer from which it si)rung by inocula- tion, and tending to run a similar course. It is evident, from the foregoing descrii)tion, that chancroid has no ])eriod of incubation or hatching. When the virus is placed in a l)osition where absorption is possible, it commences its work at once, and ra))idly reaches the stage of ulceration. In the same way the chancroid acquired in sexual intercourse has no period of incubation, this point being perhaps of all the most important, as distinguishing it from syphilitic chancre. Usually by the third day after suspicious intercourse, occasionally as late as a week, or rarely later, where the jius has had to employ several days to corrode the ei)ithelium before gaining excess to the vascular tissue beneath,* a small ulcer will bo found, which has the characters of a chancroid, characters which apply to a chancroid ulceration of whatever size, wherever situated, originating from natural contagion or from inoculation. These char- acters are : a rounded, sometimes oval margin, abrupt, perpendicular edges, looking as if they had been cut out by a sharp-edged punch, sometimes everted. The ulceration is rather deep considering its extent ; in very rare instances, shallow, like herpes ; the bottom is irregular, velvety, grayish-yellow, covered by a pultaceous, adherent substance resembling false membrane or wet wash-leather, composed of partlv-destroyed elements of the skin and pus, with perhaps some irregular, pale granulations. The whole is usually bordered by a pink areola. Under favorable circumstances there is no surrounding in- flammation, there is no hardness under or around the ulcer, which rests on a perfectly soft base. The suppuration is abundant, rather thick and creamy, mixed with organic detritus, not generally tinged with blood. There is little or no pain. Such a description applies to a type case which has never been irritated mechanically or chemic- ally. This single ulcer runs through its stages of increase, stationary period, and repair, provided it is allowed rest and is not irritated, and pursues a natural course, as follows : CouESE OF Chancroid. — It increases in size for one or two weeks, preserving its characteristics, and reaching a variable size, often not larger in diameter than a quarter of an inch. Of this size it remains * Foumior, in a carefully observed statistic of fifty-two cases, where the patient would acknowledge but one sexual contact for the previous four or five months, found twenty- four developed within the first four days, forty-one within eight days, others later, the sore being often quite large when discovered. VARIATIONS FROM NATURAL TYPE. 4,09 for a period of perhaps two weeks, undergoing no appreciable change ; or there may be no stationary period, repair setting in at once after the ulcer has reached a certain size. Finally, repair is announced by a more creamy, laudable condition of the pus, a sloping of the abrupt edges, and a clearing up of the cavity of the ulcer, which becomes rosy, granular, and gradually cicatrizes from the edges toward the center. During the whole period of its existence the chancroid fur- nishes auto-inoculable pus. The old theory, that after repair was well advanced the secretion ceased to be poisonous, is no longer tenable. Truly, the degree of virulence is lessened with advancing repair, but Fournier has recently been able to obtain occasional positive results by auto-inoculation from chancroids which were nearly cicatrized. This important fact, that the secretions of chancroid are conta- gious until the cicatrix is formed, has but two exceptions : 1. When gangrene attacks a chancroid, its discharges are not contagious, nor does the granular surface left by the separation of the slough any longer afford a poisonous secretion. 2. Certain very old chancroids, usually such as have been of considerable size and are situated in posi- tions where they are kept irritated and prevented from healing, per- haps for years, sometimes lose their poisonous properties finally, and become simple chronic ulcers, kept open by contact of irritating dis- charges, muscular contractions, and motion of the parts on which they are situated. Such ulcers are found in the anus and rectum of the male, and in the vaginae of old prostitutes. The SCAR left by chancroid varies with the depth of the ulcer. It may be so faint as shortly to disappear, leaving no trace ; or, again, may remain indelible, as a seamed and puckered, unsightly scar, of a size proportioned to the previous ulceration. But this mild and simple sequence of events in chancroid is far from being constant. All sorts of variations from the natural type occur : in («) initial form, (b) shape, (c) number, [d] size, (e) duration, (/) pain, {g) condition of base, (h) relapse, and finally the complications of : (i) vegetations, (_/) syphilitic chancre, (k) inflammation, (I) gan- grene and gangrenous phagedena, (?») phagedena, {}i) bubo, (o) lym- phitis. (a) Varieties in". Initial Form. — Usually chancroid of a mucous membrane presents itself from the first as an ulcer, but occasionally the initial pustule may be seen. This breaks, disclosing the characteristic ulcer, or, occasionally on the skin, does not break, but dries into a scab. The scab increases in size by additions of pus from beneath, and covers the ulcer ; but the pus, which may be squeezed from the sides by pressure upon the loosely-attached crust, is auto-inoculable, and if the crust be removed true chancroid is disclosed. The French call this form "ecthymatous chancroid." Again, the chancroid pustule may originate in the orifice of a sebaceous gland of the scrotum or penis. 470 CHANCROID. and be mistaken readily at first for simple acne, or the lesion may re- semble a small boil at its commencement (follicular chancroid). The primary lesion may be a papule surmounted by a inistnle, or, still more rarely, a bulla (Fournier). These latter forms are exceptionally rare. {h) Varieties in Shape. — The usual round or oval form of chan- croid is subject to exception. If a wound be inoculated, the chancroid takes the form of the wound. So of a fissure, as is often beautifully seen in chancroid of the anus, such a chancroid being frerpiently mul- tiple, standing off in rays from the puckered center, or extending up irregularly into the gut, perhaps for several inches. Two neighboring chancroids may coalesce, producing one sore of irregular shape, with borders composed of segments of circles. The ulcer may undermine the fra^num, or follow around the sulcus behind the corona glandis. It may cicatrize on one side and advance on the other, or finally assume any variety of shape from the modifying influence of gangrene or phagedena. ((') Varieties in Nl'mber. — Chancroid may be unique, or any given number may coexist. Sperino, in practicing syphilization, was in the habit sometimes of inoculating in eiglity places at once, since he found that, by so doing, the size of the resulting ulcers was smaller. Chancroid is often multiple fi'om the first, when several abrasions arc simultaneously inoculated during the sexual act ; or, starting unique, may become multiple to any extent by auto-inoculation, especially in- side the prepuce ; anal chancroid is usually multii^le. It is not uncom- mon with a tight prepuce to find half a dozen small chancroids situated just on the preputial margin, or the whole rim may be one ulceration. Usuallv, when chancroid is multiple from the beginning, each ulcer is small. {(I) Varieties in Size. — The size varies from that of the head of a pin to enormous phagedenic surfaces, covering half the belly. (e) Varieties in Duration. — A chancroid untreated never lasts less than a month. The larger the size the slower the repair, other things being equal. Gangrenous sores may continue for months, and phagedenic serpiginous chancroids, as a rule, for many months, excep- tionally for a number of years. Chancroids of the meatus urinarius, constantly irritated by urine, are very slow in getting well. Certain old chancroids of the rectum, which have partly cicatrized, forming stricture, may be kept open by local irritation, and perhaps never get well, although their secretions finally cease to be inoculable. The same may be said of certain old chantroids in the female vagina, which erode large portions of the walls of the. canal and the labia, perhaps at the same time extending over the perinaeum, and including the anus and rectum. These also finally cease to progress, but remain open for years, as simple chronic ulcers, not auto-inoculable, perhaps surrounded by hardened cicatricial tissue, attended by little or no pain VARIATIONS FROM NATURAL TYPE. 471 or inflammation ; perhaps resting on a hard base, looking pultaceous or sometimes dry and red without granulations. These ulcers are kept from healing by the condition of the patients, mostly middle- aged prostitutes, broken-down hospital cases, often suffering from syphilis at the same time, and by the contact of urine and the move- ments of the parts ; the hard, unhealthy base of the nicer proves also a decided obstacle to healthy action in the sore. This variety of ulcer has been best described by Boys de Loury et Costilhes.* These ulcera- tions in the female vagina are often mistaken for tertiary syphilitic serpiginous ulcers, especially if the patient have syphilis at the same time. The distinction is often difficult, even impossible, except by studying the history of the ulcer. Syphilitic ulcer will be found to have commenced as a tubercle, having no connection in point of time with sexual intercourse, and there will often be some tuberculization of the edges of the sore. Tubercular syphilitic ulceration, once started, may become phagedenic, just as well as chancroid ; and the contact of urine, the habits of the patient, motion, the callous condition of the base of the sore, etc. , may prevent anti-syphilitic remedies from exerting such a marked beneficial influence as might have been ex- pected, so that diagnosis becomes exceedingly difficult. Should some of the poisonous secretions, however, still remain upon the ulcers, auto-inoculation, if it takes, will at once remove all doubt, and this test may be employed. A negative result, however, does not prove that the lesion was not a chancroid at its commencement, and the probability is always in favor of such a supposition. Phagedena alone does not destroy the inoculability of the discharge. Some authors describa these ulcers as a variety of lupus. Extensive scraping and cauterization will sometimes cure them. (/) Varieties in- Pain". — Chancroid may be almost entirely painless, only attended by some itchy, prickling sensations. Any irri- tation applied to it, however, occasions pain at once, so that clinically, instead of being absent, pain is usually a diagnostic symptom of chan- croid, serving to distinguish it from syphilitic chancre. All sorts of irritating and many simple stimulating dressings are liable to cause pain, sometimes even cold water (Fournier). The position of the sore on the end of the penis, which usually hangs down, erections; which pull upon its edges, contact of urine, retention of pus on the surface, all these causes serve to inflame a chancroid and give rise to pain. In two pathological conditions pain is often very severe in chancroid — when it is attacked by gangrene or by phagedena, and when it is ad- vancing rapidly. (g) Condition" of the Base (Ijstduratiox). — The chancroid when not irritated reposes upon a perfectly soft base. When irritated * " Des Ulcerations chroniques, ou Chancres chroniques des Parties genitales de la Femme,". Paris, 1845. 472 cnANTROin. or inflamed, an indnmtion is caused, sometimes slight, sometimes ex- tensive, recalling the hardness around a boil. This is an accidental and not a natural phenomenon, and is an important distinguishing mark between chancroid and syphilitic chancre. The base of herpes, excoriations, abrasions, vegetations — in short, of any lesion about the genitals — is liable to indurate if irritated or inflamed. Sometimes this induration resembles syphilitic induration very closely, but usu- ally it is easily distinguishable. It is an inilammatory hardness, the tissues are evidently glued and matted together, tlie edges of the indu- ration lose themselves gradually in the surrounding tissues, and do not end abruptly as in syphilitic induration. There is more pain on pressure than in the latter. The induration never precedes ulceration as in syphilitic chancre, and, linally, the feel itself is different, very unlike the woody, cartilaginous, elastic feel of syphilitic induration. Besides inflammation from any irritating cause, contact of urine, fric- tion, position (chancroid of the meatus urinarius almost invariably indurates, as do most often chancroids under a tight prepuce which has become phimotic from inflammation), many substanoes commonly- applied as dressings to chancroid are directly instrumental in causing hardness of the base ; all caustics, acid or alkaline, especially if aj^- plied sparingly, and perhaps most particularly nitrate of silver, solu- tion of corrosive sublimate, or chromate of potash (Fournier). In fact, there are so many natural, accidental, and medicinal causes for induration, that it is rather surprising that any chancroids escape them all and remain soft to the end, as many of them certainly do. {h) Eelapse. — A chancroid may have fairly entered the period of repair, or even be far advanced in it, when suddenly, perhaps from irri- tation, often without appreciable cause, it relapses, resuming all the characteristics of chancroid, and advancing a second time for a vari- able period. More rarely a relapse may occur a second or even a third time. COMPLICATIONS OF CHANCROID. Of all the complications of chancroid — inflammation, vegetations, phimosis, paraphimosis, lymphangitis, erysipelas, gangrene, phagedena, simple bubo, and virulent bubo — not one is peculiar to chancroid ex- cept the last. Each and all of the others may complicate any herpetic, simple, inflammatory, or even syphilitic lesion of the genitcils, but nat- urally they are oftener found witli the more virulent sore — chancroid. This fact must be constantly borne in mind. (i) Vegetatioxs. — These papillary growths may complicate chan- croid, as they may any other lesion (inflammatory, syphilitic, or gonor- rhoeal), especially of the prepuce or around the anus (for Vegetations, see page 23). COMPLICATIONS. 473 (/) Syphilitic Chancre may complicate chancroid by appear- ing alongside of it, or on the same spot as mixed chancre (which see, joage 521). {k) Inflammation, spontaneous (from plethora, deljility, drink- ing), mechanical (from friction, erection, position), chemical (from contact of urine, lack of cleanliness, inappropriate dressings), is a fre- quent complication of chancroid. Especially is this true when the ulcer is sub-prcputial, if the prepuce be long or congenitally tight. Phimosis and paraphimosis are often encountered with chancroid, lymphangitis is yery liable to occur (with enormous oedema of the prepuce, perhaps of the whole penis), and possibly erysipelas, Avhile the retained discharges and the tension of the parts predispose strongly to sloughing and phagedena. An inflamed chancroid gets painful at once. It indurates and may become livid, its secretion grows thinner and more bloody, while its ulceration deepens. Inflamed chancroid is very liable to be attended by suppurating bubo. Abscess may form in the thickness of the prepuce, and, opening, remain indefinitely fistulous. With phimosis pus may be retained and burrow backward, sometimes in a narrow tract at the end of which an abscess forms, opens, furnishes inoculable pus, and remains fistulous. This burrow- ing may sometimes go on to an enormous extent, Vidal saw a case where the whole skin of the penis was separated up to the root of the scrotum. The integument of any portion of the body may under- mine from retained chancroid pus, by a species of subcutaneous phagedena. In patients who are run down constitutionally, clian- croid sometimes pursues a course of slow, chronic inflammation. Such an ulcer is painful, surrounded by a red areola, with perhaps a hard base and undermined border. The base looks pultaceous, discharges a thin, perhaps sanious secretion, which often dries into a scab. Chancroids of this description may increase in size and become phage- denic or remain stationary for a long time. They are sometimes at- tended by paroxysms of feverishness, with symptoms of gastric dis- turbance. {I) GrANGRENE AND GANGRENOUS PHAGEDENA. — Gangrene is a complication not confined to chancroid, as it may be engrafted upon other lesions of the penis. It is of two kinds : total (self-limiting), or progressive (phagedenic). The first-mentioned variety commonly ac- companies a high degree of inflammation, as in connection with inflam- matory phimosis or paraphimosis, where the tension of the parts is great, and they suddenly and in totality fall into gangrene. In this way the whole prepuce may be lost, artificial circumcision being neatly performed by the separation of the slough. The whole glaus penis may slough away, or a swollen and inflamed prepuce, retaining the pus of the chancroids within, perhaps suddenly becomes blackish green over a greater or less area, a slough forms, separates, letting the head 474 CHANCROID. of the i>cnis tliroiigh, leaving behind a seemingly double-headed, un- sightly member, tlie remains of the prepuce below becoming hardened, OBdematous, sometimes greatly increased in size by chronic inflamma- tory hypertrophy. Total gangrene rarely attacks chancroid, except where tiie ulcers are sub-preputial. Besides the immediate exciting cause (great inflammatory tension), the predisposing causes are any debilitating agencies, malarial or other cachexia^ old age, alcoholism, etc. Total gangrene of the whole chan- croidal surface at once destroys it just as certainly as does the thorough application of an eflicient caustic. In both cases alike neither the slough nor the pus formed beneath it in the natural process of its elimination possesses any poisonous, inoculable properties. After the slough has fallen, a healthy, granulating, non-virulent ulcer is left, which usually goes on at once to repair, with rapidity proportionate to the vitality of the individual. But just as an imperfect applica- tion of caustic to a chancroid only produces a partial slough, and does not do away with the poisonous properties of the sore, since the virus is secreted by all portions alike, and if any is left the whole is repoi- soned, so there may be spontaneously progressive gangi-ene of the phagedenic sort, attacking a chancroid not thoroughly destroying the secreting surface, and consequently not interfering with the inocula- ble properties of the pus. Under these circumstances a black slough forms on the surface of the sore, but it does not separate ; pain con- tinues, and a new slough, forms or the old one progresses ; and so on, in a phagedenic manner, sometimes slowly, sometimes rapidly, often large portions of skin and underlying tissue being destroyed before the sloughs finally separate, and leave healthy surfaces beneath. This variety of gangrene constitutes one (the less common) form of phage- dena, and is responsible for many of the extensive mutilations accom- panying chancroid. "With forming or advancing gangrene there is intense pain, and always some general constitutional disturbance, fever, etc., which does not obtain in true phagedena.* The physical signs of gangrene, when attacking a chancroid which is visible, are similar to what is observed in gangrene elsewhere. The ulcer first begins to look grayish, the patient suffering great pain ; then it becomes violet, finally greenish black, wdiile the discharge grows thin and fetid. A line of demarkation finally forms, surrounded by an inflammatory areola, and if the slough includes the entire ulcer, its separation leaves a healthy granulating surface behind. (m) PnAGEDEXA is molecular gangrene. But molecular gangrene is not able to destroy the poisonous surface rapidly enough to make the ulcer a healthy one ; hence phagedena, as applied to chancroid, signi- fies large extension of the ulcer with preservation of its specific (inocu- lable) properties. Phagedena, most commonly found with chancroid, * Cases of this sort are not uncommon in hospitals. COMPLICATIONS. 475 is not confined to tliis yariety of sore. SypliilitJc chancre is some- times phagedenic (Rollet thinks only in tlic gangrenous form) ; dif- ferent ulcerated syphilidos and scrofulides occasionally become phage- denic. Phagedena advances superficially,. or in depth, or both at once. It is pultaceous in type, or, more rarely — as detailed above — gangrenous. The latter form, often largely destructive, is comparatively rapid ; the common form (pultaceous, superficial, serpiginous, ambulant) is ex- ceedingly slow. Phagedena advancing on one side often gets well with proportionate rapidity on the other. Clerc has established that a chancroid never commences phagedenic, but always becomes so secondarily, after having existed for a while uncomplicated. Chancroidal phagedena seems often to be an'ested by coming into contact with tissue of a different order from the one it is attacking. It shows a predilection for cellular, connective tissue, as in undermining the skin of the penis. Belhomme * gives a striking instance of a phagedenic serpiginous chancroid of the skin stopping suddenly on reaching the mucous membrane. This can not, however, be always counted on, but the tendency exists, as is well shown by the fact that vessels, nerves, and glands are often dissected out and spared by the advancing ulceration. The corpus spongiosum, corpora cavernosa, and testicles may be bared by phagedena, but themselves remain untouched. Fascial expansions, and fibrous tissue generally, may be expected to oppose the destructive march of phagedena ; but sometimes nothing is spared, all the tissues being eaten through indifferently, by the variety of phagedena which destroys in depth (mainly by slough). Phagedena attacks virulent bubo perhaps as often as it does chan- croid. It seems, however, to spare all except virulent buboes. The serpiginous {serpere, to creep) phagedena (unlike the gangre- nous form) is attended by not very great pain, and no constitutional disturbance ; there may be slight headache, malaise, etc. As it com- mences, the surrounding skin reddens, the borders of the ulcer swell and undermine. The true characters of chancroid are retained by the sore throughout, the base is uneven and (sometimes with exuberant granulations) covered by the same grayish, adherent, false-membra- nous-looking material, whence the name jDultaceous chancroid. The edges are sharply cut, gnawed, uneven, abrupt. The discharge is thin, sanious, and inoculable to the end. The edges are often undermined, thin, purplish, perhaps oedematus. Pain of a burning character at the edges indicates advance of the process. This form of phagedena lays bare the penis, sometimes the testi- cles, and may travel up over the abdomen, and to any extent farther. Usually, however, the largest, most persistent chancroids originate in * " Du Chancre phagedenique et de son Traitenient," These da Paris, 1862. 47G CEAXCROID. bubo (which sec), bat the characteristics of the ulcer arc the same, whatcA'cr its origin. No detinitc daratit)n can be assigned to phage- dena. Tlie chronic sei^piginous form, untreated, always lasts many months, sometimes many years. The longest case recorded (Fouruier), commencing in the groin in a virulent bubo, was still present as an open nicer of the knee after fourteen years, having healed up behind as it advanced, and this, indeed, was not untreated, but had been under Ricord's care for several years. The course of phagedena, like tliat of chancroid, may be continued by successive relapses. Perhaps after cicatrization is nearly complete, phagedena recommences without evident cause, and the whole cicatrix reopens. The causes of phagedena are (1) general and (2) local. 1. General. — Whatever depresses the vital force— bad hygiene, in- temperance, misery, digestive troubles (Ricord), scrofula, lymphatism, scorbutus, malaria. Chronic alcoholism and old age are prominent as general causes. 2. Local. — Lack of cleanliness, phimosis from retention of pus, fatty substances as dressings, particularly mercurial ointment, which Ricord considers a very active cause, all sorts of local irritation, fric- tion, etc. Sperino,* Salneuve,f Rollet, and others, have inoculated from phagedenic chancroid, pro4ucing only simple chancroid ; and Sperino, with other syphilizers, has shown that the same pus inocu- lated on different individuals produced in some simple, in others phagedenic sores, while confrontation — that is, examining the woman from whom the man received his sore, or vice versa — has frequently revealed a phagedenic sore derived from a simple one. Hence the conclusion : There is no special phagedenic virus. Phagedena is not a property belonging to chancroidal pus, it is rather a property of the tissues of the patient — an individual idiosyncrasy. This fact is substantiated by daily experience, for hetero-inoculations % with pha- gedenic pus have rarely produced more than a simple sore, while auto-inoculation of the same pus is not unlikely to be attended by phagedena. Again, certain individuals are recorded as having had chancroids on two different occasions, both times phagedenic* In some instances, however, we find ourselves unable to detect any cause of phagedena, which may attack patients apparently in the most robust health, where none of the general or local causes mentioned above seem to have been at work. Treatment will be considered under treatment of chancroid. * " Studi clinici sul Virus sifilitico," Turin, 18G3. + "De laValeur semeioiogiquc dcs Affections ganglionnaircs," These de Paris, 1852. \ Inoculations upon one individual from another. * Xegroes suffer more than whites from phagedena, as indeed tliey do from chancroid, bubo, syphilis, or even gonorrhoea as a rule. DIAGNOSIS. ^ 477 (n) Bubo and (o) lymphangitis will bo described after the section on treatment. Diagnosis of Chancroid. — The diagnosis of chancroid is with herpes, balanitis with excoriations, exulcerated abrasions, syphilitic chancre, simple ecthyma, ulcerated mucous patch, ulcerated (tertiary) tubercular syphilide of the glans penis or prepuce, epithelioma. The distinguishing peculiarities of the four most common of these lesions — syphilitic chancre, chancroid, herpes,* ulcerated abrasion — will be described and considered side by side in the diagnostic table following syphilitic chancre. Of the others, the ulcerated mucous patch rarely presents the same depth of ulceration, or tendency to spread, and mu- cous patch furthermore is apt to coexist with other similar lesions of the mouth or anus. Dischai'ge from mucous patches is in a measure auto-inoculable, but does not of course produce typical chancroid. Finally, tertiary syphilitic ulcerations of the glans or prepuce often resemble chancroid so accurately that no physical characteristic is wanting. Usually, however, the edges are harder, as is the base, the ulceration more irregular in outline, the tendency to eat deeply more marked, the pain and inflammation less. The discharge is not auto- inoculable. With any one of these lesions there may be local inflam- mation and consequent suppurating bubo, or even lymphangitis, but, in any case, if a bubo suppurate and its pus be found auto-inoculable, it has derived its origin with absolute certainty from a chancroid, and from a chancroid only. In any case of doubt, in presence of a suspi- cious sore, there remains one infallible method of diagnosis ; namely, auto-inoculation. Auto-inoculation is most safely practiced in one of three situations : under the nipple, where Boeck has shown that chancroid naturally runs a mild course, over the insertion of the deltoid, or on the outer part of the thigh. In all of these localities the artificially-produced sore is not liable to be complicated by bubo, on account of the distance of the lymphatic glands, nor is it likely to accidentally inoculate surrounding parts. Of course after an inoculation has fairly taken, and served its end as a crucial diagnostic test, it should be promptly destroyed by a drop of acid. In certain cases it is absolutely impossible to arrive at a diagnosis without consulting this test, as where the chancroid can not be seen — sub-preputial chancroid with phimosis, intra-urethral chan- croid, anal chancroid resembling fissure. In intra-urethral chancroid, the auto-inoculability of the pus is sometimes the only diagnostic symptom ; in other cases there is a painful spot in the urethra during erection, and a lump that may be felt from the outside ; possibly viru- lent bubo accompanies it, or, in rare cases, there may arise a peri-ure- thral abscess in connection with urethral chancroid. Such an abscess * Legendre ("Memoire sur I'Herpes de la Vulve," Archiv. de Med., 1853) has brU- liantly described the difiBculty of diagnosis in some of these cases in the female. 478 cn.vNCROiD. opens, furnishes auto-inoculable pus, and remains fistulous (Ricord, ll^lot). Successful auto-inoculations have been made with pus derived from irritated syphilitic chancre, secondary lesions, especially mucous patch, or in suitable subjects may sometimes be made with pus from gonor- rluva, simple abscess, fluid around vegetations, pus from a pustule of scabies, etc., and even a pustule may be produced by simply scratching the skin of certain individuals with a clean, new lancet, going through the motions, but inoculating nothing. Pustules and ulcerations pro- duced by any of these methods need not lead to error. They are not chancroids, and never have been proved to be such, through their virulence or their characteristic intensity shown by hetero-inoculation. And, indeed, even in the first inoculation of these fluids, the chan- croidal ulcer, as above described, can not bo produced. An ulcer, in- deed, may form, and an ulcer whose pus may be feebly auto-inocula- ble, if the patient be in a condition favorable to suppuration, but the pustule is usually an abortive one, tending to dry up and scab, the ulcer is small, does not spread like chancroid, nor does it possess the well-known characteristics of the latter. Syphilitic chancre is only auto-inoculable after it has been irritated and made to suppurate freely, and so of the other substances mentioned above ; the thicker the secre- tion is in pus-corpuscles, the more likely is it to occasion a slight ulceration by auto-inoculation, sustaining Van Roosbroeck's theory of the contagious properties of all pus. Then, on the other hand, in certain individuals, any scratch, however made, will fester and pro- duce pus, but it would be difficult to confound such an ulceration with chancroid. In short, these cases of exceptional auto-inoculability of other secretions than that of true chancroid will rarely lead to error. They may serve to feebly ujDhold preconceived theories, but not to deceive the earnest searcher after truth. The real error to which the well-informed student is exposed is that of inoculating from the secretion of a chancroid which has been gangrenous, and deciding against chancroid because the inoculation did not take, and perhaps, on this account, concluding that his patient has syphilitic chancre, or making the other error of inoculating from a mixed sore,* and wrongfully deciding that there is no syphilis because auto- inoculation takes. Hence the caution to be remembered : chancroids attacked by total gangrene are no longer inoculable, and an ulcer reproducing itself by inoculation may possibly be a mixed sore. Another caution is equally important : only practice auto-inocula- tion of a phagedenic chancroid under the nipple of a patient. There is always a chance that the new sore, produced upon a subject already predisposed to phagedena, may itself take on the same morbid action, * Inoculation of a pre-existing tubercle-papule, or sypliilitic ulceration, with the pus of chancroid, as well as mixed chancre, should be remembered as possibilities. TREATMENT. 470 but the chance is less under the nipple than anywhere else, except on the face. Prognosis. — Chancroid does not endanger life, except very occa- sionally, from such complications as severe erysipelas, or extensive, sloughing phagedena, by opening a vessel or exciting peritonitis. Practically it may be said that chancroid does not kill ; even the im- mense chronic ulcers of serpiginous phagedena eventually get well. Certain results of chancroid, however, must not be forgotten. Ex- tensive cicatrices left hy phagedena may prove annoying by their sub- sequent contraction, and the actual destruction of the penis by phage- dena practically unsexes the man. Then urethral chancroid is inevi- tably followed by more or less stricture of that canal at the seat of the lesion. So, also, may permanent phimosis be produced by the cica- trices of chancroidal ulcerations at the orifice of the prepuce. Chan- croids of the pockets on either side of the frsenum may, but very rarely do, eat into the urethra, and result in artificial hypospadias. Exten- sive adhesions of the prepuce to the glans penis may occur after chan- croidal phimosis, as indeed after the simple inflammatory form. CHAPTER II. GEAFCROID. Prophylactic Treatment. — Local Treatment of Chancroid. — Local Treatment of Phagedena. — Gen- eral Treatment of Chancroid.— Bubo ; simple ; virulent. — Treatment of Bubo.— Lymphan- gitis ; simple ; virulent ; syphilitic. — Treatment of Lymphangitis. Prophylactic Treatment. — As a rule, chancroid does not come under the surgeon's notice until it is already advancing and beyond the reach of any abortive measures other than actual destruction by caustics. Bat, on the other hand, it not infrequently happens that a crack or abrasion on the surgeon's finger becomes inoculated in handling chan- croids, and then any prophylactic treatment short of caustics becomes valuable. Abortive treatment applied to chancroids naturally acquired is not as effective as against the same produced artificially by inocula- tion. All the stronger mineral and some of the vegetable acids, caus- tic alkalies and certain salts — as the sulphate of iron, chromate of pot- ash, in solution in water, so weak as not to attack the epidermis — prevent the development of the chancroid if applied over the artifi- cially inoculated point for a considerable time — about two hours — within a period of three to six, and occasionally twelve to twenty-four hours after inoculation has been practiced (Eollet). The longer the time which has elapsed after the introduction of the poison the longer must the preventive solution be locally applied to render it inactive, 480 CDANCROID. ami, naturally, if any portion (as by oblique puncture) has been intro- diiecd beneath the e])idermis, tliis epidermis must be removed in order to allow the fluid to exert its power. According to Rodet and Rollet, a concentrated solution of citric acid yields the best results. Treatment of Chancroid. — Once present in its character of true chancroid, no treatment yields as satisfactory results as the entire de- struction of the ulcerated surface by an ethcient escharotic, thus arti- ficially imitating Nature, which sometimes at once destroys the poison- ous character of the sore by total gangrene of the secreting surface. Any active caustic may be used, but among them three hold the most prominent places, as being easily manageable and least painful ; these three are : nitric acid, sulphuric acid, and the actual cautery. The lat- ter is often objectionable as greatly exciting the patient's fears, but indeed needlessly so, for the actual cautery is perhaps the least painful of all ; the idea, however, is repulsive to a patient. The caustic alka- lies deliquesce and are unmanageable, besides paining more than the acids ; the latter remark holds good of the Canquoin, Vienna paste, etc. In applying a caustic, every portion of the sore should be thor- oughly and absolutely destroyed, and all existing sores, should there be more than one ; for, should any ulcer secreting virus be left active, it will speedily reinoculate the raw surfaces left by the separation of the eschars, and the result would be other chancroids, by auto-inocu- lation, larger than those first operated upon. Hence the rule : If cauterization be decided upon, burn every portion of every ulcer, no matter what its size. If there be subpreputial chancroid, with phi- mosis, the folly of of burning chancroids of the preputial rim is at once obvious. The same is true of burning sores on the glans, or prepuce, if urethral chancroid exist. In a^^plying nitric acid it is well to use a rather blunt glass rod — a pointed one sometimes allows the acid to run off in a drop, flooding too freely the surface to be used on. The ulcer should be thoroughly cleaned and dried with blotting-paper slips. A drop of pure carbolic acid applied and then absorbed out with blotting- paper makes the acid application less painful. Now the nitric acid is thoroughly applied and left on until a white rim of dead tissue extend- ing as an areola about the ulcer announces that the base of the latter is destroyed. Now the nitric acid is dried up with the blotting-paper slips and the surface touched with liquor potassae to neutralize any excess of acid there may be. The burned surface is dressed dry with a little absorbent cotton. The eschar separates in a few days, leaving a healthy ulcer, which heals without further attention than cleanliness and a dry dressing in a few days — or a longer period if the ulcer has been large and deep. In cauterizing a chancroid under a tight pre- puce, inflammatory phimosis may come on unless the patient be kept at rest after the cauterization. Sulj)huric acid is best applied as the carbo-sulphuric paste of TREATMENT. 4.^1 Ricord. This is formed by making a paste of ])uv(i sulplmric acid with pulverized vegetable charcoal. It is applied upon the dried sur- face of the sore, and pressed down into all its inefjualities with a wooden spatula. It dries on as a black crust, which separates after several days to leave a healthy, granulating, simple ulcer ; or, more rarely, cicatrization goes on to completion under the scab. The parts about the ulcer must be protected. In using the actual cautery, the point should be carried down into every portion of the ulcer until a black dead eschar of the whole sur- face is produced. Cold-water dressing is applied afterward, and ano- dyne given until pain has ceased. All chancroids might be cured by this simple method of treatment, rest, cold, and astringent lotions being used afterward, to combat inflammation. Healing chancroids, however, need not be cauterized, nor should sores of the meatus urinarius be burned, nor very extensive ulcerations, except as a last resource, nor chancroids which are largely multiple, both on account of the uncomfortable degree of inflamma- tion apt to be provoked, and the greater liability to leave some little secreting surface undestroyed, which may reinoculate the burned sur- faces. Much pain may be spared the patient by the free use of a strong solution of hydrochlorate of cocaine before he is burned. The direct combination of cocaine with nitric acid is of no use. I have tried it at all strengths. A chancroid to be burned most effectively must be burned early. If the ulcer has lasted only a few days, one thorough cauterization cures it. If the ulcer is already several weeks old (and not phagedenic) it will in many instances get well as quickly under iodoform, calomel, or other dressing, as it will by being cauterized. The older the ulcer (unless it is already healing, under which circum- stances cauterization is out of the question) the more thoroughly must the caustic be applied to be efficient. It is never wise to depend upon nitrate of silver for caustic purjDOses. It does harm, since its caustic action does not extend deeply enough, and superficial cauterization always makes matters worse. When it is unadvisable to use caustic, or when the patient refuses to submit to the application, the surgeon is still possessed of remedies suitable to the disease. It is well to remember that greasy local applications to chancroids are bad. They become rancid, and prevent the escape of the poison- ous pus. Mercurial ointment is believed by Eicord to be of all the most harmful. I have tried salicylic acid, recently suggested. It has always failed me. Perhaps the best treatment for simjjle, uncom- plicated chancroid, when not destroyed by caustic, is to cover the en- tire surface with powdered iodoform.* The local action of this drug in chancroid is superior to anything short of cauterization, but there * For toxic local and systemic effects of iodoform, consult Taylor, "X. Y. Med. Jour.," Oct., 1887. 31 482 CHANCROID. are two objections to its use, namely, complaint of pain occasionally from sensitive patients, which can be controlled by cocaine, and the far more serious objection, the disagreeable odor of the drng. Noth- ing so far discovered covers this effectively — ether, tonka-bean, balsam of Pern are not satisfactory. The best means we have of disguising the odor is mixing the jiowdered iodoform with one third of tinely- powdered, freshl3'-ground cotlee. Cleanliness is of the first impor- tance, lodol has no value in my hands. A good expedient is dust- ing the surface with dry, ]xiwdered oxide of zinc, or calomel with a little camphor, or bismuth, and covering the whole with lint soaked in a "weak solution of aromatic wine, one part to thl-ee of water, or alcohol, one part to two of water, or permanganate of potash, gr. j-ij to the 3 j, or carbolic acid, one half of one per cent. It is sometimes useful even to large surfaces to apply pure cai-bolic acid every other day, or a solution of bromine, 3 ij to the 3 j, dressing between-timcs ■with one of the above solutions. Such dressings should be frequently changed, as cleanliness is of the first importance. In the treatment of any chancroid, especially such as are situated near the fra^num, ■where the lymphatics are most abundant, rest is of the greatest utility in preventing inflammation and the formation of suppurating bubo. For chancroid of the meatus, nothing is better than a little plug of dry lint, sprinkled with iodoform, and patience, with an alkaline diuretic, to render the urine less irritating, and the absolute avoid- ance of any sexual excitement or erotic thoughts calculated to stimu- late erection. Urethral chancroid may be benefited by the same gen- eral means and the occasional injection of a mild solution of aromatic ■wine in warm water. Sulpreputial cliancroid requires no modification in treatment, unless there be congenital or inflammatory phimosis. The prepuce, however, should not be dressed back, for fear of paraphimosis. With phimosis frequent injections of the balano-preputial cul-de-sac with Avarm water are necessary for cleanliness, and to prevent the pus from accumulating and burrowing. After the washing, any of the above- mentioned stimulating lotions may be injected, or a gr. v-xv solution of the nitrate of silver (Ricord), which, according to this surgeon, acts also as a local anaesthetic. The injection of iodoform shaken up with balsam of Peru is suitable for these cases. It is often wiser in these cases from the first to cut the prepuce freely open by two lateral in- cisions, and thoroughly cauterize everything in a state of ulceration, excoriation, or rawness, dressing open. It looks more harsh, but in the end may prove more kind. The Pafiuelin cautery is a suitable agent to deal with the cut surfaces under these circumstances. For simple or erysipelatous inflammation of chancroid, the best treatment is absolute rest, and an elevated position of the organ, aided perhaps by a lotion of lead-water externally. Where the inflamma- TREATMENT. 4§3 tioii runs high, with phimosis, and the tension of tlie prepuce becomes very great, it should be slit up on the dorsum, or entirely cut away (circumcision) if it be very redundant. When the pus issuing from beneath the inflamed prepuce begins to smell bad, the indication is to cut at once to avert gangrene or phagedena. In the treatment of chancroid it is always advisable to keep the ulcerated surfaces, if possible, covered with lint or some substitute, to absorb the pus as it flows, and protect the parts which would other- wise lie in contact with the diseased surface and run the risk of inocu- lation. In anal cliancroid the merits of each case must decide whether it is allowable to employ actual cautery. The greater the amount of tissue destroyed, the greater the degree of subsequent stricture. If an infected fistulous tract exists in connection with any chancroid, the latter should not be cauterized unless the former can be slit up and similarly dealt with. Gangrene not phagedenic should be left unmolested. The fall of the slough may be hastened by the application of a iDoultice of camo- mile-flowers, with charcoal, or a little permanganate of jDotash or liquor sodse chlorinatge added as a disinfectant, or yeast. Simple dressings for the healthy ulcer beneath are all that is required. Cliancroid of the pochets beside the frcenum frequently undermine the latter, which, when very thin, may be accidentally ruj)tured, giv- ing rise sometimes to considerable hgemorrhage from the artery of the fr£enum. To anticipate this, it is advisable to pass a double thread beneath the fraenum, and tie both ends, letting the ligatures cut through. Where the prepuce is short, and there is much oedema about the frsenum, loolving toward paraphimosis, the repeated judi- cious application of collodion to the swollen skin (after drying it) may prevent the latter complication. Where paraphimosis has come on, if it is reducible, or irreducible, without strangulation, absolute rest, collodion, and evaporating lotions are called for ; if there be irreducible paraphimosis with strangulation, the knife must be used to avoid gangrene. Local Treatment of Phagedena. — The proper local treatment for phagedena is total destruction of the base of the ulcer and a sufficient depth of the tissue around. This may be effected in a variety of ways. Scraping thoroughly with a sharp curette under ether, and then apply- ing a deliquesced solution of crystals of chloride of zinc or nitric acid to the scraped area after stopping the oozing is an excellent means. Nitric acid alone seldom suflSces. The carbo-sulphuric paste works admirably here. The actual cautery is not in my opinion as good a means as surgical scraping aided by an ordinary caustic, as suggested above. In any kind of local surgical treatment all bridges of skin must be clipped away, all sinuses slit up thoroughly, all glands lying 4S4 CHANCROID. in the ulcerated space and islands of irrejrular ily more common. The most usual seat of bubo is in the central gland or glands of the inguinal chain, those lying over the great vessels. Bubo is single or double, usually on the same side with the lesion (chancroid) or on the other side (crossed) or double for a single sore ; sometimes in double bubo, simple bubo will exist on one side and virulent on the other. Bubo only affects the first group of glands receiving the lymphatics from a part ; there is no implication of glands farther on, either in the case of simple or virulent bubo. Bubo, simple (sympathetic or inflammatory) or virulent, may appear earlv or late in the course of chancroid, even after the latter is nearly or quite healed. Simple bubo usually appears earlier (before the thir- teenth day, llairon *) than virulent bubo, although the latter, when it does commence, advances more rapidly. Puche f saw a virulent bubo come on after three years' duration of a serpiginous chancroid. Both forms of bubo are a little more commonly found with chancroid near the fraenura, where the lymphatics are numerous and large. Both forms may be attended by granulations upon the ulcerated surface, con- stituting so-called vegetating bubo. Simple Bubo. — This is the form commonly known as sympathetic bubo. It is essentially the same inflammatory glandular swelling as occurs after vaccination, or from an inflamed corn. Any inflamma- tory lesion of the penis may be accompanied by such a bubo (single or double) in the groin. Chancroid is the most common exciting cause, and especially chancroids which are inflamed. Bubo may occur with- out any visible causing lesion. Symptoms. — The patient in walking feels a little pain in the groin, and thinks he has ''strained" himself. On examination, he finds a small, oval swelling, perfectly movable, under the skin, but painful on pressure. If properly managed, this may extend no farther, but usu- ally the lump gradually grows. It becomes adherent to the skin at one or more points. The cuticle grows red, feels thick and porky, perhaps gets cedematous ; finally, a central spot of softening may be detectei(l, more acute, more in- flammator}". Periadenitis occurs with virulent bubo also, the juis forming outside the gland usually ulcerating through the skin first. In such case the first pus that flows is simple, not poisonous, and the wound looks like that seen with simple bubo ; but soon the deeper pus from the gland appears, poisons the wound, and gives it the well- known chancroidal aspect, and now the pus is freely auto-inoculable. Virulent bubo may discharge by a single opening. I'his is large at first, and subsequently enlarges, but, if fortunately adhesive inflam- mation has agglutinated its edges to the surrounding underlying tissue, no further poisoning takes place, the abscess assumes all the character of a true chancroid (abrupt edges, pultaceous, irregular base), passes through its regular stages, and finally gets well. Matters do not, howevei', always eventuate so fortunately ; the thinned skin over the suppurating gland may fail to become bound down by adhesive inflam- mation, or to give way speedily at a single point, then the pus under- mines a certain extent of integument, and perforates it in a cribriform manner. Burrowings, more or less extensive, go on. Hard, sinuous, everted edges, overhanging flaps and bridges of thin, purj)lish skin, long fistulous tracts, and poisoned pouches full of jras, serve indefi- nitely to prolong the virulent bubo, making its duration a matter of months, perhaj^s years. Finalh", virulent bubo, like any other chancroid, may be attacked by phagedena, or any of the other complications set down for chan- croid. Accidental auto-inoculation of the skin of the abdomen or thigh is not uncommon. The worst forms of phagedena are seen in connection with virulent bubo. The case which Fournier records as having lasted fourteen years and being still unhealed at the knee w'as phagedena of a virulent bubo. All the varieties of phagedena, are found, but the pultaceous, serpiginous variety is most common. It usually travels up over the abdomen, but if very extensive seems to prefer to turn the flank and go down the thigh, rather than ad- vance upon the chest, that region shown by Boeck to be unfavor- aVjle soil for chancroid. Phagedena does occur on the chest, but not commonly. The nature and character of phagedena have been described. A phagedenic bubo does not necessarily, or indeed usually, exist in con- nection with a phagedenic chancroid, wiiicli latter maybe attended by simple bubo, or leave the glands untouched ; nor is lymphangitis necessary, or indeed common. An insignificant-looking chancroid TREATMENT OF BUBO. 439 may be attended by a phagedenic bubo, and phagedenic cliancroid may have no bubo at all. riorteloup* has a case going to show that the virus of chancroid may be long retained in the glands of the groin before showing itself. A patient of twenty-six has chancroid in February, 1879, and shortly suppurating bubo. The latter is lanced, and the patient leaves hospi- tal April 15th, with chancroid well and no swelling in either groin. Six months later, having meantime had no new sore, he returns with glands swollen in each groin, and three and a half months later he again entered hospital, both groins suppurating, one phagedenic. This case is so irregular as to need confirmation, in my opinion. Diagnosis. — The diagnosis between simple, virulent, and syphilitic bubo will be found in the diagnostic table following syphilitic chancre. The hubon (TembUe does not exist in the sense originally attributed to the term ; namely, a bubo without antecedent venereal ulcer, ushering in syphilis, and furnishing auto-inoculable pus. The absurdity of this is self-evident, for a virulent bubo never ushers in syphilis, nor indeed has it anything to do with that disease. It is nothing more or less than a chancroid. A bubo, however, may suj)purate in the groin without necessarily any antecedent chancroid, as in connection with herpes, gonorrhcea, balanitis, an inflamed corn ; or spontaneously, as may a gland in the neck or axilla ; such a bubo, however, does not furnish poisonous pus. When a gland in the groin suppurates, and its pus is virulently and actively auto-inoculable, it has been preceded by a chancroid. The latter may have cicatrized before the patient presents himself, perhaps was situated in the urethra, or even in the rectum, but somewhere it is or certainly has been. The intelligence of the surgeon may occasionally be taxed to find it. There are no diagnostic signs between a simple and virulent bubo at first. When opened spontaneously or by art, the outlet does not enlarge in simple bubo ; in virulent bubo it does, and shows all the characteristic marks of chancroid. Again, if suj^puration can be arrested in an inflamed gland, it must have been simple bubo (unless syphilitic) ; virulent bubo must necessarily suppurate. Treatment of Bubo. — The preventive treatment of bubo is rest, and the avoidance of such causes as tend to inflame the chancroid. The most positive preventive treatment is the absolute destruction of the chancroid with caustic. In such a case if the simple ulcer left by the fall of the slough is still able to excite a simple bubo, yet virulent bubo and its attendant phagedena can no longer occur. Tincture of aconite and belladonna combined in equal parts are of some use locally, especially if combined with rest. Tincture of iodine I consider abso- lutely useless if not harmful in acute advancing bubo, and I no longer employ it. Eest in bed, aconite and belladonna, and a light poultice * "Ann. de Derm, et de Syph.," January, 1880, p. 54. 490 CUANCROID. will avert impoiulinfj bubo (sinii)lc) more often than an}- means with which I am ac([uainti.'d. Besides rest, there are tliroe other agents which may avert suppura- tion occasionally : 1. Blistbr, repeated as soon as the skin has re-formed. 2. Pressure, wliich. if ajiplied early and judiciously in mild cases, is sometimes elfective. 3. Leeches, plentifully applied around the swollen gland. The latter treatment is only applicable in the early stages of bubo, for, should the swelling prove virulent, suppuration is inevitable, and, if the leech-bites are near the point of opening and have not cicatrized, they are pretty sure to become inoculated and form so many chancroids. If the tendency to suppuration advances very slowly, the bubo is cer- tainly simple ; if rapidly, large, hot poultices should be constantly applied to hasten it, and the abscess may be allowed to open itself ; but, if from its very rapid course it is believed to be virulent, an opening should be made as soon as any fluctuation can be felt, to let out the poisonous pus, and save destruction of tissue. In this way burrowing may be averted, as it may also by properly applied pressure. It is a good rule to open early in any case. If it be simjile bubo, no harm is done ; if it be virulent, the chancroidal ulcer following is by so much less extensive. Small collections of pus should be punctured, large ones extensively laid open. If the skin does not appear to be adherent, some caustic paste may be preferred to incision. If any outside wounds exist (leech-bites) at the time of opening bubo, they should be carefully protected. The question of attempting to abort the bubo after suppuration is imminent or has actually occurred is worth considering. Morse K. Taylor * gives a number of interesting cases of acute inflammation in lymphatic glands, in which he claims to have invariably aborted suppu- ration by injecting into their substance twenty minims of a solution of carbolic acid (gr. viij to the 3 j). If suppuration has occurred, he aspirates the cavity, and washes on successive days with a carbolic-acid solution (gr. xij to 3 j). Tiiere is certainly no objection to trying a means so simple. When the knife is used, if the bloody, thinnish, unhealthy look of the i^us suggest virulent bubo, the poultice should be discontinued, otherwise it is better kept up for some days. All cavities, if large, should be thoroughly cleansed several times daily with warm water, and then injected with a mild solution of carbolic acid or permanga- nate of potash, dilute alcohol, or some other detergent lotion. After virulent bubo becomes an open ulcer, its treatment is that of chan- * He used a solution of 1 in 30, and injected in this way at one sitting, in different parts of a single gland the size of a goose-egg, gr. xv of potassium iodide in | j of water, j^nd repeated the injections four times in two days, he says, with success. LYMPHANGITIS. 4f)l croid. Where largo glunds lie out in the ulcer and have not suppu- rated, or if all the suppuration have come from periadenitis, in cases where the bubo was strumous, these glands should be removed. This is best done with the finger, tearing them away, or they may be tied off with a ligature. Even when cut away they rarely bleed much. Burrowing and phagedena in the groin are treated in the same manner as when occurring with chancroid. The pastes, carbo-sul- phuric and Vienna, are well suited to phagedena in this region. Where suppuration has been stayed, and in all cases of chronic bubo in which strumous degeneration of the gland plays a large part, reso- lution may be hastened by counter-irritants and pressure. The latter is conveniently applied, the patient being on his back, by placing a bag of sand or fine shot over the swollen glands, or by a spica band- age over compressed sponge laid upon the swelling, the bandage after- ward being slightly moistened. Trusses are too irritating, but it has been noticed that persons wearing trusses and afterward getting chan- croid rarely have bubo uj)on the side of the hernia, probably from previous atrophy of the gland through prolonged pressure (Eicord). If there has been periadenitis wth one or more fistulse, or in any case of protracted trouble, it becomes a question for surgical judgment whether it is not better to terminate the matter at once by free incis- ions and scraping out all diseased tissue with the surgical spoon. Such a course is always successful, and, if antiseptic dressings are used, three weeks are usually enough for a cure even in very severe cases, or enough of a cure to let the patient get up and about. If the symptoms never become sufficiently severe to justify sur- gical interference, among the counter-irritants repeated punctate cau- terization with a Paquelin cautery or mild repeated blistering are perhaps best. Tincture of iodine, has positive resolving power in this stage. Jacubowitz* claims success from interstitial injections of iodide of potassium. Internal remedies for chronic and phagedenic bubo are the same as for similar conditions of chancroid. (o) Lymphakgitis, or inflammation of the lymph-vessel, never occurs without some accompanying inflammation of the connective tissue around the yessel, perilymphangitis. Its varieties are identical with those of bubo ; namely : 1. Simple inflammatory lymphangitis, which may be found in con- nection with any inflammatory abrasion, simple, chancroidal (most common), or syphilitic (least common). 2. Virulent lymphangitis, only found in connection with chan- croid. 3. Syphilitic lymphangitis, found only with syphilis. The first two varieties are indistinguishable until they suppurate. * " Der praktische Arzt," xri, No. 1. 492 svrniLis. One or two liard, knotty cords arc felt under the skin of tlie penis, usually at the side. They commence at the chancroid (or other lesion), extend for a greater or less distance up the penis, sometimes up to the glands in the groin. Occasionally they can be felt only to- ward the root of the i)enis. The integument over them, in mild cases, is unaltered ; in severer cases their course is marked by a red line. They are painful to the touch, and during erection. The penis is often red, erysipelatous, swollen, edematous, and, in severe cases, there are fever, sleeplessness, etc. Lym2)hangitis terminates in resolution or suppuration. In viru- lent lymphangitis the latter is inevitable. In the simple form suppu- ration may occur in one or more spots, resulting in abscesses, which discharge and get well. In virulent lymi)hangitis similar abscesses form along the line of the vessel, open, furnish auto-inoculable pus, and remain as chancroidal ulcerations. Either form may exist without bubo, with sim])lc bubo, or with virulent bubo. The affection is not common, and bubo is most fre- quently encountered without it. Treatment. — Rest, cooling lead-water or spirit lotions, collodion for excessive oedema, perhaps puncture, poultice for severe pain, and oi)ening abscesses, when they form, comj^rise the treatment. Simple abscesses are best treated with water-dressings ; virulent abscesses ex- actly like chancroids, which indeed they are. Internal treatment has no influence over lymphangitis. CHAPTEK III. STPHILIS. Nature.— Fnity and Duality.— Length of Time required for Absorption of Virus.— Analogy with Vaccine Virus.— Second Attacks of True Sypliilis.— Transmissibility to Animals.— Incubation of Syphilitic Chancre.— Induration, parchment-like, split-pea, diffuse.— Ulceration.— Secretion. — Pain.— Nature of Scar.— Auto- and Ilelero-Inoculation.— Vaccinal Syphilis.— Multiple Inocula- tion.— Fluids capable of transmitting Syphilis by Inoculation.— Methods of Transmission of Syphilis.— Duration of Chancre.— Number.— Size.— Situation.— Form.-Symptoms of Urethral Chancre. — Course of Chancre. — Complications. — "Mi.xed Chancre." — Transformation into Mucous Patch. — Phagedena and Gangrene. — Treatment of Chancre. — Syphilitic Bubo. — Lymphitis. Syphilis is a general dyscrasial blood-disease caused by the absorp- tion of a peculiar virus into the circulation, manifesting itself primarily by the appearance of a poisonous sore at the point where the virus en- tered, and afterward by a succession of morbid manifestations occur- ring at longer or shorter intervals — manifestations which, in their totality, interest every organ and tissue in the body. The virus is only known by its effects. Exactly what it is has not ANTAGONISM OF SYPHILIS AND CANCER. 493 yet been determined cither by the microscopist or chemist. Different observers are constantly pointing out various vegetable organisms found in syphilitic persons in the blood or in the pathological lesions, which are different from ordinary forms and behave differently under staining, but so far every observer seems to find the alleged morbid contagium vivum in the tertiary as well as the other lesions. Whether Birch-Hirschfeld's micrococci or Lustgarten's (the last and most gen- erally accepted) * will survive the critical investigation of scientists longer than Klebs's helikomonads or Lostorfer's corpuscle remains to be seen. In any case it can not be now asserted that a living conta- gious element of syphilis exists, although it is more than probable that such is the case, and that it will be one day triumphantly demon- strated. Diday, EoUet, and Eodet failed to inoculate syphilis upon cancer- ons patients, and assume an antagonism between the two maladies. This surely does not exist. I have seen many of the varieties of can- cer upon syphilitic patients. Hutchinson, f at the forty-sixth meet- ing of the British Medical Association, recorded his belief that, while the syphilitic dyscrasia was not a cause of cancer, yet the local irrita- tion of syphilitic sores might call out local cancerous degeneration. I have seen such local epithelial degeneration of old syphilitic patches, and I have of eczematous, lupoid, warty, and other pathological condi- tions of the integument as well. Syphilis has been happily compared by Hutchinson to the conta- gious exanthemata, small-j)ox, measles, scarlet fever, as possessing all the peculiar characters common to this group of diseases, namely : it is communicated only from one diseased person to another healthy one ; it has a stage of incubation before any sign of the disease appears ; it has a stage of efflorescence, which indeed in syphilis is prolonged and marked by relapses ; it has a period of decline and sequelse — the later tertiary lesions — which do not always occur, and during which the disease often ceases to be communicable. Again, most of the vari- ous ef&orescences of syphilis, like those of the other exanthemata, tend to pass away spontaneously after a time ; thus, as Fournier aptly puts it, affording a triumph to every method of treatment. One attack confers immunity from another often for life, always for a long period. The disease is transmissible by inheritance, as in the case of the other exanthemata when the child is born before the mother recovers from disease. Finally the sequelae do not constitute transmissible disease even by inheritance. As in the other zymotic diseases, a portion of the virus, however small, is capable of infecting the whole body, as if by fermentation. Thus the analogy of syphilis with the contagious * " Med. Jahrbiicher." Herausgegeben von der K. K. Gesellschaft der Xrzte, 1SS5, p. 89. f " British Medical Journal," August 24, 1878, p. 282. 494 SYruiLis. exanthemata is clear, only its febrile symjitoms are less marked, its elliorescenees more varied, and its course much more protracted — counted by mouths instead of days — and more subject to variation as well as more amenable to treatment. Syphilis is fortunately only contagious, it is not infectious ; its poison is not volatile, is not dif- fused in the air ; direct contact of tlie virus with a surface capable of absorption is essential to the production of the disease. The arguments and theories concerning the utility or duality of the syphilitic virus are out of place in a text-book. "What syi)hilis is will be shown in the following pages ; what it is not, has been already set forth. In the early part of this century measles was not distin- guished from scarlet fever, and the best pathologists set down chan- croid, gonorrhoea, and vegetations, all as syphilitic. But truth has appeared, though slowly, and at tlie present day the great majority of the most reliable authorities on syphilis are in accord. Old Avriters are dangerous guides, for they had no aid from the light of experi- mentation furnished to the jiresent generation by Eicord, Bassereau, Clerc, and a host of others. Few at the present day can be found who could fall into the error of Hunter, and consider as gonorrhoea a ure- thral discharge producing syphilitic chancre by hetero-inocnlation, since urethral chancre is so well known ; but many still look upon vegetations as indicating syphilis, and there are some distinguished names still laboring to preserve the identity of chancroid with sj'philis, and that, mainly, because exceptional examples or obscure cases, not thoroughly well marked, seem sometimes to give the symptoms of syphilis after an apparent chancroid, and no syjihilis after a seeming chancre. Kollet * has ably dealt with these cases, about which some- thing will be said farther on ; suffice it now to remark that the fight is based upon exceptions. In the vast majority of reasonably well- marked cases, syphilis is as different from chancroid as night from day. A patient may have malignant scarlet fever and die in a day without a sign of eruption, but still he has scarlet fever, as no one denies. Even if one syphilitic chancre out of twenty were not indu- rated, the other nineteen would be amjoly sufficient to establish a rule. But the proportion is far larger, and there is, perhaps, no symptom of any disease more constant than is the induration of syphilitic chancre, yet the patient does not have syphilis because his chancre indurates — as was formerly taught — on the contrary, he already has syphilis be- fore his chancre appears. If he did not have it, he could have no chancre at all, and the induration of that chancre is just as much one of its symptoms as is ulceration of a chancroid. If a patient is ex- posed to measles, and dies during the period of incubation, before he is at all sick, he can not be said not to have the measles ; the same of a patient who has absorbed syphilitic virus : he has syphilis at once, * "Traitd des Maladies v6n6riennes," Paris, 1866. ABSORPTION OF VIRUS. 495 and because he has syphilis lie gets a sore at the point of entrance of the poison, after a period of incubation, as the first symptom of the disease. This chancre may be destroyed by caustic, or the knife, but the disease will run its course unaltered. Interval befoke Absouption. — Clcrc * tells of a medical student who washed himself immediately after sexual intercourse, and on care- ful examination for several days subsequently detected absolutely nothing ; twenty-eight days afterward chancre appeared, followed by general syphilis. Hillf relates a very important case bearing upon this point. A man in sexual intercourse tore his frasnum at 4 a. m. The wound bled freely. Fearing possible infection, he called upon Hill during the same day, within twelve hours after the accident. To quiet his fears, although there was no lesion evident except the abrasion. Hill cau- terized the surface freely at once with fuming nitric acid. The slough separated in due time, leaving a healthy surface, which cicatrized promptly. About one month afterward the scar indurated. It never ulcerated again, but the regular manifestations of true syphilis came on at the usual interval. What more striking evidence could there be of the inability of any local cauterization to interfere with the regular development of this blood-disease, after it has once been acquired ? Diday J cauterized a syphilitic chancre within six hours after its appearance ; but, although the sore healed promptly, general syphilis followed. No attempts have been made experimentally to destroy the point where true syphilis has been inoculated upon healthy subjects, but the experience furnished by the known action of other poisons may be used to form a conclusion by analogy. The rapidity of absorption of the poison of a snake-bite is well known, as is also that of rabies and the poison of a dissecting wound, and there is no reason why that of syphi- lis should be less so. The French veterinary surgeons have inoculated horses with the poison of glanders, cutting out the seat of inoculation one minute after insertion, but the disease followed just as surely as if nothing had been done. Similar experiments have been performed on sheep with the same result. Clerc* vaccinated some children, destroying the inoculated point one hour afterward with nitrate of silver ; vaccinia followed, and a second vaccination failed to take. Seven children were vaccinated by Aime Martin, || and the spot de- stroyed with Vienna paste at intervals varying from one to twenty- four hours after insertion of the virus, Xone of the children had vaccinia, but that the vaccination was protective is i^roved by the fact * "Traite pratique des Maladies veneriennes," Paris, 1866. f " On Venereal Diseases," London, 1S6S. * Quoted by Hill. t " Annuaire de la Syphilis," 1S58. | " These de Paris," 1863. 496 SYPHILIS. that in only one out of the seven cases could vaccinia be produced by subsequent insertion of vaccine lymph under the skin. Tiiis analogy seems perfect. The spot, even during the period of incubation, may be destroyed so thoroughly that no evidence of the entrance of" the poison will be manifested by a subsequent character- istic sore ; yet that the protective power of the poison (vaccine virus) operates as well as if the characteristic sore had appeared is shown by the failure of subsequent attempts at vaccination. Second Attack of Thte Syphilis. — Hutchinson* saw a well- marked case, in a physician, of two attacks of syphilis, each preceded by its characteristic syphilitic chancre. The same patient had had small-pox twice. Many other cases are found scattered through the literature of syi)hilis, and they go to prove that syphilis gets well, for, until one attack is recovered from, another can not be acquired. Diday f has collected twenty-five cases, of which he personally saw twenty. All had had syphilitic symptoms, which had disappeared, except in a few, where some late (tertiary) symptoms remained. In all of these cases there was syphilitic chancre with cliaracteristic in- duration, occurring a second time after a previous syphilis. In four- teen the inguinal glands were not indurated, and there was no further sign of syphilis. In nine, general syphilitic symptoms ajipearcd, but they were less intense than during the first attack. In two the second attack was more severe than the first. In analyzing these cases, Diday found that in none did the second chancre appear until all signs of previous syphilis had passed away, or, in some cases, where tertiary (non-transmissible sequelce) symptoms alone remained. The nearer the second attack came to the first the more feeble was the effect of (second) infection, yielding only chancre ; the gi'eater the interval the more marked the effect. The two severe cases followed their in-edecessors after more than nineteen years. The lighter attacks followed severe ones, and vice versa. Dida}- concludes that the minimum time for the cure of syishilis is twenty-two months, and that, where syi)hilitic chancre appears twice in the lifetime of an individual, the second attack should not be treated until symptoms of secondary syphilis appear, as these may never come on, the whole attack consisting simply in syphilitic chancre. Heinrich Koebner J has recently again collated the evidence on this subject. He has collected into a table over forty cases of supposed reinfection ; but that these cases of syjihilis, reoccurring in an indi- vidual, are still very exceptional, and not as common even as we might * Loc. cii. ■f- " De la Reinfection syphilitique, de se3 Degr6s ct de ses Modes divers," " Archives G6nerales de Medcciue," July and August, 1863. X " Berliner klinische Wochenschrift,'' 46, p. 549, 72. " Ueber Keinfection mit consti- tutioneller Syphilis." SECOND ATTACK OF TRUE SITBILIS. 407 be led to suppose from finding mention of nearly half a hundred in the same essay, is shown by a careful perusal of the article in question. Several of the cases detailed by Koebner were certainly tertiary ulcera- tions of the penis, mistaken for syphilitic chancre, as indeed Sigmund has already pointed out in regard to some of these very cases,* and Case VIII, on which Koebner lays most stress, is, of all, most clearly one of tertiary ulceration. The facts of this case are briefly these : A man of forty-five has S3'philis in 18GG, and his wife an ulcerated tuber- cular syphilide in 1867. In 1871 the man ai^plied for treatment of a very hard, flat ulcer, quite large, and with sharp-cut edges, saying that it had ulcerated within the previous twenty-four hours. Inguinal glands intact. His last periods of sexual intercourse were ten weeks previously with a prostitute ; nine and nineteen days before date, with his wife. The wife was examined, found healthy, and remained so ; the patient still bore evidences of tertiary syphilis upon his person. His ulcer on the penis got well under iodide of potassium, and he had no eruption or other evidence of syphilis after it. Such a case requires no comment. Since the foregoing remarks were written, a considerable number of new isolated cases have appeared, vouched for by competent writers, Gascoyne, Oaspary,f Taylor, J Thebaud, Lemaire, Venot, Malherbe, and many others, and a few articles have come out on the subject cov- ering the same ground. I find, however, nothing new, nothing to disprove the general statement that, while second attacks of true syphilis are possible, they are very exceptionally rare, much more in- frequent than the literature of the subject would lead one to suppose, and that the highest position of the observer does not shield him from the possibility of making a mistake upon a subject so surrounded with difficulties of accurate observation as this one. Hutchinson * records a case in which a woman with mild inherited syphilis got a new attack in the usual way at the age of twenty. Mer- kel II has a similar case even more strongly marked. Personally, although I have several times treated patients who had. been through long courses of mercurial treatment for alleged syphilis, and came to me with true syphilitic chancre, and have seen other cases of alleged chancre in patients whom I had known to be formerly syphilitic, yet I have been always able to unravel the points of diffi- culty to my own satisfaction, and I can honestly state that I have never seen a case of syphilitic reinfection to recognize it. While, then, a second true syphilitic infection is possible even while * Pitha und Billroth, " Eandbuch." f Quoted, " Med. Times and Gaz.," Dec. 5, 1874. X " Vierteljahrschrift f. Derm. u. Syph.," 1, 1876. * " London Hospital Reports," vol. ii, p. 164, 1865. II Quoted by Koebner, loc. cit. 32 498 SYrniLis. the subject bears the marks of late tertiary disease, yet sucli infection is eminently exceptional, and allowance must be made in the reported cases for (1) chancroid accomjxmied by some eruption, as a coincidence ; {2) ecthyma mistaken for syphilis, after which the first true syphilitic infection might pass for a second ; (3) false chancre, indurated mucous patch ; and (4) cases of tertiary ulcer faultily diagnosticated. Tkaxsmissibility to Animals. — Besides this peculiarity of only appearing once in a given individual, syphilis differs from chancroid in not being transmissible to animals. Lanccrcaux, quoting Ruiz Diaz de Isla, mentions fancifully thai even plants have been accused of hav- ing syphilis transmitted to tiiem by sprinkling them with water which had been nsed to wash syphilitic ulcers. Horses and asses suffer some- times from a disease, the "doury," jjerhaps remotely analogous to syphilis, which is transmitted only by sexual intercourse. It comes on, after an incubation of four to six weeks, with fever and cutaneous tumors (not the subcutaneous tumors of farcy). The mucous mem- branes, glands, eyes, and bones, take part in the disease. Atrophies and paralyses follow. It lasts from two months to three years, and is not transmissible by inoculation. These animals also have a local con- tagious, venereal affection (Lancereaux). Cows are said to have some- what similar affections, but it has been found impossible or very diffi- cult to propagate any of these maladies by inoculation, and their com- parison with syphilis is at best fanciful. Paul Topinard * mentions an ape which was the subject of a com- munication to the Anthropological Society in London, 18G5, who had ulceration of the generative organs followed by loss of hair and an affection of the bones. Since the earlier experiments (abortive ones) of Auzias Turenne, f the alleged syphilitic monkey of Depaul and the cat of Vernois, Lan- cereaux's guinea-pig, J Bradley's * guinea-jiig and kitten, Legros's guinea-pig, Horaud and Pencil's | dogs, horses, cows, and other animals, in some of which cases ulcers of mucous membranes, local cutaneous lesions, lymphatic glandular swelling, loss of hair, and internal gum- mata with bone lesions are reported to have been found, we have the more recent experiments in the same direction of Klebs,"^ who by in- oculating an ape with a bit of hard chancre thought he produced syphilitic symptoms ; of Hausell, () who believes that he has been able to inoculate rabbits with syi^hilis ; of Eabatel, J who failed to gain any * " Anthropoloiry," translated hy R. T. II Bartlcy, London, IS'ZS, p. 160. f " Bull, do I'Acad. de Med.," 1844, I, 10, p. 212. i "Traill^ de la Syphili.s," 2d edition, 1873, p. 596. * " Brit. Med. Journal," September 30, 1871, p. 376. II " Annale.s de Derm, et de Syph.," I, iv, p. 387. ^ "All. Wicn. mod. Zeitung," October 15, 1878, p. 418. " Archiv f. Ophthalmologic," Berlin, 1881, No. 3, p. 93. J " Rccherchcs experimentales," etc., " Lyon Med.," January 8, 1882. INCUBATION OF SYPHILIS. 4(j9 success upon any animal by inoculating gonorrhcBa, chancroid or the tissue of indurated chancre ; of Martincau, * who excised a chancre, cultivated it appropriately in a flask, injected some of the liquid into the peritoneal cavity of a pig, and in a month got some pimples on the abdomen, a conjunctivitis, a tumor on the penis, while another pig in- oculated from a hard chancre had similar symptoms ; of Martincau again, f who inoculated a monkey with syphilis, got chancre in twenty- eight days, then had papulo-erosive and diphtheroid lesions on the penis, glands, in the groin and axilla, and under the jaw, loss of flesh, alopecia of head and back, and ten months after infection ulceration in the vault of the palate. Finally, Cognard I inoculated a monkey from a cul- tivation liquid prepared by Chauveau from the pus of a syphilitic sore. The animal got lesions in his mouth and on his soles resembling those of secondary syphilis 5- another monkey had some obscure lesions from inoculation. Finally, J. Neumann * inoculated three aj)es, three rabbits, a horse, a hare, a white rat, a marten, a cat — total of inocula- tions, fifty-four — and absolutely failed in every instance. What then shall be said. Only this : The symptoms in animals who are alleged to have been successfully inoculated with syphilis are ir- regular, obscure, indefinite. They suggest but do not assert syphilitic contamination, and many experiments yield very doubtful or negative results. It can not therefore be yet asserted that the syphilitic dis- ease is transmissible to animals. The demonstration of the possibility of infecting lower animals with chancroid is much more positive. So far as experimental demonstration yet goes, it must be asserted that the sad privilege of having true syphilis belongs only to man. iNCUBATioisr OF SYPHILIS. — After the poison of syphilis has been absorbed, the break in the epithelium through which it entered heals, and the virus ferments, as it were, in the blood, until it is ready to give itself local expression, first at the point of entrance in the form of syphilitic chancre. Such an abraded point may be kejot open by dirt or by suppurating and ulcerating from the start if the syphilitic poison comes from a much-inflamed irritated chancre, and particularly so if the yirus of a chancroid be inoculated at the same time upon the same spot (mixed chancre). In such case either there is no spot to mark the entrance of the poison for many days, or a simple temporary fester appears to get well shortly, the actual syphilitic lesion not developing until after a time, or the sore may run its course as a chancroid later, becoming indurated and putting on syphilitic characters. This period of incubation, or hatching, has been critically studied by many authors, both by inoculation upon healthy subjects and, * Editorially, "Lancet," September 16, 1SS2, p. 45'7. f " Lyon Med.," December 28, lSS-3. i Editorially, "Lancet," June 14, ISSi, p. 1090. * " Wien. med. "Wochenschrift," February 21, 1SS3. 500 SYPniLis. clinically, by close observation of pntients. The results arrived at are in the main identical. The usual period after contact, or inocu- lation, at which a chancre first appears is about the end of the third week. It is not unusually at four, and may in exceptional cases be much later, reaching ten weeks. Many authentic cases of longer in- cubation are on record. Aim^ Martin * cites a girl whose chancre^ appeared seventy-two days after being shut up in jirison. Fouruier ^ has one as long, and speaks of another under the care of Guerin, and Fox, I of New York, has one of seventy-five days. The possibility of error in these few cases must not be lost sight of. The longest period of incubation that I can find among the authentic cases of experimental inoculation is forty-six days ; the inoculation was made from an in- durated chancre by Daniclssen.*" There are some apparent exceptions on the short as well as the long side of the incubative period. Hammond || has a case of thirty-six hours, Taylor-^ one of twenty-four hours, at which time a silvery spot appeared. Hill and Cooper^ cite two surgeons, whose digital lesions showed about ten days after contact with infected secretions, and Rollct J has an ordinary case of the usual kind, in which he believes the incuba- tion to have been nine days. There is, then, no case on record of an incubation less than nine days, except the cases of Taylor and Ham- mond. The latter is not a skilled observer in syi^hilitic matters : in the former the lesion was a peculiar one, and I can do nothing better than record it as an unexplained exceijtion. The shortest period of in- cubation in a case of experimental inoculation was Lindmann,:|; who inoculated himself from an ulcer on the tonsil of a friend. During the period of incubation the patient bears no sign of disease, and the habitual clinical limits are as clearly traced as any other symptom of the disease. During the fourth week after exposure a syphilitic chan- cre appears. This is, perhaps, the most valuable mark of a syphilitic chancre, and practically all sores appearing later than ten days after suspicious contact must be regarded with distrust, while those coming sooner may be more lightly considered. Induration of Syphilitic Chancre. — The period of incubation of a chancre can not, clinically, be always oljtained with accuracy. Induration can always be felt when present, and in well-marked cases * "Th(ise de Paris," 1863, p. 28. f " Syphilis chczla Femme," 1873, p. 16. X "Archives of Dermatology," 1879, No. 3, p. 267. * "Deutsche Klinik," 1858, p. 322. II " On Venereal," 1864, p. 26. ^ " Am. Jour, of Syph. and Derm.," 1871, p. 244. ^ "Syphilis and Local Contatrious Disorders," second edition, 1881, p. 81. ^ " Pluralit6 des Maladies veneriennes," p. 26. $ " Bull, de I'Acad. de Med.," July 20, 1852. INDURATION OF CHANCRE. 501 it is absolutely pathognomonic. It consists in an infiltration of the tissues underlying the chancre with small round or oval and spindle cells, some granular matter and free nuclei, and thickening of the coats of the vessels. It may only partially underlie tljc ulceration in exceptional cases. It exists in three varieties : 1. A thin superficial layer of induration, aptly called '^'parchment- like," exactly underlying the ulceration. This may escaiw notice, un- less the sore be pinched up carefully with the thumb and finger, placed on either side, and lightly pressed upon, so as not to be bent or folded by the pressure. This is the commonest form. 2. The induration may resemble a split pea, situated exactly be- neath the ulcer, which is upon its flat surface. This induration is easily felt and is unmistakable when present. It is little or not at all sensitive, freely movable over the jiarts beneath, hard like bone or wood, or like cartilage, having indeed a certain springy, elastic feel. It is sharply defined, clean cut as it were, ends abruptly, and does not shade off into the surrounding tissues, like inflammatory indura- tion. 3. The induration may be very extensive, far surpassing the bounds of the ulceration placed upon it, excavated or convex upon its surface ; but here all the characters and qualities of the induration are the same as those detailed above for the split-pea variety, only there is more of it. The skin over it is not usually red, and the feel is far different from the boggy, inelastic sensation given to the fingers by pressure on an inflammatory induration. Induration is greater or less, according to the tissue in which it is formed. It is usually greatest in chancres of the skin, lips, nipples, behind the corona glandis, and near the fraenum of the penis. In spongy tissues like the glans penis, the induration is often very slight. In certain very rare cases, it appears to be altogether absent, probably sometimes because it had not yet appeared at the moment of examina- tion, or had passed away, and undoubtedly sometimes because the true syphilitic lesion was not detected, but some chancroid, existing simultaneously, was discovered, found soft, and believed to be the ori- gin of the syphilis that followed. Again, when a syphilitic chancre becomes phagedenic, it loses its induration at once. The induration of a syphilitic chancre may precede the ulceration or may follow it. In the latter case it comes on during the first week. The parchment-like variety disappears the soonest. It has been ob- served to last only twelve days (Clerc). Usually, however, any form of induration will outlast the ulceration — remaining, indeed, for two or three months. More rarely it lasts for years, as a cicatricial hard- ness similar in feel to the true syphilitic induration, Eicord records one case of thirty years' standing. Fading induration may suddenly reappear, and increase on the outcropping of general symptoms. Four- 502 SYPHILIS. nier* first described certain indurations which occasionally appear in the neighborhood of a syphilitic chancre, though not immediately con- nected with it. They are formed in and around the lymphatic vessels, and niay, very rarely, also ulcerate. Ulceratiox of Syphilitic Chaxcre. — Properly, sj-philitic chan- cre does not ulcerate. It consists, in more than half the cases, simply of an excoriated surface, looking red and bloody, perhaps pultaceous, very superficial, not infrequently scabbed when exposed to the air. In- deed, it may never even excoriate, although this is exceedingly rare, the lesion consisting in a simple indurated tubercle, which scales oil' a little at the top, but from which the epithelium is never absent — in other words, which is never even moist. Chancre, however, especially of the genitals, rarely escapes more or less inllammation, hence it is the rule to find some shallow, occasionally deep, ulceration. When shallow, the ulcer is round or oval, with slanting borders, often a red base, sometimes partly covered with a pultaceous deposit. When deep, the borders are never abrujit, as in chancroid, but always sloped off. The cavity is funnel-shaped. The borders of the ulcer are ad- herent all around, never by any chance undermined, as they occasion- ally are in chancroid. Sometimes the induration left behind on the healing of a chancre reulcerates. Character of the Discharge. — Pus does not form as such on true syphilitic chancre, unless it be inflamed, when the thickness of the pus will vary with the degree of the inflammation. Ordinarily the discharge is sero-purulent, or purely serous in appearance, often bloody, and sometimes, on the dry, indurated papule^ there is abso- lutely no discharge at all. Paix. — In unirritated syphilitic chancre as a rule there is abso- lutely no pain. A patient often carries a chancre for a considerable time without susi^ecting its existence, and sometimes, undoubtedly, it comes and goes without being discovered at all. In this way may be explained many singular cases of undoubted syphilis, apparently not preceded by any primary lesion. Cicatrix. — The scar left by chancre varies. In the majority of cases where there is only a slight excoriation or exulceration, no scar whatever is left behind. In other cases the scar is proportionate to the depth of the ulcer. These scars are occasionally pigmented. At first they are discolored — of a dark, vinous hue, like the ordinary syphilitic tubercle, of a color aptly compared by Fallopius to the flesh of raw ham. This color may be followed by tlie true copper-colored (Swe- diaur) or bronzed pigmentation. The latter sometimes approaches a black. It clears off gradually from the center, to leave the scar finally whiter than the surrounding skin. Induration generally vanishes, but there may remain a cicatricial hardness about the scar permanently. * "]6tude clinique sur I'lndiiration syphilitiquc primitive," "Arch. Gen.," 1858. AUTO-INOCULATIOJf. 503 Inoculation. — Ilctoro-inoculatioti of sypliiliLic virus upon healthy individuals was first performed by Wallace in 1835, with virus derived from mucous patches. It has since been very tlioroughly studied by the few experimenters who have practised it, aided by the light of chancroid inoculation. Clinically, vaccinal syphilis has furnished am- ple opportunities to study the eii'ccts of hetero-inoculation — accidental it is true. Auto-inoculations have been performed without number, the result (with some little exception to be mentioned below) having been invariably negative, unless the chancre had been previously irritated by friction, savin-powder, tartar-emetic, or other irritant, or was itself in a state of inflammation, producing pus. Under such circumstances auto-inoculation will often produce a pustule, followed by a small ul- cer, remaining open, perhaps, for some time, furnishing pus, also auto- inoculable, but this ulcer has not the rapid march or the characteristic appearance of chancroid, and has never been proved to be such, by being inoculated upon a healthy individual and there producing a characteristic chancroid not followed by syphilis.* This may be and has been done by inoculation from a mixed chancre, but never from pure syphilitic chancre. The pustule and ulceration produced by auto-inoculation of chancre are similar to what may also be produced by inoculation of pus of other syphilitic lesions, or sometimes with the pus of any indifferent abscess ; in other words, they are the pustule and ulceration of simple inflammatory irritation, not the special poisonous sore known as chancroid, which is so freely inoculable ; and as simple dirt and irritation may call out a mucous patch or pustule upon a syphilitic subject, so may also auto-inoculation of some of the syphi- litic products. The difference between the inoculation of chancroid and syphilitic chancre has been strikingly illustrated not a few times. The three famous cases of Lindmann, Warnery, and Danielssen are perhaps the most conclusive. Lindmann inoculated himself a number of times with chancroidal pus, always with success, but with no syphilis ; finally, as the doctrines of syphilization were in vogue, believing him- self protected, after having produced a dozen chancroids, he inocu- lated himself with matter taken from the ulcerated tonsils of a syphi- litic friend. This was followed on the eleventh day by a papule (not a pustule, as after the previous inoculations). The papule ulcerated slightly, and in forty-five days a general syphilitic eruption apj^eared. The doctor now recommenced his inoculations with chancroid matter, and when last heard from was still continuing, then having reached the twenty-seven hundredth successful chancroid ulcer. Warnery, of Lausanne, under the same " syphilization " delusion, inoculated him- * I have given this point considerable attention in another place, " Venereal Diseases," 1880, p. 10 et seq. 504 SYPHILIS. self plentifully with cliiincroitls, which took, but iiroclucecl only local ulcers. Finally, he employed the syphilitic virus once, and an indu- rated chancre appeared after twenty-three days' incubation, followed by syphilis in due course. Daniclsseu, a discijile of syphilization, in- oculated a man, who had elephantiasis, two hundred and eighty-seven times with chancroid, until be had temporarily exhausted the irrita- bility of the skin, and no more chancroids could be produced by inocu- lation. In other words, the patient was " syphilized," as it is called. Now, one inoculation was made with true syphilitic virus. An indu- rated, syphilitic chancre appeared, and in sixt3'-eight days a general syphilitic eruption followed. Since then very little has been said by its advocates of " syphilization " as a prophylactic. The course of syphilitic chancre observed by hetero-inoc^ilation is briefly as follows : A chancre is always produced with or without ul- ceration, a mucous patch never, although certain published observa- tions state the contrary. A strict analysis of these cases proves that they commenced as indurated chancre, and became mucous patches only secondarily after an interval. The first result of hetero-iuocula- tion has often been a pustule, just such a little fester as might appear after the prick of a pin, but this pustule heals entirely in a few days. It is accidental, and in most instances nothing remains to mark the inoculated point except the dry speck of blood. This finally rubs off, and the skin becomes absolutely normal. No change occurs for a period varying from ten to thirty-nine days in the re]iortcd cases. Then the first signs of chancre appear, not as in chancroid by a pus- tule, but as an indurated papule (which, becoming larger, may be called a tubercle), of a dark, vinous-red color, without pain, or, per- haps, with a little itching. This may remain dry, being covered after a while with a scaly crust, or may, and usually does, ulcerate after a few days, often scabbmg secondarily. The epidermis may raise as a pustule before ulceration. The ulcer has sometimes been noted as appearing from the first, but usually at a mean of five days after the papule. It persists for a variable period, several weeks, possibly months, and, getting well, leaves often a pigmented cicatrix behind. The neighboring lymphatic glands indurate, do not sujipurate, and general syphilis follows. This is the course with no appreciable variation, no matter what fluid is inoculated — chancre secretion, pus from mucous patch, blood, or other discharge. An apparent exception to the above course exists for vaccinal chan- cre, where chancre-virus or syphilitic blood is introduced along with vaccine virus. Here the vaccine virus, having a shorter incubation than the syphilitic, develops sooner, and the vesicle runs along regu- larly, perhaps, at first, but varies from the true type after a time, in that the base indurates and the surface ulcerates ; or, perhaps, it may MULTIPLE INOCULATION. 505 scab, the whole resembling a large, scabbed, ecthymatous pustule. Sometimes only the syphilitic virus takes, when, after a long incuba- tion, the regular papulo-tubercle of syphilitic incubation appears and runs its usual chronic course ; or the vaccine vesicle may be imperfect and abortive, the sore soon putting on the appearance of a cutaneous chancre, and general syphilis following in due course. There is one source of error in regard to vaccinal syphilis ; namely, that the vaccinal fever may develop latent, possibly unsuspected, syphi- lis from which a child is already suffering by inheritance or previous contagion. Here the vaccination will always be accused of being the cause of the syphilis. The distinction is easy. If vaccination devel- ops latent syphilis, it does so as does the application of a blister or other irritant, and a more or less general eruption comes on quickly, usually starting from the point of irritation, vaccinal or other ; where- as, in true vaccinal syphilis, there is first a period of incubation, then a local chancre, then indurated glands, and after a second incubation a general (at once) syphilitic eruption, which does not tend to start from the irritated point. Chancres of inoculation are of course liable to the same complications as chancre naturally acquired. When the inoculating fluid is rubbed upon a scarified or a blis- tered surface, the lesion appears multiple at first, many little papules springing up in the patch, as if many separate points had been simul- taneously inoculated, which is, indeed, the case ; these, however, soon coalesce into one mass, forming one lumpy, tubercular chancre-patch. This explains at once how syphilitic chancre may be multiple, several different points having been inoculated at the same or nearly the same time. Multiple In-qculation. — In testing this point it has been found that, where many points were inoculated at the same time, usually all took and appeared simultaneously as chancres. "Where the intervals of inoculation were a few days apart upon the same individual, nearly all took. Puche inoculated twice at twenty-two days' interval ; chancre appeared upon both points at the same time. In other cases the sec- ond inoculations have appeared to require a longer incubation than the first. Again, inoculations made upon different individuals, with virus derived from. the same lesion, have required different, periods of incubation for their development. These apparent exceptions to the fact first noted by Hunter, that syphilis was not reinoculable upon an already infected person, are still further borne out by the results of other experiments, such as those of Wallace, who produced an indurated chancre by using chancre-virus upon a man who had reached the eruptive stage of the disease. Wal- lace, Bidenkap, Sperino, Lee, and others, have performed auto-inocu- lation soon after the appearance of chancre, in some cases with suc- cess, producing a small, ill-defined, indurated chancre, usually with 506 SYPUILIS. short incubation. Fonrnier and Pnclie believe that about two ]icr cent, of auto-inoculations of syphilitic chancre take, presumably when some irritation (inflammatory) of the chancre exists, but the vast ma- jority, especially where the chancre is fully developed, 3'ield only nega- tive results, and in no case does the auto-inoculation of syjjhilitic chancre produce the pustule and rapidly advancing characteristic ulcer known as chancroid. The rule, then, is practically this : reinoculations of syphilitic virus upon patients already syphilitic i)roducc no result. Auto- or hetero- inoculation u])on a patient with very young chancre is occasionally successful. A more constantly favorable result might be expected from hetero-inoculation during the late tertiary stage of the disease. At both of these periods the patient is not fully protected, the system not being saturated with the syphilitic poison at first, and the virus being at a minimum toward the end. Between these periods very rarely will reinoculation of any syphilitic virus produce any effect, although an irritative ulceration may be produced in some subjects by the inoculation of any inflammatory pus, and chancroid is inocula- ble at will in its full vigor on all subjects. This subject finds an apt and analogous illustration in the results of inoculation Avith vaccine virus. Any number of such inoculations made at the same time may take fully. Eeinoculations practiced be- fore the first inoculation has taken, or while the vesicle is young, will also yield positive results, but to a less degree. Then, while the pro- tecting power of the virus lasts, the result is invariably negative, or only abortive pustules are produced (false takes). Finally, after a variable period the protection becomes weak or exhausted, and inocu- lation produces a partial or even perfect result. Secretions capable of transmitting Syphilis hy Inoculation. — This subject has been carefully studied by inoculations, as well as clinically by confrontations, that is, by examination of the individual from whom a given patient acquired his syphilis, and comparing the lesions. The first confrontations of syphilitic chancre were made in 1852, by Bassereau.* Later, the confrontations of Diday, Eodet, Fournier, Clerc, Musset, Eollet, were published by Dron.f Fournier % followed, and numerous other contributions, since made, furnish in all a very full collection from which to draw deductions.* The results arrived at have been identical. Inoculations of healthy subjects with the fluid secreted by syphilitic chancre, mucous patches, any secondary cutaneous or mucous lesion yielding a discharge, and of syphilitic blood (Pellizari, Waller, Lindwiirm, Gibert, and the anonymous Palati- * " Des Maladies de la Peau symptomatiques dc la Syphilis," Paris, •f- "These de Paris," 1856. % Ricord's "Lc9ons sur le Chancre," 1858. » RoUet, " De la Syphilis inocule6," " Ann. de Derm, et dc Syph.," IS'ZS-'Y*, No. 5, pp. 330-355. FLUIDS CAPABLE OF COMMUNICATING SYPHILIS. 507 nate) drawn from a patient with an eruption, taken eitlicr from a papule or tubercle, or from the healthy skin between the lesions — all such inoculations yield indurated chancre aft.er a period of incubation, ■which chancre is succeeded by general syphilis. Whether the blood of syphilis is poisonous in the -intermediary periods between the erup- tions, when the skin and mucous membranes are sound, is not yet established, but certain observations of vaccinal syphilis would go to prove that it is, as well as the recent case reported, in which skin-graft- ing has produced the disease (Deubel *), a very doubtful case reported by Fereol. Another case has also been reported, the name and refer- ence to which I have mislaid. The secretions of other pathological lesions not syphilitic will not produce syphilis unless some of the patient's blood be inoculated at the same time. Gonorrhoea, acquired from a syphilitic patient having at the time only gonorrhoea, reproduces itself as gonorrhoea, and not as syphilis. The same is true of chancroid, even by inoculation, if no syphilitic blood be inoculated along with the pus. Certain confronta- tions and inoculations of mixed chancre go to prove that from such a sore may be derived either simple chancroid or mixed poisonous chan- cre. Diday inoculated pus from a pustule of acne produced upon a patient " in full syphilis " by the administration of iodide of potas- sium. The result was negative. The same is true of the vaccine virus. Pure vaccine virus, taken from a syphilitic patient before there is any pus in the vesicle, will produce vaccinia only, if no blood is inoculated. This is well shown in some of the vaccino-syphilitic epidemics, where many children were vaccinated at the same sitting, from the same child, the virus being taken from arm to arm. Often, in such cases, the result has been that those first vaccinated developed vaccinia only and no syphilis ; others a little later, when the virus was giving out, developed vaccinia, followed by indurated chancre on the same spot, usually before the vaccine pustule got well ; finally, those last vaccinated developed only an abortive vaccine vesicle or none at all, while indurated chancre appeared after incubation upon the vaccinated spot, and general syphilis followed. The recent important case of Dr. Cory deserves mention here. After three negative experiments, this gentleman finally succeeded in inoculating himself with syphilis, using pure lymph without any blood — at least, so it is alleged. The committee appointed (Drs. Humphrey, Ballard, and Hutchinson) to examine into these experiments report f it as their opinion ^'that it is possible for syphilis to be communicated in vaccination from a vaccine vesicle on a syphilitic person notwithstanding that the operation be per- formed with the utmost care to avoid the admixture of blood." This report seems to read between the lines that the committee thought * "Gaz. Med. de Paris," November 5, ISSl. f "New York Medical Record," editorially (citing " Brit. Med. Journ."), June 21, ISSi. 508 SYPHILIS. that Dr. Cory, in sjiite of his care, did get a little blood mixed with his lymph. The long and imjiortant subject of yacciual syphilis can not be discussed here for want of space. Suffice it to say, syphilis can be communicated by vaccination, but only, t^o far as has yet been clearly proved, when blood has become mingled with the vaccine lymph, or where a true chancre lies hidden under the vaccine vesicle and mingles its discharge with the vaccine lymph. If pure lymph be taken early, neither does chancre follow at the vaccinated point nor syphilis afterward ; but, since a little blood may readily be mixed with the lymph and not be perceived, no amount of caution is too great, and in no case should vaccine lymph, derived from an in- dividual even remotely suspected of being syphilitic, be employed.* If not the lymph, much less should the vaccine scab be used, as it necessarily contains, besides vaccine lymph, both pus and blood, and a portion of the solid tissue of the skin of the individual from whom it was taken. The natural conclusion is that it is wiser always to use lymph from the calf and never humanized virus ; and, as pure virus in sealed tubes can now be sent from the vaccinal farms over the entire globe, remaining good in any climate, there is no necessity of taking risk in any case. Inoculation has failed to produce positive results from ulcers of the late tertiary period of syphilis. Diday f inoculated sixteen times with blood from patients suffering from tertiary syphilis (nodes), always with negative results. The fact that patients with tertiary syphilis may occasionally accpiire a chancre and the earlier eruptions anew, and the other undoubted fact that such patients may procreate healthy offspring, render it still more certain that late tertiary syphilis is no longer either communicable or transmissible. Bumstcad mentions one case of probable transmission of syphilis by inoculation from blood in the tertiary stage. The victim was a surgeon of Ohio, who reports that he inoculated an abrasion on his finger while operating upon a case of syphilitic necrosis of the skull. Chancre and general syphilis followed in due course, A case of this sort needs wide confirmation, for a surgeon with a wounded finger runs so many risks of contagion from sources which he hardly suspects, that it is rather a matter of surprise that all surgeons do not become sooner or later inoculated in some accidental manner from a source unknown to themselves, a cir- cumstance which has happened surely to several surgeons who have communicated the fact to me and shown me the initial lesion upon the finger. As for transmission, on the other hand, women who have posi- * Hutchinson has published an admirable set of personal cases of vaccino-syphilis with his characteristic clearness and thoroughness, in his " Illustrations of Clinical Sur- gery," fascic. vi, London, 1877. t " Gazette Medicalc," 1849. METHODS OF TRANSMISSION. 509 tivc tertiary symptoms undoubtedly procreate diseased cliildron some- times, just as they as certainly often produce healthy ones. Ilonce, tertiary syphilis may be said to be generally, but not always, free from the dangers of transmission and of communicability. The older the disease, the less apt it is to be transmitted. The male loses the power of transmission seemingly long before the female. None of the physiological secretions or excretions can produce syphilis by inoculation. Mucus from the mouth of a syphilitic patient having no lesions of the mucous membrane at the time has been tested often. Profeta, of Palermo, and Diday * have inoculated saliva with- out success. If mucous patches exist, then the saliva produces chan- cre when inoculated, as shown by the interesting cases of tattooing re- ported by Maury and Dulles, f Yidal * has proved the harmlessness of tears, and the sweat and urine have been in a similar way relieved of blame. The semen has been inoculated by Mireur, J taken from a man in the full bloom of secondary eruptive disease. Milk from a syphilitic woman is neither inoculable experimentally nor does it give the disease to the child who drinks it. Voss's * three cases are always referred to. Two of them received a Pravaz's syringeful of milk subcutaneously, and nothing ha^jpened. The other got a local abscess, and in five days after the appearance of this alleged chancre a syphilitic eruption appeared. This short (five-day) secondary incu- bation immediately deprives the case of all value. Padova and Profeta have failed to inoculate syphilis by using milk. Ajjparent infections by milk, without any recorded primary lesion (Melchior Robert, Lane, Parker, Mahon, Bell, and others), are set off by other carefully ob- served cases, where children suckled by a syphilitic nurse have escaped disease, even where the nurse had a specific lesion of the nijDple (Duges, Eicord, Cullevier, Nonat, Vernot, and others). Where the nurse has a syphilitic lesion of the nipple, the child surely becomes poisoned if it have a fissure or other abrasion of the lips through wdiich the poison can be absorbed ; but in such case syphilis in the child is always preceded by chancre of the lips or mouth. Cerasi's || case of alleged transmission of syphilis by milk to a child carries its own condemnation with it, since the lesions found on autopsy were those of inherited disease. Methods of Traistsmissiois" of Syphilis. — Syphilis always com- mences as a chancre, with two exceptions — or rather one alleged ex- * Cited by Gallois, " Recherches sur la question de I'innocuite du lait provenant des nourrices syphilitiques," These de Paris, 18*77. f "Am. Jour. Med. Sci.," January, 18*77, p. 44. X "Ann. de Derm, et de Syph.," No. 6, t. viii, 1877. *"St. Petersburger med. Wochenschrift," No. 23, 1876, and "Brit. Med. Journ.," November 11, 1876. II "Gaz. di Roma," July, 1878, and " Jahresb f. gesmmt. Med.," Bd. ii, Abt. 11, 1878, p. 520. 510 SYPHILIS. ception, for the matter is not yet successfully proved, namely, the clioc- en-rctour ; the other a real exception — that of inherited disease. Choc-en-retour. — This is a misty condition, prohably only a high- sounding title to conceal ignorance. In it the ovule of a healthy woman is supposed to be infected with syphilis by the semen of the syphilitic father, a semen which the direct test of inoculation proves to be void of any poison. The syi)hilitic germ grows, and in its turn poisons the mother, who thus becomes diseased without the necessity of having any primary lesion. The evidence on this point consists in reported cases wherein no chancre has been observed, but, unfortu- nately, all such evidence, no matter how much there may be of it, is negative at best. We must accept practically the fact that many a woman, possibly the greater number having syphilis, gets the disease without it having been possible for the physician to have seen the primary lesion, yet this does not prove that she never had it. And it is also true that many a woman has a syphilitic child, but no symptoms herself at that time, and none for a long time afterward, when she becomes plainly syphilitic in her symptoms. This is choc-cn-rctovr, but no one can possibly say that this woman may not have had a local lesion at some time without knowing or suspecting it herself ; so that, while we accept the facts practically, we need not accept the expla- nation of clioc-en-retour scientifically, since it does not appear very reasonable, and particularly until the question of the possibility of infection of the child by the father, the mother remaining sound, has been finally settled. The semen being harmless by inoculation, if it finally becomes proved (as it may well be) that the mother remaining healthy the child is healthy whether the father is syphilitic or not, in such case the scientific explanation of clioc-en-retour falls to the gi'ound of necessity. Inherited Syphilis. — When a child is born with inherited s\'philis, it naturally never has had a chancre — a primary lesion. No one doubts that a mother in active syphilis aborts, miscarries, or jiroduces a diseased child. As to whether the father can produce a diseased child by infecting the ovum through impregnation without infecting the mother (and through her the ovum), this is a question upon which there is much controversy to-day, and which is not yet settled in spite of the able contributions to the subject made by many competent ob- servers. That a father may have syphilis and still have a healthy child is proved by Mireur.* The same author demonstrates that * Hippolyte Mireur has collated the evidence on the subject under discussion in an admirable essay, " Sur rilerodite de la Syphilis," Paris, 1867. He leans toward the belief that, if the mother escape, a syphilitic father can not produce a syphilitic child. He gives the following case (page 26) : About a year after contracting chancre, followed by well- marked secondary symptoms, which had disappeared entirely under treatment, M. C married. Ten months afterward his wife was delivered of a vigorous, healthy child, " the METHODS OF TRANSMISSION. 511 both parents may still suffer from tertiary lesions, and produce seem- ingly healthy children. When the mother has syphilis, it has been shown that she may have a healthy child while under treatment, and a diseased one if the treatment be left off before she has passed the viru- lent stage of the disease. This is demonstrated by Thurman's case.* In this case the virulence of the disease seems to have extended over an exceptionally long period. Ricord and Baerensprung believe that the child is rarely if ever infected if the mother acquire her disease after the seventh month of pregnancy. Chabalier's case f bears upon this point. Finally, that a man himself syphilitic, with a syphilitic wife and a non-syphilitic mistress, may have a diseased child by the former and a healthy child by the latter — a child known to be his by an inherited peculiarity of the thumbs — the two children being born within fifteen days ,of each other, seems to be fully proved by Char- rier's case.^ Much, very much, has been written upon this truly interesting sub- image of his father," who remained perfectly well up to the age of two years. At thi3 date a little indolent erosion appeared upon the lip of the father. The latter paid no attention to it, but continued to fondle and kiss his child. After a time there appeared upon the lip of the child a livid, indurated excoriation, one centimetre in diameter, accom- panied by indolent bubo under the jaw. After a time, in spite of treatment, the child developed a characteristic syphilitic roseola and mucous patches at the anus. Mireur (page 91) relates the case of a syphilitic mother and father, where the dis- ease ran its course without specific treatment. After two miscarriages and a still-birth at term, the fourth and fifth children were born alive, but developed syphilitic eruptions shortly and died. The sixth and seventh children were born healthy and continued well, notwithstanding the fact that both father and mother had subsequently " gummy tubercles and ulcers scattered abundantly over the extremities," for which they finally placed them- selves under specific treatment. * In Thurman's case (" Journ. de Med. et de Chir.," Toulouse, October, 1851), two syphiUtics were married. Both had been treated, apparently recovered, and never after- ward, while under observation, manifested any sj-mptoras of syphilis. Seven children were born, became covered with a syphilitic eruption, and died. Pregnant for the eighth time, the mother was brought under the influence of mercury. The child was bom healthy, and grew up sound. Pregnant for the ninth time, the treatment of the mother was repeated, a healthy child resulted, who remained well. Pregnant for the tenth time, treatment was neglected. A child was bom, seemingly well at first, who developed a syphilitic eruption, and died after six months. In her eleventh pregnancy the mother again took mercury. A healthy child was born, who remained well. f In Chabalier's case (" Journ de Med. de Lyon," May, 1S64), Madame X , at the end of the seventh month of pregnancy, had intercourse with her husband, who had been traveling for five months. Thirty-eight days afterward (during the ninth month of preg- nancy) Chabalier found three indurated chancres on the vulva. The child was bom at term, seemingly healthy, and was immediately given to a healthy wet-nurse. One month after confinement the mother left her child to join her husband on his travels. At the end of six weeks Chabalier was called to see the infant. He found it covered with a papulo- vesicular eruption, with intense coryza, and mucous patches on the scrotum and in the mouth. At the same date the mother, while traveling, developed mucous patches at the vulva and anus. The child died. X "Archives Gen. de Med.," 1862, vol. ii, p. 324. 512 SYPHILIS. jcct, and it has been strongly asserted that syphilis may be communi- cated by the father to his child, the mother remaining sound. This side of the question has, pcrhai)S, its ablest advocate in Kassowitz,* while one of tlie stillest upholders of the other side of the question — namely, a healthy mother a healthy child, so far as syphilis is con- cerned, no matter what the condition of the father as to that jiarticu- lar disease — is Adam Oewre, of Christiania, whose writings through translations and reviews are well known to every one familiar with the modern literature of syphilis. A host of other writers, of greater or less merit, swell the list with individual cases and comments. I can not pretend to do the subject full literary justice here, and will not attemi3t it. I simply record my own convictions, or, rather, serious impressions, for I am open to other convictions when the weight of evidence changes. The great stumbling-blocks to me, standing in the way of my seriously accej^tiug the fact that a child may be born syphi- litic and still have a healthy mother, are the failure of direct inocula- tion upon such mothers, and the so-called Colles's law,f namely, a child born syphilitic can not poison its own mother, but may poison a healthy wet-nurse. Caspary,J so far as I know, is the only one who has directly inoculated a mother sujiposed to be healthy, but who miscarried of a S3'philitic offspring, the father being syphilitic. In this case four inoculations on the arm with the secretion from broad condylomata mixed with blood failed to take. As to Colles's law, none of Kassowitz's forty-three presumably healthy mothers, although having and living among syphilitic children, are reported to have be- come diseased, and no one among the numerous supporters of that side of the question has yet brought forward an alleged healthy mother of a syi)hilitic child who has afterward herself in any way become syphi- litic. The cases cited by Kassowitz in controversion will not bear close scrutiny. Cazenave's case is only one of the old cases cited by Colics himself and commented on by Cazenave. Brizio Cochi's case proves, if anything, a syphilitic father, a syphilitic mother who has no noticeable secondary symptoms (a circumstance not very uncom- mon), finally, an ulcerated nipple on account of nursing, and the acci- dental outbreak of tertiary symptoms. I have had a case wherein an oldish woman came to me with tertiary syphilitic ulceration in the nose and throat with loss of bone, and a gumma on the cheek with loss of bone, together with tertiary eye-lesions. She had never been treated for any disease, always having been well, but she narrated with tears in her eyes how she was childless, having lost a number of chil- dren through abortion, miscarriage, and early death of the offspring, * " Die Ycrerbung der Syphilis," Braumiiller Wicn, 1876. f Abraham CoUes, " Practical Observations on the Venereal Disease and on the Use of Mercury," London, 1837, p. 285. X " Vierteljahrsschrift fiir Derm, und Syph.," Ilefl iv, 1875, p. 437. METHODS OF TRANSMISSION. 513 and how she remembered that lier liusband had a bad skin disease, was a great drinicer, and was constantly taking medicine for a disease about which she knew nothing. >Slie had no idea that either he or she had or had had syphilis until I told her. Medicine promptly cured her lesions, but she never could forgive her husband because he had not told her the nature of his disease (she had been always well) in order that she might have been treated, and so, perhaps, have saved for her old age one of her babies, whom she hotly lamented in all honesty. Miiller's case is not clear enough to require comment. The same remark applies to Guibout's case — nothing is clear about it, no subsequent history of the mother to prove that she had syphilis after her alleged chancres of the nipple. Eanke * has brought forward the only case which seems to prove what is claimed. The father, of thirty, had had syphilis at nineteen, and no symptoms for nine years. This is peculiar. If such a man may not marry with impunity, then no one can, and the profession to be honest must condemn every syphilitic to celibacy. It is alleged that a syphilitic child is born one year after marriage ; another, two years later. The latter, at the age of two weeks, gets ulcers in the mouth and a spotted eruption. The mother suckles it, and gets what Kanke considers a hard chancre at the nipple, followed by a mottled eruption. This disappeared under mercurial treatment, and a relapse got well in the same manner. The father and elder child remained well, l^o one had been employed to draw the breast. This case is peculiar. Did the mother nurse the first child ? How did the father, being and remaining well for nine years, his syphilis being eleven years old, succeed in giving his chil- dren syphilis ? Who vouches for the purity of the wife — or, indeed, for the fact that she did not have syphilis before either child was born ? This is really the weak spot in the case. So many motives make it impossible to get at the bottom facts in the case of a woman. For instance, the following case is personal to me, and many physi- cians can doubtless duplicate it. A young lady in good social stand- ing is engaged to marry a man, who seduces her, and brings her to me with a chancre on the vulva followed by roseola, glandular engorge- ment, mucous patches, etc., all of mild type, but well marked. The lover's symptoms were more severe. I treat this lady for two and a half years, her family and friends being in total ignorance that she is in any way ill. Her lover breaks oS his engagement with her after the first few months, and after the first roseola she never has any symp- toms except a few mouth-spots. She has now long since ceased treatment, and looks the picture of radiant health. If such a pa- tient had married a man who had been syphilitic eleven years before and well for nine years, no power could draw from her a confession * " Mediciniscb-chirursrisches Centralblatt," Aus. S, 1S79, p. 374. 33 ^ > .1 514 SYPHILIS, that she had liad syphilis before marriage. She miglit suckle her child, get an ulcerated fissure at tiie nipple, and a rash might appear upon her, and I am constrained to believe that such a set of circum- stances is more likely to have obtained in Ranke's case than that his case should demonstrate what thousands of others have failed to prove. A single exception contrary to all experience proves nothing. We must simply set it down as an exception which our feeble perceptive powers can not grapple with, otlierwisc we must conclude that a child may have inherited syphilis when ncitlicr of its parents have had the disease, for Dujardin-Beaumetz reports a case which, having an intense macular and ulcerative sy])hilide. died. Parrot found characteristic osteophytic growths on the cranial bones, of the usual rosy tint, due to inherited syphilis, and characteristic changes in the epiphyseal carti- lages, yet the mother of this child tvas perfectly healthy, mid alioays had been so, as was and had been the husband, and they had had five healthy living children. "What can any one say to this case, except that the mother in some manner acquired syphilis after the birth of her fifth child, and through ignorance or for some other reason denied the fact ? There is no other exi^lanation possible in my opinion. Scareuzio's case I have not been able to see in the original. Hyde * cites it — the child at the age of seven mouths being alleged to have given its mother chancre on the nipple followed by papular syphilide and mucous patches. The child was seven months old at the time, and had had plenty of opportunity to acquire syphilis since its birth ; and I do not make out from the report that the child was examined medically before it was seven months old, although at the age of a month and a half it is alleged to have been icteroid and to have had blennorrhagic conjunctivitis ; therefore the case loses its value. In this question of the inheritance of syphilis comes up naturally a consideration of syphilitic placenta (Fraeukel f), whether the latter allows the poison to pass through, and many other interesting ques- tions, mainly theoretical. In a treatise like the present, such dis- cussions are out of place. Suffice it to say, gumma of the placenta does occur, and degeneration of the blood-vessels of that structure. Inheritance in the Second Generation. — Bearing upon this question I have only one well-observed case — a girl witli inherited disease and syphilitic mother, both of whom I attended for many years. The child had the characteristic teeth, eruptions through childhood, gum- raata at the developmental period, then rather severe cerebral syphilis with prolonged ocular troubles. Her symptoms were pronounced and varied, and all got well under large doses of the iodide of potas- sium. She married and continued to suffer from cerebral syphilis in relapses from time to time for several years, when she died of another * "Archives of Dermat.," July, 1880, p. 314. t "Uebcr Placentarsyphilis," " Archlv f. Gynjekologic," 1873, Bd. v. p. 1. METHODS OF CONTAGION. 515 malady. Iler child was f;it and healthy, and, although living in dirt, poverty, and neglect, and siiowing eczcmatous eruptions and boils in the hot weather, never had any symptom which could justify a sus- picion of syphilis. In the discussion on syphilis before the London Pathological Soci- ety * in 1876, Mr. Simon brought forward a very suggestive case of a lady whose father was syphilitic, and who had a child with symptoms considered syphilitic. Hutchinson f believes ho has seen a case — but acquired syphilis could not be positively excluded. Atkinson, J of Baltimore, published what seems more nearly a conclusive case than any I can find, but here, as in other exceptional phenomena, great care must be exercised in drawing conclusions. Generalizations are dangerous in any case even from a great number of instances, much more so when the number is small. Hill and Cooper * have collated a number of cases of twin births from syphilitic parents, showing that in such cases the two children may suffer unequally — one dead, the other lightly affected ; or both born alive and having the disease with differing intensity ; or one dead, the other apparently perfectly healthy, but in a few weeks showing seri- ous (even fatal) symptoms ; or one child suffering severely, the other apparently well — but the reporter does not say how long the child re- mained well. Chancre is produced wherever upon the body of an unprotected person the syphilitic virus is brought in contact with an abraded sur- face. That it may make for itself a way through the tender epithe- lium of mucous membrane, if left long enough in contact with it, as does the poison of chancroid, has not been proved, but, from certain cases, seems highly probable. It can not get in through the epithe- lium of the skin without an abrasion of the latter. The methods of contagion are immediate and mediate. The latter method is much more common for syi^hilis than for chancroid, owing to the numerous lesions of all parts of the body capable of secreting the poison, their long duration, and apparent insignificance. Hence syphilis is very often transmitted by means other than sexual contact. Surgeons and accoucheurs get chancre of the fingers by inoculating abraded s]")ots in the exercise of their professional duties, and in their turn may spread the disease. A midwife, || with a syphilitic lesion upon her finger of which she was aware, communicated the disease directly and indirectly to forty-five persons. She was cojivieted and sentenced to twelve months' hard labor. Chancre is not infrequently transmitted in kissing, a little mucous patch in the mouth of one * Vol. xxvii, p. 421. f "Lond. Hosp. Reports," vol. ii, p. 154. X "Archives of Dermatology," January, 1877, p. 106. * Op. cit., p. 64. II "Brit. Med. Journ.," February 17, 1883, p. 335. 51G SYPHILIS. party poisoning anv fissnro on tiie lips of the other with which it may come in contact. Both of these methods are immediate. Chiklren acijuire chancre of the lips from nursing-women with mu- cous patches of the nipple, and, on the other hand, healthy nurses get chancre of the nipple by suckling children with inherited S3'philis who have mucous patches of the lips. In this way nurses have been ac- cused of giving syphilis to their nurslings, when the truth was that they (the nurses) received the disease from the children. Colles's law, that a child with mucous patches of the mouth can not produce ulcer- ation of the nipple if it sucks its mother, depends sim])ly upon the fact that its mother already has syphilis before tlie child is born, and consequently can not get a new chancre of the nipple. Many interesting examples of mediate contagion have been re- corded. Puche speaks of a gentleman with a long prepuce, who, after marriage, encountered an old mistress, with whom he had intercourse. Returning home shortly, without having washed, he repeated sexual intercourse with his wife, depositing the virus from his prepuce in her vagina, lie escaped, but, in due course, she developed chancre and general syphilis. A similar authentic instance is related of a woman who proved un- faithful. Her husband, embracing her shortly afterward, relieved her of tlie poison left in her vagina by her lover, himself developed chancre, while she escaped. Smokers of a pipe sometimes get chancre of the lips, the virus being deposited upon the mouth-piece of the pipe by some previous smoker who had mucous patches of the lip. Toys may communicate the dis- ease to a child; tooth-brushes, even cigars, to an adult. These and many other objects have been the recorded means of mediate contagion. Glass-blowers get syphilis in the same manner, as they work in sets of three at tlie same tube, passing it from month to mouth. Syphilis sometimes runs through a whole family, from the use of the same spoons or cups, passed from one mouth to another. Washer-women become infected in cracks of the fingers through the virus contained upon soiled clothes. Wet-cups * once started an endemo-epidemic of syphilis. Transplanting teeth has proved another source of mediate contagion, catheterization of the Eustachian tube has done the same. Hardy f records that in 1876 an ear specialist in Paris inoculated thirty to forty persons with a Eustachian catheter. He (Hardy) had treated five of these. The disease has been communicated by the operation of circumcision, with instruments which were infected with syphilitic virus, and, in the religious rite, possibly though not prob- ably, by the act of sucking the wound. J Vaccination is a familiar in- * Rollct, p. 620. + -' Gaz. dcs n6p.," September 10, 181S, p. 833. X K. W. Taylor has written an excellent essay on tbis subject, " N. Y. Med. Jour.," December, 1873. DURATION OF CHANCRE. 517 stance of mcclicite contagion. In ull sucli cases chancre precedes the development of general syphilis. Duration of Syptiilitio Chancre. — The duration of sypliilitic chancre is from two weeks to several months. In about fifty per cent, of the cases a general syphilitic eruption appears before the chancre has cicatrized. A chancre once healed occasionally rcindurates and renlcerates. Number. — Syphilitic chancre is most often unique, because com- monly only one point is inoculated. It may be multiple to any extent, according to the number of points deprived of epithelium and capable of absorption which are primarily exposed to infection.* When mul- tiple, however, it is usually so from the first and not consecutively, like chancroid, because its secretion is not auto-inoculable. Size. — Syphilitic chancre may occasionally reach a large size, as large as a quarter or half dollar. This is, however, exceedingly rare ; commonly it does not grow to the size of a nickel penny ; it is often as small as a split pea and sometimes smaller. In size and general appearance it compares unfavorably with its more formidable-looking rival, chancroid. Situation. — Syphilitic chancre occurs indifferently on all points of the body. No regions are exempt from it, or even less liable, as is the case with chancroid. Syphilitic chancres of the head, face, and breast are not very uncommon. They reach their full size and devel- opment. Indeed, chancre of the lip is particularly prominent, large, hard (spherical), and chronic in its course. The genitals, of course, furnish the favorite seat, but simply because they are most often exposed. The favorite position on the penis seems to be the mucous layer of the prepuce, often just behind the corona glandis. Urethral chancre is not very uncommon. A well-marked case is reported in the " American Journal of Syphilography and Dermatolology," f of a patient who was treated for gonorrhoea, his symptoms being creamy dis- charge from the urethra, with pain on urination. After a while he developed a general syphilitic eruption, and enlarged, indolent, painless ganglia were felt in the groins. An endoscopic tube was now intro- duced, and detected on the roof of the urethra, one and a quarter inch from the meatus, the chancre, as a slight oval ulceration, not yet healed. There was no lumpiness around the urethra, no painful spot on erection, no blood in the urethral discharge, but undoubtedly the case was one of urethral chancre ; for gonorrhoea does not produce ulceration of the urethra. The endoscopic tube introduced long after- * During the past year a gentleman under the author's care acquired syphilis through multiple points of contagion, and had eight simultaneous chancres, all of about four weeks' incubation. I have seen another case of multiple chancre on the nipple, eight on one side, four on the other. Fournier has a case of seven on one nipple, sixteen on the other. f 18V1, page 3Y— Keyes. 51S SYPHILIS. ward disclosed a faint whitened cicatrix, marking the position of the old ulcer on the roof of the canal. These appearances were veriiied by several gentlemen. Another (unpublished) case has been observed by the author. Chancre of the skin around the genitals and anus is not very uncommon. In the female, vaginal chancre seems to be rare. Fournier, out of 249, saw only one in the vagina. Binet, * in 128 of the female genitals, found only two in the vagina, and states that no others have reported the lesion save himself and Fournier. Cervical chancre is not uncomnn)n. liusamon f saw thirteen in 1,374 venereal sores upon and about the genitals of prostitutes in Moscow. Chancre in the mouth occurs notably upon the tonsil. J Form of Syphilitic Chancre. — Syphilitic chancre appears after an incubation of not less than ten da3's, usually not till the end of three weeks, as a reddened spot, which quickly excoriates ; or as an elevated solid papule, which excoriates or ulcerates. It may take any one of four forms, in the following order of frequency : (1) Erosion ; (2) Ulceration ; (3) Deep ulceration, funnel-shaped (Huntcriau chancre) ; (4) Indurated papule, which remains dvj. Other varieties, such as the herpetiform chancre of Dubuc, the mucous tubercle of the skin, the small silvery spot looking like lichen planus (Taylor *), the ulcerated fissure at the nipple, the diphtheroid chancre (Morrow, || Taylor), are all exceptions so rare that tlicy do not call for classification — their simjile mention identifies them. (1) Erosion. — This form is believed to include two thirds of all syphilitic chancres. Bassereau put it at three quarters. Its favorite seat is mucous membrane. It is very common inside of the prepuce. It is oval or a little irregular in shape, with a polished, raw-looking sur- face of a vinous red, sometimes very dark from extravasation of blood or from jDigmentation, or of a more subdued gray color ; occasionally there is a central adherent pultaceous membrane (Clcrc), but usually the only discharge is a sanious serum, and that scanty ; no pus being visible whatever. This is indeed an erosion, and not an ulcer. The induration of this form is most often parchment-like, as if the erosion reposed upon a thin sheet of parchment slipped beneath it. The in- duration is sometimes central, occasionally annular. These erosions are flat. Sometimes an erosion may cap an enormous induration as large as a marble, as on the lip, and not be attended by an a}ipreciable discharge of pus. The surface of these elevated, indurated erosions * " La France Med.," 1881, p. 38. f " Vicrteljahreschrift fiir Derm. u. Sypli.," vii, 1880, p. 517. X R. W. Taylor, "N. Y. Med. Jour.," May 24, 1884, p. 577. « " Medical News," September 8, 1883, p. 277. I! " Venereal Memoranda," New York, 1886. FORM OF CHANCRE. 519 sometimes granulates, becoming papular. Large flat erosions may occupy the skin, but they usually scab. (2) Ulceration. — Superficial ulceration with slanting edges is found with parchment, but more commonly with the split-pea, induration. The ulcer may be quite superficial if the induration stand out x>romi- neutly, or the induration itself may be excavated, when the ulcer will be deep. The base is often grayish, discharging a slight amount of sero-purulent fluid. (3) Hunterian Chancre. — This form is less common than either of the above, but is actually an advanced condition of the last variety. The induration is often extensive, far overreaching the edges of the ulcer, which latter seems to have eaten down into it. The induration is the specific, cartilaginous, elastic, woody induration of syphilis. The ulcer has sloping, adherent edges, never undermined, not the abrupt borders of chancroid, and. the funnel-shaped appearance of the ulceration is not found in any other variety of sore. The shape is rounded or oval. The discharge is similar to that of the last-described ulcer. (4) Indurated papule loliicli does not ulcerate is found sometimes on the skin after inoculation, natural or artificial, and occasionally on the penis, even on the mucous layer of the prepuce in patients whose prepuce is loose, short, and dry. These indurated tubercles would undoubtedly excoriate or ulcerate if kept moist, and in fact the elevated excoriated chancre often remains for weeks as an induration before the surface erosion apj)ears. Indurated pajpules of the skin, which do not erode or ulcerate, scale off after a time, or become covered with a scaly crust. The color of these papules is a dark vinous red. Under any of the above forms may uncomplicated syphilitic chancre api3ear. The course is about the same in all. They rarely heal within two weeks, and often last for months. There is rarely more than one of them, and, if two or more coexist, they are usually of the same type. The induration, which generally may be found from the first, occa- sionally does not appear until after some days. It may disa23pear within a fortnight, but usually outlasts the sore, even remaining behind in the cicatrix. Chancre uninflamed and unirritated is painless. The symptoms of urethral chancre, which can not be seen, are usually a discharge coming on long after suspicious connection, gener- ally thin, often bloody, a painful spot along the urethra during erec- tion, and a lumpiness felt through the skin ; but all these signs are sometimes lacking except the discharge, and even tliis may be quite creamy. The endoscopic tube may be used in certain cases, making an absolute diagnosis of ulcer, and the condition of the inguinal glands goes largely to clear up its nature. Urethral chancre is more often situated just within the meatus, and may be seen by separating the lips of the latter. 520 SYPHILIS. Course of Chaistcre. — Syphilitic chancre progresses slowly, reach- ing its lieight in a few days or weeks, and then, wilii or Avithout a stationary period, repair begins by a change in color of the sore, which beconies more rosy, the induration often simultaneously commencing to abate. Thicker pus forms u])on the ulcer, and it goes on to cica- trization from the edges. The poison of the secretion remains to the end. COMPLICATIONS. The complications of S3'philitic chancre are : (a) vegetations ; (b) inflammation ; (c) chancroid (mixed chancre) ; (d) transformation into mucous patch ; (c) phagedena and gangrene ; (/) syi)hilitic bubo, which is indeed not a complication, but a necessary accompaniment of syphi- litic chancre ; (r/) lymphangitis. («) Vegetations. — AVarty growths are liable to spring up around syphilitic chancre of the prepuce or anus, as they are with other forms of irritative disease (chancroid, balanitis, gonorrhoea). These arc rare and purely accidental. Syphilis as a poison has nothing to do with their production. (b) IxFLAMMATiox may complicate syphilitic chancre, from posi- tion, meclianical or chemical irritation, etc., occasioning pain, and a more purulent discharge, which latter may be auto-inoculable, produc- ing an abortive pustule, or a small, transient ulcer, and liable to lead to the further complication of suppurating bubo, {c) Chaxcroid may complicate syphilitic chancre, the two sores existing together side by side, each with its own peculiar characters, or the same spot may have been simultaneously or successively inocu- lated by the two poisons, giving rise to what is known as ''mixed chancre,"' a sore which possesses the characters and qualities of both of these lesions. The two poisons are distinct, and run their own course, each unmodilied by the other, but, if both develop upon the same spot, the character of the lesion is altered, and it becomes a mixed sore. When a syphilitic chancre is inoculated with chancroid pus, the ulceration rapidly deepens and progresses, putting on all the characters of chancroid; but the syphilitic induration remains. On the other hand, when a chancroid is inoculated with syphilitic virus, the ulcer is unmodified, but, after a proper incubation, syphilitic in- duration sets in. These facts, which have been proved experiment- ally, have been also verified clinically by confrontation. If a given abrasion be inoculated with both poisons in sexual intercourse, the chancroid develops first, and, for a time, nothing but a chancroid ex- ists, furnishing auto-inoculable and hetero-inoculable pus producing chancroid only, and not syphilis. After a certain variable incubation, however, the soft sore indurates spontaneously, and then the chancre is mixed, capable of imparting chancroid alone by contact, since the COMPLICATIONS OF CHANCRE. 521 chancroid poison is more virulent, more contagious, than the syplii- litic ; or mixed chancre, followed by general syphilis. Finally, if the period of incubation of the syphilitic virus happens to be very long, the chancroid may get well, or be cured by cauterization, but in due time the syphilitic chancre appears upon the same spot, and then hetero- inoculation will produce only the syphilitic chancre, with its inevitable accompaniment, general syphilis. The literature of experimental syphi- lis furnishes some very striking examples of mixed chancre. The fol- lowing two are particularly instructive : Melchior Robert inoculated a student with the secretion of a mixed chancre. A classical chancroid followed, the pus of which proved auto-inoculable. After the ulcer, the result of inoculation with the mixed poison, had nearly healed, induration set in, the sore reulcerated, and general syphilis followed. Lindwiirm had a female patient with multiiDle chancroid. Upon one of these only he inoculated the secretion of a syphilitic chancre. ISTo change occurred. The patient got nearly well, and left the hos- pital, but eight days afterward she returned ; the ulcer which had been inoculated had broken out afresh, and had indurated. This sore remained open, while all the other chancroids got well and remained well. General syphilis followed. Mixed chancre, then, is a reality, and does exist clinically. Hence the rule : Wherever the secretion of an ulcer possessed of specific in- duration, and followed by syphilis, produces by auto-inoculation a characteristic chancroid ulcer, itself auto-inoculable, such indurated ulcer is invariably a mixed chancre. Mixed chancre is liable to all the complications which may affect either form of ulcer, even virulent bubo. The methods of acquiring mixed chancre clinically are self-evident. Both poisons may enter simultaneously through the same abrasion. An individual with either variety of sore may inoculate himself, dur- ing sexual intercourse, upon the same spot with the other virus. {d) Teansfoemation- iistto Mucous Patch. — A chancre, which has lasted until the period for secondary manifestations has come on, may granulate upon its surface, retain or lose its induration, become covered with a whitish pellicle, and, in short, change into a mucous patch. This change has been critically studied by Eicord, Fournier, Deville, Devasse, and others. It is most often observed upon women and children, and particularly upon thin skin and mucous membrane where there is continual moisture, a circumstance greatly favoring the change. (e) Phagedejsta and G-angeeke. — Phagedena, already studied in connection with chancroid, may also, though more rarely, compli- cate true syphilitic chancre. The form most usually seen is the gan- grenous. The gangrene may involve all the induration, in which case the latter ceases to be perceptible. The iDultaceous and serpiginous 522 SYPHILIS. varieties of pliagedena are very rarely found with pure syphilitic chan- cre. Their existence, especially the latter, •which is most uncommon, makes it probable that the chancre was originally of the mixed vari- ety. Sometimes the ulceration outstrips the induration, in which case the latter disappears ; rarely both advance together. In four hundred and fourteen cases of syphilitic chancre, Bassereau found l^hagedena in sixt}'. In ninety-eight cases, Fournier found eleven of phagedena. A healing chancre may reulcerate and then become phagedenic. Bassercau, Diday, and others believe that, when syphi- litic chancre is i)hagedenic, the tyi^e of the general syphilis which fol- lows is severe. For diagnosis of syphilitic chancre, see Diagxostic Table. Fro(/no^is. — If the chancre is syphilitic, so also is the patient. For (/) syphilitic bubo, and (g) lym})hangitis, see below. Treat meni of Sijpliililic Chancre. — No amount of cauterization nor any local treatment can prevent the development of general syphilis after the poison has once been absorbed, much less after the chancre has appeared. Cauterization often hastens the healing, but indura- tion is liable to reap^Dear and to reulcerate, and nothing is gained to compensate for the pain of the ojieration. General syphilis is inevita- ble. At the present day the plan of treatment recently revived by Auspitz* (who reported thirty-three cases), of excision of the jirimary lesion, has had a few ardent advocates, and a fair trial at the hands of many operators. It had been tried before and given up. Meyer, in 1840, Hueter,t in 18G7, advocated it; Ulrich, Coulson, Langenbeck, Thiry, Vogt tried it, deciding some for, some against, its efficacy. In 1882 P. A. Morrow + wrote a full resume of the 220 cases then re- ported from all sources, with sixty alleged cures, and decided against the treatment from the mere standpoint of weight of evidence. Since that time much has been written, but the weigiit of evidence has been steadily accumulating against the value of the measure, until now at this date, though still practiced considerably in Germany, it has been abandoned by the profession of the world at large. I have treated a number of patients from whom chancre had been excised at the hands of others. I have found the cases both light and severe, as the ordinary run is in those who have let their chancres alone. I do not believe the excision of the primary lesion has the least possible modifying effect upon the development of subsequent syphilis, or in any way moderates its intensity. I have offered excision as a tentative experi- ment to many, but, as I could not promise any benefit, my offer was always declined, except in one instance already published.** This was * " Vrtljahresschrift f. Derm. n. Syph.," 1877, i and ii, p. lOL t "Bed. klin. AYochcnschrift," No. 27, 1867. X "Jour, of Cutaneous and Venereal Diseases." vol. i, Xo. 3, December, 1882, p. 65. * "New York Medical Journal," April 25, 1885, p. 404. SYPHILITIC BUBO. 523 a physician who came with a small dry pimple on the back of his penis which had been present less than twenty-four hours. I cut it out cleanly with considerable surrounding tissue. It healed promptly and never reappeared, nor did the scar indurate, yet the patient liad a very sharp papular syphilide at the regular time, in no way moderated by his attempted abortive treatment. The best local treatment consists in the use of dry lint, or any mild astringent lotion, or, perhaps better, sprinkling with iodoform, or calomel, or the use of black or yellow wash. The sore is not pain- ful, and will leave less of a scar if unmolested than if irritated and inflamed. Mixed sore is better cauterized to destroy the chancroidal vii'us, and the local treatment of phagedena is the same as already set down for that complication attacking chancroid. There is one im- portant difference, however, namely, that the phagedena attacking syphilitic chancre may be kept up by the general debilitating influence of syphilis u]3on the patient's vitality, and consequently, in these cases only, the antidote to that influence, mercury, given internally, has, a favorable effect in retarding the progress of phagedena. Internal treatment of syphilitic chancre is the same as that of early syphilis, and treatment should be commenced in all cases when the diagnosis is undoubted. It has a marked beneficial effect upon the duration of the chancre. Where there is the least shadow of a doubt, no mercury should on any account he administered until an eruption has cleared up the diagnosis. (/) Syphilitic Bubo. — The term "syphilitic bubo" has been ap- plied to the indolent enlargement and induration of those lymphatic glands receiving the absorbents from a syphilitic chancre, not to the other glandular enlargements occurring in the course of syphilis. Syphilitic bubo consequently may occur in many different situations, according to the position of the chancre. It is usually found in the groin, because syphilitic chancre more often occurs on or around the genitals than elsewhere. Thus the inguinal glands are affected in chancre of the penis, urethra, groin, lower part of abdomen, scrotum, thighs, perinasum, buttocks, anus, or rectum ; the submaxillary in chancre of the lips or mouth, the preaural in chancre of the face. In like manner the sub-hyoid, post-cervical, axillary, epitrochlear, or other gland, may be the seat of syphilitic bubo. With syphilitic chancre of the genitals, the cluster of glands in the groin becomes enlarged and indurated, not a single gland but a group, which group, since Ricord, has become classical under the name of "pleiad." The pleiad consists of one gland larger than the rest, with one or two or half a dozen smaller glands, nearly all equally indurated on either side. The indu- ration in some cases is not very strongly marked. The glands rarely become very large, varying from the size of a pea to that of a marble, and they retain their round or oval shape. They are freely movable 524 SYPHILIS. under the skin, nsnally each distinct from the others. There is rarely any pain even on pressure, thou^jh slij2:ht tenderness may exist at first. This pleiad of indolent indurated glands may be (direct) unilateral, on the same side with the chancre or crossed, or (usually) bilateral, the glands on the same side with the chancre being most markedly affected. This induration of the glands exactly reseniljles, in its woody, ivory- like feel, the induration of the chancre, but in some cases is more soft and elastic, like cartilage or India-rubber. The induration appears during the second week of the existence of chancre. Fournicr records, as unique, a case in which the induration of the ganglia was not de- tected until the twentj'-sevcnth day after the appearance of chancre. Sometimes instead of the usual pleiad there is but a single indurated gland, perhaps as large as a nut. Another variation is the develop- ment of a single enormous syphilitic bubo, as large as an og:g, on one or both sides. These were found by Bassereau on dissection to con- sist of an agglomeration of many separate glands matted together by large indurated lymphatic cords, and tough, thickened layers of con- nective tissue. Occasionally a hardened lynii)hatic trunk may be traced from the induration of the chancre to the indurated glands. In strumous subjects the glands are apt to be very large, and to be due to strumous degeneration as well as specific induration. Submaxillary and axillary syphilitic bubo often consists of one very large, hard gland. The glands constituting syphilitic bubo usually reach their full development in from one to three weeks. They then remain stationary for several Aveeks or months, occasionally for over a year. They are habitually present when the first general erujitions appear, and may at this time undergo a sudden increase in size and induration. Sometimes, on the contrary, without known cause, the glands speedily return to their natural size, and all induration dis- appears. Suppuration of syphilitic bubo takes place so rarely that it may be said practically never to occur. But the syphilitic as well as the healthy gland is subject to inflammation from injury, friction, or from inflammation of the chancre, and then suppuration may come on. Strumous glands also may degenerate, mat together, and slowly sup- purate. AVhen a syphilitic bubo suppurates, its pus is never auto- inoculable. "With suppuration, there is of course pain in the affected gland. With " mixed chancre," suppurating bubo is not uncommon, and even virulent bubo may occur. Fournicr thinks that pus once formed in a syphilitic bubo is more capable of absorption than in any other form of bubo. Syphilitic bubo bears no relation to the number or size of the chancres. Large buboes often become adherent to the skin. In three hundred and sixty-eight cases of syphilitic bubo, Basse- reau saw suppuration in five per cent. Syphilitic bubo is so constant an accompaniment of syphilitic chancre that practically it may be SYPHILITIC LYMPHANGITIS. 525 said to occur invariably. Fournier, in analyzing two hundred and sixty-five cases of sypliilitic chancre, found ganglionic induration absent in five. Two of the individuals were very fat, and possiljly the ganglia existed, but could not be found. The causes of the absence of induration in the glands are believed to be occasionally phagedena of the chancre (Fournier), or the excessive smallness of the lymphatic glands in some fat people (Ricord) ; finally, in those rare cases where indurated chancre occurs a second time in patients who have had syphilis, the glands may not indurate. Syphilitic, spontaneous bubo {bubon (TembUe) does not exist. For diagnosis of syphilitic biibo, see Diagnostic Table. Treatment. — The treatment of syphilitic buboes is that of early syphilis, but treatment has indeed little or no effect upon them, as they often persist long after the early cutaneous eruption has disap- peared under treatment. Inflammation and strumous complications are to be met appropriately. {g) Syphilitic Lymphangitis is a specific induration of the lymph-vessels and surrounding cellular tissue. Hard, smooth, and knotty cords are percejjtible under the skin of the penis, feeling like the vas deferens, varying from the size of a knitting-needle to that of a goose-quill. They are insensitive to pressure, and the skin over them is not red. Starting in the induration of the chancre, they often do not reach to the root of the jDcnis, but may extend to the ganglia. Sometimes, but rarely, the surrounding induration includes the blood- vessels. There may be one or more of these cords on one or both sides of the penis. Lymphangitis, when present, generally precedes adenitis, coming on shortly after the induration of the chancre. It melts aivay usually during the disappearance of chancrous induration, lasting from three weeks to six months, and more. Earely inflammation or suppu- ration may occur, but the pus is never auto-inoculable. If the chan- cre be mixed, so may be the lymphangitis. Eollet states that syphi- litic lymphangitis occurs in about twenty per cent of cases. Xo spe- cial treatment is necessary, except what may be required for inflam- matory complications. 52(3 SYPUILIS. CHAPTER ly. SYPHILIS. Diagnostic Tabic of Sypliilitic Cliancrc. Chancroid, Herpes, and Ulcerated Abrasion.— Of Syphilitic Bubo and the Bubo of Chancroid.— Of Syphilitic Lymphangitis, and tlie I,ynii)linngiiis of Chan- croid.— General Syphilis.— Secondary, Tertiary, :Malignant, Irregular, and Intenncdiary Syph- ilides.— Prognosis of Syphilis.— Duration.— lulUience of Gout and Scrofula upon the Course of Syphilis.— The Ten General Characteristics of Syphilides.- Concomitant Symptoms of Sec- ondary Syphilis.— Secondary Incubation, Syphilitic Fever, Alopecia, Indolent Glandular En- gorgement, Sore Throat, Analgesia. The following table is intended to serve as a summary of the broad, classical characteristics of syphilitic chancre and chancroid, with their accompanying buboes, as well as for the differential diagnosis of syphi- litic chancre, chancroid, herpes, and ulcerated abrasions ; of the bubo of chancroid, and that of syphilis ; and of the different forms of lymphangitis. Ulcerated {Balaniiic or other) Abrasion. Syphilitic Chancre. 1. Nature. — Al- ways a constitutional affection. 2. Cause. — Sexu- al intercourse with a patient suffering from syphilitic chan- cre, or some second- ary syphilitic lesion of or near the geni- tals, vaccination with syphilitic blood, ac- cidental or designed inoculation of any vehicle containing the syphilitic virus upon an abrasion of any portion of any tegumentary expan- sion. 3. Situation. — Usually upon or near the genitals, not very infrequent on the head, hands, or nip- ple. 4. Incubation. — Constant, not less CJiancroid. Always a local disease. 2. Sexual inter- course with a patient suffering from chan- croid of or near the genitals ; accidental or designed inocula- tion with the secre- tion of chancroid, or that of virulent bu- bo. Herpes. 1 . Sometimes a local disease, some- times a neurosis. 2. Mechanical ir- ritation, friction, as in sexual intercourse ; chemical irritation, as of acrid dis- charges. As a se- quence of cold, fever, or as an essential neurosis. 1. Always local. 2. All of the causes mentioned for herpes, except the last three. 3. Very rarely encountered except on or around the genitals. 4. None after ab- sorption of the poi- 3. Of very fre- quent occurrence up- on the genitals. 4. None. 3. Same. 4. None. DIAGNOSTIC TABLE. 527 Syphililic Chancre. than ten days, usu- ally three weeks. 5. Commencement. — Begins as an ero- sion or a papule, and remains an ero- sion or ulcerates. 6. Number. — Usu- ally unique or simul- taneously multiple ; never multiple by successive auto-inoc- ulation ; never con- fluent. v. Physiognom>/. — (a) Shape : round, oval, or symmetri- cally irregular. (h) Lesion is ha- bitually flat, capped by erosion or super- ficial ulceration ; or scooped out ; or deep, funnel-shaped ulcer, with sloping edges. Sometimes the pap- ule is dry and scaly. (e) Edges : slop- ing and adherent, sometimes promi- nently elevated. {d) Bottom : smooth, shining. (e) Color: somber, darkish red, gray, Chancroid. son. Ulcer usually fully formed on the second or third day ; very rarely com- mences later than the seventh. 5. Begins as a pustule or ulcer, and invaiiably remains as an ulcer. 6. Usually mul- tiple, both simulta- neously and by suc- cessive auto-inocula- tion ; often conflu- ent. Y. («) Shape : round, oval, or un- symmetrically irreg- ular, with border de- scribed by segments of large circles. (5) Always true ulcer, excavated, hol- lowed out. Herpes. Ulcerated (Jialanitie or other) AOrcmion, (c) Edges : sharp- ly cut, abrupt, often undermined. (d) Bottom : un- even, warty, irregu- lar, without luster. (e) Color : yel- low, tawny, false- 5. Begins as a group of vesicles, rarely as a single vesicle, and remains as an ulcer. 6. Generally mul- tiple, simultaneously and by successive crops of vesicles ; sometimes confluent. V. (a) Shape : irreg- ularly rounded, with borders described by segments of small circles left by the different vesicles. (6) Ulcer usually superficial ; some- times in solitary her- pes there is but one vesicle, and the ul- cer is absolutely cir- cular (Fournier) ; in this case there are no neighboring patches of vesicles to clear up diagnosis. The base and general physiognomy of her- petic ulceration are, in other respects, similar to those of chancroid, but of less virulent aspect. 5. Begins as an abrasion or fissure, and remains as an ulceration. 6. Generally mul- tiple and confluent. 7. Irregular, of any shape, otherwise resembling superfi- cial chancroid ulcer. 528 SYPHILIS. Suphilitie Chancre. or black, lesion some- times livid and scaly, occasionally scabbed. (/) Sei-iction : slight, scro-sanguino- lent, unless irritation provokes infianinia- tion and a supply of pus. 8. History. — Not found on patients who have had syphi- lis previously. Chancroid. membranous - look- ing, sometimes bright. (/) Secretion: abundant and puru- lent. S. Found indifTer- cntly upon all. Herpes. Ulcerated {Balanitic or other) Abrasion. 9. Inocuhhility. — Not auto - inocu- lable without great difiBculty, unless irri- tated, and secrctiug thick pus. 9. Readily auto- iuoculablo, produc- ing characteristic chancroid ulcer by the third day. Course. — 10. Rapidly pro- progressive, gressive, cicatriza- 10. Slowly cicatrization slow. 11. Srnsihilifl/.— Rarely painful. 12. Induration. — Constant, parchment- like, and very faint, or cartilaginous and extensive, terminat- ing abrupth', not shading off into parts around, almost in- sensitive to pressure, movable upon parts beneath the skin, and not adherent to the tion slow. 11. Often pain- ful. 12. Absent in typical cases. An induration may be caused by irrit.ints or by inflammation. It is boggy, not clas- tic, sensitive to press- ure, shades off into surrounding tissues, is adherent to parts around, disappears promptly on healing 8. Found by pref- erence ui)on patients with long prepuce and tender balano- prcputial mucous membrane, often showing marked ten- dency to return monthly, fortnightly, or at irregular inter- vals after lack of cleanliness, a ca- rouse, or unusual sexual intercourse. 9. Sometimes au- to - iuoculable wiih great difficulty, when secreting thick pus, producing abortive pustule, not charac- teristic chancroid ul- cer. 10. Docs not usu- ally tend to get much larger than the size at which it started; limitation and cica- trization rapid. 11. Stinging heat at commencement. 12. Inflammatory induration, capable of being produced by the same causes as in chancroid, and be- having in a precise- ly similar manner. 8. Found indiffer- ently upon all on the action of efficient causes. Most com- mon on patients with long, tight prepuce, who are not cleanly in their habits. 9. Same. 10. Same. 11. Usually pain- ful. 12. Same. DIAGNOSTIC TABLE. 529 Syphilitic Chancre. latter. Induration may disappear in a few days, usually out- lasts the sore, and may remain for years in the cicatrix. 13. Transmission to Animals. — Not transmissible. 14. Phagedena. — May occur rarely. 15. Bubo. — Syplii- litic bubo constant. 16. Lymphangitis. — Syphilitic lym- phangitis possible. lY. Prognosis. — For local conse- quences good, but syphilis follows. 1 8. Treatment. — Local treatment but slightly effective. Chancroid. of the sore, or before that time. 13. Transmissible with difficulty. 14. Much more common. 15. In about two thirds of cases glands are unaffected, in the other third inflamma- tory or virulent bubo occurs. 16. Inflammatory or virulent lymphan- gitis possible. 17. For local con- sequences more se- rious ; no after-effect. 18. Local treat- ment curative. Herpes. Ulcerated [Balanilic or other) Abrasion. Syphilitic Bubo. 1. Nature. — It is a specific affection, with peculiar characteristics. 2. Frequency. — It is a constant symp- tom attending syphilitic chancre. 3. Number of Glands involved. — In those regions where multiple glands are found, it is generally poly-ganglionic ; these may be unilateral or bilateral in the groin, rarely matted together into one large mass, but, when so, the latter retains the characters of indolence, etc. 4. Date of Appearance. — It develops during the first or second week of syphilitic chancre. 5. Size. — The glands are usually only slightly enlarged. 6. Induration. — The glands are specifi- cally indurated, feeling like cartilage or wood. 7. Evidence of Inflammation. — None; the glands are freely movable among the 34 13. Not transmis- 13. Not transmis- sible, sible. 14. Very rare, if 14. Same, at all possible. 15. Glands are 15. Same, very rarely involved. Inflammatory bubo may occur, virulent bubo is impossible. 16. Inflammatory 16. Same, lymphangitis alone possible. 17. Good in all re- 17. Same. spects. 18. Same. 18. Same. Bubo of Chancroid, 1. It may be simple (inflammatory), such as might attend any inflammatory lesion, or virulent. 2. It is a complication occurring about once in three cases. 3. Usually consists of a single gland in any region of the body. In the groin it may be bilateral. It is never a group of small, movable glands. 4. There is no fixed period of appear- ance. 5. The gland is greatly enlarged. 6. No hardness except inflammatory. *!. Every appearance of inflammation. The gland becomes fixed (peri-adenitis), the 530 SYPHILIS. Swphiliiic Bubo. tissue. The skin is neither adherent nor rcJ, nor is there any pain. The most prominent feature of the swelling is its in- dolence, 8. Termination always in resolution, ex- cept in occasional cases, where, from sim- ple inflammation or strumous degeneration, suppuration ensues. 9. Auto-Inoculahiliti/. — In cases of sup- puration the pus is not auto-inoculable. The abscess docs not become a chancre, or a chancroid ulcer. It docs not extend, and never becomes phagedenic. 10. Kahiral duration is a few weeks or months. 11. Proffnos^is good as far as local re- sults are concerned, but the patient invari- ably has syphilis. 12. Locaf treatment inefPective, except for complications ; general treatment of doubt- ful efficacy, but sometimes serviceable. Syphilitic Lymphangitis. 1. Occurs only in case of syphilis, and has peculiar characters. 2. Feels hard, like the vas deferens, of the size of a knitting-needle, or of a goose- quill ; no pain on erection or on handling. 3. Skin uncolored. 4. Termination by gradual resolution. Very rarely there is suppuration ; but, in such cases, the pus discharged is not auto- inoculable. 6. Treatment unnecessary, and of little effect, except in case of inflammatory com- plication. Bubo of Chancroid, skin adherent, the part feels hot, there is pain, the skin reddens, the prominent feat- ures are those of inflannnation. 8. Teriiiinatiou occasionally by resolu- tion, usually by su]ipunition. Viiulent bubo invariably suppurates, and becomes an open chancroid ulcer. 9. When the bubo is inflammatory, the pus is not auto-inoculable ; where it is viru- lent, the pus is invariably readily auto-in- oculable. Such an abscess becomes a true chancroid, and may extend or become pha- gedenic. 10. Natural duration is a few weeks, or many months, as a chancroid ; possibly years, if it becomes phagedenic. 11. Prognosis good for Inflammatory, less so for virulent bubo, esi)ecia]ly if it becomes phagedenic, in neither case docs syphilis follow. 12. Local treatment useful and necessary to avert suppuration, cure chancroid left by virulent bubo, and lessen complications. Mercury harmful. Antisyphilitic treatment absolutely useless. Lymphangitis of Chanci-oid. 1. Exists as simple inflammatory lym- phangitis, or in virulent form ; the former liable to complicate any inflammatory affec- tion, the latter found only with chancroid. 2. Some inflammatory hardness. Pain on erection and on handling. 3. Skin red over inflamed vessel. 4. Termination by resolution or suppu- ration. Virulent lymphangitis invariably suppurates, in which case the pus discharged is auto-inoculable, and the openings become chancroids. 5. Local treatment advisable to quiet pain, avert suppuration, or limit extent and severity of chancroids left behind by the suppuration of virulent lymphangitis. GENERAL SYPHILIS. Usage has adopted the name "primary syphilis" for the syphilitic chancre and its accompanying adenitis and lymphangitis. These manifestations, although the expression of constitutional poisoning, GENERAL SYPUILIS. 531 are never themselves general, but always strictly local. A chancre never does nor can appear elsewhere than at that point through which the poison first entered the body, llcncc inherited syphilis has no primary stage, but is general from the start. The adenitis constituting syphilitic bubo invariably affects the gland or glands in direct com- munication with the lymphatic trunks coming from the chancre ; the other lymphatic glands of the body, which may become indolently en- larged, do so only after the second period of incubation. The latter do not belong to the primary period, but form a part of general syphi- lis. And so of the lymphangitis of primary syphilis, it affects only those vessels passing between the chancre and the syphilitic bubo. Hence primary syphilis, so far as its manifestations go, is purely local. Not so with general syphilis. There is no organ or tissue of the body through which it may not manifest its presence by symptoms, or uj)on which it may not exercise its power. The lymphatic glands all over the body may suffer, some habitually more than others. The skin from crown to sole, the nails, the hair (the teeth in inherited dis- ease), and the mucous membranes, especially around the natural ori- fices, have their peculiar affections, due to syphilis. The eye and the testicle do not escape, and each and every viscus is liable to be invaded, as are all the tissues, connective, fibrous, muscular, cartilage, bone, brain, nerve, and vessel. Not only this, but the all-embracing arms of general syphilis include the functions as well, any of which may be disordered by it, and each and all of the special senses may be perverted or destroyed — including the sexual appetite. The symptoms of all the forms of local, special, or general paralysis of motion or sensation may be occasioned by syphilis. Finally, the intellect may succumb. Acute and chronic mania, dementia, lunacy, idiocy, all the above and many more, form a category of symptoms comprehended under the one term general syphilis. General syphilis has been arbitrarily divided into a secondary and tertiary stage. For convenience of descrijotion and treatment, such a division is a good one, and will be retained in this treatise. Secondary sypliilis includes all the earlier affections of the tegu- mentary expansions, cutaneous and mucous, and many of the lighter affections of the eye, testicle, and other glands, with some of the vari- eties of nervous syphilis. Tertiary sypliilis follows secondary, and consists of the later and the ulcerative skin-affections, the deeper lesions of connective tissue, muscle, bone, cartilage, and of the internal organs (visceral syphilis), with the deeper and more serious lesions of the eye, testicle, brain, and all morbid conditions occasioned by what is known as gummy deposit. The line between secondary and tertiary syphilis is not always well marked, and, although in typical cases the lesions become progressively 532 SYPHILIS. deeper, commencing as mere efflorescences in the secondary stage, and gradually increasing in severity to the most extensive ulcerations and destructions of bono and cartilage in the tertiary, yet some of the symptoms naturally belonging to the secondary group, as the mucous patch and scaly eruptions, frequently crop out in the tertiary stage, while more rarely nodes come on with early syphilis, and occasionally most extensive ulcerative or other tertiary (gummy) lesions a])j»car within the first few months after chancre, perhaps all the lighter sec- ondary eruptions liaving been omitted. Til is latter form, where tertiary symptoms come on in place of the secondary, is called '' malignant syphilis." The former variety is known as "irregular syphilis." Inherited and nervous syphilis will be described separately. Certain of the eruptions which occur late in the secondary stage and early in the tertiary have been grouped by Ilardy under the title of "intermediary syphilides." The distinction drawn between sec- ondary, intermediary, and tertiary syphilitic symptoms is nsefiil as a guide to treatment. Mercury, as a rule, is advantageous in propor- tion to the nearness of the symptoms for which it is given to the pri- mary lesion (chancre), while iodine is nearly a specific for the later manifestations. The intermediary symptoms require both medicines combined. Secondary syphilis lasts often a year, sometimes two or more. Tertiary syphilis (except as malignant) does not commence till after the expiration of at least one year from the appearance of chancre. It may never show itself, or may appear after a period of health of many years, often five or ten, sometimes as late as fifty-two (Fournier). There can be no absolute certainty about the dates of syphilis, or about what symptoms will appear. The whole secondary stage may be skipped under treatment, or even without treatment, some late ter- tiary ulceration alone evidencing the fact that the patient had gcncj-al poisoning at all. Syphilides. — The most conspicuous symptoms of general syphilis affect the skin, and are known as syphilides or syphilodermata. The prominent primary lesion characterizing the cutaneous affection gives it its name, and in syphilis most of the confusing epithets of derma- tology may be dispensed with. Thus, if a papule be the prominent lesion, or a vesicle, or a pustule, the affection is not necessarily called a lichen, or eczema, or impetigo, but a "papular," "vesicular," or "pustular syphilide," as the case may be ; adding "general," or "in groups," according to the physical distribution of the lesion. Ulcer- ated syphilides, again, are spoken of as superficial or deep, serpiginous or perforating, making the nomenclature of syphilis exceedingly sim- ple, since the words themselves describe the affection. Prognosis. — As to the character of the general syphilis which is PROGNOSIS. 533 to follow upon a given chancre, the peculiarities of the indiviflual have more to do with it than anything else, excepting, of counse, judicious treatment. Certain authors have advanced that phagedenic syphilitic chancre is followed by severcv syphilis. The condition of the patient allowing him to have phagedena, it is fair to presume, is also such as will cause him to suffer severely from his syphilis; but it docs not necessarily follow, for the cause of the phagedena might have been a local one or one only acting temporarily, and then the succeeding gen- eral syphilis might be mild. Nor indeed does Diday's idea prove trust- worthy, that the length of incubation of the chancre, or the length of secondary incubation, portends the character of the general syphilis which is to follow. There is undoubtedly a measure of truth in this, for, if the quantity or quality of the poison absorbed, or the state of the individual, be such as to allow the first local and general mani- festations of the disease to be long delayed, it is reasonable to suppose that the whole course of the malady will be mild. The same natural inference may be made with some reason in connection with the mild- ness or severity of the chancre. But neither of these rules is reliable. Not infrequently we see cases of protracted, severe, obstinate disease attending a chancre of very long incubation. And the syphilide fol- lowing the chancre which never ulcerates is sometimes more intracta- ble than the same eruption following a large, excavated, ulcerated, primary lesion. Syphilis acquired from a mild case may be severe or mild. The following three cases will tend to demonstrate the fact that individual peculiarity has more to do with the form of syphilis than anything else : In 1865, in the cutaneous wards of St. Louis Hospital, under Prof. Hardy's care, were two cases, man and wife. The man had severe malignant syphilis, with large gummy deposits in his skin ; some of them ulcerating ; all occurring within a few months after chancre. This man had poisoned his wife while he yet carried his chancre. She had a very mild papulo-erythematous syphilide, bearing none of the characters of malignancy. The woman from whom the man acquired his disease was sought out and found. She also was a simple case of ordinary mild syphilis. The ]3oison in these three cases was identical, handed directly from one to the other, but the results were so widely different that it would have been hard to convince a layman of their identity of origin. What the idiosyncrasy is which makes syphilis bad in one case and light in another can not be affirmed. Scrofulous and strongly lymphatic individuals, although a little more prone to suffer from severe suppurative and ulcerative lesions than others, are by no means the only ones who have severe attacks. The most obstinate and long-enduring cases are frequently found in connection with the gouty diathesis, the predominant eruptions in such cases being scaly and tu- bercular, and nervous syphilis being not uncommon. 534 SYPUILIS. Perhaps the best light that can be thrown upon the question of prognosis may be derived, not from the time of ajiitearance, but from the character of the first eruption of the secondary period. If this eruption be scanty and i)urely erytiiematous (roscoUi), or even papular, the case will probably be much more mild than if the earliest eruption were vesicular, or, still worse, })ustular, especially if comi)licated early by iritis. Finally, if extensive tubercular eruptions and ulcerations appear in place of the usual secondary symptoms, the case is one of malignant syphilis, and the j)rognosis becomes grave. There is no just foundation for the opinion which has been advanced, that syphilis acquired from a secondary lesion runs a more severe course than if it were acquired from contact with a chancre. As far as the virulence of the poison is concerned, the converse of the above proposition would theoretically appear more probable, for the secretion of a syphilitic chancre seems more readily inoculablc than that of secondary lesions. Further, it is certain that as the disease advances its transmissibility by inheritance declines. A syphilitic mother will abort in her early preg- nancies, then produce a dead child at or before term ; next a child who may die in a few weeks, with specific eruptions ; then another who may have only mild symptoms of inherited syphilis ; and, finally, in the tertiary stage of the mother, her children may be born healthy, and continue so indefinitely. Youth and strength do not insure a mild attack to a patient with syphilis, nor does age or debility neces- sarily imply a severe one ; on the contrary, old age generally is that period of life most kindly treated by syphilis. Babies with inherited syphilis suffer more than any other class. The malady is often fatal with infants. Next in severity come the cases acquired in early man- hood — from eighteen to twenty-eight. Malignant syphilis has this to be said in its favor, that, although exceptionally severe, when the out- burst is well over the malady often ajipears to have exhausted itself ; and such patients, in my opinion, are less apt to suffer seriously in later life than some of those who have very simple lesions in the earlier part of their malady. Excesses of every sort, of wine, of women, of work, are liable to intensify the type and duration of existing syphilis. Climate also seems to have some influence. Treatment throws confusion into the natural order of appearance of the eruptions, postpones their outbreak, light- ens their character, shortens their duration, and, in the most favorable cases, almost prevents them entirely. All local irritations tend to call out eruptions at the points irri- tated, and to maintain them there. A child born with inherited syphilis may give no evidence of his malady until he is vaccinated, whereupon an eruption may speedily appear, become general, and be attributed to the innocent vaccination. A blister in the same way, even upon an adult, may call out dormant syjihilis. Not infrequently DURATION. 535 a cold, great heat, any excess, a fatigue, an irritating or sulphur bath, friction, electrization, maybe the exciting cause calling dormant syph- ilis into action and occasioning an eruption. Patients who work much with the hands are more liable than others to eruptions of the palms. Perspiration upon overlying portions of skin often intensifies a given eruption at such points, as under the female breast, around the um- bilicus, between the scrotum and the thigh. Lack of cleanliness around the anus and under the prepuce is a powerful predisposing cause to mucous patches, while the use of tobacco chewed or smoked is pro- verbial for its power of originating and maintaining the same lesions in the mouth. A mucous patch of the tongue is often occasioned and indefinitely prolonged in a syphilitic subject by friction of that mem- ber against the rough edge of a tooth, and the suction of a baby on the nipple calls out mucous patches there. Wounds upon a syphilitic sub- ject sometimes provoke the development of a sy]3hilitic outbreak around them ; sometimes they heal kindly as upon a healthy person, some- times they fail to heal, and gradually put on the characters of syphi- litic ulcerations. There is considerable difference of opinion in the profession upon this point. When a bone breaks in a syphilitic sub- ject, even in one with latent syphilis, who has apparently long been well, it may fail to unite unless the patient is pretty thoroughly dosed with the iodide of potassium. A knowledge of all these facts is of great importance in making a general prognosis. Bad hygienic surroundings materially aggravate and prolong syphi- litic manifestations, to such an extent, indeed, as often to render specific treatment absolutely unavailing or even harmful, until the patient is removed from such surroundings. DuKATiois' OF Gejsteral Stphilis. — There is no disease so protean in its form as syphilis. " Age can not wither her, nor custom stale her infinite variety." Syphilis finds expression through every tissue. Its symptoms simulate those of a vast number of other diseases, and some of its forms may be so obscure as to baffle accurate diagnosis without the assistance of the touchstone treatment. So true is this, that it has passed into a proverb among certain of the less well informed of the profession, in face of an obscure disease, " If you do not know what to do, treat the patient for syphilis. " The unscientific looseness of such a course needs no comment ; but the existence of the proverb is the best argument to substantiate the protean type of syphilis. Only minute and careful investigation into the more obscure manifestations of the disease can lead to accuracy of diagnosis, which is of more impor- tance in this than perhaps in any other malady. Hence the difficulty of saying when syphilis has ended, or indeed of deciding that it ever does end, since it so often permanently modifies the diathesis of the 536 SYPHILIS. individual who has suffered from it. Syphilis may occur in so mild a form that the patient may never know he has it ; or, again, with such intensity that extensive lesions of the skin, bone, and other tis- sues, may come on within the lirst year, with i)aralytic symptoms of great extent and severity. Syphilis may manifest itself as a mild eruption after chancre, disappearing possibly without treatment, and then (exceptionally, it is true) lie latent for many years, as long as fifty-two years, to reappear with characters due only to syphilitic dis- ease. In Fournier's case, a gentleman of seventeen had acquired chancre, followed by some secondary eruptions, which were pronounced syphilitic. No further symptoms had appeared until the age of sixty- nine — fifty-two years after the chancre — when he had suffered from syphilitic caries of the upper jaw. At seventy-two he applied to Fournier for a gummy tumor of the thigh, which got rapidly well under the iodide of potassium. Now, in this case, had the patient died at the age of sixty-eight, he might, with seeming justice, have been reported as an instance of cure, for over half a century would have intervened since his last syphilitic symptom. I have a personal case where syphilis was latent for about forty years. This one case gives at a glance the practical answer to the whole question of the duration of syphilis. Every physician of any consider- able experience with syphilis can recall analogous cases, though, per- haps, less striking. Syphilis, once acquired, stamps its impress upon the individuality of the patient, and becomes a part of him, and no power on earth in a given case can say when that impress disappears. A half century may pass away and the trail of the serpent be still visi- ble. This is a fact, and as such must be recognized. It is of vast practical importance, and to shut our eyes to it would be folly. That we do not so shut our eyes, even those of us who believe in an early and radical cure of syphilis, is sufficiently shown by the avidity with which, in doubtful cases of skin or bone disease, the history of the patient is carefully inquired into for a record of pre-existing syi)hilis, which, if found, no matter how distant, makes the diagnosis, establishes the treatment, and often leads to a cure. Yet, in spite of this assertion, who shall say that syphilis may not be cured ? Occasionally cases are seen where syphilitic chancre is acquired a second time, followed by crops of secondary eruptions, and surely in these cases the old syphilis must have been cured, or the new one could not have appeared. Yet in some of these cases tertiary symptoms have been present when the second chancre was acquired, but this again only coincides with the evidence furnished by clinical observation ; namely, that the virulence of syphilis disappears in the late tertiary period ; that during this period neither the blood nor the pathological secretions will infect a healthy subject with the disease, and that such patients may be the parents of perfectly healthy chil- DURATION. 537 dren, who never manifest the faintest sign of syphilitic poisoning. The necessary conclusion, then, is this : that while symptoms wiiich can depend upon no other disease than syphilis may crop out at any period during the life of a patient who has once had syphilitic clian- cre, yet the virulence of the disease and its contagious properties do die away in time, what are left being more properly sequelae in the received acceptation of that term. The above is the possibility of the duration of the effects of syphilis, and must be recognized by every intelligent physician who wishes to accept facts and desires to view syphilis in a practical light. The probability of the disease in most cases, however, is that its manifesta- tions will disappear finally after a few years, and this under intelligent management becomes almost a certainty. Syphilis is no longer the terrible scourge it proved itself in the fifteenth century. It is rarely fatal except in the visceral form, and the majority of patients escape this stage entirely. It is hardly too much to state that, of the two diseases, gonorrhoea and syphilis, the former sends more patients to the tomb than the latter. ISIeither kills directly ; both do so by their sequelae. The classical mode of death as resulting from gonorrhoea is through stricture, to fatal bladder and kidney disease ; 'and whatever the ratio of deaths to attacks may be in the two diseases, it is highly probable that more deaths actually occur from gonorrhcBa as their first cause than from syphilis. Syphilis, again, has the advantage of being a manageable disease. Its symptoms yield to treatment far more readily than do those of any other chronic malady, and it is precisely in that period where the dis- ease is most destructive to tissue and to life, the tertiary stage, that remedies are the most brilliantly effective. Syphilis, as encountered in the higher walks of life, is a mild but terribly lurking and insidious disease. It may escape attention altogether. Many ladies come by it honestly, but never know they have it. Children develop some obscure symptoms, the significance of which escapes not only the parents but also the family physician ; and even a man may get chan- cre, followed by some light eruption, consider it of no importance, and get, well spontaneously, marry and have healthy children, himself remaining entirely free from any evidence of the disease, and dying in a green old age. SypJiilis and Marriage. — The practical question in this context is : During what time are symptoms liable to recur before that long latent period may be expected, which is to terminate all manifestations of disease, and in which the patient is certainly well, probably cured ? Or, still more practically, the question may be put : If a patient pre- sents himself with syphilitic chancre, at what period may he safely marry ? Roughly, and on the average, this last question may be answered 538 SYPHILIS. by saying, after about four years ; or, to be safer, at a period not earlier than four years after chancre, when it can be proved that no svnii)tom of syphilis has shown upon the ])atient for a year, during which year he has been at least six months without treatment. And, indeed, it is wiser to say to any one asking the question that it is bet- ter not to marry until five years after chancre, although such applicant must be informed that many patients marry with im])unity at a much shorter period. For the female I think live years is little enough, and more would be better. Patients do marry in all stages of the malady. Fournier* says that out of 572 private female patients with syphilis 81 were young women who had contracted the disease from their hus- bands during the first few months after marriage. Patients Avill marry before they are well in spite of every caution thev may be given, but in such case they should be made to bear the responsibility themselves. A gentleman came to me once with a chancre, stating that the cards were out, and that he must and would marry in a few days. I could not dissuade him. He married. On the ground of preventing conception, in which his wife's wishes coin- cided with his own, he wore a protecting cover during intercourse for a period of nearly three years — being constantly under treatment, and his wife ignorant that he was sick. After three years I allowed him to have relations naturally. It is now more than a year since he re- ceived this permission. His wife has not become pregnant. She is well, and he has remained so. In a doubtful case of a man who per- sists in marrying too soon, it is well to insist that he shall continue specific treatment until his Avife shall have become pregnant at least. Yet it is not safe to give a positive guarantee to a patient even in five years. Presumably he is incapable of communicating the disease, but relapses of symptoms of a contagious character do certainly occur in some patients even after this period. Under all circumstances a patient with syphilis who marries should watch himself carefully, and not have contact with his wife if there is upon his penis at the time any moist lesion, excoriation, or abrasion, no matter how innocent such lesion may appear, or what may have been its cause. The more prolonged and consistent the first mercurial course has been, the better the guarantee of immunity which can be given the patient. Causes of the Protracted Duration of Syphilis.— Those patients most often do badly, other things being equal, who follow irregular and uneven courses of treatment, now pushing medication to excess, in the hope of killing the disease, which is impossible, now giving up all treatment in despair. It is very rare for bad symptoms to appear upon a patient who falls into the hands of a conscientious physician, one who recognizes that the disease can not be jugulated, that the eliminative and not the abortive treatment must be followed, and who quietly and * "Syphilis and Marriage," 1880. INFLUENCE OF GOUT AND SCROFULA. 539 steadily pursues the enemy tlirough its periods of repose as well as during its moments of eruption, confident tliut, by mildly and persist- ently keeping up this treatment by extinction, he will triumph at last over the disease. In mild cases so treated there may be but one faint eruption, or perhaps but a few little spots, with epitrochlear, glandular induration and a few mucous patches, to mark the disease, the whole of the symptoms only lasting a few months after chancre, and the pa- tient's after-life being healthful. This, however, is the exception. Ordinarily some mild symptoms continue to crop out from time to time for perhaps on an average two to three years, after which comes the period, be it cure or not, during which the patient bears all the marks of health, is unable to communicate the disease, and reproduces healthy offspring. Finally, there are exceptional examples where late tertiary symp- toms appear after long years of latency, as already observed ; of malig- nant syphilis, which is controlled with difficulty by treatment ; and of other inveterate specimens of disease where relapse after relapse fol- lows through long series of years, perhaps in spite of a continuous in- telligent treatment. These last cases may be mostly ranged under three heads : 1. Those living in bad hygienic surroundings, and giving them- selves up to excesses of every sort. 2. Patients peculiarly susceptible to the disease. Thus I have sev- eral times remarked a profound susceptibility to syphilis to exist in a given family otherwise healthy. In many instances I have known two brothers or a father and son to acquire the disease, and both to have it in about the same general type. I have now under my charge two brothers with syphilis. They had a third brother who died of cerebral syphilis in early manhood. The present two cases are inveterately in- tense, chronic, and relapsing in type, and one of them has had cerebral lesions of the most serious character. All derived their syphilis at different periods of life from different sources, and all possessed excep- tionally good health in other respects, and came of a healthy, long- lived stock. One gave his disease to his mistress, who had it in an exceptionally mild form. 3. Patients possessed of a strong tendency to gout, or of decidedly scrofulous diathesis. Inflijencb of Gout and Scrofula upon the Couese of Syphi- lis. — Both gout and scrofula may exercise a disturbing influence upon the course and the manifestations of syphilis. In the rheumatic or gouty subject the cutaneous symptoms partake of the gouty type. They are apt to be dry, erythematous, papular, tubercular, scaly, of a par- ticularly livid red, of great chronicity, leaving much pigmentation behind. Certain purely gouty eruptions are almost indistinguishable from similar ones produced by syphilis, and these, when occurring 540 SYPHILIS. upon a patient who lias had syphilis, give rise to great difficulties of diagnosis, and are most often mistaken for syphilides and treated as such, either without elfect or until they spontaneously disa}ipear, when the specitic medication gets the credit of the cure. Such gouty erup- tions are the dry, papular patches or single papules ahout the hands, on the ]ialnis or back, upon the feet or elsewhere ; scaly patches, gen- eralized papular and scaly livid eruptions on the extremities or back, especially such as occur during the spring or fall, and during the heats of summer (from the acridity of the perspiration). The different forms of psoriasis, as seen upon an individual of the gouty habit, possess many of the characteristics belonging to syphilitic eruptions, and often lead to error. These eruptions which have been just mentioned do not itch (as a rule), and their diagnosis (when found upon a syphilitic pa- tient), from inspection alone, is always difficult, sometimes impossible. Treatment may be required to solve tlie problem. Syphilides on a gouty patient get well quite promptly, while other eruptions are not sensibly affected by antisyi^hilitic remedies. Besides this simulation of syphilis by certain gouty eruptions, whether they occur on a patient who has had syphilitic chancre or not, the gouty diathesis tends to make the type of syphilis an obstinate one. During the employment of treatment, and in spite of it, in some such cases, a new eruption will crop out, while the tendency to relapse, and to the recurrence of scaly, jjapular, and tubercular patches, is some- times disheartening. Finally, the gouty diathesis seems to predispose to the development of nervous symptoms in syphilis, both of the rheu- matic order in early disease (pain), and to lesions of bone, of fibrous tissue, and, later on, of nerve-substance, such as furnish the different forms of paralysis. Scrofula, on the other hand, leads to moist eruptions in syphilitic poisoning, the vesicular, pustular, early and late ulcerative. Most of the lymphatic glands become involved, but they are usually not so markedly indurated. The eruptions are often slow in coming out, and slow in getting well. The cicatrices of ulcers are not so liable to be deeply pigmented ; they are often somewhat irregular, puckered, ridged, and drawn like the scrofulous cicatrix, unlike the round, de- pressed, smooth, thin, glistening, non-adherent, characteristic cicatrix of syphilis. The type of the whole disease is apt to be slow, chronic, pustular, ulcerative, inveterate, often attended by destructive bony lesions. Again, in a syphilitic patient, a gland may suppurate, and then ulcerate with all the appearances of struma about it, and yet yield only to antisyphilitic treatment. General Characteristics of Sypuilides. — All the syphilitic affections of the skin have certain general characteristics which stamp them as a class. Every mark is not possessed by each eruption, yet the majority belong to each and every syphilitic lesion of the skin. GENERAL CHARACTERISTICS OF SYPIIILIDES. 541 They arc usually well marked, and may be grouped under ten beads : 1. Polymorphism of the initial lesion. 2. Rounded form of the patches of eruption, and of the ulcers. 3. Livid color, like the meat of raw ham, then coppery (pig- mented), then gray, then white. 4. Absence of pain and itching. 5. Earlier eruptions superficial and generalized, usually symmet- rical. 6. Later eruptions in groups, involving the cutis vera. 7. Scales white, usually not adherent, superficial. 8. Crusts greenish, black, irregular, thick, adherent. 9. Ulceration with abrupt edges, adherent, not undermined, slug- gish, and bleeding easily. 10. Cicatrix rounded, depressed, thin, non-adherent, white, smooth at first, often pigmented, then clearing off from the center toward the circumference. To these special characteristics may be added for the earlier out- breaks, the general accompanying phenomena of syphilitic fever, alo- pecia, headache, osteocopic pains (worse at night), analgesia, anaesthe- sia, indolent lymphatic ganglia, iritis, sore-throat, and mucous patches in, upon, or around the natural orifices. 1. Polymorphism. — This applies to the earlier and generalized eruptions. With other cutaneous diseases, it is the exception to have an eruption composed of many elementary lesions ; with syi^hilis it is rather the rule. An erythematous syphilide is usually also at the same time partly papular. The papular furnishes examples of ery- thematous spots, and very often some vesicles, some pustules, and some scales, and so of the other generalized eruptions. This is partly ac- counted for by the fact that the elementary lesion often develops in successive crops, and therefore shows during its different stages as an erythema, a papule, a vesicle, a pustule, a tubercle, or a scaly spot. One lesion, however, always exists in excess, and from this lesion is the eruption named — as, papular syphilide. 2. Rounded Form. — In a generalized eruption the groups of ele- mentary lesions are gathered into rounded clusters, but this is more specially shown in the later circumscribed syphilides, be they groups of pajmles, vesicles, pustules, tubercles, or indeed ulcerations. The tendency to a rounded form of the group is marked. 3. Color. — The color of the syphilides is not a frank, inflammatory red, but a vinous, empurpled redness, resembling, when well marked, the raw meat of ham. This color is found also in many of the gouty, papular eruptions, and in psoriasis, rarely with other eruptions. The color of the syphilides passes by pigmentation from the dusky, violet- red, into what is known as copper-color, and from there on sometimes. 542 SYPHILIS. by a deep pigmcntatiou, to brown or black, the skin around the lesion being usually also pigmented to a certain extent. This pigmentary coloration sometimes lingers for years, but usually clears oiT after a few months, disai)ponring first centrally, the clearing oil' extending peripherally in all directions. Finally, the spot becomes brilliantly white, 4. Pain and Itching. — The syphilides are not accompanied by any itching or pain ; neither the eruptions nor the ulcers ordinarily fur- nish any disagreeable subjective sensations. Occasionally there are some heat and prickling with an eruption as it is coming out, but it uever amounts to actual itching. Syidiilitic ulcerations are also free from pain, except as occurring upon dejiendent portions of the body, where the imperfect circulation tends to set up some inflammation around or in the throat, where the constant motion seems often to lead to the same result. This absence of subjective phenomena is of great importance in diagnosticating syphilitic eruptions. Errors, however, are liable to occur with gouty and scrofulous eruptions, most of which are also entirely devoid of pain or itching. Other features, however, distinguish the latter. Sometimes eruptions are seen which, although evidently syphilitic, are yet attended by itching. In such cases an attentive inquiry will usually disclose the cause of the excep- tional peculiarity. The patient may be found to have a naturally irritable, itchy skin, a pruritus which always troubles him, and which the syphilitic eruption by no means relieves. He may be afflicted with urticaria along with his specific eruption. Not uncommonly, in hos- pital patients, prurigo from pediculi coexists with some syphilitic- exanthem. I have seen an eruption produced upon a patient with chancre and gonorrhoea by an overdose of copaiba which might have given rise to confusion of diagnosis. Contrary to the rule, the earlier syphilitic eruptions of the scalp are usually attended by itching. 5. The earlier eruptions are distributed habitually all over the body, and are superficial, mainly congestive in character. There is no deep alteration, nor any destruction of tissue, as proved by the fact that the earliest eruptions (erythematous and papular) leave no scars. Those coming a little later leave faint scars (pustular and vesicular). The development tends to be symmetrical, the eruption coming out on the flanks and sides of the thorax, the forehead, along the edge of the hair, on the sides of the nape and the margins of the nostrils, on the palms and soles, etc. 6. The later eruptions are grouped ; tubercle, pustule, or ulcera- tion, whatever be the lesion, it is now no longer generalized, but gathered into groups ; and that the lesion is deep and there is destruc- tion of tissue, are shown by the depression of the cicatrix. These lesions usually leave a scar whether they ulcerate or not, and this dis- GENERAL CnARACTERISTICS OF SYPIIILIDES. 543 tinction of leaving cicatrices without previous ulceration is enjoyed by no other class of eruptions save one, the scrofulous. A tubercular non-ulcerated lupus will also leave scars, but such scars are tlie irregu- lar, stretched, burn-like cicatrices of lupus, and not the round, de- pressed, white scars of syphilis. 7. The scales on the cicatrices, and on the patches of scaly syph- ilitic eruptions, are thin, white, non-adherent, lamellar, very dill'erent from the dense, thick, imbricated, adherent scales of psoriasis. 8. The scabs formed on syphilitic, ulcerative, rupial, and pustular lesions are rough and adherent, dark-colored, of a greenish black, some- times loosened by an underlying accumulation of pus, but more often seemingly set into the skin, and tightly adherent. They may be of light color where the lesion has been pustular, but, light or dark, the green shade is rarely totally absent, and is often brilliantly marked. 9. Characteristics of Ulcers. — With the exception of the chancre and of the ulcerated mucous patch (both of which may vegetate, and are always liable to be elevated instead of depressed), the ulcerations of syphilis resemble chronic, indolent ulcers. They are rounded or oval, with abrupt edges cut away like those of a chancroid ; the base is covered with the yellowish, false-membranous-looking deposit, some- times bluish, like boiled sago. The edges and base of the ulcer are usually hard, and the former generally, but not invariably, firmly ad- herent, and not undermined as in the ulcerations of scrofula. These ulcers do not bleed easily, are generally atonic and sluggish, and usu- ally entirely painless. Apparent exceptions to the rule in regard to pain are often due to the dependent position, or other cause sufficient to excite inflammation, or to the situation of the ulcer over a bone, the periosteum of which latter is suffering from painful syphilitic disease. 10. The cicatrices of such syphilitic lesions as have destroyed tis- sue, whether there has been any surface ulceration or not, are generally rounded, very thin, depressed, smooth, shining, and non-adherent. They are usually at first uniformly pigmented, of a coppery hue, more or less deei^ (nearly black in brunettes). This pigment clears off from the center to the circumference until only a dark border is left, which sometimes lasts for months, but finally the whole cicatrix acquires al- most a pearly whiteness. Cicatrices over bone may adhere if they have been connected with bone lesions. The cicatrices left by an ulceration partaking of the nature of both syphilis and scrofula are often com- plex, that is, a scar irregular, uneven, bridled on its surface, contracted in parts, not much pigmented, perhaps with a vein running across it, and often adherent at points ; possessing, in a word, some of the char- acters of a strumous cicatrix added to those due to syphilis. These complex cicatrices are best marked about the neck, where glands have suppurated on strumous subjects w^ho are also syphilitic, and are not very uncommon after rupia. 544 SYPHILIS. COXCOMITANT SYMPTOMS OF SECONDARY SYPHILIS. — The pllCnom- cua which most frequently precede or accompany the first cutaneous outbreaks are sypliihtic fever, indolent engorgement of the lympliatic glands, headache, osteocopic pains, alopecia, and sore-throat, with mu- cous patches, and perhaps iritis. A few words will serve to describe these symptoms. They follow the period of secondary incubation. SECONDAilY INCUBATION. Primary incubation (as already described) extends from the moment of suspicious contact to the appearance of the chancre. Then primary syphilis is ushered in ; but now there is another period of rest, wherein the disease seems to be purely local, for there are no general symptoms. This period dates from the appearance of the chancre to the appear- ance of general symptoms. It invariably exists whether treatment be commenced or not, and has been named the period of secondary incu- bation. Primary syphilis may, and often does, extend through this whole period, and even longer, but still it is a j^eriod of incubation, for the general organism shows no sign of suffering until a lapse usu- ally of many days. The shortest length of period of secondary incu- bation yet reported is twelve days (Gibcrt and Rollet) ; that is, twelve days elapsed after the appearance of the chancre before any general symptoms became evident. Rollet observed it again of one hundred and thirty days' duration. Diday* observed one case in which the secondary incubation was one hundred and sixty days ; the patient had also inflammation of the lungs. Bassercau saw an incubation of five months, and Ricord puts down its greatest possible limit at six months. The mean length of the period is forty-six (Diday) or forty-seven (Rollet) days, as established both by experiment and clinical experi- ence. This period may often be lengthened materially by the inter- vention of early treatment, but even then it is customary for some slight eruptive disturbance to appear about six weeks after the advent of chancre. It must not be forgotten that the entire secondary period may be skipped, the disease first appearing in its tertiary form. This state of affairs may appropriately be termed delayed syphilis. I have seen a number of such cases in Avhich I have treated the patient myself, and no eruption or evidence of syphilis has appeared after the first glandular post-cervical or epitrochlear enlargement has come to confirm diagno- sis — until after the lapse of several years. I have had one striking case in which I treated the suspicious sore, but could not make up my mind that it was syphilitic. I waited in vain for confirmatory symptoms, giving no treatment. These first appeared in the fourth year as an ulcer (tertiary) in the throat and nose, attended with loss of * " Ann. de Derm, et de Syph.," January, 1880, p. 44. SYPHILITIC TEVER. 545 bone. I have seen other patients who after an alleged 8oft chancre (not treated internally) have stated to me that there were no symptoms of syphilis until many years later, when they have applied to me for the treatment of tertiary lesions, giving me the foregoing history. These cases of delayed syphilis or suppressed disease do certainly occur, but they are not at all common. Their consideration must necessarily be omitted in computing the length of the period of secondary incuba- tion. The latter is on an average Just over six weeks, the first incuba- tion just over three, making the habitual average appearance of the first eruption after suspicious sexual contact about ten weeks. SYPHILITIC FEVER. About a week or more before the appearance of any eruption, while the chancre is perhaps showing signs of getting well, the patient is liable to exhibit more or less marked symptoms of fever, but, as in nearly all of the symptoms of syphilis, so in this one, the intensity va- ries in different cases from nothing upward. The poison of syphilis is at work during the period of secondary incubation, and produces more or less cachexia by directly diminishing the quantity of the red cor- puscles of the blood. In 1844 Grassi,* the enterprising apothecary of the Hotel Dieu, by frequently repeated analyses found this diminution of the red corpuscles to vary in different cases from eleven to sixty-five per cent, and noted also that the percentage of corpuscles increased under the administration of the iodide of potassium. Wilbouchewitch,f by counting under the microscope, found that syphilis produces ane- mia directly, reducing the number of the red blood-cells. He decided that the use of mercury in small doses increased the number of red cells under these conditions for a time, but persisted in diminished them. I X investigated the subject personally later, and found that syphilis does reduce the number of the red blood-cells, that the con- tinued use of a small dose of mercury (which I have named the "tonic dose") arrests the diminution and causes an increase of the red cells, and that this tonic dose may be persisted in indefinitely — as far as I have investigated, over five years — without losing this tonic effect and power of increasing the number of the red cells and maintaining them in their increased proportion. In early syphilis some diminution of the red corpuscles seems to be constant ; bat, while it varies greatly in cases where no treatment has been employed, under early judicious treatment the amount of decrease is certainly less. This syphilitic hydraemia, then, is constant, but it may be so slight as not to be ac- * Ricord, "Lemons sur le Chancre," 1860, p. 1S9, 2cl edition, edited by Fournier. f "Archives de Physiologie," Browa-Sequard, 1874. p. 516. :j: "Treatment of Syphilis," etc., "Trans. Internatiooal Medical Congress," Philadel- phia, 1877, p. 726. 540 SYPHILIS. compauicd b\- any observable fever ; while, again, tlie amount of febrile disturbance may be considerable. Hence it sometimes ajipears that syphilitic fever, as such, is entirely absent. Lancereanx believes that it is present in two thirds of all cases. When present as distinct fever, it is-marked by physical and mental depression, loss of appetite, functional disturbance of the jirimiv via\, and a temperature running up in the evening, according to Cnntz,* sonu'times to nearly 104° Fabr,, but falling again rapidly after a few days. As a rule, it does not get so high. The fever may be continuous, or may occur in paroxysms, chiefly toward night, followed by sweating. The type of the fever may be also remittent, or even occasionally intermittent, Avith regular tertian paroxysms of chill and fever. Again, the fever may be low and typhoid in ty]ie. The spleen is occasionally enlarged in cases of this fever, says Baiimler.f I have not yet observed it, Fournier has not seen it, Schuster J met it once. Sometimes it is accompanied by nausea, hebetude, and stupor ; or, again, the jxatient may feel quite comfortable and as well as usual, retaining his appetite, or even eating more than his ordinary amount of food — bulimia (Fournier). Whether there be much or little true fever, the hydraemia commonly announces itself by sallowness of the comjilexion, with pallid face, pinched features, and sunken eyes. The nervous depression is sometimes prominent, occasioning melancholy, with sad looks, a gloomy view of life, even to a tendency to suicide. The patient exaggerates his sufferings, and is often wofully depressed, complaining of general malaise, fatigue, and feebleness. Parox3-smal or continued neuralgia, vertigo, feelings of faintness, may come on ; these perhaps spontaneous, or, again, provoked by movements of the head. Where the hydrgemia is marked, shortness of breath is com- plained of, and palpitation ; a soft, blowing sound may be heard at the base of the licart and in the vessels of the neck. Epistaxis and oedema of the feet, perhaps, occur, and tenderness or swelling of the joints. With or without these symptoms of hydrasmia, pain is almost con- stant in syphilitic fever and during the earlier eruptions. This pain usually affects the fibro-osseous system, and is known as osteocojiic (oo-Teov-KOTTTetv, lone-hreahmg), on account of its peculiar intensity. It assumes a multitude of forms, occurring in the nucha, back, loins, be- tween the ribs, constituting a pleurodynia sometimes mistaken for pleurisy, in the shoulders, elbows, knees, and sternum (Baglivi). These pains are movable sometimes, shifting rapidly from one part to another. They may occur only at night, or may be continuous, in which case they are often decidedly worse at night. Pressure some- * "Das syphilitische Ficber," Leipzig, 1873. f V. Ziemssen's "Cyclopaedia of Medicine," art. "Sypliilis." % "Archives f. Derm. u. Syph.," 1873, p. 283. SYPHILITIC FEVER— TREATMENT. 547 times affords them temporary relief, or, on the other hand, evokes them where they are not spoutaneous. A diagnostic value has been attached to the fact that pressure over the lower or upper third of the sternum produces pain not otherwise complained of. Among the pains of early syphilis, headache is prominent, often of an excruciat- ing character and usually worse at night. The joints may stiffen and be hard to move, on account of pain. Effusion occasionally occurs in and around them, giving to syphilitic fever the aspect of mild acute inflammatory rheumatism. Jaundice with accelerated pulse may come on during or just before the eruption, rarely lasting over a few weeks, and due to hepatic engorgement, or, possibly, as Lancereaux suggests, to compression of the bile-duct by enlarged lymphatic glands, since this cause is certainly sufficient to produce icterus occasionally in advanced syphilis. The pulse of syphilitic fever rarely reaches higher than 120°. The fever is usually greater according as the erup- tion is early and abundant. Sometimes it quickly abates and disap- pears as the eruption comes out, or it may continue and get worse for weeks. Occasionally there are some slight feverish symptoms just be- fore other crops of eruptions which succeed the first general outbreak. The diagnosis of syphilitic fever is made by a study of the history of the case. Treatment is mainly tonic and hygienic ; these means being per- sistently pushed while the general treatment of syphilis is kept up. Anodynes are sometimes required to master the pains. Although Grassi found that the number of red blood-corpuscles did not increase under the administration of mercury, the explanation plainly is, that in those days mercury when used was given in heavy, and not in tonic doses, and my researches show * that such a mercurial course directly induces antemia and reduces the number of the blood-cells. Indeed, modern authors are in accord in deciding that mercury is the coiTect treatment for syphilitic fever and the early syphilitic osteocopic pains. Quinine has no value in reducing temperature in this fever or curing the attack. In inherited disease there appears to be no fever. Holm f found in some Copenhagen children that the temperature in the period of eruption ranged below the normal, while, in the cases of some children with acquired disease, the temperature was normal or with a slight evening rise. There seems to be no reason for this, and I think con- firmation is needed before the report is generally adopted. A few words will suffice for the other ordinary concomitants of the earlier general syphilides, alopecia, general indolent glandular engorge- ment, sore-throat, iritis, mucous patches, paralysis, anaesthesia, anal- gesia, bulimia, jaundice. * "Trans. International Med. Congress," ]8v7. f Referred to by Hill and Cooper. Second edition, p. 109. 548 SYPHILIS. ALOPECIA. Falling of tlic liair due to syphilis is of two kinds. Wlicre there are scabby sores on the :?calp. and especially in later iilcerative disease, the hair-follicles over limited areas become destroyed, in which case the fallen hair is not reproduced. Ordinarily, however, general bald- ness occasioned by syphilis is only temporary. In fact, baldness is not usually produced, but only a considerable thinning of the hair gener- ally, or in mottled patches, not only of the scalp, but of the eyebrows, eyelids, whiskers, and, to a degree, of the whole body. Alopecia is sometimes complete over the entire body. More or less local alopecia is sometimes met with (on the fron to- temporal region) in cases of in- herited syphilis (Barlow,* Parrot f). In acquired syphilis the thinning of the hair is due to one of two causes (that is, when there is no eruption or ulceration involving the hair pai)ilUv) : (1) The syphilitic hydrremia, which, like thin-bloodedness from any other acute cause (fever), temporarily impairs the vitality of the hair- papilla?, causing the hair to lose its luster and then to fall out. (2) A seborrho^a, the sebaceous matter clogging the hair-follicle, pressing upon the papilla, ultimately leading to the fall of the hair, and possibly, in some cases, to the atrophy of the papilla. The dried sebaceous matter mixed with scales may usually be scraped away jolen- tifully from the scalp around the hairs. Treatment. — Although some falling off of the hair is often inevita- ble, yet the cpiantity may be lessened by attention to the hygiene of the scalp, shampooing once a week with ammonia or borax in warm water (a teaspoonful to the pint) to get rid of the accumulating seba- ceous matter, and the use afterward of a stimulating lotion, of which a little may be rubbed upon the scalp nightly. One of the best of these is : 5 Tr. capsici, 3 ij-v. Glvcerini, 3 j- Aqua) Colognicnsis, ad 3J. M. "Where sores infest the scalp, general treatment alone is to be relied upon. INDOLENT GLANDULAR ENGORQEMEl^T. Coincidently with the first outbreak of general syphilis, sometimes preceding the eruption, more often shortly following it, there is a marked tendency to a general indolent engorgement of the lymphatic glands. This concomitant symptom rarely fails, and it furnishes a diagnostic mark of the first importance in all doubtful cases. The * "Lancet," August 22, 1877. f "Progr^s Medical," 1878, No. 22. SOKE-TIIROAT. 549 enlargement of the glands does not necessarily depend upon the occur- rence of an eruption, since it is encountered where close observation fails to detect any neighboring cxanthcm. This is particularly true of the post-cervical and epitrochlear glands. The engorgement of the glands is indolent, painless. They are usually of a cartilaginous hard- ness, insensitive to pressure, varying in size from a small pea to a marble. The coincident indolent engorgement of certain glands is almost pathognomonic of syphilis. These are the post-cervical (posterior chain), markedly two little glands lying high up on either side of the nucha, upon the occipital bone ; a gland over the mastoid process of the temporal bone ; and the epitrochlear gland (or glands) on either side, just above and without the inner condyle of the humerus. Other glands may also become indolently engorged, but more rarely ; as, the lateral or the cervical, the axillary, the inguinal (where the chancre is extragenital, and where these glands consequently have escaped pri- mary infection) ; but the glands of most assistance to diagnosis are undoubtedly the post-cervical and epitrochlear, and these should be sought for in all cases to confirm the diagnosis of general syphilis. SORE-THROAT. Sore-throat is a concomitant symptom of all stages of general syphi- lis. There are three type varieties : 1. A diffuse general redness, with or without ulceration. 2. A certain amount of chronic congestion, and brawny thickening about mucous patches or atonic ulcers. 3. Destructive ulceration from gummy deposit. The first variety is an early secondary phenomenon, and alone of the three is a concomitant of the early syphilides ; the second may occur along with the later secondary and earlier tertiary lesions ; the third is tertiary. They will be described in connection with the other symptoms. Eecently Fournier * has noted, as a concomitant symptom of the earlier secondary period of syphilis, certain aberrations of cutaneous sensibility, such as loss of ordinary cutaneous sensitiveness (ausesthe- sia), inability to appreciate the sensations of heat and cold, and com- plete insensitiveness to pain (analgesia) ; these either general or more commonly confined to limited areas of skin, notably the extremities. The back of the hand over the wrist is a favorite location. The trouble is a passing one, not lasting more than a few months, and has been observed by Fournier chiefly in women. It is questionable whether hysteria may not often play a prominent part in the causa- * "Annales de Dermatologie et de Syphilographie," tome i, 1869, p. 4S6. "Sur la Syphilis," Paris, 1873. 550 GENERAL TKEATMENT OF SYPrilLIS. tion of these phenomena. Fonrnier's observations include over a hun- dred cases. Iritis conchiucs the group of concomitant symptoms. It will bo described later. CHAPTEK V. OENERAL TREATMENT OF SYPHILIS. Hygienic, Tonic, Specific Trentineiit.—Syphilization.— Treatment of Early Syphilis.— Bad Efifects of Mercury.— Method!? of administering Mercury.- Treatment of Late Syphilis.— Mixed Treatment. —Treatment by the Iodides.— Methods of administering Iodine in Syphilis.— Quantity of Iodide which may be required.— Duration of General Treatment. The general * treatment of syphilis is hygienic, tonic, and specific. The latter is often inelfective unless aided by the former. Neither should be depended upon alone. They form component parts of one rational system. Hygienic Treatment. — The hygienic treatment of syphilis includes all the ordinary laws of health. Eegularity of the habits — especially of those of eating and sleeping, and of those involved iu the perform- ance of intestinal functions — is all-important. No deviations need be made from ordinary diet. Excesses of any kind are bad, even emo- tional (fear, anger), and especially excesses in strong drink, in work, in venery. The function of the skin should receive attention through scruiDulous cleanliness. Warm baths are more cleanly and relaxing to the skin than cold. If baths be too hot early in the disease, they are apt to call out a more plentiful crop of eruption. Catching cold should be avoided. It is apt to induce and prolong mucous and ulcerative patches about the mouth, nose, and throat. Singing, and loud and continuous talking, are objectionable in subjects having weak throats. Experience has taught that tobacco in all forms, and even highly- seasoned food, is certainly injurious, in irritating and keeping up an outcrop of mucous patches. Air, exercise, and light, essentially neces- sary to all animal well-being, are particularly so in the case of obsti- nate chronic or advancing disease. Change of air in some of these cases is essential to the success of treatment, as a trip to the country, change from tiie seaboard to the mountains, or from inland to the shore, and then perhaps back again, six weeks being usually long enough in any locality to obtain its maximum effect for good. I have more than once observed, when I could not so manage it with a patient in New York that his stomach could be made to toler- * The local and special means rcfiuircd for the difTercnt manifestations of the disease will be detailed under the heads of the symptoius requiring them. HYGIENIC AND SPECIFIC TREATMENT. 551 ate a high enough dose of the iodide of potassium to control liis lesions (this notably in tertiary conditions), that a few days in tlie country would so hold the patient up that he could take his dose, and that his symptoms would promptly change for the better. I have noticed the same fact in connection with patients sent to me from Chicago and elsewhere ; they could with ease and advantage tolerate heavier medi- cation in New York than at home. The rule is positive. Many ob- stinate bad cases of late secondary and tertiary disease, which fail to respond to treatment in their homes, especially if that home be in the city, make rapid strides toward recovery as soon as the air and sur- roundings have been modified. Mercury and the iodides will not cure all syphilis, as many practitioners seem to believe. The old chronic cases, remaining from year to year in our large hospitals, and relapsing endlessly in the damp and crowded tenements of our large cities, are not in need of medical treatment, for this they have and of the best ; but what they need is intelligent hygiene, and with its assistance many of them would recover. In the hygienic category naturally belongs all tonic and supportive medication. Cod-liver oil, iron, quinine, and all lesser helps, find ample space to vindicate their claims at some part of the treatment of most cases. Without them specific treatment is often unworthy the name. In the hydrsemic stage. Just before and during syphilitic fever and the earlier exanthemata, as well as during portions of the later cachexige, these remedies are of the greatest value, and may occasion- ally be used alone with advantage until the general tone of the patient can be elevated ; after which the prompt efficiency of the specifics, in- telligently administered, gives them a claim to the title of being the most reliable drugs used in the practice of medicine. There are, how- ever, certain phases of syphilitic cachexia over which no tonics act with the same efficiency as minute doses of mercury, especially corro- sive sublimate, in women preferably combined with iron. Specific Treatment of Syphilis. — But few known remedies have been left untried in the treatment of syphilis. Besides the old-fashioned sarsaparilla, guaiac, mezereou, stillingia, cundurango, and a host of other vegetable remedies, we have in these modern days cascara amar- ga, tuyuya, the vegetable combination suggested by Simms, called succus alterans, and many other inferior and purely quackish reme- dies. The claims of few of these need detain us. Most of the syphi- lides, especially the earlier varieties, are self-limiting, and will get well under any treatment — one might even say in spite of treatment. Mild cases, especially in married women, often go untreated, unrecog- nized indeed, and the patients never suffer any considerable incon- venience. It is on cases of this order that anti-mercurialists build their theories, substantiating the latter by reference to cases in themselves inveterate and malignant in spite of the use of mercury, or perhaps in 552 GENERAL TREATMEXT OF SYPniLIS. connection with it? improper use. No treatment may be better than overtroatmcnt. Indeed, the lesions often get well spontaneousl}' upon the advent of some other malady.* This seems to be especially true of erysipelas. Ch. Mauriac,f in a monograph, maintains that erysipe- las acts updn syphilis in a general as well as in a local way, lesions get- ting well which are never touched by the erysipelatous redness, but less promptly as they are more distant. The different vegetable decoctions and infusions, of which sarsa- parilla takes the lead, assist digestion, promote the action of the skin, encourage the functional activity of the kidney, and please the patient. They may be adjuvants in certain cases, and should be perhaps ranked along with hygienic and tonic means, but they have not merited by their action any right to the term curative in its narrowest sense, since they do not demonstrably postpone relapses or shorten the duration of existing symptoms any more tlian other hygienic and tonic means. I think it is not doubtful that Zittmann's decoction is a remedy of posi- tive value, especially in late syphilis, when there is cachexia, ana?mia, irritable stomach, loss of appetite, moderate constipation, and particu- larly when the stomach will not take the iodides kindl3\ The senna encourages intestinal action, the sarsaparilla undoubtedly has an influ- ence, because if left out the remedy is decidedly less effective, and the mercury is presented in a suitable way to exercise its tonic effect. But the old-fashioned Zittmann's decoction was full of unnecessary ingredients in its composition, and was troublesome to make, difl&cult to take on account of the quantity required as a dose, and its adminis- tration was surrounded by unnecessary rules and precautions. Start- ing with the original decoction, and then modifying it by McDonnell's formula, I have gradually dropped one thing after another until I have now come to use (often with decided advantage in cachectic cases of old syphilis needing a tonic course) the following formula, of which I usually order a tablespoonful to be taken several times a' day, regulat- ing the dose somewhat according to the purgative effect : 5 Eydrarg. chlorid. corros., gr. j. Alumiuis, 3 ss. Ext. sarsaparillaj, o ^j- Glycerin, 1 j- Syr. senna?, ' 3 j^^- Spts. anis., 3 j- Extr. glycyrrbizaj, 3 j- Aquae foeniculi, q. s. ad = viij. M. I have not found the advantage in pilocarpine wliich it has been suggested it would afford. As to the succus altcrans alone, I am sure it is unnecessary in sec- ■" Pctrowsky, referred to in "Medical Record," May 6, 1882, p. 487. f "Etude clinique sur riufluence curative de I'erysipule dans la Syphilis," Paris, 1873. SYnilLIZATION. 558 ondary syphilis, and powerless in tertiary. I liaye seen the ravages of tertiary ulcerative disease go on unchecked for months under its ex- hibition in wine-glassful doses, at the hands of another practitioner. That it may not be of some service in combination with the more po- tential drugs, I can not state ; I have heard reputable gentlemen say that they thought it was. I have not observed the fact, although I have tested the combination largely. In any case tlie quackish and pretentious manner in which the medicine is being forced upon the profession is enough to condemn it, and to make any honest man doubt its claims. That it does no good, I can not affirm. That it does what it pretends to do is false, in my opinion. SypMlizat'ion has long since been, judged and discarded. The preparations of gold and copper can not be at. all depended upon, and the bichromate of jiotassium * certainly does not do in this country what has been claimed for it in Europe. The Hot Springs of Arkansas require a word of serious comment here. That they have a positive value, I am sure. I visited the springs a few years ago, and remained there long enough to see their workings. I have sent many patients there, have deterred many others from going, and seen patients in all stages of syphilis who had been to the springs before their first visit to me. From such premises I think I may reach conclusions which shall be reasonably just. The physicians who practice at the springs are not in accord as to the spe- cial property of the waters which gives them their value. Some think that the water is like any other hot water, and that jaatients do well at the springs simply because tbey come there determined to take care of themselves, and to make the treatment of their malady their first object. True it is that the waters are almost void of any mineral in- gredient. The waters of the so-called old Iron Spring (I think it is called so because the house erected over it is made of corrugated iron, and not because of any iron in its water) deposit a tufa which clings in masses to the hill out of which the spring flows, but I am informed that the actual mineral contents of the water is only about eight grains to the gallon, which is practically nothing. Lime seems to be the main ingredient. The water of this spring is used at the main hotel of the place for drinking-water, and it is as pure, bright, sparkling, and tasteless as any water I have ever seen. Taken cold, it certainly has no obvious effect ; taken hot, it is diuretic and diaphoretic more positively than ordinary hot water. It does not nauseate. Others of the local physicians impute the effect of the waters to something sui generis in the quality of the heat they contain ; others ascribe it to silicon, which the water is said to contain ; others to elec- tricity, in which also the water is said to abound. My own investiga- tions showed me that a foot-bath at 110° Fahr. was impossible. The * " Die Syphilis-Behandlung ohne Quecksilber," J. Edmund Giintz, Berlin, 18S2. 554 GENERAL TPiEATME-NT OF SYrniLIS. feet could not possibly be retained in water of that temperature, a thing perfectly possible (but not pleasant) at home in Croton water, A thermometer held in the mouth while making the attempt to take this foot-bath was raised to 103° Fahr. An ordinary bath at 98° Fahr. was unpleasantly hot, and caused the perspiration to trickle from the face in streams. The immediate aftcr-eiToet of the bath (unlike that of an ordinary hot bath) is one of exhilaration, followed in a couple of hours by reaction and a desire to sleep. The immediate eilect of the water I found to be stimulating, not soothing. An inflamed joint soaked in this water is harmed by it, and the pain intensified, con- trary to what is experienced with ordinary hot water ; acute eruptions are said to be aggravated by the water. This I did not personally have an opportunity of testing except in a case of generalized eczema, which certainly was aggravated at the hot springs, and began to get well at the (cold) sulphur potash spring a few miles away. Old chronic ulcers, whether scrofulous, s}-philitic, or accidental, are stimulated promptly into granulation by the local effect of these waters. The appetite im]n-0Tcs under their use, and the ordinary functions seem t,o be performed better than when they are not used by the visitors to the place. The uterine function seems to be stimulated by the baths, and stories of a return of menstruation after the change of life, of impreg- nation after long sterility, and the like, arc told by the natives. Para- lytics, and peo^ile recovering from apoplexy, seem to thrive at the springs. But all this is not the cure of syphilis, and my observation showed me plainly that the physicians, who did well at the springs used most unsparingly mercury by inunction, and iodide of potassium internally in enormous doses. And this is exactly wherein the value of the springs seems to lie. Patients broken down, cachectic, with faulty stomachs, who have syphilitic lesions which fail to yield at home be- cause they can not tolerate a sufficiently high degree of medication — these are the patients to send to the hot springs. There, under the assistance of the hot water internally and the baths, they can take a mercurial friction day after day, without salivation, w'hicli would over- whelm them at home, and their doses of iodide of potassium can be quadrupled without upsetting the stomach. I have verified this over and over again. This is the only class of patients I ever send to the sj)rings — those requiring stiff medication for serious lesions who can not at home be made to tolerate a sufficiently high dose to pull them through. I could multiply illustrative cases of this order almost indefinitel}'. One i^atient several years ago I sent to the springs under escort of a nurse and a relative. lie had been going persistently wrong by the head at my hands and those of several other physicians. He had had several hemiplegic attacks, serious ocular troubles, aphasia, double SYrillLIZATIOX. 555 vision, and mental derangement. His head was gone for all purposes, and lie was obliged to give up business entirely. No efforts of mine or others could by any of tlic adjuvants, belladonna, arsenic, milk, carbonated waters, alkaline waters, get the daily dose of this patient above three hundred grains of the iodide of potassium — and his symp- toms were gradually gaining upon him until his case seemed hopeless. Then he went with difficulty to the springs, and there, with no aid be- yond the use of the waters, his daily dose of the iodides was run up to eight hundred grains, and under this he recovered, and by after- treatment at home became able again to resume his business. I have had a number of cases of this sort, and, particularly when the brain and cord are seriously involved, I advocate the hot spring at any price in money, time, or comfort. It is certainly worth while. But for ordi- nary syphilis I do not consider the springs of any value. They do not shorten the duration of the disease, prevent relapse, or cure it in any sense. The lesions of early syphilis disappear rapidly under the heavy medication administered at the springs, but I do not think there is any special value in this, because it makes the patient less willing to take prolonged continuous treatment, in which alone in my opinion lies his best hope. The patient going to the springs is almost invariably told that he must come back in a year, and then in another year, if he wishes to be cured. But no number of courses guarantees a man against the possibility of subsequent relapse. Therefore, I believe the rule should be : Send no patients to the springs who do well under ordinary medi- cation at home — send only the debilitated, the cachectic, and those afflicted with serious late lesions (notably those of the nervous system), who have not the stomach to bear at home a sufficiently high grade of medication to effect their cure. The specific treatment of syphilis consists in the intelligent adminis- tration of mercury and of some of the preparations of iodine. It is divided, for convenience of description, into — 1. Treatment of early syphilis ; 2. Treatment of late syphilis — mixed treatment. The proper duration of treatment will be discussed at the end of the section. 1. TREATMENT OF EARLY SYPHILIS. G-eneral treatment should be commenced as soon as the diagnosis of syphilis is positive. To be positive on such an important point requires more evidence than is furnished by the simple physical char- acters of the sore, be they ever so positive. Diagnosis sufficiently ac- curate to commence treatment upon can only be made by confronta- tion — establishing the syphilitic disease in the person from whom the 556 GEXEILVL TREATMENT OF SYnilLIS. cliaucre was derived, or by waiting until some positive corroborative signs of secondaiy sypliilis appear. When tlie diagnosis is sure there is no need of further delay. In all cases of doubt the honest surgeon must hesitate, and many cases arc doubtful at first. In all such it becomes the duty of the surgeon and of the patient to wait for abso- lute proof of its presence before treating a disease wliich possibly ma}' not exist. By following the opposite course the surgeon perhaps throws doubt and discontent, sometimes even torture, into the wliole subse- quent life of the patient, Avho is constantly alarmed by every pimple, every ache, every unusual feeling he may have through life, fearing it may be the Ijeginning of the long-delayed onslaught of his imaginary foe. A few days of mercurial treatment in some cases will disturb the regular development of symptoms, perhaps prevent their appearance altogether in a form whicli would be readily recognized, and, in face of such a case, if the diagnosis of the nature of the chancre had been doubtful, how much more so would be that of the subsequent syphilis ! llence the rule in all cases of doubt : Do nothing but frankly tell the patient that he must wait ; or, if he has not the grace to appreciate pure honesty and must have something to do while waiting, give a jjlacebo while studying the nature of the sore and awaiting develoj)- ments. As soon, however, as the diagnosis "syphilis " is satisfactory, commence general treatment. All through syphilis mercury has power, an eliminative and controlling power if not a curative one. Curative it is not in the sense of aborting or materially shortening the natural course of the disease. The best that can be said of it is that the symj)toms of syphilis are controlled by mercury better than by any other known drug, unless it be the iodidic preparations, and these latter do not posti^oue relaj)se or give as good a guarantee against severe late tertiary symptoms as does a prolonged, thorough course of mercury. This is simply the expression of a personal opinion, but it tallies with the present belief of the majority of the best authorities upon this subject at the present date in all civilized lands. Because such distinguished gentlemen as Diday, Sigmund, and Zeissl have expressed a belief that many cases of syphilis get well as kindly with- out mercury as with it, is nothing to the point. They so state because they believe mercury to be an evil in itself to be avoided when possi- ble. When they encounter a bad case of syphilis, they use mercury, choosing it as it were for the short horn of a dilemma. They seem to say. Syphilis, is a bad thing, but if not very bad, do not let us add to the patient's misfortunes by inflicting upon him another bad thing — i. e., mercury. Yet, they say, mercury docs control the symptoms, else why do they employ it in severe cases ? In such cases they seem to say. Mercury is bad, but less bad than severe syphilis. Now, if it can be shown that mercury in itself is not bad any more than is a SYrniLiZATioN. 557 knife ; if it is bad only when improperly used ; if it can he used so as to be a tonic as well as an antisyphilitic remedy — then the whole logic of the position of these gentlemen falls to the ground. For, if mer- cury is useful in severe cases, and does control the symptoms of syphilis, and can be so used as not to injure the patient — then, in logic, to be consistent, the drug should be used for all cases, the light as well as the severe ones. This demonstration of the harmlessness of mercury, of its tonic in- fluence, I think I have clearly made.* I have shown that moderate doses of mercury continued for any length of time (up to several years, a time amply long so far as syphilis is concerned) not only do not debilitate but act as a tonic in health, in disease, in syphilis, augment- ing the number of red cells in the blood. I have amplified the sub- ject, showing that mercury can not be held responsible for late lesions, in another place. f Finally, upon this foundation, I devised a method of treatment which I called the tonic treatment of syphilis, J so nam- ing it because in it mercury can be used in such a way as to exercise its tonic influence, while at the same time it is controlling the disease. I have been persistently misunderstood in this matter. It is not as a tonic, or because it is a tonic, that mercury cures syphilis, or allevi- ates it, but mercury may be so used in the treatment of syphilis that over and above its specific influence it may still not only do the patient no harm, but may be actually a tonic to him, doing him good — a point that no one has hinted at before, and many do not yet believe ; and on this account only I have called this method the tonic treatment of syphilis. Since my demonstrations were made, no one has pretended seriously to controvert them except Hermann Schlesinger. This gentleman, in an extensive essay,* which received a prize from the medical faculty at Gottingen, and represents an enormous amount of excellent work, makes an experimental inquiry into the action of the continued use of small doses of mercury upon animals. He confirms, by numerous ex- periments upon rabbits and dogs, the conclusions which I reached, but he declines to agree with me in calling the action of the mercury a tonic one, because, although the number of the red cells is increased and held high, yet he claims that this is due to a retarding influence on the process of oxidation, and he thinks that only the process of destruction is retarded, and that the mercury leads to an increase of the deposit of fat. He states (after Petrouski) that iron, when acting as a tonic, increases the number of red cells, the weight, the body heat, the pulse, and the excretion of urea. Mercury does not act in all * "Effect of Small Doses of Mercury," etc., "Am. Journ. Med. Sci.," Jan., 1S76. f "Treatment of Syphilis," "Trans. Int. Med. Congress," 1876. X "Tonic Treatment of Syphilis," New York, ISVyT * "Arch f. cxp. Path u. Pharm.," Bd. xiii, Heft v, p. SIV. 558 GENERAL TREATMENT OF SVnilLIS. these Tvavs ; therefore. sa3'S Sclilesingcr, it is not a tonic. But tliis seems like siilittiiii;- liairs. Syphilis destroys red cells, mercury arrests the destructire process. Animals sick and wrll, men sick and well, thrive upon it if given in sufficiently small doses for an indefinite period ; no" harm comes to their tissues or organs. Therefore, why is it not a tonic, even if it does not increase the heat, the pulse, and the excretion of urea ? Schlesinger found tinit goats, sheep, and hens did not do well on mercury ; dogs and rabbits did. Dogs grew fat, and although confined died healthy. One dog kept a year showed a great increase in tiie number of his red blood-corpuscles. lie was tlien let out of his cage and got sick (as might have been expected), had diar- rhoea, lost appetite, and suffered a loss in the number of his red cells. He recovered, however, while at large, still taking the mercury. After his death the only lesions found were an atheromatous patch in the aorta, and some fatty degeneration along the urinary tubules, the vessels and glomerules being healthy. It seems to me that in this case there is nothing to show that lack of exercise and confinement for a year did not cause the atheroma. It is certain that the urine was nor- mal, for it was examined. In man I do not know that mercury has ever been accused of causing kidney disease. Finally, tonic doses of mercury in man do not lead to inordinate accumulations of fat obvious to the eye, as was the case in this dog, and it may be questioned whether he got his projoer tonic dose of mercury, and was not overfed as well as under-exercised. In the early manifestations of syphilis mercury is specially potent. Under its kindly influence the chancre heals, the early eruptions fade. If given continuously and intelligently from the first, syphilitic fever rarely amounts to more than a little pallor, with occasional osteocopic pain, and the early eruptions are less generalized than they would otherwise be. In many cases of early syphilis the iodides have a more prompt controlling effect over the lesions than the mercurials. This is often the case in ulcerative throat and mouth troubles, precocious ulcers and bone lesions, pains, and sometimes in the case of the earlier eruptions. Yet it is not well, I believe, to use the iodides too freely in early syiDhilis. They are not essential in this stage, and by using them freely the patient gets accustomed to them, and when the time of urgency arrives late in the disease he may not be able -to digest enough of the drug to do what is required of it. The careless use of the iodides early in syphilis is like going to battle Avith one's whole army, and not holding any force in reserve. Along with the tonic course of mercury hygienic and ordinary tonic means should be constantly employed in most cases. Mercury properly administered may be taken for years without any injury to the individual, or to his constitution, either immediate or remote. It has no connection as a cause with the appearance of severe tertiary BAD EFFECTS OF MERCURY. 559 forms of syphilis. Accumulating experience derived from more accu- rate observation has established this truth beyond cavil, although the ancient superstition as to the injurious after-effects of mercury still measurably taints popular belief.* I have seen a great many cases of very severe tertiary lesions upon sypliilitic patients who never had taken any mercury, and can not believe that this drug has anytliing to do with suppressing tljc disease early and allowing it greater strength with which to strike the patient later. With Dr. Van Buren I have published f two very strong illus- trative cases on this point, and I could add very many more. I have dealt with this subject also in another place. J Engelstcd,* of Copen- hagen, states that out of 7,434 cases of constitutional syphilis treated in hospital between 1864 and 1876, 493 cases of very severe destructive lesions occurred in patients who had never taken any mercurial treat- ment at all. How many more would have had serious lesions had their malady not been moderated by a previous mercurial course can only be conjectured. Bad Effects of Mercury. — Occasionally a patient appears who tolerates mercury badly. He may be unable to take a certain form — the protiodide, perhaps, because it causes pain and diarrhoea — but can take another. Most people tolerate the bichloride kindly, but I have seen a few patients who could not take any form of mercury in an}'- thing approaching an efficient dose without suffering therefrom great loss of vitality, and being thrown into a condition of apparently hope- less mental and moral depression. This curious condition is not the same as the mental and emotional depression caused by the onset of early syphilis, and it must be carefully differentiated from it. The latter exists and is common ; this mercurial depression is rare, but it certainly occurs. Words can hardly describe the awful gloom that settles down on an individual upon whom mercury exercises this pe- culiar power. One form of the remedy produces it as well as another ; striking relief is afforded, obviously, by discontinuing the drug, or, what will often answer, lessening the dose. These symptoms may be observed before mercury has produced any effect upon the mouth or gums. When a patient positively can not take mercury at all, then * The sweeping assumptions and broad assertions of a recent author of a pretentious volume in folio (" Ueber die Wirkungen des Quecksilbers auf den meuschliehen Organis- mus," Dr. Jos. Hermann), which would seem to ascribe all possible evils, and especially the symptoms of syphilis, to the effects of mercury, are too little substantiated by the facts adduced to call for any discussion here. An extensive mercurial bibliography (but nothing else of value, not even a good suggestion) can be found in " Die Anti-Mercurialis- mus in der Syphilis-Therapie," J. K. Prokseh, Erlangen, 1874. f "Archives of Dermatology," 1. ii, p. lOS. X " Treatment of Syphilis," " Trans. Int. Med. Cong.," Phila., ISVG. * "Klinisk Veilcdning til Diagnose, Behandlung," etc., 1877, and "Am. Journ. Med, Sci.," January, 1878, p. 231. 560 GENERAL TREATMENT OF SYPHILIS. we have to fall back upon the iodides (which also sometimes fail us), gold, the vegetable remedies, or somethiug else — touics, mineral waters, and the like. The other bad effects produced by mercury arc salivation and diar- rhoea, with griping pain. The well-known poisonous effects of the stronger mercurials (bichloride, biniodidc, bicyanidc, etc.) render it unnecessary to discuss death from an overdose of one of the latter class. The general intelligence of modern practitioners renders it equally unnecessary to more than allude by name to mercurial tremor and mer- curial cachexia, neither of which could occur except after an inordinate, unjustifiable use of the drug, although mild tremors arc noticed some- times after mercurial baths. (For the irritating effects of mercury used locally, see Inunction.) Salivation. — Salivation is harmful. It should not be aimed at. The greatest effect that it is allowable to produce by mercury is to ** touch the gums," as it is called. When the gums are touched there will be an increased flow of saliva, a faint coppery taste in the mouth, some tenderness of the gums, tongue, perhaps of the whole buccal cavity. Pressing the teeth firmly together causes slight jiain, while a little swelling of the gums and a faint reddish line at the neck of the teeth may be noticeable. Sometimes ulceration along the edges of the tongue or gums, or on the inside of the cheek, is caused by mercury, while there is still no tenderness about tlie mouth, nor a very markedly increased flow of saliva ; but this is rare. The mouth should be inspected before commencing a mercurial course, so that the condition of the teeth and gums may be known. A patient with ragged teeth covered with tartar is not in a fair condi- tion to test the therapeutic effect of mercury ; his gums, naturally tender, will become affected long before his point of true tolerance is reached. It is, therefore, wise in commencing a mercurial course, to send the patient to a dentist, with injunctions to have the tartar en- tirely removed from his teeth, both to make the observation of the effect of mercury more accurate, and to remove one source of local irritation capable of keeping up mucous patches. The quantity of the drug necessary to produce an effect upon the gums varies with each individual ; minute doses will occasion it in some cases having special idiosyncrasies ; others may take enormous doses before the symptoms yield or the gums become affected. The point of satura- tion or "tolerance" of a given patient can only be learned by close observation of the symptoms just described. After this we have his gauge, and can temper his treatment according to the urgency of his symptoms. Should salivation accidentally occur, or be encountered in practice, it requires treatment. The effect of mercury is by no means increased by keeping a patient salivated ; on the contrary, the disease is not benefited, while the patient is positively injured. BAD EFFECTS OF MERCURY. 5gl The cause of salivation is special idiosyncrasy with a small dose of mercury, or no idiosyncrasy with large doses. A mouth kept dirty or containing bad teeth is more apt to suffer. The influence of cold and wet during a mercurial course seems sometimes (though very rarely) capable of inducing it. Bumstead mentions a patient who became "profusely salivated a month after the cessation of a mercurial course as a consequence of exposure to the rain." Symptoms. — In salivation the salivary fluids flow freely, sometimes to an enormous extent ; the breath is fetid, the metallic taste is very marked ; the gums are sore, perhaps bleeding ; the teeth feel too long for the patient to shut his mouth — tapping lightly upon them causes pain ; the tongue swells, showing marks of the teeth ; the lips and cheeks may also become tumefied. Often there is febrile excitement with mental depression ; the lymphatic glands in the vicinity become swollen and painful. The teeth may fall, or portions of the soft or bony parts necrose, in extreme cases. Articulation is indistinct and painful, deglutition almost impossible. The above is a description of a severe type case of mercurial stoma- titis. Between this and the mildest increase in the salivary flow with "touching of the gums," the affection assumes all shades and varie- ties of intensity. The patient should be cautioned to report for in- spection on the advent of the earliest of these symptoms, that possibly impending salivation may be averted. Treatment. — Salivation may often be kept off by the administra- tion of large doses of the chlorate of potash during a mercurial course, and that, too, without interfering with the effects of the mercury, as Ricord has shown, but it is better to hold this remedy in reserve for exhibition in case symptoms of mercurial) zation should suddenly run high. During salivation, or any sore mouth from mercury, ten to twelve grains to the ounce of chlorate of potash in water, or any bland, fluid, should be kept constantly on hand (warmed), and with it the patient should repeatedly rinse his mouth and throat. At least one drachm, and not more than two, of the same remedy daily should be introduced into the patient's circulation, either through the stomach, if he can swallow, or by the rectum. A mild solution of carbolic acid or of Labarraque's solution, or water rendered pink with a little per- manganate of potash, should be occasionally used as a gargle, where there is great fetor of the breath. The free use of the hot bath is of advantage in cases of salivation, and of a bland, mild diuretic, prefer- ably a diluent water such as Poland or Bethesda. The diarrhoea, unless very profuse, should not be stopped, for the escape of the mer- cury takes place most freely from the intestine, next by the kidneys and skin, and these channels should be kept open and their activity encouraged. A little tincture of belladonna may be given to restrain the salivary flow and comfort the patient, or atropia may be used 86 562 GENERAL TKEATMEXT OF SYPHILIS. hypodcrmically, y J o" of a grain at a dose, repeated every six hours until the pupils show the elfect. Astringent gargles, Labarraijue's solution, tincture of myrrh, hot milk, cold tea, and other substances (gum-water) may be used as mouth-washes tentatively. These means will gener- ally promptly overcome salivation. In all other respects the treat- ment of salivation is symptomatic. An anodyne or a laxative may be required — the physician selects the one with the use of which he is most familiar. Nourishment must be kept up by hot broths, milk, and soft articles of light food, until a subsidence of the swelling allows the patient to swallow solids. Diarrhoea with griping pains is apt to come on in many patients who arc fairly under the inlluence of mercury. If kept up, the patient loses appetite, runs down, and fails to derive benefit from his mercu- rial course. When any mercurial shows signs of disagreeing by the production of these symptoms, it is better to lower the dose, if the syphilitic lesions are under control ; otherwise, to change the mercurial preparation for a milder one, putting the patient at the same time upon a rice-and-milk diet, with linie-Avater and moderate doses of bis- muth, or to administer the mercury by some other method — inunction, fumigation. Opiates and astringents may be combined with the mer- curial, to prevent its irritating effects, but it is better to avoid them if possible, or in any case to try first the means above suggested. Elimination of Mercury from the Body. — Mercury gets out of the body chiefly through the intestinal canal, then through the salivary glands, the kidneys, the skin. Schuster,* of Aix-la-Chapelle, has made a study of the elimination of the drug to determine how long it re- mains in the system after the patient has ceased taking it by inunc- tion. His methods (the Ludwig-Fiirbringer modified by Schridde) seem to have been very thorough. Sometimes mercury is found in the urine during and after a mercurial course, sometimes it is absent. Its quantity in the urine is not great. In the contents of the rectum it is always present in large quantities. Forty examinations of fseces found mercury in relatively large quantity during the inunction course. It continued for five and a half months after the end of the course, never later. From this, Schuster concludes that mercury is not stored in the organism, but is eliminated at a uniform rate during six months, after a long (forty-five days) inunction course. He thinks that traces might be found at eight months, but not later. Many patients, ex- amined eight and twelve months after treatment, did not show a trace of mercury under analysis. Vajda and Faschkis,t reflecting the doc- trines of the Sigmund school, tried to prove that mercury is irregu- larly eliminated from the organism through the kidneys. They claim to have found mercury in the urine, two, three, five, seven, and thir- * "Journ. of Cut. and Venereal Diseases," September, 1883, p. 353. \ "Ueber den Einfluss des Hydrargyrum," etc., Wien, 1880. METHODS OF ADMINISTERING MERCURY. 5G3 teen years after the cessation of relatively short courses of inunction. Schuster objects to these conclusions because the patients furnisiiing the urine in the last-mentioned set of cases had remained a certain time in Sigmund's wards — several of them as long as thirteen days — before the urine was tested. Schuster believes that in this time they inhaled enough mercury from the patients being treated by inunc- tion to show traces in the urine. Vajda's experiments, showing absence of mercury from the air of the wards, are balanced by Lese- mann's * report of one hundred and forty-four cases in the Kalinkin Hospital, St. Petersburg, who states that, notwithstanding the small amounts of mercurial ointment used (3j to 3 j), stomatitis occurred not only in patients under treatment, but in those using no mercury. Pie ascribes this to mercurial vapors in the ward, but it seems like begging the question when one man finds what no one else has ever observed. Consequently my impression is that the last word has not been spoken, and the evidence is not all in, the reports thus far com- ing from prejudiced persons, those having a point to make. Such observers can never view a subject in a judicial way. Yet Schuster's investigations are valuable and must stand for the present — ^until con- troverted. Methods of administering Mercury. — The effects of mercury are produced no matter how the drug is employed ; hence the choice of a method depends mainly upon the ease of its administration, the promptitude of its action, or upon the desire to i^roduce or to avoid some local, useful, or disagreeable effects. It is on this account that, for treating general syphilis, the method by the stomach is the best. Since it is necessary to continue the use of mercury for a long time, unremittingly and continuously, it becomes at once apparent that the docility of the patient is taxed severely to keep him under treatment at all, and common sense avers that the ordinary patient will take his medicine steadily by the mouth in many cases where he would abso- lutely refuse to continue it by any other method — as by the hypoder- mic injection, inunction, fumigation. All of these methods have their value in the rapidity of their action, and from the fact that they spare the stomach ; but, for prolonged, regular treatment, the latter organ must be relied upon. Even the advocates of other methods do not propose them for continuous use, but only to combat symptoms — call- ing the disappearance of an eruption a cure of sj^philis, and the next eruption a relapse. Among the methods in common use for the administration of mer- cury at the present date, five require mention. They are, in the order of their I'espective value to the practitioner : 1. By the stomach. 2. Local. * "St. Petersb. med. Wchnschr.," March 13, 1883. 56-4 GENERAL TREATMENT OF SYrniLIS. 3. Endcrmic (inunction). 4. Fumigation. 5. Hypodermic. 5. Hypodermic Injections. — In favor of this method, first used by Scarenzio, of Pavia, in 1854, it may be said that eru])tions, iritis, and lesions relievablo by mercury, seem to yield very rapidly during its employment, as a rule. The method employed is tlwt of Lewin,* more or less modified. From one sixteenth to one eiglith of a grain of sublimate, with perhaps a little morj)hine, dissolved in fifteen minims of water, is injected once or twice daily under the skin — preferably of the back below the scapula, or deeply in the gluteal region. Any number of other mercurial preparations have been used and had ardent advocates. Calomel is bad, because it very often causes abscess ; the urate of mercury is said to be very bland — I have not tried it ; various albuminates and mercuric peptones have given good results, but their preparation is troublesome and they do not keep. The same objection (that of instability) holds against that admirable preparation devised by Licbreich, the formamida of mercury. It is difficult to procure in this country, and will not keep. I have used it subcutaneously with admirable effect in some severe cases where I wished to spare the stomach. It does all that can be expected of a mercurial, and is less irritating in its local effect than simple corrosive sublimate. But the latter answers perfectly well. It is always at hand and easy to pre- pare, and, if freshly made in distilled water and deeply injected, it never (in my hands at least) produces local abscess, although it often causes moderate pain. It is prompt in its action, and a dail}^ dose of one sixteenth of a grain is usually enough, but may be doubled. The objec- tions to the hypodermic treatment are, however, sufficient to condemn it unless in exceptional cases, where the patient can not take the drug by the stomach for any reason, or when a very speedy and pronounced action is required for a short time. Abscess may follow the puncture, or a hard, painful lump, lasting some time. Salivation may be pro- duced unless considerable Avatchfnlness is observed. The injection of calomel, or yellow oxide of mercury, in vaseline-oil, now popular in Paris, is not, in my opinion, to be commended. Its effect, often brill- iant, sometimes fails, while the pain experienced occasionally disables the patient for days. I do not think that the method can ever be- come popular in private practice. I have tested it only among dis- pensary patients, and have abandoned it. 4. Fumigation. — This method is an excellent one, but not practi- cably applicable. It requires an expenditure of time and care, such as the ordinary patient will not continue to give it*for a long time. It is useful where prompt and kindly action of mercury is aimed at. Im- provement of symptoms sets in rapidly after the baths are commenced. * " Beliandlung der Syphilis mit subcutaner Sublimat-Injection." FUMIGATION. 505 Salivation is rarely induced. Fumigations may be taken daily, where the patient is robust and bears the treatment well, for three or four days, but then the interval must be lengthened, and once a week is usually enough to keep up the mercurial effect. Depression, headache, faintness, tremors, occasionally salivation, or diarrhoea, attend this mode of treatment, when the patients are impressionable. Langston Parker* has done much to develop this form of treatment. f The best method of fumigation is that found in Turkish bathing establishments. The simplest method for domestic use is the follow- ing : Direct the patient to procure at a tin-store a piece of tin ten inches long by three and one half broad. This should be bent to a right angle at two and one half inches from either end, or at a con- venient distance for the action of a flame from a low (tin) spirit-lamp placed beneath the table, formed by bending the ends of the tin (Fig. 112). Upon this ''table " the powder to be volatilized is scattered. The patient undresses entirely. The lamp and tin, covered with the mer- curial selected, are placed in position beneath a cane-bot- tomed chair. The patient, naked, sits upon the chair, and wraps himself and the chair completely in a couple of thick blankets, drawing the latter snugly be- neath his chin. A Bunsen burner attached to the gas-fixture by a rubber tube will give a better volatilization than a spirit-lamp — but the latter answers very well. A pan of steaming, boiling water is now placed under the blankets. As soon as the confined steam has rendered the body warm and slightly moist, the spirit-lamp under the chair is ignited. The bath lasts from fifteen minutes to half an hour. Profuse perspiration usually comes on. After fifteen minutes, if the patient is uncomfort- able, the light may be extinguished, but remaining in the fumes five or ten minutes longer is of advantage. The patient now wraps one * " On Syphilitic Diseases," London. f Mercurial fumigations are administered in most of the Turkish and Russian battling establishments in all large cities ; but it is the universal experience of physicians that the proprietors of these establishments are prone to tamper with patients, and invariably fail to carry out instructions received from the physician. Otherwise the facilities of such establishments of mingling steam with the fumes of mercury are unequaled. In these institutions, where the head is also immersed in the fumes, the black oxide is the most suitable mercurial to be employed — from one to two drachm doses. Fig. 113. 566 GENERAL TREATMENT OF SYPHILIS. of the blankets aroiiud him aud lies down, without wiping off the mercury, until he has cooled. Of the different mercurials generally used in fumigation, calomel is the best. About a !^cruple is enough for a batli ; the diminution or increase of this dose is regulated by circumstances. Calomel is better than the other substances used, because it volatilizes promptly with a heat easily attained by a spirit-lamp, and whatever of the fumes escapes into the room is not irritating to the fauces. The red oxide of mercury also volatilizes without reduction. All the other substances in common use — metallic mercury, mercury with chalk, the gray oxide, the black oxide, the binoxide, the yellow oxide, the bisulphuret — are exactly the same thing ; they all reduce lirst, and tiien the metallic mercury vola- tilizes. Pure metallic mercury boils at GG2°, and is apt to sputter on the application of dry heat before it volatilizes. It takes considerable heat to vai)orize it. AVhen the red sulphuret of mercury is employed, the fumes are tiiose of sulphurous acid and metallic mercury ; the former is often irritating to the pharynx and lungs, and the prepara- tion should not be used without circumspection. Calomel is often objectionable if the head is kept in, as the inhalation of its vapor in some instances gives rise to intense paroxysms of coughing, often pro- longed, spasmodic, and painful ; others inhale the calomel vapor with- out distress. The black oxide, 3 j or 3 ij, can be used if a Bunsen burner is employed. Its fumes are very bland. 3. Immctmi.— This is perhaps, of all, tlie best means of exhibiting mercury. It spares the stomach, and is thorough and efficient ; saliva- tion produced by it is usually announced by coming on slowly, and need not generally be allowed to become severe. It may produce any of the bad effects of mercury, but is not likely to do so if watched. But it can not be used for continuous or for very mild treatment. The dose can not be strictly regulated, because it is impossible to know how much is absorbed ; its application is very dirty, and it sometimes produces a local eruption (mercurial eczema) which is annoying. I have tried preparations made with lanolin, but dislike them. The oleates, which I formerly used, I have given up. They, too, irritate the skin— not always, but oftener than ordinary mercurial ointment. I believe that there are only two methods of using mercurial in- unction that are generally satisfactory. One, not the best one, but suitable for some cases, and especially for infants upon whom it is de- sired to try the inunction method, is the method known as Tcale's. Some mercurial ointment is spread upon a ])atch as large as the palm of the hand or thereabouts, and this is bound about the arm, forearm, leg, thigh, body, as the case may be, the ointment being kept upon the thin skin, changed from time to time, and shifted when the under- lying skin begins to show signs of redness, or to itch. Such a band- INUNCTION— LOCAL USE OF MERCUKY. 507 age, or two of them at a time, may be worn night and day, sometimes for weeks, without being shifted. In other cases they have to be changed every few days, because the skin begins to show signs of irritation. When the bandage is removed, the surface sliould be thoroughly washed with warm soap and water and left dry. Decidedly the best method of inunction, in my opinion, is that practiced at the hot springs. When I use inunction upon the adult I generally employ this method. The patient takes a bath, a long one, in hot water. After drying himself he sits astraddle a chair, with his face toward the back of the chair, his arms folded upon the back, and his chin resting upon his arms. An attendant now rubs in broadly, and with a vigorous circular motion of the hand, over the entire back a given quantity of mercurial ointment, generally one eighth or one sixth of an ounce at a rub. The friction continues for twenty minutes. If the frictioner fears mercurialization, he may pro- tect his hand with a rubber glove. The ointment thus rubbed in is left upon the back, and the patient puts on first a thin gauze under- shirt (which he wears a week as a mercurial shirt), and over this his ordinary undershirt and customary clothing. At the end of twenty to twenty-two hours the patient takes another hot soap-and-water bath, is thoroughly washed and dried, and takes another friction, as on the previous day, again putting on his mercurial shirt. Such a course in New York generally produces mild commencing salivation in a week, if it is thoroughly done. Inunction is most valuable in severe chronic lesions of the brain and spinal cord, and when a prompt, thorough mercurialization is desired for any reason. 2. Local Use of Mercury. — The local treatment of the various syphi- litic lesions is, of course, subordinate to the general treatment, but yet it is often of considerable importance, and spares the patient the necessity of considerable internal dosing. An outline of many general applications for local use will be given here to avoid repetition. If any special local means is particularly ap})licable to any individual lesion, it will be alluded to again when considering that lesion. Local Measures stcitable to Cutaneous Lesions. — The early erwp- tions require no local treatment, except for such of the lesions as ap- pear upon the hands and face and cause an unsightly appearance. The best local applications for these lesions are the mercurial ones. Tertiary groups of dry lesions also sometimes improve faster under local mercurial applications, or if a mercurial solution is injected into the subcutaneous tissue beneath them. Ulcerative forms do better under iodoform, or sometimes stimulating applications (chloral). The mercurial local applications to do good locally must stimulate as much as possible, and irritate as little as possible. Hence there must be a graded strength in all local applications, and, if their use causes 568 GENERAL TREATMENT OF SYPHILIS. the skiu iuA'olvod iu the lesions to grow red, ghissy, or to excoriate, they are too strong, and must be discontinued. I use mostly the following formuliy : 9 Ilvdrarg. oleat., 5 to 10 per cent. 5 Ilydrarg. chloiid. corros., gr. j-iv. Spts. rcct., q. s. Glycerin, V[ xx. Aquffi, ad 3 j. R Hydiarg. ammoniat., 3 j- 3 jss. Ungt. atiiuc rostr, § j. R Ilyilrarg. chlorid. niitis, 3 j-ij- Adipis, . 3 j. R Ilydiarg. oxid. flav. 3 ss- 3 jss. Ungt. aquae rosse, 3 j. R Ilvdrarg. acid nitrat., used pyre with a glass rod, or diluted and applied only to small areas at a time. R Hydra rg. oxid. rub., gr. xx- 3 ij. Ungt. aqutC rosae, 3 j. R Hydrarg. iodid. virid., gr. xv- 3 j. Ungt. aqua? rosse, 3 j. R Ungt. hydrarg. nitratis, diluted at first. Preparations of tar and oxide of zinc are often also in place. Mucous imtches upon the skin do well if kept dry and painted with the bichloride solution, or touched with the acid nitrate of mercury, diluted three to five times. Mucous patches at the anus, alongside the scrotum, under the foreskin, between the toes, under the breasts, or between any two overlying portions of skin which keep the surfaces moist and sodden, and favor putrescence, require cleanliness, disinfec- tion with Labarraque's solution, permanganate of potash, or corrosive chloride of mercury, in mild solution, to be kept as dry as i^ossible by the interposition of absorbent cotton, and dusted with calomel, pure or combined with bismuth, oxide of zinc, or iodoform. The nitrate- of-silver pencil is of service in these cases. Ulcerated Lesions upon the Shin. — The local treatment of these is often simply protective and disinfectant ; cleanliness, balsam of Peru, the use of the black and reduced yellow washes, iodoform powder, or simple mutton tallow, to prevent the edges of the ulcer from sticking to the dressings. This is when the ulcers are fresh, and being actively treated by internal means. "When they grow old with hard edges, an uneven base without granulations, then they call for l(5cal stimulating measures, scraping, scarification of the edges, hot local fomentations, the prolonged hot bath. Chloral, gr. v-xx in the ounce of water, is a useful local application to make granulations sprout. Strapping USE OF MEKCUKY I5Y THE STOMACH. 5fj9 with adhesive strips, pressure by rubber blindage, all local measures of a surgical sort applicable to chronic ulcers, come into play lierc. If dead bono lies at the bottom of an ulcer, it must separate before tlio ulcer will get well. Sinuses must be opened and scraped, and full attention given to hygienic and general dietetic measures in the treat- ment of the more obstinate of these cases. Local Treatment of Lesions upon Mucous Membranes. — Cleanli- ness is the first requisite in the management of all syphilitic lesions upon mucous membranes, and the removal of all irritating agents. The teeth should be cleaned with a soft brush, all tartar removed, jagged edges of teeth filed down, and old stumps extracted. Tobacco should be stopped where there are mouth lesions, for its use either in chewing or smoking will often more than counterbalance the effect of local and general treatment. The sexual parts and anus, if involved, must be kept as far as possible clean and dry. Gargles and soothing mouth-washes, borax, alum, chlorate of potash, flaxseed infusions, myrrh, tannin, and other substances may be used with advantage in a general way when the mouth is the seat of syphilitic lesions. A mouth- wash made with one grain of Keith's muriate of hydrastin to the ounce of water, or more, seems sometimes to give considerable com- fort. I formerly thought very well of local mercurial fumigations, but I have discarded them, finding mercurial solutions as good, and easier to use. Upon mucous patches, milk -spots of epithelial thickening and moderate ulceration, nitrate of silver, the solid or mitigated stick, sometimes a solution with a brush, varying the strength from gr. j to gr. X to the ounce of water. Sulphate of copper, as a mounted pencil, to be used lightly by the patient himself once a day. Bichloride of mercury in solution, about gr. ij to the ounce, applied with a brush. The acid nitrate of mercury pure, and applied sparingly with the blunt end of a glass rod. This I consider the best application of all, but as a drawback the pain it produces upon some patients is very severe, and lasts several hours. It need not be reapplied more than once a week, and is very effective. I sometimes order it for patients to use themselves upon the lesions of the mouth or elsewhere, reduced in strength, 3 j in § J of water. Upon the anus, and under the prepuce, mucous patches and ulcers are treated as already described when speaking of these lesions upon the skin. 1. Mercury by tlie Stomach. — This means must be adopted in the vast majority of cases, and it is only in examples of rare idiosyncrasy that it is objectionable. As already stated, the general action of mer- cury taken by the stomach is not so rapid as by other means. It may. however, be so taken for any length of time, is very little troublesome, can be continued while traveling, and without making the patient 570 GENERAL TREATMENT OF SYPHILIS. conspicuous to his friends, and it can be so used as to act as a tonic as well as a specific, and to do the patient no possible harm while he is taking it.* ScA-eral forms of mercury have proved themselves by experience to be especially adapted to prolonged use by the stomach in syphilis ; they are the protiodidc, tlie bichloride, blue-pill, and gray powder ; the latter has been used chiclly with infants. Calomel is usefnl in those cases in which it is desirable to bring the patient very rapidly under the full influence of mercury. Administered in one-twclfth-grain doses every hour, it will often "touch the gums" in twenty-four to forty-eiglit hours, and with safety, for its prompt discontinuance on the first appearance of signs of salivation prevents the development of the latter. These preparations leave little to desire, and among them any patient can bo suited. I rarely use the biniodide, as it is too irri- tating to the intestine. I have experimented with tiie tannate, which is being brought forward rather prominently of late years in Germany and France, but I do not find it better than the drugs we already use, and the different preparations vary greatly in their effect in my hands. Gray powder and blue-pill are good preparations when the protiodide proves too irritating to the intestine, as it sometimes docs. The bi- chloride is a very tonic preparation, especially Avhen combined with tincture of cinchona, and is more prompt than the others. My choice, however, is the protiodide. I do not like the other drugs as well, for the simple reason that they do not irritate the intestine sufficiently, and frequently first announce that the patient has reached the satura- tion point by the mouth in the way of a slight touching of the .gums rather than first by the bowels, as is the customary way in the case of the protiodide. This irritation of the bowels gives warning that the full dose is reached, and the patient is still a long way from salivation ; and I consider this an advantage, for the griping and diarrhoeal effect can be controlled, if need be, for a time, by mild opiates, and the half or tonic dose habitually used does not upset the bowels at all. Lately several enterprising pharmaceutical chemists have been endeavoring to produce a pure protiodide of mercury, for the drug as habitually made is very unstable, and promptly changes in part into metallic mercury, with traces of the biniodide, and these changes take i:»lace in spite of the exclusion of light and air. This alleged pure drug does not change if slightly protected in a yellow bottle, and is itself not green, but of a brilliant canary yellow. These yellow pills I can not advocate, and do not use often ; they (as made in one-sixth, one-fifth, one-quarter-grain granules) are too powerful, too much like the bin- iodide in their action. They irritate the intestine too much in most instances, and can not be taken comfortably by the patient in sufficient doses. It is not important, from my standpoint, that this yellow drug * "The Tonic Treatment of Syphilis," New York, IS'?! TONIC TREATMENT. 5Y1 is pure protiodido and the green drug an impure article. The latter serves me best, and I therefore adhere to it, pure or impure. A reli- able, trustworthy, uniform preparation is what is desired — one that a patient may obtain as well in one part of the country as another. Such a preparation I believe exists in the French granule (sugar- coated) of Gamier and Lamoureux. The little pill keeps for ever in all climates, and all the loills seem to be uniform in their effect. As compared in irritative (intestinal) influence with the yellow granules of American manufacture, I find the latter powerful in this direction as one to three ; that is, if it takes eighteen of the French granules a day to produce diarrhcea, with pain, six of the American will produce about the same irritative effect. When the patient is of a strongly constipated habit I sometimes employ the American granules, other- wise always the French, when the protiodide can be taken at all. Sometimes even the French granules are too irritating, and occasion- ally a patient can not take even one granule without feeling its effect upon the bowels. In such case blue mass, gray powder, or small doses of bichloride may be used instead of the protiodide gi-anules. I consider about one half of a grain of blue mass equal in effect to one sixth of a grain of protiodide, and about one thirtieth of a grain of the bichloride to be an equivalent dose ; and often use one of the sub- stitutes alone or combined when the protiodide proves unsuitable. Tonic Metliod of Treatment by Mercury. — By this title I mean the use of mercury in such a way in the treatment of syphilis by elimination (persistent long course of a specific drug), that the mer- cury, over and above its antisyphilitic effect, shall act as a tonic — that is, shall increase the number of the red blood-cells, and the gen- eral consciousness of health and vigor in the patient, I do not mean that mercury cures syphilis because it is a tonic, but that it may be used efficiently in such a way that it shall be a tonic. Even if it were not a tonic, I should use it if it were the best drug with which to control the manifestations of the disease ; but if it can (measurably) control the disease, and yet not hurt the patient, so much the better. For more details of the tonic treatment I must refer to another place.* The outline of treatment is the following : The same drug should be used continuously if possible. It may be changed occasionally for a time to meet an emergency — i. e., when, in spite of the tonic dose, as is often the case, there suddenly occurs an outcrop of fresh symptoms. Now, instead of using the " full dose," some other more active means may be employed, as bichloride internally or by injection, fumigation, inunction, etc., until the new symptom yields, after which it is well again to revert to the original drug and fall back upon the " tonic dose." The standard fractional dose being selected, preferably in form of * " The Tonic Treatment of SyphiUs," D. Appleton & Co., New York, 1811. 572 GENERAL TREATMENT OF SYPniLIS. granules — oue sixth grain of protiodide (one contigrammo), one half grain blue mass, one thirtieth grain bichloride — it remains to find the "full dose" and the "tonic dose." No combination containing opium can bo used in selecting a standard fractional dose. The diet and liabit should be regulated, and the course commenced by causing the patient to take one granule of the standard (I i)refcr the Garnicr and Lamoureux one-centigram me granule) preparation immediately after each meal for three days — that is, three a day. For the next three days he takes four a day (one in the morning, two at noon, and oue at night) ; then, for three days, five a day (two in the morning, one at noon, and two at night) ; then, for three days, six a day (two in the morning, two at noon, and two at night) ; then, for three days, seven a day (two in the morning, three at noon, and two at night) ; then eight, and so on, adding one granule to the daily dose each fourth day — if there is reason for haste I make it each third day — until per- nicious medicinal etiects of mercury begin to show themselves, which are, with the protiodide, usually griping pains in the abdomen, and at least two free watery stools a day. An occasional pain I pay no attention to, and free movements of the bowels I do not regard so long as these movements are not watery. Mild colicky diarrhcea is what I wait for, and when this comes I write down the daily number of pills required to produce it, and name this number the "full dose." Such a dose may and usually does promptly control syphilitic symp- toms, and it may be maintained, and its obvious objectionable features done away with, by giving the patient a certain number of half-grain granules of opium to take along with his protiodide. If blue-pill, gray powder, or bichloride be used, the full dose may first announce itself by commencing irritation at the mouth before the intestines show disturbance. This full dose can not be maintained without injuring the patient (as I have proved in another place), and it must only be used for a short time when required for emergencies. Half the full dose is the "tonic dose," and sometimes one third the full dose is all the patient requires to keep him moderately free from symptoms, which is all he can ask. If, when the patient is first seen, his symptoms are so severe that he can not wait to find his dosage by this method, he may be more actively treated by bichloride, by fumigation, or inunction, until his active symptoms are over — and then, after a rest, his full dose may be sought in the manner above described — and his tonic dose obtained. Few patients can take more than twelve granules a day for their full dose, and more stop at nine. I have known a patient go to twenty. If a patient can not take three a day I consider him unfit for treatment by the protiodide. The size of the "full dose" varies greatly for different individuals. TONIC TREATMENT. 573 The patient then is not to be kept at his full dose. If he has act- ive symptoms he may be kept at three quarters of the full dose, or the latter may be maintained by opium until the emergency is over. If the symptoms arc not active, a rest should be given for several days until the ill effects of the mercury have entirely subsided, and then the ''tonic dose" may be commenced with the idea of continuing it daily, month after month, for an average of about two and a half years. Under this dose — one half or one third of the "full dose" — the patient will often, but of course not always, enjoy better health than he did before he got his chancre — that is, he will eat, drink, sleep, and work with greater satisfaction to himself. Truly, he will have occasional drawbacks in the form of mouth-spots and of out- cropping syphilitic symptoms, and these must be met by appropriate local means or by temporarily putting in a portion or even the whole of the "reserve dose," to constitute the "full dose," protected by opium until the flurry is over. This is the outline of treatment. Under it intermediary or ter- tiary symptoms may never appear. When they do, the iodides and vegetable preparations may be added, the granules being kept up. There is not any truth in the statement that there is danger in giving the protiodide of mercury in connection with the iodide of potassium on account of possibility of poisoning the patient by the formation within the body of the biniodide of mercury. I do it daily. The patient may prefer his medicine at a single dose, and it is not well to be inflexible about the accurate " tonic dose " after a time. I often give the granules for a year, and then common mixed treatment — to be mentioned presently. But again, I often give practically nothing whatever except the granules for the entire treatment of, in the shortest cases, eighteen months, the longest, three and a half or four years — this being continuous treatment. When purely gummatous symptoms occur, I usually stop the mer- cury entirely, to resume it for a time after the iodides have controlled the symptoms. If intercurrent maladies come on, the treatment may be suspended entirely during their existence, without ultimate detriment to the pa- tient. In any case of intercurrent diarrhoea the tonic dose should be suspended. When something besides the tonic course is required, the bichloride of mercury may be given in a bitter menstruum, increasing until the symptoms yield, or some disagreeable result of mercurialization seems imminent, carrying the dose to one eiglith or one sixth of a grain.* * Muriate of ammonia is frequently added to solutions containing the bichloride, to increase the solubility of the latter, where large doses are given. A saturated solution of hydrochlorate of ammonia dissolves seventeen times more bichloride than simple water. 574 GENERAL TREATMENT OF SYPUILIS. Tlie common solution in tincture of bark (or the elixir) is as good as any that can be desired : IJ Hydrarg. bichlorid., Ammouii sesquichloriil., ail gr. jss.-iij. Tr. cinchoua} co., § iij. M. S. : Teaspoonful, largely diluted in water, aftir eating. Or the old New York Hospital formula — 1} Ilvdrarg. biclilorid., pr. iv. Tr. ferri sesquiehlorid., 3 j. S. : Ten drops in water after eating — may be exhibited with good effect in anaemic cases where the stomach is not weak, as in the earlier outbreaks attended by syphilitic fever, where a tonic is particularly required — in some cases indeed to the total exclusion of mercury. When it is deemed advisable to give the bichloride in pill-form, it may be combined with reduced iron, as in the followinsr : Hydrarg. bichlorid., gr. j. Ferri redact., 3 jss. Gum. tragacanth.. Glycerin!, [q- s. M. F. pil. No. XV. In an^Bmic women the New York Hospital formula is a good one, in which blue-pill, gr. ij, is combined with gr. j of the dried sulphate of iron in pill-form. The quantity of either ingredient of the pill may be increased if circumstances require. Finally, the gray powder (hydrarg. cum creta) may be employed, increasing from two-grain doses. Trousseau's suggestion of one-tenth-grain doses of calomel every one to three hours for the intense early headache of syj^hilis must not be forgotten. In advocating a methodical course of mercurial treatment like the "tonic course," I do so with the conviction that it possesses many merits and no fault that I recognize except one — difficulty in keejoing the patient up to his course. I have found, however, much less trouble with intelligent patientst than with others, the objection with intelli- gent patients being that they expect too much of the course, and sometimes become disheartened when they see symptoms appear, and others persist while they are taking it. On this head they can be comforted by the assurance that the course is eliminative, not suppres- sive ; that, if a few moderate symptoms persist, local treatment is a suitable adjuvant ; that, if new symptoms appear, then is the time to add the reserve dose, or part of it, or to throw in some iodide of potas- sium for a time. They can also be assured that they are taking mer- cury in the mildest manner, that it will not hurt them if they con- tinue taking it for several years, that it will not remain in the system. MIXED TREATMENT. 575 and that their chance of positive cure and escape from late tertiary symptoms is exceedingly good under this method, although such im- munity can not be positively assured by any method. My experience with the method now covers fourteen years, and for thirty years be- fore that a somewhat analogous method was carried out in the office by Dr. Van Buren before me, and by both of us after I joined him. The results have been satisfactory. TREATMENT OP LATE SYPHILIS. If there is no intermediary or tertiary set of symptoms, as is often the case, there is never any positive necessity for the use of iodide of potassium unless the early symptoms are severe or much protracted. Generally, however, some of the later symptoms come to the surface, and then the iodides must be used — in connection with mercury in all cases excepting those of pure gummatous deposit, in which only the iodides are required. Wlieu both drugs are combined, the treat- ment is called mixed. Mixed Treatment. — When during the tonic course there is a call on the part of the symptoms for the iodides, they may be given while the granules of mercury are continued, or iodides internally may be perfectly well combined with fumigation, or with the use of mercury by inunction, as practiced at the hot springs. Often, however, it is better for a long course to combine all the drugs required in a single dose. This may be done by using biuiodide or bichloride of mercury with any of the iodides. The objection made by many, myself formerly among them, that bichloride of mercury was converted, in part at least, into biniodide when placed in solution along with iodide of potassium, is not worth maintaining, I think. The effects of the bichloride com- bination seem to be generally better than the other, and that consid- eration overpowers all purely chemical objections. When iodides are given in combination, a little ammonia (Paget) is often added, under the idea that the effect of the iodides is intensified, and the tolerance of the patient to the drug increased. There is also no objection to combining iron with the prescrij)tion, or arsenic (when required either for the eruption for tonic purposes or to make the pa- tient bear the iodide better). An excellent combination of this sort for prolonged use is the following : 5 Hydrarg. chlorid. corros., gr. j-iij. Liq. potassse arsenit., ni xij-l. Ferri ammonio-citrat., 3 ss.- 5 ij. Aquae ammonia, 3 ss. Potassii iodidi, 3 ij- § j. Syr. aurantii corticis, § jss. AquEE, q. s. ad f 3 iij. M. S. : Teaspoonful in water three times a day. 576 GENERAL TREATMENT OF SYPUILIS. Such a mixed formula is not usually called for, and those more generally useful are such as the following : TJ Ilyilrarg. binioiiuli, gr. ss.-ij. Aiuiuonii iodidi, 3 ss. . Totassii iodidi, 3 ij- 3 j- Syr. aurantii corticis, 3 jss. Tr. aurantii corticis, 3 j. Aquae, q. s. ad 3 iij. M. S. : Teaspoouful in water three times a dav. Or, 5 Ilydrarg. chlorid. corros., gr. j-iij. Sodii iodidi, 3 ij- 3 j. Syr. zingiberis, 3 ij. AquiP, q. s. ad 3 iij. M. S. : Teaspoonful in water three times a day, and so on, tiic possible com- binations being endless. The Iodides. — Often the iodides have to be used alone and pushed to the point of tolerance. Also, when the tonic mercurial course is being followed, the iodides often hare to be combined with it. Under these and many other circumstances, it is better to prescribe the iodide of potassium in the form of a saturated solution in distilled water, and make the patient measure out each dose into a conical (not a cylindrical) minim glass : B Potassii iodidi, '% j. AqUcB destillatfe, q. s. ad f 3 j. * M. S. : A minim is a grain. This method is an admirable one when the dose has to be run high. The iodide of potassium is prepared in the form of five-grain compressed pills, but most patients tolerate the solution better, and no one can take very large doses in the solid form on account of tlie irritating effect upon the stomach. The iodides are agents of the very highest value in syphilis, and in purely gummatous and many of the nervous symptoms their action in very large doses is most gratifying. The iodide of potassium is the most efficient of the group. The iodide of sodium comes next. It is not so soluble, but a fifty-per-cent solution is perfectly stable. It is borne better by the stomach, but from my experience I judge that it requires nearly twice as much of this drug to produce an effect as of the stronger iodide of potassium. I have tested the iodide of ammo- nium and the iodide of calcium, but have practically discarded them. The so-called iodide of starch has sometimes given me good service. This is a mechanical rather than a chemical iodide. It is ordinarily made as directed in the pharmacopoeia with raw-wheat starch. I have had it made with cooked-rice starch, and like it better. It is well borne by the stomach but disagreealjle to take. It may be conven- iently swallowed in capsules containing ten or even twenty grains, or the powder may be mixed in water, milk, or broth, and so taken it THE IODIDES. 577 does not dissolve. The iodide of starch may be given in place of any of the iodides in common use. I have given as much as a heaping dessertspoonful at a dose. The tincture of iodine in starch-water I have abandoned for the prepared iodide of starch. The disagreeable after-taste left in the mouth by iodide of potassium may be best masked by peppermint or chewing liquorice-root. At the time of tak- ing the drug the sirup of currants or orange-peel is probably the best. The best time to take the iodides is during the third hour after eating, when the contents of the stomach are neutral and yet tlie organ is not empty. Even on an emjjty stomach the drug goes well if very largely diluted in water ; or, better, an efEervescent mineral water (Vichy or carbonic-acid water — soda water) ; or, better still, in milk.* The Dose of the Iodides. — There is no limit. I have given two and a half ounces daily. I have known of even larger daily doses be- ing given at the hot springs. If the diagnosis is correct, and if the iodides in excess are indicated, I know nothing which ought to arrest the increase in the dose except a subsidence of the symptoms — unless the iodides themselves are doing harm — of which I shall speak pres- ently. I have read somewhere of a death produced by one enormous dose of the iodide of potassium, but I can not find the reference. I believe the dose was one ounce, and had not been worked up to — ^but this is only an impression. The Bad Effects of the Iodides. — These, for the most part, are irritations of the cutaneous structures or mucous membranes. They are so strongly pronounced in some patients that they can not possibly be made to take the drugs very freely. Any one will sooner or later suffer from the medicinal effects of the iodides if he takes enouffh of the drug, but the variation in this particular is very wide. I knew one medical gentleman who at one time in his life could not touch his tongue to the moistened cork of a bottle containing an iodide-of-potas- sium solution without feeling the effects for a day upon the mucous membrane of his nose ; and another gentleman who experienced mild symptoms of iodism if the tincture of iodine touched his skin — at least, he affirmed the fact — and he was a physician of high intelli- gence. On the other hand, I have seen a patient take an ounce a day and suffer no ill effects, not even acne, although the metallic taste in the mouth is always much complained of when the dose runs high. The bad effects of the iodides f are five : J * Keyes, "New York Medical Journal," April 25, 1885, p. 467. f The supposed power of iodine, long administered, to cause atrophy of the testicles (the breast in the female), and abolish sexual vigor, is purely hypothetical. Temporary diminution of sexual appetite seems occasionally to depend upon the internal use of iodine, but the abolition of the power, or atrophy of the testicle, never — although syphilis may undoubtedly cause both the latter. X "L'lodisme," by Dr. Elisabeth N. Bradley, Paris, ISSv, is an excellent monograph covering the general subject. 37 578 GENERAL TREATMENT OF SYRUILIS. 1. Possible iudircct causation of salivation. 2. lodism. 3. Irritation of mucous membranes. 4. Cutaneous eruptions. 5. Anajtnia with nervous prostration and debility. 6. Albuminuria. 1. Salivafion. — A moderate amount of tenderness in the mouth, soreness of the gums at the line of the teeth, and increase of salivary flow, is complained of occasionally by persons taking iodic preparations. I have never seen such salivation run iiigh or be more than very mod- erately annoying. It has been alleged, with cases in support, that the iodides may suddenly make mercury, lying peacefully in the system, active, and thus cause salivation. I have not seen this, and it must be uncommon. Indeed, there are those who state that iodides act by liberating mercury and making more efficient that which is being taken. Although there may be a measure of truth in this it is not strictly true, because many cases of early syphilis are helped by the iodides when they have taken no mercury ; and I have seen cases of pure gummata in patients who had taken no niA'Cury early in their course, and who none the less improved rapidly under the iodides. 2. lodism. — A peculiar jioisonous effect is produced upon some pa- tients by the use of iodine, especially in the form of iodides. The symptoms are general irritation of the nerves, with depression ; the ears ring, the head aches, neuralgic pains are felt deep in the bones and muscles. There is more or less general torpor, with physical and mental depression. This affection is rare. It may occur from the least touch of iodine, or large quantities may be required to produce it. It occurs with or without irritation of the cutaneous or mucous expansions. 3. General irritation of more or less of the mucous expansions of the body, with perhaps some nervous phenomena, headache, pains in the bones (iodism). In mild cases this takes the form of "catarrh," or a simj^le cold. A sharj) coryza sets in, with sneezing and a plenti- ful watery discharge from the nose, perhaps with reddened conjunc- tivae and streaming eyes. Bumstead mentions, in rare instances, loss of vision, due apparently to sub-retinal effusion. The lining of the frontal sinuses may be hyperasmic and swollen, occasioning consider- able pain. The fauces and mucous lining of the lungs participate 'u\ these hyperaemic and secretory changes occasionally. Tiie symptoms sometimes reach a high grade, from swelling and oedema. A marked increase of the salivary flow is observed. J. S. Cohen,* of Philadelphia, has seen two cases in which he believes that oedema of the larynx was caused by the use of large doses of iodide of potassium. The stomach and intestines suffer less often than the nasal and * "The Hospital Gazette," August 9, 18'79, p. 3S3. BAD EFFECTS OF THE IODIDES. 5Y9 bronchial membranes, if the precautions arc observed of never giving the iodides solid, except in small quantity, during or immediately after a full meal. AVhen a large quantity is given, it must always be in solu- tion largely diluted, and taken two or three hours after a meal, or even upon an empty stomach. Sometimes a patient will take his dose just as well directly after a meal, and then for simple convenience he may as well do so. In irritable cases, however, a neglect of these precau- tions not infrequently produces pain in the pit of the stomach, loss of ai)petite, griping, diarrhoea. Mild attacks usually subside even with a judicious continuance of the remedy. But in rare cases the symp- toms are so violent that the drug has to be discontinued. The iodide of sodium is much less irritating than the iodide of for it with favorable effect, potassium, as has been already stated, and may often be substituted 4. Cutaneous Eruptions. * — There are four types of eruj)tions caused by iodic preparations. These are, in the order of their relative fre- quency, acne, erythema (more or less eczematous), purpura, and a bullous eruption. (1) Acne. — A few pustules or papulo-pustules of acne (simplex or indurata) generally appear during a course of the iodides. Their favorite site is about the forehead, cheeks, shoulders, back, buttocks, and extensor aspect of the limbs. They are usually unirnportaut, but sometimes they occur in profuse crops, covering nearly the whole body, and are then painful and unsightly. With acne may be associated large tuberculo-pustules and boils — ecthyma. (2) Erythema. — Iodic erythema, as commonly observed, covers the slopes of the nose and portions of the cheeks and forehead. It is fol- lowed by branny desquamation. It may occur upon other surfaces, isolated or in large patches, particularly on the forearms. It is some- times attended by papulation. Papules may appear, not acneic and not surrounded by erythema. The erythema may run on to eczema about the face and scalp. Mercier mentions a case where in the same patient, on two occasions, small doses of the iodide of potassium pro- duced a severe eruption of eczema rubrum over the whole body. (3) Purpura may be caused by large, sometimes by moderate doses of the iodides ; chiefly in debilitated, anaemic subjects, suffering from syphilitic cachexia and tertiary lesions. It occurs sometimes in pa- tients who seem to be well nourished. The best-marked cases of pur- pura hgemorrhagica, in the author's experience, are encountered in connection with advanced tertiary disease, as in giving large doses of iodide for nervous syphilis. Iodic purpura rarely gets above the knees. It is accompanied by some oedema. It may occasionally reach the thighs, or be seen upon the hands. It often ceases to ap- * An excellent study of this subject by Pellizzari appeared in the " Archives of Der- matology," July, 1881, p. 264. 580 GEXERAL TREATMENT OF SYPHILIS. pear upon cli.^contimiing the drug, or change of air. The exliibition of cod-liver oil, astringent preparations of iron, and other hygienic and tonic measures, are indicated. Purpura due to the iodides was noticed by Kicord. and written about by him as early as 1842. (4) A ju'cidiar bullous eruption due to the ingestion of the iodide of potassium has been noted by many observers who have written ex- haustively about it. Eicord first described it as a rui>ia. I have seen only two cases in which tliere were groups of bull;v scattered over the body, mainly upon the trunk and face, and a moderate number of separate single lesions. Most of the bulhi^ were umbilicated at first, and some of them readied a large size. The possibility of confound- ing it with varioloid has been pointed out. Its course, however, is different, and any attentive observer can not fail soon to refer it to its true source. Among the writers who have noted it are Bradbury, Virchow, Bumstead, Boinet, Pinger, Cazenave, Hutchinson, Taylor, Fournier, Duhring, Hyde, T. Fox, Finney, Duckworth, Farquharsen, Pellizzari, Van Ilarlingen, Morrow, Tilden, and others. Thin * has described it pathologically. Hyde \ intimates that all the iodic bul- lous eruptions may bo grouped into three sub-forms : 1. Simple bulla, seen in the old and cachectic. 2. A rarer polymorphic form — bulla3 mingled with papules, macules, and tubercles. 3. A quasi-bullous eruption, first described by T. Fox, and resembling variola — a rare form found on the face, backs of the arms, and forearms — a semi-solid umbilicated lesion which does not collapse on puncture, being filled with insi)issated grumous contents. These lesions shrivel or dry to a crust when the use of the iodide is suspended. 5. Anmmia with Nervous Prostration. — I have seen several cases in which patients long under treatment for severe nervous lesions due to syphilis, by continuing their treatment too long and at too high a dose, gradually became anaemic without losing flesh, restless, nervous, de- spondent, tremulous, unable to eat, and apparently too weak to do any work. I have seen two patients from this cause give up work and one of them pre^^are to die. One could not sign his name, so weak and unsteady was he, and yet both recovered in a few weeks after leav- ing off the iodide, going away from town, and resorting to general tonic measures : milk, phosphates, rest, and the like. 6. Albuminuria. — I have also seen more than once very mild albu- minuria with hyaline casts coincide with the use of very large doses of the iodide of potassium. Xo symptoms of ordinary albuminuria attended this state of affairs, and the albumen and casts promptly dis- appeared on leaving off the drug. This phenomenon is not at all com- mon in my experience. Most patients support the largest doses they can tolerate without showing any sign on the part of the kidneys. I * " Medico-chir. Trans.," vol. Ixii, 1879, p. 189. \ " Journ. of Cutaneous and Venereal Diseases," December, 1886, p. 853. DURATION OF TREATMENT. 581 do not believe that permanent kidney disease can be caused by the continued or excessive use of the iodide of potassium. Means by wMcTi the Bad Effects of the Iodides may he diminished. When the stomach is to such a degree irritated that the iodides can not be taken at all, sometimes in emergency the large intestine may be used for a few days. I have thrown in moderate doses in this way, well diluted, and I believe with good effect, but the intestine soon be- comes rebellious. When the irritative effects of the iodides run too hio-h, the dose, if allowable, should be stopped for a few days, and then resumed in milk or largely diluted in an effervescent alkaline mineral water. At the same time there may be added some acetate of potash to the solution, which by acting upon the kidney carries off the offend- ing drug. Diluent mineral waters (Bethesda, Poland) may be added, Pellizzari states that in most of the bad cases of the evil effects of the iodides the urinary secretion was affected, and that in the most severe cases the urine contained albumen. The tincture of belladonna com- bined with the iodides in moderate doses — ttix with each dose — seems to have a good effect sometimes. Moderate doses of arsenic certainly moderate the bad effects of the iodides. Quinine is said to aggravate them, but I have not observed it. Iodoform has been given as a substitute for the iodides. Hill praises it in small doses for gumma of the tongue. I have used it in small and large doses, and have nothing to say in its favor. Moreover, iodoform is sometimes poisonous. Death has been caused by it when used as a dressing upon a wound. It is accused of causing feeble ac- tion of the heart, coma, nervous disturbances amounting to mania, urticaria, albuminuria, erythematous rashes, etc. It has caused death when administered internally (Oberlander), the maximum dose being gr. xijss. in a pill, and altogether too much harm may come of it if used freely to make such a course wise, while the good coming from its use in moderate and small doses can not be attested by my experi- ence. E. W. Taylor,* in an excellent paper, has recently summarized "what is known about the evil effects of iodoform, used locally. DUEATION OF TREATMENT, The duration of the virulence of the disease is believed to subside in the third year, and therefore the rational period during which to maintain continued treatment is about the same. In other words, it is fairly logical to assume, since syphilis is a malady continually viru- lent for a given period, continually present during that time with alternations of lull and outbreak, that treatment should be the use of some means that shall control the symptoms without injuring the patient, that this means shall be continued during the whole period * " New York Medical Journal," October, 1887. 5S2 GENERAL TREATMENT OF SYPniLIS. of vimlence — in moderation thirins: the Inlls. in greater energy during the outbreaks of symptoms. Such a rational course is the " tonic treatment " I have advocated. Cases generally do well under it if sufficient trouble is taken to maintain it. There arc two classes of cases that apply for treatment : 1. The patient who comes with syphilitic chancre. 3. The patient who comes with a late, obstinate form of disease, after perhaps years of apparent health. 1. The patient who comes with chancre should be gently urged until his ** full dose '' of mercury is found, llis " tonic dose " should then — as soon as the urgency of his symptoms will allow — be continued unremittingly until some reason appears for a change. Moderate local lesions upon the mouth or elsewhere should be treated locally as they appear. When a sufficiently severe outcrop of new symptoms appears, it should be treated by the "full dose" if required, or by the temporary exhibition of the iodides along with the mer- curial dose. This is to be continued, with general tonic and hygienic adjuvants, for eighteen months. If then there has been no symp- tom of syphilis present for a year, treatment may be stopped until u new outcrop appears, if it ever does. In ordinary cases, the course is pushed to two or three j^ars, until there has been a period of six months in which there has appeared no symptom of syphilis — moderate sore mouth in smokers may be disregarded in making this estimate. After such a healthy interval coming on after a period of one year from chancre, continuous treatment may be stopped. The patient is then watched, and new short courses instituted if outbreaks appear, the course being kept up for a considerable period after the symptoms have been overcome by treatment, such treatment being usually mixed. This is the treatment by elimination or by extinction, and I have made its bounds as definite as the case allows, but absolute accuracy is impossible. It is impossible to say to a given patient after he has followed this course that he will never have a relapse ; but he can be told that he has all the guarantee that medicine can afford him, and that if he does have late symptoms the great probability is that they will be mild, and it is almost a certainty that they will promptly yield to a mixed treatment. 2. IMiere the jyatient first comes for treatment ivith serious or ob- stinate disease which has come on at a late period after chancre, there will be generally found to blame, either : 1. The gouty constitution. 2. The scrofulous diathesis. 3. Intemperance, excess, or misery — in short, bad hygiene ; or, 4. A short mercurial treatment, at fi-st, per- haps carried to salivation, which, in the treatment by extinction, is always to be avoided. The proper course to pursue with such a case is to adopt a treat- ment suited to the lesion, mixed or iodide alone, and to use it, aided THE SYPIIILIDES. 533 by hygiene, until the lesion has disappeared ; then to commence a course of mixed treatment, and continue it mildly for a year or more, watching for relapse ; finally, to terminate with a mild, pure mercurial course, extending over some months. This seems to be the most bene- ficial course, but in old, obstinate cases it will not always prevent subse- quent outbreaks. In such cases the main reliance is in tonics, hygiene, and the symptomatic treatment of the outbreaks. It must be remem- bered that mercury has power, more or less marked, over all shades and dates of syphilis. . It is useful in the tertiary stage, although un- doubtedly not so useful as in the secondary. CHAPTEE yi. SYPHILIS OF SKm AND MUCOUS MEMBRANES. Syphilides, Secondary and Tertiary.— The Secondary Syphilides.— Concomitant Symptoms on Mu- cous Membranes. The Syphilides are those manifestations of general syphilis found upon the cutaneous envelope. There are two groups, the secondary and the tertiary. Those occurring in secondary syphilis are : 1. Roseola. 5. Bullous syphilide. 2. Papular syphilide. 6. Vesicular syi^hilide. 3. General pustular syphilide. 7. Squamous syiDhilide. 4. Pigmentary syphilide. 8. Tubercular syphilide. With these occur on the mucous membranes : 1. Erythematous patches. 3. jMucous patch.es. 2. Ulcers. 4. Scaly patches. These are all general eruptions, except the pigmentary and scaly syphilides, and they belong to the group called secondary, about in the order in which they are given. Thus the roseola and papular syphilide always appear early ; the tubercular and scaly syphilide always late. The former require mercury alone for their removal ; the latter demand a mixed treatment, a combination of the iodide of potassium with mercury, to insure the most prompt and effective action. The syphilides which belong to the tertiary stage of the disease are : 1. Ecthyma. 4. Tertiary ulcerations. 2. Rupia. 5. Gummy tumor. 3. Groups of pustules. With these occur on the mucous membranes : 1. Mucous patches. 3. Deep chronic ulcers. 2. Scaly patches. 4. Destructive gummv ulcerations. 584 SYnilLIS OF SKIN AND MUCOUS MEMBRANES. Tliese (tertiary) affections, it will be noticed, are none of tliem gen- eralized. Tiiey all occur in patches. Tlicv will bo considered later. The concomitant symptoms of the frrouj) are atTections of the bones, of the larynx, of the internal organs, and nervous syphilis. SECONDARY SYPHILIDES. 1. EosEOLA. — Tins is an erythema, or simple redness, occurring in small, flat patches or blotches of irregularly crescentic or circular form and slightly indented margins, each blotch varying from the size of a split pea to that of a copper penny. Occasionally the blotches become confluent. Instead of being flat, the patches of eruptions may be raised above the level of the surrounding skin by the presence of minute papilla? upon the reddened area. The patches of roseola resemble exactly what would be an exaggeration of the mottling (marbling) of the integument, which any fair-skinned individual may observe faintly upon his own person by exposing the abdomen to cold air for a few moments. This erythema is the lesion proi)er, but, following the rule of polymorphism in syphilitic eruj)tions, it is customary to find other lesions besides the erythema, such as jiustules leaving scabs in the hair, and pustules and papules elsewhere, scattered through the erup- tion, especially about the head and face. The patches of erythema at first disappear entirely upon pressure ; but, where the eruption has been intense or of long duration, a faint, tawny, yellowish-brown stain is left after pressure (pigmentation), which indeed outlasts the erup- tion and is removed only by time. A small amount of fine desquama- tion attends the disappearance of the eruption in Avell-marked cases. This exanthem is usually the first to appear after chancre, generally at about six weeks, sometimes three weeks, occasionally after several months, but rarely after the fourth. Its advent usually coincides with the secondary engorgement of the lymphatic glands. It often comes on slowly, and may never be observed by the patient until his attention is attracted to it by his physician, or it may be called out rapidly by the heat of a bath, by a cold, or other exciting cause. If the jiatient have had no syphilitic fever, he is less likely to have noticed the erup- tion. When it comes on slowly the chest and flanks are first invaded, and an inspection of these surfaces with the light shining obliquely across them will reveal sometimes the beginnings of a roseola, as yet invisible to casual inspection. In rapid cases twenty-four hours are sufficient to cover the whole body with the eruption, including even a few blotches on the palms and soles. In perhaps the majority of cases the eruption is confined to those portions of the skin covered by cloth- ing, the hands and face escaping, or being so faintly marked as not to attract attention. When roseola comes on early, it lasts from one to six weeks ; when. ROSEOLA— PAPULAR SYPIIILIDE. 585 however, it first appears some montlis after cliancrc, it usually lasts several months. Treatment greatly influences its duration. Kclapse occasionally occurs. Diagnosis. — Patients with syphilophobia arc apt to mistake the natural marbling of the skin produced by cold for syphilitic roseola. Heat causes this marbling to disappear. Non-specific roseola is at- tended by some positive febrile symptoms, often by nausea, disappear- ing when the eruption comes out. The latter runs a rapid course. It is more frankly inflammatory than the syphilitic roseola, and occurs chiefly in children. Copaibal roseola is frankly inflammatory, usually itches, sometimes excessively. The history shows the ingestion of copaiba (of which the urine smells), and abstinence from the balsam effects a speedy cure. Urticaria occurs in raised patches, and itches greatly. The concomitant symptoms distinguish measles. The non- inflammatory character of syphilitic roseola, its lack of itching, and the accompanying indolent engorgement of the lymphatic glands, ren- der its diagnosis easy. When itching is complained of with syphilitic roseola, pediculi, urticaria, or some accidental eruptions are to be sus- pected. 2. Papular Syphtlide. — This eruption may follow a roseola, or a roseola may be transformed into a papular eruption, or the latter may be the first eruptive outbreak observed after chancre. The papules constituting the initial lesion may be miliary in form (like those seen on the spots of roseola), in which case they are often early surmounted by a minute vesicle. The papule is often larger, but acuminated, or it may be broad and flattened (this is a common form), about the size and shape of a split pea (lenticular) ; or, finally, this last form of papule is sometimes greatly exaggerated, reaching the size of a penny. The type varieties, then, of papule in the earlier general papular syphi- lide are two, the acuminated and the flat. The general characteristics of the eruption are the same in each. The papular syphilide is super- ficial and precocious. The color at first is rosy, but soon darkens to the purplish hue of syphilis. Pressure removes the color at first, but later some pigmenta- tion occurs, and then pressure is no longer effective. This final tawny coloration often outlasts all prominence of the papule. Desquamation sets in early. Fine scales become detached, especially around the base of each papule, forming a sort of little ruffled border of white. Biett considered this circular desquamation of the base of the papule of great diagnostic value. It occurs, however, occasionally in the case of large non-syphilitic papules. Sometimes the desquamation is so consider- able over closely-grouped broad papules that a diagnosis with squa- mous syphilide becomes difficult. One form of papular syphilide is peculiar : Broad, flat papules appear, scattered irregularly, esjjecially seen about the face, forehead, and neck, and on the scalp. Each pap- 586 SYPUILIS OF SKIN AND MUCOUS MEMBRANES. iile is covered by a thin, 3'ello\visli, superficial scale, like a scab, raised at the borders, and distinctly dej)rcssed centrally. The raised edge is sometimes distended by a slight amount of serum, the whole looking like a flattened, partly desiccated bulla. Sometimes each lesion is sur- rounded by a reddened (livid) areola. Shortly the large superficial scale becomes detached, the papule pales, flattens, disappears, and leaves no scar. The papular syphilide, though general, is usually most marked at the back of the neck, on the forehead, back, and flanks. There is no pain or itching with this eru})tion. Scabs in the hair are likely to coincide with it, and the indolent, engorged post-cervical and epi- trochlcar ganglions are rarely absent. The eruption may come before the third week from chancre, or after the fourth month. Its dura- tion is from three to eight weeks ; it may be prolonged for months by the recurrence of successive crops of papules. Diaynoais. — A papular syphilide is liable to be confounded with two eruptions only. (1) When the acuminated papules are few, and scattered about the temples and over the forehead, they greatly re- semble a form of acne seen in middle age upon rheumatic subjects. The syphilitic eruption may be usually distinguished by a certain amount of pigmentation around the older papules, a feature not ob- served in acne. (2) The flat papules, few in number, livid in color, and attended by no itching, situated over the backs of the hands, wrists, forearms, and sometimes extensively over the body, and consti- tuting one of the forms of lichen planus seen on rheumatic subjects, are very liable to be mistaken for syphilitic lesions. The patches, however, are more irregular in shape and size, and often present a slight umbilication (without desquamation) at some period of their course, which, together with the history and lack of concomitant phenomena, serves to distinguish this affection from a syphilide. With the papular syphilide are apt to coexist scabs in the hair, en- gorged ganglia, perhaps patches of erythema and pustules occasionally, and pretty certainly mucous patches, erythema or ulceration of some mucous membrane, especially that of the fauces. Small, circular red- dened spots on the palms and soles are also a very constant accompani- ment of a generalized papular syphilide. These are attempts at papu- lation aborted by the thickened epithelium. They appear as circular depressions, reddened centrally and partly deprived of epithelium, which latter is undermined at the edge of each depression as a whit- ened, fringed circle. Several of them may usually be found on each palm. An exactly similar condition is sometimes seen on the palm after an attack of lichen urticatus of the extremities. The severe itching attending the latter eruption insures against error of diagnosis. This affection of the palms is sometimes described as syphilitic psoria- sis. It is more justly an aborted papular syphilide, or results from GENERAL PUSTULAR SYPHILIDE. 587 previous small patches of eryfcliema. It may be found when there is no other syphilitic eruption upon the surface. Its appearance is char- acteristic, almost pathognomonic of syphilis. Iritis sometimes accom- panies a severe outbreak of syphilitic papules. 3. General Pustular Syphilide.— There are three varieties of generalized pustular syphilide belonging to secondary syphilis : (a) Superficial pustules complicating other lesions. (b) General syphilitic acne. (c) Superficial ecthyma. (a) Superficial Pustular Sypliilide. — With a roseola, or papular syphilide, or occurring alone, there may be some superficial pustules scattered on the scalp, or along the forehead, or about the upper lip, at the base of the nose, at the labial commissures, or, indilfferently, over any part of the body, more or less thickly. The pustules are small, superficial, ephemeral, without any hardened or elevated base ; •they often run together and dry up, forming scabs — brown, rough, un- even — like those seen in impetigo. The patches always tend toward a circular arrangement. Instead of drying up under the scabs, slight ulceration may take place, with, not infrequently, vegetation of the surface by the excessive growth of granular tissue. This feature is especially noticeable at the angles of the lips, or around the base of the aliB of the nose. Indeed, any moist, ulcerated surface may granu- late, the feature being an epi-phenomenon, and not essentially a char- acteristic of syphilis. Occasionally, in syphilis about the labio-nasal furrows, the lips, and chin, minute, dry, irregular, papular prom- inences occur in rows and segments of circles where there has been no previous moist surface. These warty excrescences rarely get larger than the head of a pin ; they are of a dead-gray color, sometimes pig- mented. They last several weeks, then dry up and disappear without leaving any cicatrix. Hardy has described the eruption as ''syphilide granuleuse." There is nothing about the slight pustular eruption above described characteristic of syphilis, except the pigmentation of the skin in the brown areola which forms about the scabs, and the tawny, vinous-red color of the skin left after the fall of the latter. A very faint, central depression marks the sj^ot of the pustule, and from this central depres- sion the clearing up of the pigmentation begins, progressing centrifu- gally. The eruption may relapse, several crops appearing successiveh', especially on the scalp. {V) General Sypliilitic Acne. — This eruption occurs scattered over the scalp, face, and the extremities, the lower rather than the upper, or it may cover the whole body. Each pustule is distinct, and out of most of them grows a hair. They are not prominent, usually small, often but little larger than a grain of millet, occasionally quite large. Each separate pustule rests on a reddened base, which itself never sup- 5S8 SYnilLIS OF SKIN AND MUCOUS MEMBRANES. pnrates, the pustule being superficial. Each pustule grows slowly, tak- ing from two to three weeks to develop and break, and then the Huid hardens into a dry scab. Tlie hard base of the pustule has meantime been getting brown, and becoming surrounded by a copper-colored areola. Wh&n the scab falls, the elevation constituting the base of the original pustule remains as a papule, with a faint central dei)ression. This papule becomes gradually absorbed, leaving a purplish, pigmented discoloration, which is very slow to disappear. Sometimes a slight, superficial ulceration remains. This is followed by a minute, round, white, depressed cicatrix, very ditferent from the puckered scar of ordinary acne. General syphilitic acne rarely appears before six months after chan- cre, being later than the superficial pustular syphilide, and earlier than the superficial ecthyma. It may appear very early, indeed as the first eruption, but it is believed to indicate a bad form of syphilis, espe- cially if accompanied by iritis. Svphilitic acne lasts ordinarily about two months, but this limit may be gi'eatly prolonged by successive crops of eruptions. Diagnosis. — The coppery areola distinguishes syphilitic acne from other varieties, but where the eruption appears late, and is confined to the forehead, temples, and face, it is sometimes hard to distinguish it from the simple acne occurring late in life on gouty subjects. {c) Superficial Ecthyma. — Tliis eruption is constituted by red- dened patches upon which pustules develop. The latter may be um- bilicatcd, much resembling variolous pustules. The pustules vary in size from that of a pea to (occasionally) nearly an inch in diameter. They are round, either scattered or collected into groups, in which latter case they may run together (confluent). The pus is thick, often bloody, and there is a dark-red areola (afterward coppery) around each pustule. The pustules do not repose on a hardened base. The crust is rough, dark brown, with a greenish shade, and underneath it there is ulceration. The latter heals under the scab, leaving a slight cica- trix (often pitted, like the scar of vaccinia), which for many months retains its purple, coppery color, gradually whitening from the center. Syphilitic superficial ecthyma is found anywhere on the body, often on the scalp. It occurs in bad cases of syphilis, especially where cachexia comes on early. It rarely appears before about the close of a year from chancre, and may be delayed a couple of years or more. On the other hand, it occasionally comes on as the first eruption, within some weeks after chancre, accompanied by early cachexia, not yielding readily to treatment, and often followed by extensive ulcerations. Diagnosis. — When febrile symptoms accompany the outbreak of syphilitic ecthyma, as they sometimes do, and the pustules are umbili- cated, the disease is not uncommonly mistaken for variola — an error to be avoided by a study of the history of the case, the course of the PIGMENTARY SYPHILIDE. 5S9 eruption, and the absence of other symptoms of variola. Cachectic ecthyma may be confounded with the syphilitic. The former appears in children and the aged, chiefly on the legs, is more purulent, more inflammatory, less or not at all pigmented, and has no accompanying history of syphilis. The superficial ecthyma of secondary syphilis differs from the so- called ecthyma of tertiary syphilis in that the latter has an elevated, hard, empurpled base, ulcerates deeply, leaves a considerable, depressed scar (not pitted) ; is, in short, a gummy infiltration of the skin, ulcerat- ing superficially. All the pustular syphilides have the common char- acters of lack of pain and itching, and the presence of the areola, first of vinous-red, then of copper-color, from the pigment. 4. PiGMENTAKT Syphilide. — This syphilide has been described by Hardy.* It appears between the fourth and twelfth month. It con- sists of a coffee-colored pigmentation of the skin, without elevation of the surface and without desquamation. The size of the spots varies from that of a silver five-cent i^iece to a quarter of a dollar. The bor- ders of each spot are irregular, and many of the patches run into each other. The intervening skin seems whiter than normal, and some- times actually is so. This eruption occurs chiefly at the sides of the neck, perhaps ex- tending down over the breast. It maybe found elsewhere. Lymphatic patients, with white, fine skin, chiefly women, are subject to it, but dark skins also have it. Diagnosis. — In pityriasis versicolor there are desquamation, itching, and the parasite constituting the affection may be readily demonstrated by the microscope. Freckles are smaller and more generally distrib- uted, never confined to the neck. Remarhs. — This eruption is sometimes, possibly always, simplv a pigmentation left behind by a roseola or other syphilide (Fox).f It is often very faint, so that it can only be seen by viewing the neck side- wise with the light shining across it. It is found in some patients who deny any previous eruption upon the site occupied by the pigmentation. It may last one or two months or indefinitely, and is entirely uninflu- enced by treatment. It is rarely detected by the patient, and is of lit- tle importance, except as an additional means of diagnosis in obscure cases, since it only occurs on syphilitic patients. 5. Bullous Syphilide, — A syphilitic pemphigus upon adults has been observed in a few cases (Bassereau, Zeiss, Hardy, and Fox), occur- ring among the secondary symptoms, confined to the palms, soles, backs of the fingers, and bends of the elbows, and relievable by mercu- * " Le9oii3 syr la Scrofule et les Scrofulides et sur la Syphilis et les Svphilidcs," Paris, 1864, p. 175. f " On the so-called Pigmentary Syphilide," '' Am. Journ. ifed. Sci.," April, 1878, p. 356. 590 SYPHILIS OF SKIX .VXD ilUCOUS MEMBRANES. rials intcrnall}'. This eruption, so common in inherited syphilis, is of the utmost rarity in adults. G. Vesicular Syphilide. — This is a rare form of syphilitic erup- tion. There are three varieties : {a) Varicelloid syphilide. (b) Generalized vesicular .-yjihilide. ((■) Vesicular syphilide in gruups. {a) Varicelloid SypliiUde. — This form comes early if at all — before the sixth month after chancre. Small, red, perhai)s slightly elevated spots appear as large as a i)ea. Upon these arise one or more pointed, round, or umbilicated vesicles, surrounded at their base by a dark-red areola afterward becoming brown. The contents of the vesicles quickly become purulent and dry up into a greenish-brown, adherent crust. This scab falls in about a fortnight, leaving a purplish discoloration, which slowly disappears. There are usually but few spots of eruption, scattered over the face, limbs, and body. Successive crops of vesicles may prolong the eruption for several months, and ordinarily some other early syphilide coexists with it, Diagnosis. — V^'hQXi there is considerable syiihilitic fever there is danger of confounding this eruption with varioloid. This may be avoided by observing the color of the patches, the areola around them, the course of the affection, and concomitant symptoms. {b) Genercdized Vesicular Syphilide. — This is a vesicular eruption, not very common, appearing chiefly on the trunk and extremities, rarely on the face. The vesicles are small and acuminated, scattered or united into patches. When scattered, eacli vesicle is surrounded by the characteristic areola ; when in groups, the surface from which they spring is of a vinous-red, which coloration extends slightly be- yond the border of the patch. The vesicles behave in two different manners. After remaining a while translucent they may dry up, the liquid being reabsorbed ; slight desquamation follows, the brown areola pales, and no scar is left : or the vesicles become purulent, break, and little darkish scabs form (isolated and not confluent as in eczema) ; the scabs separate slowly and the brown stain disappears, leaving no scar. The eruption, in itself slow, is made more chronic by relajjse. Diagnosis. — In ordinary eczema the vesicles are small, ephemeral, and break quickly, leaving an oozing surface or a confluent scab. The eruption itches, and there is no coppery areola. (c) Vesicular SypliiUde in Groups. — The patches of syphilitic herpes are situated on a base of specific color. The vesicles are of different sizes, from a grain of millet to a pea. They are arranged in irregular groups or describe circles or segments of circles. The vesi- cles last about a week, and are succeeded by little scabs or by a fine des- quamation. After these disappear the color pales, and no scar is left. Successive crops of eruption are the rule. SQUAMOUS SYrillLIDE. 591 Diagnosis. — Color, areola, and .slowness of development distin^'uish this eruption from ordinary herpes. 'J.lie circinate form does not pro- gress centrifugally, as do other forms of circinate herpes. 7. Squamous Syphilide. — Nearly all the eruptions of syphilis go through a desquamative stage, and thus a patch of eruption which is essentially papular, tubercular, or pustular may finally become scaly, and, remaining so for a considerable time, pass for a squamous syphi- lide. So also does pityriasis occur in syphilis, as of the scalp with early alopecia ; sometimes in little patches along the margin of the scalp with the other syphilides ; again, with syphilitic cachexia, furfuraceous desquamation of the scalp, or even of the whole body, may be encoun- tered, with a dry, rough skin. In none of these cases, however, can it be affirmed that pityriasis is an essentially syphilitic lesion. It is rather a local consequence of general blood deterioration, and may be induced by many causes other than syphilis. There are, however, two varieties of essentially scaly syphilide where the scale is the j)rominent lesion from the first. These are : [a) Generalized squamous syphilide. [h) Palmar and plantar squamous syphilide. {a) Generalized Squamous Syphilide. — This eruption occurs in two varieties — as a guttate or diffused psoriasis, and in the circinate (lep- rous) form. The characters of the eruption are the same in both. They may be met together on the same subject. The patches vary from a split pea to a penny in size — or much larger in the circinate or gyrate form — have (as a rule) the deep syphilitic color, are but slightly elevated above the surface, not papulated. The scales are white, very fine, not adherent, not imbricated (as m true psoriasis). After a few weeks the scales fall. They may be replaced by others, finer than the first, and thus several desquamations occur. Finally, the color pales and the darkened spot disappears, leaving no cicatrix, provided the eruption has not been a mixed one (tuberculo-squamous), which form does leave scar from interstitial absorption. The circinate form starts as a circle, or segment of a circle, inclosing healthy skin, does not generally increase in size, and lasts from a few weeks in the earlier variety to some months in the later, where there is more interstitial thickening of the skin. This eruption does not appear before six months from chancre, and may come on after an interval of many years. It may coexist with other sj^philodermata. Scaly syijhilides, appearing before six months from chancre, are usually the remains of previous papular eruptions. The squamous syphilide appears upon the trunk, the members, the face, and along the forehead at the edge of the hair. It shows no tendency to locate at the elbows and knees, like the non-specific form. The later its appearance after chancre, the longer does it tend to remain. Diagnosis. — ySlhen not associated with other specific lesions, the 592 SYPEILIS OF SKIN AND MUCOUS MEMBRANES. squamous sypliilido is often dinicult to clistin2:ni.sh from non-specific scaly disease. Much light is thrown upon such cases by a study of the jirevious history, on such points as the well-known inveterate tendency of ordinary ]isoriasis to relapse, its tendency to outbreak in the spring and fall. Neither eruption itches (usually), and both have the same livid redness of color under the scales, but ordinary psoriasis tends to cluster about the elbows and knees, and upon the scalji ; its scales are thick, imbricated, tightly attached, and lying in several layers, so that it is ditRcult to scrape tlieni all away and get down to the livid redness of the patch beneath, and when the scales are all rudely rubbed olf tlio patch is very apt to bleed. Common lepra, where the scales come off in patches, is usually much more extensive in its distribution than the syphilitic variety, and often of indefinite duration, Avhich the syphi- litic is not. In the syphilitic affection the scales are more lamellar, finer, less adherent, not imbricated, or in thick layers, while the dura- tion of the eruption is not so great. Finally, antisyphilitic treatment has a marked and often rapid effect in the one form, wliile it does not modify the ordinary variety. The circinate form in some of its stages exactly simulates ordinary ringworm, but the diagnosis may be made by the absence of spores, and by watching the course of the eruption, which, in syphilis, remains stationary, while in ringworm a progressive centrifugal enlargement is observed. (b) Palmar and Plantar Squamous SijpMlide. — This eruption con- consists of rounded, livid colored patches on the palm or sole, slightly prominent, hard, covered by adherent, grayish scabs. The patches may be isolated or confluent, and may reach a large size, extending up to the wrist or malleolus. Deep fissures may form upon them, caused by motion of the parts. These may bleed and occasion enough pain to restrict movement of the fingers. At the limits of the patches there is usually a characteristic livid areola. This eruption differs from the small circular depressions of the palm with an undermined circumference of white, hard epithelium, left by the papular or ery- thematous syphilide of the palm, and already described (the squamous). Palmar affection comes on later in the course of the disease, is often of more considerable extent, and lasts for several months, sometimes for several years. Diagnosis. — The diagnosis with ordinary psoriasis is difScult, unless other concomitant symptoms lend their aid. Ordinary palmar psori- asis is of a higher color, and not so circular in its figure. It generally itches, has no marked areola, and is pretty sure to coincide with other patches of psoriasis (perhaps at the elbows and knees). Scaly patches confined to the palm or sole always excite a suspicion of syphilis, and call for a profound study of the patient's general condition and history, A patient may have had syphilis and still have psoriasis later, not due GENERAL TUBERCULAR SYPIIILIDE. 593 to specific disease, and no error is to be more carefully guarded against than that of imagining that, because an individual has once had syphilis, all his subsequent eruptions must necessarily be due to the continued action of the virus. The touchstone treatment generally reveals the fallacy of this supposition to the intelligent practitioner. Scaly patches, which continue for years in spite of well-directed treatment, are not syphilitic as a rule. Treatment. — In the squamous palmar syphilide the local meas- ures most effective are. tar, red oxide of mercury (in ointment), and the pure acid nitrate of mercury, well rubbed in with a glass rod over small areas at a time, the aiojolication to be renewed in about ten days. 8. Gefeeal Tubercular Syphilide. — Tubercular eruptions are well on the boundary-line of tertiary syphilis. They are more fre- quently grouped than discrete, and often leave cicatrices without previous ulceration. Still, the eruption does occur in a discrete, general form, and may be ranked as a late secondary or early tertiary symptom. The tubercle is a large papule, involving the thickness of the skin. A subcutaneous, gummy tumor is. not a tubercle. Tuber- cular eruptions, generalized or in groups, are rarely seen early in. syphilis. A generalized papulo-tubercular eruption may come on at four or five months, but groups of tubercles rarely appear before a year after chancre, and they may come on at any indefinite date. Basse- reau notes a case at forty years. The farther from chancre the erui?- tion appears, the more certain is it to be a patch of tubercles and not a general eruption, and the more marked in such a patch is the tend- ency to ulceration. There are two forms of this eruption : {a) General tubercular syphilide. {h) Tubercular syj)hilide in groups. {a) General Tubercular Syphilide. — The lesion in this eruption is a solid, round, oval, pointed, or flattened tumor, about as large as a pea, at first shining and of a deep red, then of raw-ham or coppery color. They are scattered irregularly, or lie so as rudely to describe circles or segments of circles. Sometimes the eruption is confluent in spots, in which case the skin between the lesions is similarly colored. After a time a superficial scale covers each tubercle ; this becomes detached, and then the little tumor sinks away without ulceration. A slight, depressed, and pigmented spot marks for a time the site of the lesion, which also finally disappears, leaving no trace, or perhaps a very superficial cicatrix behind. This scar is the result of interstitial absorption of the substance of the true skin, and does not necessitate previous ulceration. Diagnosis. — The general tubercular syphilide appears over the whole body, perhaps more prominently on the face and forehead. Its 38 594: SYPHILIS OF SKIN AND MUCOUS MEMBRANES. characters arc so marked that it is hardly possible to confound it with any other allection. Treatment is mixed, with local mercurials. {h) Tubercular Sijphilide in Groups. — The lesions in this eruption are usually smaller than in the disseminated form, otherwise the same description applies to them. They may be no larger than a grain of millet, but they seem to involve a considerable thickness of the true skin. They may be assembled into irregular groups of rounded con- tour, or form circles, segments of circles, figures of eight. Sometimes each tubercle continues distinct from its neighbor, or they may run into each other, forming a continuous raised welt, inclosing healthy skin, or a roughened, thickened, livid patch. In the circinate form the first tubercles undergo absorption, and are replaced by others cir- cumferentially, causing the ring to grow larger centrifugally, as in ringworm, except that tiic tubercles which have disappeared usually leave little, smooth, round cicatrices behind, first livid, then white. Patches of very small tubercles leave no scar. Groups of tubercles may occur anywhere, but the forehead, cheeks, lips, and nose are favorite sites. Groups of syphilitic tubercles, in the period of decline, become covered by a fine desquamation, and, as each patch lasts a considerable time (from a few weeks to several years), the eruption goes by the name of tuberculo-squamous syphilide. Such patches show the tubercular character of the eruption more strongly at the border where fresh tubercles are springing up, while toward the center of the patch many round, white, smooth, thin cicatrices show where tubercles had previously existed. Such patches are encountered mainly about the forehead and nose. This scarring without ulceration is caused as follows : The syphilitic tubercle is due to a diffuse hyper- plasia of small cells in the substance of the true skin. These cells, which partake of the nature of so-called gummy exudation, grow at the expense of the natural tissues, and cause the atrophy of more or less of the substance of the latter, even while there is apparently an hypertrophy, as evidenced by the little tumor called a tubercle. When, however, the adventitious, newly-formed cells go into atrophy, and are absorbed during the progress of the eruption, then not only does the tubercular prominence disappear, but the scar left attests the atrophy and absorption of the true elements of skin-tissue which took place during the deposit of the morbid material. This element is of diagnostic importance. In only two erup- tions — the tubercular (non-ulcerated) syphilide, and the tubercular (non-ulcoratcd) scrofulide in groups (i. e., tubercular non-ulcerated lupus) — is this important feature observed, and the mechanism of the formation of scar is the same in both eruptions. Groups of syphilitic tubercles may soften rapidly and ulcerate, but then the affection becomes frankly tertiary in type. The course of this syph- ERYTHEMA. 595 ilide is always slow, its duration being extended by successive crops of tubercles. Diagnosis. — It is perhaps possible to confound the circinate form of tubercular sjphilide with ringworm, but the greater infiltration of the skin, and usual existence of scars, deeper color, and absence of spores, should protect the practitioner from error. Patches of syphilitic tubercles on a livid base are very apt to be mistaken for non-ulcerative lupus. In this latter affection the tubercles are flatter, softer, par- tially translucent, less livid ; there is some swelling of the subcutane- ous cellular tissue ; the cicatrices upon the patches are puckered, irregular, often ridged with flat, tight, adherent, shining portions, resembling somewhat the cicatrix of a burn, usually with a few veins running oyer the surface. Treatment of the tubercular syphilides is mixed, with locally mer- curials. CONCOMITANT SYMPTOMS ON MUCOUS MEMBRANES. The affections of the mucous membranes found in secondary syphilis are four : 1. Erythema. 3. Mucous patches. 3. Ulcers. 4. Scaly patches. 1. Erythema. — The liyperremia of mucous membrane seen in sec- ondary syphilis usually attacks the fauces. It generally comes on from three to eight weeks after chancre, and looks and acts a good deal like the erythema occasioned by ordinary cold. It often extends backward into the pharynx and upward into the posterior nares, possibly occa- sioning a little deafness, especially if the tonsils become engorged, as is not infrequently the case. The nasal mucous membrane is some- times similarly affected, occasioning symptoms of ordinary catarrh. It occasionally extends downward into the larynx, resulting in slight catarrhal laryngitis, with hoarseness and some cough, occasionally tem- porary loss of voice. Diday mentions an aphonia occurring early in syphilis, where the voice is not visibly affected, except in the higher notes (in singers), which can not be sounded. A few days of mercu- rial treatment restores the voice. The lesion is evidently hypergemia. Erythema of the fauces is often attended by oedema of the submucous tissue. Faucial erythema usually accompanies the earliest outbreak of cutaneous syphilis. The tendency to the formation of ulcers or mucous patches upon the erythematous surface is great ; but, if these do not form, the diagnosis of the affection is not revealed by any spe- cial characteristics it possesses, unless it be that the inflammation is less frank, the color more dusky, and the complaints of the p)atient less urgent than they would be from a similar amount of hyperemia dependent upon a cold. The syphilitic erythema is sometimes seen in patches, and may be punctate. o9G SYPHILIS OF SKIX AND MUCOUS MEMBRANES. Eicord, iu bis "Iconograiihie," gives a i)late (XV) of an ervthcmu of the glans peuis coiueiding witli a cutaneous roseola, and this plie- nomenon, by no means common, may be occasionally observed. Bum- stead noticed it in a case prior to the detection of any cutaneous symptom.- The erythema of the throat may resolve, or (more frequently) ulcers or mucous patches appear. Treatment is general and local, as ah-eady given. 2. Ulcers. — Ulcers superficial in character, round, oval, or irregu- lar in shape, are found upon the mucous membranes early iu secondary syphilis. They are very frequently encountered in connection with the erythema above described. Their favorite seat is in the fauces, upon the tonsils, on the half-arches, on the soft palate and uvula, along the sides and tip of the tongue, especially if there be a rough portion of projecting tooth against which the tongue rubs, on the inside of the cheeks, very often at the angles of the lips, inside the lower lip, under the tongue, along the fra?num, etc. ; in short, any portion of the mu- cous membrane of the buccal cavity may be affected, even the gums. These little ulcerations are usually superficial in character at first ; if they become deeper, the border thickens, grows red and angry, and a dirty-white pellicle covers the lesion. If they remain superficial, the mucous membrane seems to have been rubbed off, leaving a raw sur- face, smooth, glistening, red at its edges. Salt, pepper, etc., on the food occasion sometimes a stinging sensation at the abraded points. The surfaces of these ulcerations are prone to become aphthous, cov- ered by a grayish-yellow exudation. Ulcerations of similar character may affect the nasal and genital mucous membranes in both sexes, especially if the parts are not kept perfectly clean. The superficial ulcers ajipear early and late during the whole course of secondary syphilis. Lack of cleanliness, the use of tobacco, imperfect teeth, etc., are efficient exciting causes. The ulcerated sur- faces sometimes vegetate, i. e., become covered by exuberant granula- tions. Deeper ulcers in secondary syphilis may depend upon continuance and extension of the foregoing varict}^, from continued irritation (a projecting tooth, use of tobacco) ; or result from ulceration of mucous patches. The favorite seat of such deeper ulcerations is on the tonsils. The whole of the fauces may become brawny around them, dusky in color, thickened. The ulcers themselves have raised, sharply-cut bor- ders, yellow, unhealthy bases, and bear a strong resemblance to ordi- nary chancroid. They are encountered also at the angles of the lips, inside the cheeks, on the tongue, and are found upon the preputial mucous membrane, and about the anus, extending up into it. They often lead to considerable destruction of tissue in a slow, chronic way, eroding the whole tonsil, or at the anus destroying tissue and resulting MUCOUS PATCHES. 597 ultimately in stricture. This ulcer and ulcerated chancroid arc the most frequent causes of so-called syphilitic stricture of the rectum. The ulcers above described belong to secondary syphilis. They commence superficially and not from within, and are thus distin- guishable (as well as in their march) from gummy ulcerations of mu- cous membranes belonging to tertiary disease. The symptoms of ulcerations of the fauces usually complained of are sore-throat, perhaps difficulty in swallowing, and often pain under the jaw, caused by sympathetic swelling of the submaxillary glands. That erythema and ulceration of the other mucous membranes, oesophagus, stomach, intestine, bladder, urethra, etc., may occur in secondary syphilis, although highly probable, is not proved. Symp- toms from these quarters are uncommon. Tertiary ulcerations are known to affect these membranes. Treatment is general and local, as already given. 3. Mucous Patches. — The mucous patch is a lesion peculiar to syphilis. It is a round, oval, or oblong, pale or rosy, moist spot, usually elevated above the integument, sometimes flat or even de- pressed. The surface is slightly, sometimes heavily, furred, especially in the mouth. This lesion occurs plentifully about all the mucous orifices, especially around the anus, throat, mouth, and in the pre- putial cul-de-sac. It may develop upon the site of an existing chancre, converting the latter into a mucous patch. The true skin may also be covered by mucous patches, chiefly in regions where two surfaces of skin lie in contact, especially if they are also habitually moist — under the female breast, on the scrotum or upper part of the thigh, between the toes, at the umbilicus. They are seen also at the edges of the nails. The soft skin of babies is peculiarly subject to mucous patches. Mucous patches vary in size from the head of a large pin to that of a penny, or become larger if several run together. When occurring upon the skin, they are occasionally dry, Avart-like (condylomata), elevated considerably above the surface. Sometimes upon the skin they scab over. Condylomata are seen to best advantage about the anus, periuseum, and scrotum ; but even upon the skin the whitish moist pellicle, resembling furred mucous membrane, may cover them. The surface of a mucous patch either upon the skin or mucous mem- brane may granulate, forming a prominent vegetating surface. Mu- cous patches around the anus and genitals, especially in the preputial cul-de-sac (vagina in female), are very constantly attended by the for- mation of a viscid, badly-smelling secretion, which, in its turn, if not removed, irritates the skin, causes itching, and may excite a plentiful outcrop of vegetations, lack of cleanliness being the immediate cause of these latter, which themselves are accidental, and not in any sense syphilitic. Mucous patches subjected to friction, or left dirty, are apt to ulcerate. Such ulcerations are seen about the anus, extending 598 SYPHILIS OF SKIN AND MUCOUS MEMBRANES. perhaps into the rectum, along the sides of the scrotum from friction, between the toes, where they may become very painful, at the angles of the lips, on the tonsils. The secretion of mucous patches is contagious, and when they are present on the lips, or anywhere within the buccal cavity, the patient can not be too urgently warned of the possibility of spreading the disease among members of his own family, by kissing or using the same spoon, cup, pipe, etc., as other members of the household. Mu- cous patDhes of the mouth are often of irregular shape, owing to the irritation of friction against the teeth. At the angles of the lips, and on the dorsum and sides of the tongue, they are often more or less fissured. The whitish pellicle on the surface is thick and adherent, sometimes covering the whole patch, sometimes having a circinate dis- tribution. The buccal patches are usually fiat, sometimes slightly depressed. Upon the tongue they may vegetate, while extensive ul- ceration upon the tonsils is not unusual. In connection with such ulcerations, the tonsils swell, there is a good deal of inflammatory thickening and induration around, swallowing may become painful, the submaxillary glands enlarge. Since the use of the laryngoscope, mucous patches have been re- peatedly seen within the larynx and trachea. They do not become large in these situations, or secrete much, and they disappear in a few weeks, even without treatment. Symptoms are hoarseness, perhaps aphonia, no pain, cough, or ex- pectoration. Mucous patches come on with the earliest syphilides. They appear upon the skin, usually in connection with the papular syphilide, espe- cially the broad, flat variety. They may outlast several crops of differ- ent eruptions, and they relapse (especially about the lips, tongue, and tonsils) with more pertinacity than any other symptom of syphilis. They occur late along in the secondary and even in the tertiary stage of the disease, but become gradually less and less prominent, until finally they pass over into the scaly joatch of mucous membrane, so closely resembling the mucous patch in some of its features. Nothing is of more importance in the prevention of mucous patches than thorough cleanliness, nothing more active as an exciting cause (upon a syphilitic patient) than local irritation, prominently the use of tobacco, smoked or chewed (for the mouth), or snuffed (for the nose), the retention of a naturally irritating secretion from lack of cleanliness for the anus and genitals. Mucous patches do not leave cicatrices un- less they have ulcerated deeply. The tonsils may hypertrophy and look excoriated in secondary syphilis without being the seat of true mucous patch. Diagnosis. — The only maladies with which the mucous joatch can be confounded are certain forms of so-called canker sore, or aphthous SCALY PATCHES. 599 sore mouth, and a sort of a ringworm-looking herpetic condition of the mouth and tongue seen in neurotic patients. The former sometimes copies the mucous patch (the exulceratcd mucous patch) to perfection, and there is no point of diagnostic differentiation that I can mention. The only difference is that these spots are, as a rule, more subjectively tender than the exulcerated mucous patch, and more likely to occur singly than in groups. The second affection is often an inherited one. The scalded circular and oval patches suggest and do not closely imi- tate syphilis. The papillae are prominent and red in places, pale in others, and the epithelium shed off certain rounded areas. The tongue is very tender, and the malady likely to persist, relapsing par- oxysmally. Treatment of the mucous patch, simple or ulcerated, is general and local, as already given. 4. Scaly Patches. — These patches, sometimes described as mu- cous patches, and sometimes as psoriasis, resemble mucous patches to casual inspection, but are found on closer observation to differ. They appear on the inside of the cheeks, especially near the angles of the mouth, and on the sides, tip, and dorsum of the tongue. They are rounded or irregular in shape, often gyrate on the back of the tongue. They are flat, smooth, shining, and of the bluish-white color of skimmed (city) milk. When mild, they are not at all sensitive ; when severe, they become whiter in color, and the epithelium, whose thickening constitutes the lesions, cracks in places, causing pain. The scales are very firmly adherent, so much so that it is often impossible to scrape them off, and very rough handling fails to provoke bleeding. The patches may become confluent and cover the greater part of the dor- sum of the tongue, making it feel stiff and uncomfortable for the patient. These patches sometimes occur along with the true mucous patch, but usually they appear later in the course of the disease. They may be found at any time, even during tertiary syphilis, and often remain long after all other symptoms have disappeared. They are sometimes seen in inherited syphilis. Smoking is an efficient exciting cause. They are rebellious to internal measures, and are more effectively treated locally. They indicate a continuance of the syphilitic diathesis. The diagnosis between these patches and ordinary non-specific ich- thyosis of the tongue, or tylosis, is often impossible from inspection, alone. In either condition the mucous membrane on the inside of the cheek may look as if it had been lightly varnished over with collo- dion. The tylosis, however, occurs on the gums at times, and on the soft parts beneath the tongue and in the floor of the mouth, which is not the case, so far as my experience goes, for syphilitic scaly patches. Moreover, the non-specific epithelial thickening is likely to be more pronounced and irregular than the syphilitic scaly patch. Wart-like 600 SYPHILIS OF SKIN AND MUCOUS MEMBRANES. promineuces of pure white and great hardness, and uneven' patches of peai'ly thickening, are found in the non-spccilic form. Fissures more or less ulcerated occur in both, but more on the dorsum in the non- specific malady, on the sides of tiie tongue in the syphilitic form. Epithelial- degeneration sooner or later is to be feared in the non-spe- cific form, which, moreover, does not yield at all to antisypliilitic treatment, and is often scarcely modified by local means. A test by treatment must be appealed to to decide the nature of some doubtful cases. I remember one case which occurred in a young man who had no syphilis. It failed to yield to treatment. Later the youth acquired syphilis, and under the treatment of tlie latter the tongue became much better than it hud been before, although it did not entirely clear up. Treatment. — These scaling patches require internal mixed treat- ment, and locally iiowcrful stimulants. I think the acid nitrate of mercury the best. Tobacco must be stopped. I know several old cases of syphilis in which smoking for a few days will produce the white appearance over almost the entire dorsum of the tongue. In these gentlemen (all with ancient syphilis) nothing will keep the tongue clean except the cessation of smoking. These i^atchcs, indeed, have been called smoker's patches (''plaques des fumeurs"). CHAPTER yiL SYPHILIS OF SXm AFD MUCOUS MEMBRANES. The Tertiary Syphilides. — Concomitant Symptoms on Mucous Membranes. The results of tertiary syphilis, as seen upon the tegumentary ex- pansions, are most advantageously considered in connection with the lesions of the same structures encountered in secondary syphilis already discussed. Tertiary is a far graver form of syphilis than secondary. Its pre- siding genius is destruction, the tendency of its lesions is to softening and ulceration, and the medium through which these changes are ef- fected is a substance known as gummy material, either diffused through the tissues or collected into circumscribed tumors. This gummy ma- terial is a specific neoplasm analogous to tubercle, cancer, lupous de- posit, etc. It is a hyperplasia of cells, which have not generally the vitality to become organized. They grow at the expense of the tissue in which they are formed, and after reaching a certain stage of devel- opment undergo a retrograde metamorphosis, and either become ab- sorbed gradually, without solution of continuity of the tissue in which TERTIARY SYPHILITIC CACHEXIA. 601 they are deposited, or break down in mass, occasioning abscess or ul- ceration — in either case leaving indelible cicatrices behind. Certain of the new formations due to tertiary syphilis become organized, lead- ing to permanent thickening, sub-periosteal exostoses, pachymeningi- tis, chronic laryngeal thickenings, etc. Tertiary symptoms rarely appear during the first two years after chancre. After that period they may come on at any indefinite time, having been observed as late as fifty-five years. The appearance of tertiary phenomena (unlike the secondary) is rarely marked by the occurrence of any preparatory or accompanying febrile excitement. Cachexia is apt to accompany them, but even this is often lacking, and, except for the visible lesion upon the skin, the patient may con- sider himself in perfect health. Tertiary lesions of the skin and mu- cous membranes are rarely attended by any considerable heat, burning, itching, or pain — in fact, are usually devoid of any sensitiveness what- ever. The course of tertiary affections is generally slow, occasionally terribly rapid. Sometimes they yield promptly to treatment, some- times they are particularly rebellious, lasting for years. As a rule, however, skillfully -directed and long -continued treatment masters them, but it can not restore lost parts, or remove the indelible injuries sometimes left by the ravages of the disease. Tertiary sypliilitic cachexia requires a word of description. It oc- curs at times independently of any visible or tangible lesion ; or, again, may accompany any of the recognized forms of tertiary disease. It is probably always due to some physical change (amyloid, gummy) in the blood-making organs or the viscera, or to some nerve-change, rather than to any specific poisonous effect of syphilitic virus — since at this, the tertiary period of syphilis, the virus has lost its transmissi- bility, and seems to have worn out its intensity by lapse of time, while none the less the changes it has instituted upon the organism continue in full force. Syphilitic cachexia is attended by loss of aiDpetite and strength, and by general anaemia. The sufferer becomes mentally de- pressed. He looks thin and pinched. The skin is tawny, dry, dirty- looking, without luster. The hair thins, the epidermis exfoliates ex- cessively, occasioning a more or less general furfuraceous desquamation. The heart and vessels of the neck exhibit the aneemic murmur, the pulse is small and rapid, and some anasarca is apt to be observed. Sleep is disturbed, and mental activity lessened. The patient may be nervous and fretful, or very despondent ; occasionally he keejos cheerful. This general condition indicates great depression of the vital force. It sometimes resists treatment effectually, so that none of the so-called specifics are of any avail. It calls for tonics and change of life and air, and, if not relieved, becomes progressively worse, either carrvlng off the jDatient or favoring his death by some intercurrent malady. 602 SYPniLIS OF SKIN AND MUCOUS MEMBR.VNES. The existence of sypliilitic cachexia with other syphilitic lesions always demands careful hygienic and tonic as well as (or perhaps rather than) specific treatment. TERTIARY SYPHILIDES. The tertiary lesions of the integument arc : 1. Ecthyma. 4. Tertiary ulceration. 2. Eupia. 5. Gummy subcutaneous tumor. 3. Pustular syphilide in groups. With these occur on the mucous membranes : 1. Mucous patches. 3. Deep chronic ulcers. 2. Scaly patches. 4. Destructive gummy ulcers. 1. Ecthyma. — In tertiary syphilitic ecthyma there is gummy infil- tration of the true skin. After a few days a pustule appears on the top of the solid elcA'ation. This grows rapidly and breaks, or is scratched off. The matter dries up into a dark-brown scab, perhaps containing a shade of green. Underneath this pus forms, increasing the thickness and roughness of the scab, while the solid portion of the lesion increases also in size, and becomes surrounded by a livid areola. The scab growing from beneath may finally become larger than the ulcer, but the livid areola and the interstitial thickening of the skin extend usually beyond it. Often the scab is depressed, let-in, as it were, inlaid into the skin, and firmly adherent to it. If removed, an ulcer, with sharp-cut edges and pultaceous floor, is found, very closely resembling a chancroid. This form of deep ecthyma may occur separately or in groups ; in the latter case giving rise to a scabbed patch of irregular form, under which there is ulceration, which may become circumscribed and heal under the crust, or, rarely, advance as a serpiginous ulcer. The favorite seat of this eruption is the lower extremities. It may occur anywhere upon the body. The duration is often many months, by successive crops of ecthymatous pustules. An indelible, oft-en deeply-depressed scar results, which remains of a livid color long after the fall of the scab, and is bronzed more or less in different subjects. Blanching commences centrally, until finally the cicatrix is of a jiearly white, perhaps surrounded by a faint ring of pigment, which is slower in disappearing. Mixed treatment is the most valuable. 2. KupiA. — The lesion in rupia is a bulla, quickly becoming pustu- lar, the pus usually mixed with blood. It may be a flat pustule. It varies from the size of a pea up to (in bad cases ) a penny. It rests usually upon a flat base surrounded by a red areola. The pustule breaks in a few days or dries into a crust, under which ulceration pro- gresses. New supplies of pus are furnished from beneath, while the PUSTULAR SYPIIILIDE IN GROUPS. G03 ulceration progresses slowly at its circumference. Tlius the first crust becomes lifted up by the formation of a slightly broader layer of scab beneath, and, this process going on for weeks or montlis, finally a prominent, rough, oyster-shell-like scab results, marked by concentric layers of a blackish-brown color, often shaded with green. A new bullous ring may form outside the crust, and, in drying, rapidly in- crease the size of the latter. These scabs may grow to over an inch in height and reach enor- mous lateral dimensions, especially if the ulcerations under several bullae have become confluent. Pressing upon the crusts will usually cause pus to ooze out from the side. The scabs may remain on until cicatrization has occurred, and then, falling, leave a purple, depressed, slightly irregular spot, which behaves like the sj)ot left by deep ecthy- ma, finally becoming white. On the other hand, the scabs sometimes become detached, leaving an indolent ulcer with sharp-cut borders of chancroid-like aspect, and tending to extend superficially but not in depth. Eupia is found upon all |)ortions of the body, scattered or in groups, and may coexist with other tertiary or late secondary lesions (patches of tubercles, scaly patches). It is believed to indicate a bad general condition. Treatment is mixed, combined with a large share of tonics and hygiene. 3. Pustular Stphilide in" Groups. — In this affection a red spot first appears. Upon this a groujD of small pustules develops. These become confluent and break, their secretion drying up into a thick, greenish crust. Outside of this the purple color forms an areola, as in the other varieties of syphilitic ulcer covered by a scab. The ulcer extends slowly and the scab keeps pace with it or falls off in part, show- ing a granular (perhaps fungous), unhealthy ulcer beneath, secreting a sanious, plastic pus, which readily reconcretes into scab. The scab so formed is broken up, granular, cracked, and not prominent as in rupia. New pustules at the circumference slowly tend to increase the size of the patch. After a time it becomes limited, the scab contracts and dries up, the areola becomes more bronzed ; finally the scab falls, leaving the characteristic scar, which whitens very slowly, especially on the lower extremities. Instead of healing under the scab, the ulcer may become serpiginous, extending superficially but not in depth. These patches occur singly or several at a time upon any part of the body, but preferably upon the face, scalp, neck, and breast. Diagnosis. — The pustular syphilide in groups is liable to be con- founded with the pustular scrofulide in groups, both having the same general character. The scab of the latter, however, is black or light colored, not greenish ; the borders of the ulcer are irregular, fringed, undermined ; in the syphilide, smooth, sharp-cut, abrupt, adherent. G04 svrniLis of skix and mucous membranes. The cliaucroidal aspect of the base and the cojipery areohi are only marked in the syphilitic affection. The color of the scrofulide is l^aler. The cicatrix of the sypbilide is smooth, depressed, thin, violet ; at first bronzed, then white ; of the scrofulide, irregular, prominent in parts, pevhaps puckered, adherent ; violet at first, then pinkish white. Treatment is mixed, with iodide in excess. 4. Tertiary Ulcerations.— The syphilitic ulcer appears in two varieties : {a) Superficial ulceration, stationary or serpiginous. (b) Deep, destructive ulceration. Probably all ulcers encountered in syphilis, even in the very super- ficial forms seen in secondary syphilis, are due to the softening of the so-called gummy exudation, since this exudation is nothing more than aborted connective tissue — connective tissue gone astray under the influence of the syphilitic poison. In fact, all the lesions of syphilis, external or internal (except the purely congestive), are dependent ujion this cell hyperplasia ; but the longer after chancre it occurs, the more prone it is to collect in considerable masses, to form rapidly, and to soften and disintegrate promjitly, thus breaking down into ulceration and sweeping away any tissues in which it may happen to have been deposited. This considerable collection of new-formed, lowly-vitalized ccll-hyperplasia, infiltrated through the structures of the true skin or involving the subcutaneous tissues as well, is always the precursor of syphilitic tertiary ulceration. {a) Suj)C)'Jicial Ulceration, Stationary or Serpiginous. — This form of ulcer may commence as rupia, ecthyma, or a crop of pustules, the ulceration, naturally occurring under the scabs of these lesions, in- stead of healing slowly, either shedding the crust and remaining indo- lent and superficial, or progressing in a serpiginous manner. Often, however, the precursory lesion is the tubercle ; a group of which, hard, shining, livid, indolent, varying in size from a small pea to a small nut, after remaining a while stationary, soften, inflame, and ulcerate. This ulceration has the syphilitic characters — sharp-cut, prominent, hard, adherent borders, a smooth, indolent, false-membranous bottom. There is habitually no pain. An ulcer so instituted may remain long stationary, but usually gradually becomes serpiginous, i. e., creeps over the surface. The advance may be centrifugal in all directions, or along a narrow track in curves, inclosing healthy portions of skin ; or, what is most common, advance may take place in one direction, while the opposite edge of the ulcer is cicatrizing. Unless kept off by dressings, such ulcers are constantly more or less entirely covered up by thick, uneven, greenish scabs. The process of repair announces itself by a limitation of the ulcer, a flattening of its sharp borders ; the base becomes red and granular, DEEP ULCERATIVE SYPHILIDE. C05 approaching the appearance of a healthy ulcer, and cicatrization goes on, the scar passing through the usual transformations of the syphi- litic cicatrix. This scar may he somewhat uneven, owing to the dif- ferent depths to which the ulcer has penetrated at different points. Several patches of superficial ulceration not infrequently coexist upon the same individual, usually in dilferent stages, while cicatrices — some white, some bronzed, some purple — show that the, disease is already of long standing. Treatment is very. effective, usually, in this form of ulcer, which is not necessarily attended by any marked cachexia. Untreated, succes- sive outbreaks prolong it for years. Kelapse is liable to follow a treat- ment too soon interrupted. The favorite seat of serpiginous syphi- litic ulcers is around the Joints, on the back, and on the face. Diagnosis. — Occasionally the serpiginous ulcer is mistaken for old phagedenic chancroid. The distinction is made by a study of the his- tory, the position of the lesion, and, above all, the effect of inocula- tion ; finally, by treatment. Treatment is mixed, with the iodide of potassium in excess, or, if destruction of tissue is rapid, iodide of potassium alone, in rapidly- increasing doses until progress is stayed, and then by diminishing the dose and adding mercury gradually, as in the mixed treatment. Locally, after poulticing, iodoform and mercurial jn-eparations yield beneficial results. {1)) Deep, Destructive Ulcer. — This is a gummy infiltration of the skin appearing in the tubercular form. It occurs by preference upon the nose, the ear, the lip, and the head of the penis. The tubercle is often quite small, and ulcei'ates so quickly that the ulcers seem the j^ri- mary lesion ; in other cases the tubercles remain some time before softening. A thick, black, rough, greenish crust forms over the ulcer, which continues its ravages beneath, progressing inward, destroying everything in its track, including cartilage and bone. If the crust be removed, an uneven ulcer is revealed, resembling the deeply de- structive, phagedenic chancroid in all its features. Exposure to the air causes the crust to reform. During the whole course of this affec- tion there may be no constitutional disturbance whatever, no cachexia, and locally no ajapreciable amount of pain or discomfort. This form of ulcer may last for years, with periods of repose and paroxysms of progress. It is not usually so amenable to treatment as the serpigi- nous ulcer. The whole nose, ear, lip, or large portions of the penis may be eaten away by it. Its cicatrix behaves like other sv]3hilitic scars, except that it is uneven, from the different depths to which ul- ceration has progressed, and may be bridged or bridled. Diagnosis. — The diagnosis is with lupus exedens, true cancer, chancroid ; the former for the nose, lip, or ear ; the two latter for the rest of the body, especially the penis. Lupus occurs usually in the 606 SYPHILIS OF SKIX AND MUCOUS MEMBRANES. yoniig, giimmy ulceration in the old ; Inpns lias a less livid border, a pure black or li^lit-brown scab. The histor\' throws much light on the subject, and above all things concomitant lesions, exostoses, optic neuritis with mydriasis, gummy ulceration of the palate or pharynx. Finally, the effect of treatment is to be invoked. This form of disease, occurring with inherited syphilis, is almost invariably mistaken for lupus cxedens, and treated as such. Epithelioma commences as a tubercle or a wart, which remains a long time before beginning to ulcerate ; the borders of the ulcer are everted, knobbed, irregular ; the floor is more uneven, the fetor greater, and the neighboring glands become involved, which very rarely occurs with the other ulcers under consideration, except chan- croid. Especially on the glans penis is tertiary, destructive ulceration liable to be mistaken for phagedenic chancroid, and ineffectively treated. There is absolutely no feature among the physical charac- ters of the two ulcers which distinguishes them. Chancroid com- mences by a pustule, syphilitic ulceration does not : but this can rarely be verified. There is perhaps something distinguishing in the appear- ance of the ulcers, which appeals to the practiced eye, but it can not be described in writing. Inoculation is an infallible test, the history of the case is of vast importance, the effect of treatment often abso- lutely diagnostic. Cauterization is rarely more than temporarily bene- ficial. Treatment is that of late syphilis. Local applications are not very serviceable. 5. Gummy Tumor of the Subcutaxeous Tissue. — Gummy tumor may develop wherever connective tissue is found, consequently it abounds in and under the skin. In the thickness of the latter it forms a tubercle, under the skin a tumor. In rare instances, gummy deposit in the subcutaneous tissue occurs as an infiltration instead of in its usual circumscribed form. The skin becomes raised, thickened, reddened ; there are little ]n-omincnces upon it which ulcerate and then comport themselves like the syphilitic ulcer. Laucereaux has well described this infiltration, and refers to Vidal de Cassis. Gummy tumors appear first as little hard subcutaneous lumps, freely movable over the subjacent tissues, the integument slightly movable over them. They are not sensitive to pressure. As the tumors slowly increase in size (they sometimes remain stationary for months), the skin over them becomes involved, and the tumors attached to the underlying tissues so that they cease to be movable. Now a purplish discoloration of the skin commences ; the tumor, previously hard and painless, becomes somewhat sensitive, and softens centrally, the skin breaks down, and a thick, puriform material, not pus, often mixed with blood, is discharged. After discharging, the LESIONS OF MUCOUS MEMBRANES IN LATE SYPHILIS. GOT lesion remains as a characteristic, deep, indolent, syphilitic ulcer, whose edges at first are undermined, remaining stationary or progress- ing, and in some cases strongly resembling cancerous ulcers, or, finally, tending to scab over and healing with the characteristic scar. Gummy tumor often forms under the periosteum of superficial bones (clavicle, skull, tibia, ulna), grows quickly, and may ulcerate, and behave like the corresponding lesion, subcutaneously situated, the differences being : that it is deeply attached from the first ; that bone may be felt through the ulcer, and that a superficial scale of bone may become necrosed, thus complicating and prolonging the case (carious ulcer). Subcutaneous or subperiosteal gummy tumor, instead of coming quickly to the surface, may diffuse itself laterally after soften- ing, and occasionally burrow a short distance before opening. Subcutaneous gummy tumor may be single or multiple. The most frequent seat is on the buttocks, neck, head, and extremities. They rarely reach a size larger than a nut, but may become as large as or larger than an egg, after softening. Their structure, here as else- where, is small rounded cells, more or less gelatinous ; granular, in- tercellular tissue, with a few fibers, fusiform cells, and small vessels. The constant tendency everywhere is to undergo retrograde metamor- phosis, either liquefying and ulcerating out, or becoming cheesy and going through absorption with or without cretification.* Trecdment is that of late syphilis, by the iodide of potassium. AFFECTIONS OF MUCOUS MEMBRANES ENCOUNTERED WITH TER- TIARY SYPHILIDES. These are four : 1. Mucous patches. 3. Deep chronic ulceration. 2. Scaly patches. 4. Destructive gummy ulceration. The first three of these conditions have been already described It is only necessary to add further that mucous patches become less fre- quent and scaly patches (sometimes called " milk-spots ") more com- mon as the distance in time from chancre is increased. The chronic ulcers of the fauces or mucous membrane of the cheeks at or near the angle of the lips, surrounded by more or less brawny infiltration of the neighboring tissues (already described), are found in tertiary as well as in late secondary syphilis. They are similar to some of the serpiginous or stationary chronic cutaneous ulcers, and undoubtedly often depend upon a moderate amount of gummy infiltration of the tissues. A favorite seat for these late gummy ulcers is the posterior wall of the pharynx, high up, often extending into the posterior nares, * Gummata sometimes appear out of time in early syphilis, malignant or otherwise. R. W. Taylor has collected some interesting examples of precocious gummata, and added some personal cases. " Am. Journ. Med. Sci." July, 1887. 608 SYPHILIS or SKIN ANT) MUCOUS MEMBRANES. and encroaching on the upper surface of the soft pahite, which is not necessarily involved. To see them it is often necessary to lift up the soft palate with a suitable curved probe, while the mouth is widely opened, or even to use an inverted laryngoscopic mirror. These ulcers have raised- borders, are covered by a tough, whitish secretion, and are often raw-looking in parts. They are encountered also on the mucous membrane of the nose, causing a slight catarrhal llow, and accompa- nied by the occasional discharge of bloody scabs from the nose, or *' hawked up " in the morning while clearing the throat. When the ulcers are extensive (serpiginous), they indicate long-standing, inveter- ate disease. Their presence may occasion i)ain in swallowing, and perhaps in breathing. Treatment is general and local, as already given. 4. Destructive Gummy Ulceratiox.* — This form of ulcer is one of the most serious encountered in syphilis. It may develop as a gummy nodule or as diffuse infiltration of the submucous tissue, or be primarily subperiosteal on the wall of the pharynx, or in the nasal cavit}', or on the hard palate. It develops first as one or more deep, round, hard, insensitive swellings, possibly a diffuse infiltration. The mucous membrane may be unchanged in color at first or slightly yel- lowish, if the tumors are superficial. As the latter grow, the mem- brane over them darkens in color, becomes oedcmatous, then softens and rapidly gives way, leaving a deep, irregular yellow ulcer, with distinct loss of substance, surrounded by a line of inflammatory red- ness. Such ulcers often spread with alarming rapidity, perforating the soft palate or cutting off the uvula within a few days, even hours. The explosion may take place as if by electricity, and twenty-four hours deprive a patient of his soft palate. Deglutition is sometimes painful, sometimes painless, according to whether or not the ulcer is put upon the stretch in swallowing. Any subjacent bone becomes rapidly eroded and necrosed, so that the progress of the ulcer may destroy all the soft and portions of the hard palate, more or less of the turbinated and ethmoid bones, with the vomer and portions of the posterior bony wall of the pharynx, leaving a vast ulcerated cavity to represent what were the fauces and pharynx. The disease may extend inward occasionally and affect the membranes at the base of the brain, giving rise to epilepsy or other nervous phenomena. The voice be- comes nasal, food and drink pass forward and out of the nose in swal- lowing, and yet with all this the patient may be cheerful and suffer little, often absolutely no pain. The secretion of these ulcers is very foul and has a peculiar odor, in itself suggestive if not pathognomonic. Portions of bone die and are discharged from time to time, or may become incased in new bone during the process of repair. The dead bone, thus remaining incased, * Gumma of the tongue will be described later. DESTRUCTIVE GUMMY ULCERATION— TREAIjIENT. fJ09 acts as a local irritant, and keeps up ulceration and suppuration per- haps long after treatment lias removed all progressive disease. When taken early these ulcerations yield readily to energetic treat- ment, later they may i^rove very rebellious. But Nature accomplishes wonders when repair docs take place. Cicatrization binds down any portions of the soft palate which may have escaped destruction, and leaves a characteristic seamed and distorted condition of the pharynx, perhaps entailing a permanent alteration in the voice, sometimes ren- dering the deglutition of fluids difficult, and perhaps only leaving a small opening to mark the ^ite of the uvula. Such a condition of throat is always the result of syphilis, never of scrofula, or so rarely that practically the word ''never" is allowable. It has been written that scrofula may cause these throat-ravages in children, because children are found on whom a syphilitic history or parentage can not be traced, who have ulcers and other evidences of so-called scrofula and destructive ulceration of the soft palate, perhaps not quite so promptly relievable by the iodide of potassium as similar fresh condi- tions in the adult. I have seen several striking instances of this faulty diagnosis, and have effected a cure with the iodide treatment. The treatment of pure gumma, wherever found, is an iodide pushed rapidly. Mercury is not necessary, although it may be combined in small quantity with the iodide without bad effect, and the iodic course may be followed by a moderate mercurial course, with, I believe, good effect. The iodide in some cases must be pushed with a bold hand to save tissue and minimize scar. CHAPTER YIIL SYPHILIS OF THE EYE.'' Lachrymal Apparatus.— Eyelids.— Chancre, Mucous Patches, Gummy Tumors, Ptosis.— Conjunc- tiva. — Sclera.— Cornea.— Iris.— Mydriasis, Iritis, Varieties and Complications, acquired and hereditary.— Prognosis.— Treatment.— Vitreous Humor, Hyalitis.— Crystalline Lens, Cataract.— Cyclitis.— Choroiditis, exudative and atrophic— Retinitis.— Neuritis Optica.— Paralysis of Mus- cles.— Periostitis. All the tissues of the eye and also its surrounding parts may be affected by syphilis. The disorders thus induced are usually grave, are sometimes tedious, and are prone to do damage to vision. They can rarely with safety be left to take their own course, and in a satis- factory degree they yield to suitable and early treatment. * Chapter VIII is written by Prof. Henry D. Noyes, M. D., at the request of the authors, who fully indorse the opinions therein expressed. It appears in the first person, as conveying the personal experience and convictions of the writer. 39 CilO SYPHILIS OF TUE EYE. Tlie imprint of syphilis on the eye may be made daring any period of its career. Even chancre lias been fonnd upon the superticial parts, while, during the secondary and later stages, a variety of lesions may appear. Hereditary syphilitic taint is a frequent occurrence in the eye. To give due attention to the various lesions which may occur, I adopt the anatomical order from without inward, both for simjilicity and completeness. THE liACHRYMAL, APPARATUS. A certain proportion of cases of stricture of the lachrymo-nasal duct are occasioned by syphilis. There are no special features which characterize these cases from others. Neither can tlie usual local treat- ment by probing and sometimes by the employment of injections be omitted. It is not necessary to dwell on this point, but it is proper to call attention to the not very infrequent agency of syphilis in eti- ologv. It is not necessary to have pronounced disease of the nasal bones or cartilage. There will be a degree of thickening of the Schneiderian membrane, such as is found in ordinary nasal catarrh, and inquiry will bring out a syphilitic history. There may be perfora- tion of the septum narium, or of the floor of the nares, or caries of the turbinated bones testifying to the tertiary stage of syphilis, and with these lesions there may be stricture of the lachrymo-nasal ducts on one or both sides. When such conditions exist, full doses of iodide of potassium will be required to effectuate the employment of probes. Neither the constitutional nor the local treatment is to be omitted. I may add that in precisely such cases as these the use of probes of the largest sizes, viz., from ten to fifteen of Theobald, have been indis- pensable. To bear in mind the importance of antisyphilitic treatment in cases so pronounced as just described would be quite natural, but, in not a few cases which resist treatment to an unexpected degree, the secret of failure will be found in inattention to a syphilitic taint. It has occurred to me to see a case of gumma in the skin overlying the lachrymal sac. The diffused character of the tumor, that it over- spread the anatomical limits of the sac, that it could be grasped be- tween the thumb and finger, and the existence of a syphilitic history, established the diagnosis. THE EYELIDS. Primary chancre has been noticed both in adults and in children. The sore presents the same appearance as when situated on the geni- tals, and its treatment does not require any special remark. If on the cutaneous surface, it does not greatly endanger the eye ; but, if on the THE EYELIDS. 611 mucous surface, or, as has been seen, on the caruncle, it becomes a serious thing. The accident is, however, so rare that it does not seem worth while to enlarge on the subject. Mucotis patches occur both on the cutaneous and conjunctival sur- faces of the lids. I have seen them as large as a three-cent piece, but have not seen any more serious result come from them than a slight catarrhal conjunctivitis. Weak astringent washes, as of alum or sul- phate of zinc, or touching them with a solution of nitrate of silver, gr. V vel X, aquae ad 3 j, is the needful local treatment. Various forms of secondary cutaneous eruptions may appear on the skin of the eyelids, and the eyelashes and brows are liable to be lost when the hair of the scalp is being shed, but these are incidents which only call for passing mention. Somewhat more imjDortant is the fact that gummata develop in the eyelids and adjacent parts. They may grow to be as large as a hazel- nut. In one instance under my notice, such a tumor appeared in the skin over the lachrymal sac, and months after the first tumor had dis- appeared another occurred upon the border of the lower lid. These developments belong to the late stages of syphilis, the tertiary period. ; in the instance above alluded to, several years had elapsed since the first infection. A mistake is not unlikely to be made in these cases, because cystic tumors, and less frequently fibrous tumors, are of common occurrence in the lids. They, like gummata, usually grow slowly and painlessly. But it is not always true that gummata grow slowly ; they may attain considerable size in two weeks. The skin is sometimes thickened, and raised above the surrounding level. The most important guide in diagnosis is that the swelling in- volves all the tissues where it is located, and, as it were, incorporates them all into itself. This, in connection with its indolent, painless character, the possible discoloration of the skin, and the constitutional symptoms and history, will guard one against the error of attempting to apply the knife or other instruments to the removal of these tumors. Like other gummata, they melt away under a suitable course of con- stitutional treatment. Drooping of the upper lid (ptosis) is caused by affection of the third nerve, and will be alluded to when speaking of paralysis of the motor nerves of the eyeball. Co2irJU]srcTivA. — The kinds of inflammation which syphilis may cause in this membrane (meaning the ocular conjunctiva) are : First, sores from primary infection ; second, mucous patches ; and, third, gummy growths.* The last belongs quite as much to the subcon- junctival connective tissue as to the mucous membrane. All of the above lesions are rare. The most frequent is an ulceration which I * See case by J. L. Nemir, " Archives of Ophth.," vol. xii, p. 228. (U2 SYPHILIS OF THE EYE. have seen coexisting with mncous jiatches in tlie mouth. The com- mon site is near the margin of the cornea, where a reddened and ele- vated spot apjiears, resembling a severe phlyctenula. It rises higher and is more extensive than such eruptions usually are, and it soon presents ulceration. The surface not only becomes excavated, but shows a jelly-like, semi-transparent tissue upon the eroded part, and this may spread to the cornea. The ragged, angry, irritated look of such an elevated ulcer, with the broad thickening of the base, and the large vessels running into it, its encroachment on the cornea, its slow recovery, the pain, lachrymation, and photophobia which attend it, mark the case as dependent on a constitutional vice. The search for corroborative symptoms of syphilis will usually be rewarded by success. I have seen this lesion oftener in women than in men. The local remedies are : Bathing the eye with lukewarm water for short periods, say fifteen minutes four or six times daily ; the use of solution of sul- phate of atropine, gr. ij ad 3 j, droiii:)ed into the eye three to six times daily ; protection against strong light by a shade or blue glasses, and the avoidance of remedies of an irritating quality. Besides these local means, the constitutional treatment should not be omitted ; the only caution to be observed being to have regard to the state of the general health, and if needful to exhibit tonics as preliminary to, or in con- nection with, the specific remedies. This caution is not unimportant, because very many of these patients will be found to be in a feeble or cachectic condition, and their diet must often be as carefully directed as their medication. THE SCLERA. This structure is occasionally involved in syphilitic lesions. They api^ear under three forms : First, as episcleritis ; second, as simple scleritis ; third, as gummy scleritis. The first of these varieties may be confounded with a conjunctival process, and the distinction is not very easily made because the subconjunctival connective tissue is com- mon to both structures. The second variety appears as a patch of injection at any part of the eyeball, of irregular outline, with moder- ate injection, and mild or almost no subjective symptoms, such as pain, photophobia, or impaired vision. It is apt to be rebellious and ])ersistent, or if it last long the deeper structures are apt to partici- pate, and then by haziness of the vitreous and changes in tlie choroid and retina vision will suffer. The tliird or gummy infiltration will be easily recognized by signs of interstitial deposit, elevation, and red- ness ; and it is apt to spread to deeper parts, and may even lead to the destruction of the eye and to enucleation. It is the most rare of the varieties of syphilitic scleritis. Interesting cases have been re- THE CORNEA. 013 corded by Sturgis,* by Dclaficl(],f by Loring and Eno4 by Von Ifip- pel,* by J. A. Andrews,! and by otbcrs. Treatment. — In local applications it is proper to employ atropine to guard against pupillary adhesions, while, if there be decided tenden- cies to inflammation of the ciliary body, a solution of eserine sulphate, gr. ss. ad 3 j, may be used twice or three times daily. In some in- stances both may be used — the atropine once daily and the eserine twice daily — because the former is more effective than the latter. Further, warm fomentations for half an hour to an hour three times daily are comforting and salutary. In constitutional treatment no special suggestions are needful beyond what belongs to the stage of the funda- mental disease and the special condition of the patient. THE CORNEA. In a preceding paragraph the occurrence of the ulceration of the cornea in mucous j)atches of the conjunctiva has been alluded to, and needs no further mention. I have not seen these ulcers go on to per- foration. Inflammation of the cornea, as the effect of hereditary syphilis, is a very common disease among children. It usually appears between six months and two years of age, while it may remain latent until the fifth year, or be seen as late as the fifteenth year. In one instance I have seen it appear so late as the thirtieth year. It is commonly pre- ceded in young children by cutaneous eruptions, especially about the buttocks, and by glandular swellings. Often the children have coryza, with swollen lips, flattened nasal bones, and badly-formed or perishable teeth. Mr. Hutchinson first called attention to the importance of the teeth as a significant mark ; that the incisors are notched or pointed, or very small, or crooked, or decayed. The canines as well as incisors may be abnormal. The general health is bad, and the whole nutrition perverted. The disease is not violent in its onset. A slight congestion appears about the cornea, a little opacity w^ou its surface. There was moder- ate photophobia and pain, often no lachrymation. When the disease has deeply involved the corneal structure the subjective symptoms be- come intense, and are often most distressing. The alterations of tissue consist usually in opacity and vasculariza- tion. It is rare that ulceration, except of the minute superficial kind, or suppuration, occurs. The opacity, which at the beginning is faint, * "Scleritis Syphilitica," "Arch, of Dermatology," January, IS'ZS, p. 112. f "Transactions of the American Ophthalmological Society," 1871. X Ibid, 18*74, p. 174. * Graefes, " Archiv fiir Ophthal.," viii, p. 288. II "Syphilitic Gumma of the Sclera," "Arch, of Ophthalm.," vol. xi, p. 458, 1882. 01-i SYPHILIS OF THE EYE. soon spreads over tlie Miiole surface, and into the depth of the cornea, and becomes more intense. It even affects the posterior epithelial surface, and, because of its extent, is commonly called keratitis diffusa. Of course sioflit is at once injured, and may be reduced to mere per- ception of light. The disease may penetrate deeper into the eye, and involve both the iris and choroid. I have under observation a boy, now fourteen years old, who exhibits the effects of inflammation both of cornea and iris and ciliary body — the cornea mottled with diffused and spotted ojiacities, the pupil closed and adherent to the lens, the tissue of the iris atrophied so as to be translucent in many places, and the periphery of the iris drawn backward by contraction of exudation and its adher- ence to the ciliary processes. The duration of these cases under skillful treatment is from one to three months, when taken at an early period ; but the continuance may be much longer if the disease have taken a severe hold before suitable treatment is undertaken. The prognosis as to vision will vary with the severity of the attack, but in general it may be considered favorable. The disease may occur among adults, is less frequent, and requires no special descri])tion. The method of treatment must first have respect to the constitu- tional trouble. By this I mean rigorous attention to food, exercise, and bathing, as well as administration of mercurials. Food in easily- digestible form must be given in quantity and frequency which the stomach will permit ; milk, beef-tea, chopped beef or mutton, either roasted or broiled, bread, and eggs, are to be the chief reliance, while sweets and fibrous vegetables are to be excluded. The child should be taken out of doors daily, with proper j^rotection from the light by a veil, and a tepid bath should be given every other da}'. With these hygienic measures the tonic and specific treatment must be combined. It is often advisable to give cod-liver oil, sometimes quinine, or the sirup of the iodide of iron ; some practitioners think iodide of potas- sium imjDortant, but it has not seemed so in my experience ; while the readiest method of introducing mercury is by putting the blue oint- ment upon a flannel bandage which shall be swathed around the abdo- men. The ointment must be renewed night and morning, and the skin carefully sponged with warm water to prevent it from becoming irritable. By this management no unpleasant effects take place, and the influence of the remedy is seen in the gradual improvement of the health and appetite. The treatment of the eye consists in fomenta- tion, by compresses wrung out of hot water, for a period of one hour or two hours at a time, three times daily. The compresses must be changed as fast as they become cool, and the water must be kept as hot as the hand can bear. This treatment is laborious, but is unequaled in efficacy ; sometimes poultices may be more conveniently used. A THE IRIS. Q15 solution of sulphate of atropine, ^r. ij ad ^ j, should be dropped into the eye three or six times daily. As the photophobia and acute symptoms abate, the duration of the fomentation may be shortened, until witli increasing amendment it may be stopped. It is well to keep up the atropine, so lon;j as any hyperaamia remains. Inunction should be persisted in for about two months, unless contra-indications forbid. If the skin become fretted, some other part of the body may be chosen for the ointment, or hydrargyrum cum cretd in doses of five grains, administered three times daily. The twenty-per-cent oleate of mercury is apt to irritate the skin. Usually the chief specific remedy demanded is some form of mercury, but in older subjects the iodide may also be required. The extreme importance of using specific remedies in these cases, as well as of guarding them as above indicated, can not be too strongly insisted upon. THE IRIS. There are two afl:ections of the iris which result from syphilis — paralysis of the sphincter of the pupil, causing mydriasis, and inflam- mation. It is not necessary to say much upon mydriasis. It occurs under two conditions. In the one it is associated with evident paralysis of other twigs of the third pair of nerves. So that, besides dilatation of the pupil, there may be ptosis or divergent strabismus, or diplopia. Another condition in which mydriasis appears does not present any sign of lesion of the third nerve, so far as other twigs are concerned, but appears to be associated with obscure changes in the brain, or at the base of the skull, which may not at the time declare themselves by noticeable symptoms. Nothing definite can be predicated upon this fact, but it serves to awaken expectation of a coming disaster. It is also true that mydriasis is caused by irritation in the upper part of the spinal cord, or of the cervical sympathetic, and by causes wholly removed from syphilis. It is often seen among the insane, and among those called merely nervous. Furthermore, it must be stated that monocular mydriasis, without impairment of any other branches of the motor oculi, results from severe use of the eyes, and is attended by paralysis of the accommoda- tion. This happens among miniature-painters, engravers, and such classes of workers. While saying thus much, to guard against error, it must be added that monocular mydriasis occurs from syphilis, unconnected with either diplopia or ptosis. (For detail of such a case, see a paper by Meric, in the '-British Medical Journal" for January 8, 1872, p. 29, and in the same paper are cases recorded in which mydriasis was combined with ptosis, all other branches of the third nerve remaining intact.) Gl(] SYPHILIS OF THE EYE. As to the constitutional treatment of syphilitic mydriasis, nothing special need be said. For local treatment the contraction of the pupil may always be temporarily secured by putting between the lids a solu- tion of sulphate of eserine or of the muriate of pilocarpine. But the remedy has only a temporary effect, and can not easily bo graduated to answer a useful purpose. The faradic current is sometimes used, and Duchenne says he has had success by putting one pole on the sclera and another on the temi)le ; but this treatment is not to be commended. Iritis. — The most frequent alTection of the iris which syphilis pro- duces is inJJammation. It lias been calculated that about (ifty per cent of all cases of iritis are due to syphilis. The attack may occur within a few weeks or months after the primary affection, or it may come among the later phenomena of the secondary stage. Although the contrary has been maintained, there are no marks in the iris by which the syphilitic origin of an inflam- matory attack can be asserted. In other words, syi^hilitic iritis has the same symptoms as other forms of the disease. The tendencies of syphilitic iritis are especially to the formation of plastic exudation, and, when this reaches the exuberance of gummy nodules, it is very rare that such a case is not caused by syphilis. On the other hand, iritis syjahilitica may exhibit only serous effusion. The most frecpient cases are those in which a moderate quantity of plastic matter is thrown out upon the pupillary border, and causes adhesions between it and the crystalline lens. A brief enumeration of the symptoms of iritis is as follows : The pupil refuses to expand when the light is obscured, and is apt to be of small size ; the iris-tissue is altered in color, and likewise indistinct in texture ; the color of the pujiil is smoky, and not jet-black ; perhaps the pupil is irregular, and at its margin may be seen black specks of exudation ; the effect of a drop of a solution of atropine is either not to cause any expansion of the pupil, or to give it an irregular form, the margin being festooned ; there is hyperemia of the sclera and conjunc- tiva, in the immediate neighborhood of the cornea, whose deptii and extent will vary with the severity of the attack ; there may be cliemo- sis ; there is lachrymation ; the lids do not oj)en fully, and may be a little swollen ; light is offensive ; pain is seated in the ej'C, but more often upon the forehead and temple, or at the vertex and occiput, trac- ing the course of the supra-orbital branch of the fifth nerve ; vision is always impaired, and sometimes is reduced to perception of light. In serous iritis, the aqueous humor will be very dim, and so abun- dant as to make the anterior chamber unusually deep by pushing back the iris and lens. There are cases in which tlie whole anterior cham- ber is occupied by a semi-gelatinous substance, as if a thin and not well-clarified jelly had coagulated there. This mass has sometimes been mistaken for a dislocated crystalline lens. It consists of plastic COMPLICATIO.XS OF IRITIS. 617 exudation diffused through the aqueous fluid. Its appearance when undergoing absorption is striking, because the lower part of the cham- ber will be murky and clouded, wliilo the upper part will be compara- tively clear and display the iris and some of the pupil. In other cases plastic material exudes in nodules upon the free sur- face of the iris, presenting masses like mustard-seeds, or larger bodies, located upon any part of the membrane, but more commonly around the pupil. Sometimes this substance is so abundant as to be precipi- tated to the bottom of the anterior chamber as hypopyum. These masses are sometimes vascular, and their color is always a reddish yel- low. They are correctly called gummata, and have been extracted and found to present under the microscope the features of true gummy exudation. This material, it must be understood, infiltrates the whole thickness of the iris, and its adhesion to the lens is consequently dense. The cause of impairment or loss of sight is found in the turbidity of the aqueous humor, in deposits upon and proliferation of the epi- thelium of the posterior face of the cornea, and in the obstruction of the pupil. The reason why the pupil in the beginning of iritis is always small is, that the hypersemia and swelling of the tissue compel the iris to push inward in the only direction in which it can find space. So far from the narrow ptipil being due to contraction of the sphincter pupillEe, the muscular fibers are reluctant to act because of the sodden condition of the tissue. Inasmuch as a large part of the iris lies in contact normally with the crystalline lens, adhesion between the two surfaces is inevitable, and this is true even when the pupil is well di- lated by atropine, as is illustrated in cases of serons iritis. A true picture of iritis can not be presented without bringing into view complications which often accompany it. The minute opacities above alluded to, which are often fonud on the inner surface of the cornea, especially on its lower half, are in part precipitations, but also result from participation of the epithelium of the membrane of Descemet in the inflammatory process. The ciliary body and choroid are still more frequently affected. The evidence of the fact is not easy to obtain in the early stages of the inflammation, but all obstinate and persistent cases of iritis pass over into irido-choroiditis. Especially is this true when the plastic exuda- tion is copious, or when the pupil has not been dilated. In old cases the iris sometimes gets a greenish tint or a chocolate-brown, its fibers look atrophied, none of the normal tracery can be made out, but a blur overspreads the surface, and haemorrhages are apt to occur. The vitreous humor is hazy, the retina suffers, and often the eyeball be- comes soft to the touch, or even reduced perceptibly in size. Vision in these complicated cases is extremely bad. The sclerotic hyperemia may not be great, but is persistent, and the globe is both painful and acutely sensitive to pressure. Photophobia is often extreme. If com- 618 SYrniLis of the eye. plete jiosterior synechia be tlio result of iritis, it happens in course of time that an accuniuhition oi" lluid takes place between the iris and the suspensory ligament of the lens, which pushes the periphery of the iris forward and gives it the shape of a ring-cushion. As a result of this condition, the globe in time becomes hard, and secondary glau- coma with excavation of the o}itic nerve sets in. In such old cases the iris-tissue may atrophy so much as to be semi-transparent, while its fibers show like the warp of muslin before the cross-threads are woven in. In other bad cases, the iris is stuck fast to the lens-capsule so com- ]iletely as to exhibit the convex outline of the lens and to preseut at its periphery an evident furrow. The attempt to take out a piece of iris in these cases often results in getting aAvay only the front layer of the membrane, while its posterior, deeply-pigmentcd layer, sometimes erroneously called the uvea, remains adlierent to the lens, and frus- trates the operation. The formation of a tough fibrous membrane across the pupil, and thickening of the anterior capsule of the lens, are consequences to be naturally looked for in badly-treated or severe cases ; while, as a result of irido-choroiditis, cataract not seldom arises. Iritis may attack both eyes, either in succession or simultaneously, yet is frequently confined to one eye. The description above given applies to acquired syphilis in its various stages, but iritis occurs as the effect of hereditary sy2)Mlitic taint. It indeed may occur in utero, as is shown in clearly-developed symptoms of irido-choroiditis in new-born infants — the pupil cora- l^letely shut by false membrane, the eyeball reduced in size, the color and texture of the iris abnormal. Hereditary syphilitic iritis usually develops in the early months or years of infancy. I am treating a child one year old, in whom, after the disappearance of an attack of keratitis, which was recognized as due to syphilitic taint, iritis began. It was not attended by great external hypera?mia nor pain, there was very little lachrymation, no swelling of the lids, and moderate photo- phobia ; but the iris was almost concealed from view by a patch of yellowish-white lymph; which occupied all the anterior chamber, ex- cept at the upper outer third. The aqueous humor was so turbid, and the iris so discolored, as to look nearly black. The globe was hard, and the appearance of this patch at first suggested a chronic choroido- iritis, instead of an acute attack. This in reality is a sample of gummy exudation, precisely like tliis form of iritis in adults. Such cases are uncommon, but have been noted by writers. They yield to suitable treatment, but great injury to sight usually remains. The prognosis in iritis depends on the amount of lesion which has been inflicted at the time when treatment is begun. Firm and exten- TREATMENT OF IRITIS. 019 sivG attachments to the lens, and implication of the choroid, prolon-;^ the disease, and do more or less injury to sight. Success in dilating the pupil is speedily followed by abatement of symptoms. A very large proportion of cases of iritis, under early and judicious treatment, make a recovery in all respects perfect. Treatment. — This is naturally divided into local and constitutional, and the former is by far the more important. The first and indispen- sable object of local treatment is to secure full dilatation of the pupil : measures to control hyperasmia are next in order ; and, finally, reme- dies to relieve pain. Under the first head the only effective substance is sulphate of atropine. It has entirely put aside the extract of belladonna, and in only a few exceptional cases does it j)roduce conjunctival irritation, and must be substituted by duhoisine or by the alkaloid of stramonium, viz., daturine. The strength of the solution of sulphate of atropine usually prescribed is gr. ij vel iv ad | j. It should be ordered in such frequent repetitions as the obstinacy of the adhesions shall com- pel. Sometimes the instillation of three drops, three times daily, will tear some or all of the adhesions ; frequently the same quantity must be repeated six times daily. In obstinate cases the solution may be ordered four times within an hour, three times daily, making twelve applications. When the pupil fails to yield to such solicitations, the effect of atropine will often be enhanced by leeches to the temple, say three to six at a time. When the pupil begins to dilate, the inflammatory s3'mptoms usu- ally decline ; especially is this true of jiain. The energy with which atropine is employed is the peculiarity of the naodern treatment of iritis, and is the chief ground of success. A word of caution must be interposed as to the liability of bringing on symptoms of poisoning. This effect is not very rare. The patient finds his fauces extremely dry, and, on inspection, their surface will be found congested and a little cedematous, the pulse is quickened, a mild delirium appears, and, in. advanced toxic conditions, violent delirium and dangerous prostration will ensue. All this results from absorption of the atropine into the general circulation. Some persons experience unpleasant effects of this kind very easily. If the pupil do not exj)and, even if aided by the application of leeches, I have sometimes resorted to the expedient of procuring a rapid but mild salivation by mercurial remedies, and found that, when the gums were touched, the pupil either yielded to the mydriatic, or the inflammation began to subside without expansion of the pupil. If it should not be deemed wise to employ this treatment, because of the feeble state of the patient's health, the operation of iridectomy is some- times advisable. It is not fitted to the early states, but rather to the later period of a tedious inflammation. 020 SYrUILIS OF THE EYE. The removal of Lypera?mirt often ensues wlicn full mydriasis is ob- tained ; but, if this be not so, leeches may be ajuilied to the temjile near the hair ; three to six may be used, and may in some cases need repetition. Care should be observed not to be too free in depleting weakly subjects, and leeches must be regarded as having only a sub- ordinate value. A mild jnirgative is often needful. Eelief of pain is important. Hypodermic injection of morphine may be needed to procure sleep, because at night that jmin is most troublesome. ^Moderate degrees of pain are relieved by instructing the patient to rub tlie forehead with a mixture of extract of belladonna and powdered opium and. mercurial ointment. A more ctHcicnt topi- cal anodyne is the oleate of morphine (Squibb's), applied with a pencil and allowed to dry into the skin of the forehead and temple. The tincture of iodine applied with a brush is sometimes effectual. So, too, it is often a comfort to heat a folded napkin and press it against the forehead. Wet compresses, if of any use, should at the onset be cold, and in the latter stages be lukewarm. In a case of protracted iritis, the prolonged use of slippery-elm poultices is of the utmost benefit. They may be applied for two hours at a time, three times a day if necessary. The eye must be guarded against excessive light by blue or smoked glasses, although rigorous confinement to a dark room is not good practice, because of its weakening influence on the health. It will be found that feeble and cachectic subjects are more difficult to cure than the robust. If only one eye is involved, the patient should not use the other in any fine work. Exposure to the wind and smoking are to be avoided, and no attempt made to use the eye on near objects. The question of constitutional treatment is important to be settled. In former times it was assigned the chief part in the cure. By some, at the present day, it is almost ignored. I have seen a very large number, and, indeed, the majority, of cases of syphilitic iritis recover without being subjected to any of the so-called specific remedies. As above remarked, the facility of cure depends most upon the readiness with which the pupil expands and can be kept open. I have also said that sometimes the mercurial treatment will bring about prompt resolution when mydriatics faik I must also say that where the plastic exudation is in large quantity, as when the so-called gummata make their appearance, mercurial inunction, or blue-pill by the mouth, may wisely be employed to aid in the disappearance of the exudation. I have seen entire absorption take place without this rem- edy, and in feeble patients would be unwilling to use it, but would give the vigorous the benefit of it. I have no hesitation in stating that the usefulness of either mer- cury or iodine to cure iritis is excei^tioual and not the rule. TREATMENT OF IRITIS. 021 On the otlicr hand, I must with equal readiness admit tliat specific constitutional treatment ought to be em2)loyed to counteract the poison whose potent influence has induced the iritis. This treatment is aimed at the general disease, and is to be selected and adapted according to the rules which are set forth in another part of this treatise. Accord- ing to this view of the question, a practitioner is not compelled to dose a syphilitic patient with mercurials to protect his sight from the mis- chiefs of iritis, except under conditions specified, but should stead- fastly adhere to that .plan of treatment which the general welfare of the system demands, and attack the eye-disease with the local reme- dies which have been designated. I have several times observed patients with active iritis in one eye, who have already been brought under the influence of mercury, attacked with the same inflammation in the other. This certainly proves that no preventive virtue can be ascribed to the mercury, and argues against the beneficial influence of quick mercurial ization in curing the acute attack. In addition to the above remarks on treatment, I should speak of certain peculiar conditions calling for special measures. In cases of iritis serosa, where there is but little plastic exudation, the pupil will dilate readily, but often the pain and redness do not abate. On test- ing by the finger, the eye will be found tense and the anterior cham- ber will be too deep. Under these circumstances, paracentesis by a broad needle or a Graefe's cataract-knife is indicated. It is not neces- sary to draw off all the aqueous humor, but the proceeding may need several repetitions, as indicated by the recurrence of pain. The place of puncture should be at the margin of the cornea ; the instrument should have a very sharp point, and be entered in a plane jjarallel to the surface of the iris. It should be withdrawn slowly, because a rapid gush of aqueous humor causes severe pain. If, after an attack of iritis has passed away, the pupil should be tied to the lens by extensive adhesions, relapses of inflammation are likely to occur, and the morbid process is prone to penetrate to the ciliary body and choroid. Hence arise opacities in the vitreous humor and in the crystalline lens. The area of the pupil is sometimes occupied by a false membrane, and the capsule of the lens may undergo thickening. If posterior synechia is complete, that is, if all the pupillary edge be glued to the lens, an accumulation of aqueous humor sometimes takes place behind the iris, which makes it bulge forward toward the cornea in a series of protuberances or as a complete ring, leaving the pupil retracted. The peripheral parts of the iris sometimes come into actual contact with the posterior surface of the cornea, and the tissue always undergoes atrophy. So great sometimes is the waste of the tissue that in spots it becomes a mesh-work of fibers through which (322 SYPUILIS OF THE EYE. the light of the ophthalmoscope can be thrown. This has already been alluded to. On the other hand, after iritis, the membraue some- times becomes greatly tliickencd by formation of new tissue both in its stroma and on the posterior surface. The remedy for the conditions of adhesion and obstruction is iridec-' tomy. Its efficacy will, however, be in the inverse ratio to the severity of the lesion. In the worst cases, especially in those last described, it is sometimes scarcely possible to be performed, and seldom, if done, is of much service. Where the iris is turgid with new vessels the opera- tion is attended by great bleeding, and no good, but rather harm to the eye, may ensue. In spite, however, of these drawbacks, this operation offers the only chance to rescue the eye from serious and cumulative mischief, and may be the only means of avoiding the necessity of extirpating the organ. For cases of moderate posterior synechia it may be needless to do anvthing, or the simple pulling away of the attachments by a fine pair of forceps will suffice. This proceeding is attended by only sliglit reaction, and requires a small wound at the border of the cornea — the iris is seized and pulled ujion until the adhesion breaks, and is then let go, without being dragged into the wound. The forceps employed should not have teeth. This operation, suggested by Passavant, is preferable to other methods of detaching the pupil, such as that de- vised by Streatfield. But it is now much less frequently employed than it was a few years ago. VITREOUS HUMOH. A common effect of inflammation of the iris and ciliary body and choroid is the production of opacities in the corpus vitreum. They are either effusions from the surrounding vascular tissues or prolifera- tions and degenerations of the cells of the vitreous. The anterior part of the mass is most frequently affected. The opacities jiresent every variety of form, such as molecules, fibers, tangled nets, flakes, and membranes. They sometimes develop rapidly, more frequently they occur slowly. A noteworthy instance of rapid development is the fol- lowing : Lieutenant D had hard chancre in March, 1872. In the following September, double iritis took place, and disappeared in four weeks, leaving a few adhesions of the pupil of one eye. Vision in the right eye was |§ ; in the other, |^. In June, 1873— about eight months afterward — a sudden development of opacities occurred in the vitreous of the left eye, totally abolishing vision, but leaving percep- tion of light. No external hypersemia of the globe existed — the fun- dus could not be discerned. The appearance of the vitreous was like that of a tumbler filled with muddy water in whicli a quantity of torn VITREOUS HUMOR, 623 and broken leaves are floating. He had been under mercurial treat- ment, both at the time vvlicn the chancre appeared and during the attack of iritis ; in tlic hist instance it was maintained for three months. When, tlie acute hyalitis appeared he was directed to take a wineglassful of Zittman's decoction three times daily, and by a life of regulated exercise in the country to keep his general health in tlie best condition. After six weeks the vitreous became so clear that the fundus could be perfectly examined. No lesions of the choroid could anywhere be found, and vision was restored to |g-. The other eye was not affected. A case precisely like the above is not often observed, but a process slower in development and less in degree is a not rare effect of syphi- litic poison. It usually requires a long time for vitreous opacities to clear up — generally some of them remain permanently. The CRYSTALLiisrE LENS is, so far as I know, never the seat of syphilitic changes, excepting as they ensue in the course of inflamma- tions of the choroid, the ciliary body, or the iris. More especially from chronic cyclitis and choroiditis does the nutrition of the lens become impaired and its transj^arency become damaged. In other words, it is changed into a cataract. The transformation of the lens-fibers begins in the deeper or posterior layers very often, and the lens when wholly opaque is either of a dead white or yellow tint, or becomes, in old cases, completely calcified. As a result of iritis, the anterior capsule sometimes presents opacities, by proliferation of the epithelium of its posterior surface. Nothing is gained in the attemjDt to cure opacities of the lens or its capsule by antisyphilitic medication. The case will admit only of surgical treatment, and in all cases the likelihood of success depends on the degree to which the integrity of the deep tissues has been pre- served. It is always imperative to make a rigid investigation of the degree of perception of light, and the limits of the field of vision. Only by so doing can a patient be secured against the pain and disap- pointment of a needless operation. The operation for cataract under these circumstances is always com- plicated and may be quite difScult. For a discussion of this subject it is proper to refer to treatises devoted to diseases of the eye, while it is right to add that the probabilities of success in this class of cases are not encouraging. THE CILIARY BODY. I should not make special mention of inflammation of this part of the uveal tract, were it not that certain acute lesions of this tissue sometimes present themselves which have very stiiking features. It is 624 SYPHILIS OF tue eye. the most highly vascular structure of the eye, autl of necessity partici- pates in the inllammatery changes of the iris and choroid. But it is entirely hidden from direct inspection, either by the naked eye or by the ophthalmoscope. I have before alluded to a retraction of the periphery 6t the iris which indicates adhesion between it and the cili- ary processes. So far as superficial vessels may indicate the existence of cyclitis, the same kind of hypcra^mia appears as when the iris is in- flamed ; that is, the anterior ciliary vessels become engorged. Ci/ch'tis, as an independent affection with unmistakable features, has appeared to me under two forms. In one there are no other symptoms than circumcorneal injection, and a little discoloration of the iris, without impairment of the action of the pupil ; the vision may be dim. In the other and more important form, the inllanima- tiou presents gummy exudation more or less conspicuous. I shall speak only of the latter condition, and by relating the following- case : A man, about thirty-two 3"ears of age, had had syjDhilitic symptoms about four years ; had had iritis. A few weeks before I saw him sud- den blindness fell upon his left eye, without pain, irritation, or visible redness. lie was able to perceive only an intense light. The globe was not hard or tender to touch. The pupil dilated fairly by atro- pine, and no illumination of the bottom of the eye could be obtained by the ophthalmoscope. The vitreous simply gave back an inky hue. As the eye turned in various directions a white object suddenly flashed across the field, in most instances starting from the inferior part of the globe. It was evidently close behind the lens, and never retired to the depths of the eye. When he looked strongly downward a white patch was discovered close to the border of the crj'stalline lens, situated in the ciliary body, or its near neighborhood. This had the look of plas- tic exudation. The nature of the disease was then assumed to be a plastic cyclitis, with a localized exudation not very abundant, from which a mass had been broken off, and floated about in the anterior part of the vitreous. The general opacity would be the necessary ac- companiment of this condition. The patient had been treated by spe- cific remedies, and they were again prescribed, but, after a period of two months, no improvement was obtained in vision, and the exuda- tion had scarcely altered its appearance. There was never any visi- ble hyperaemia or pain. In other cases plastic cyclitis appears in a much more formidable way. In addition to the pain, swelling of the lids, and vascularity, characteristic of a severe attack of inflammation of the globe, a swell- ing soon begins to arise at some portion of the eye near the cornea. The spot from wllich it springs may be more intensely red than other situations, and the locality where I have most often seen it is at the upper part of the eyeball. The tumor grows rapidly, and within a CYCLITIS— CHOROIDITIS. C25 week I have seen it become liirger than a buck-shot, its base occupying nearly one fourth the circuriil'erence of tliis part of the globe. There is always severe iritis, the pupil is totally obscure to the ophthalmoscope, and the anterior chamber filled with turbid aqueous humor. The disease occupies several weeks in its course, and the tu- mor will entirely disappear. Sometimes its site is marked by a dark- bluish discoloration. Sometimes the eye becomes soft and slightly reduced in size, but this is not a uniform result. In no instance have I seen any vision restored. It is not needful to dwell upon the subject of treatment, because the measures suitable to a similar process in the iris would be indicated. In some cases I have been obliged to extirpate the eye, because of the severity of the pain. THE CHOROIDEA. The frequent participation of this membrane in the inflammations of the iris has been repeatedly alluded to, and need not be further mentioned. The similarity in structure of the two tissues causes a great resem- blance in their morbid processes, but in many instances it becomes impossible to see the changes which occur in the choroid, because the pupil and refractive media become so soon and so deeply clouded. A form of choroiditis which may take place without affection of the iris, and without visible hypersemia of the globe, is known by the name of acute choroiditis disseminata. Illuminated by the ophthalmoscoiDe, the vitreous will be faintly hazy, but through it will be discerned a number of small isolated specks of a light-yellow color upon the pos- terior wall of the eye. These specks are more apt to exist near the equator, but may appear upon the central part of the fundus. • They are seldom bigger than one fourth of the area of the optic nerve, often are much smaller. They show an unmistakable elevation, and in some instances a retinal vessel may be seen to pass over them. The optic nerve is always hypersemic, but does not show infiltration. None of the choroidal stroma appears clear, so far as the degree of pigmentation natural to the individual will permit a Judgment. These spots of exudation are sufficiently characteristic to secure an easy recognition of the disease, and they suggest the features of iritis gummosa. The picture thus sketched, after two or three weeks, be- gins to undergo alterations. The yellow specks grow fainter, but an aggregation of pigment takes place at the border of the deposit. After a time, with its more complete disappearance, the place it occupied in the choroid is found to have become thin by the destruction of the epithelium ; and finally the stroma of the membrane is absorbed, leav- ing only a dead- white patch, whose border is deeply marked by black pigment. In old and severe cases the aspect of the interior of the eye 40 626 SYPHILIS OF THE EYE. is most striking:. Circular, oval, and roiiiided white spots with black edges are clustered thickly over the surface, ]iresenting a brilliant con- trast to the red color of the choroid, while upon the apparently normal surface pigment-dots are strewed about to give evidence of the exten- sion of the disease over all the tissue. There may also be light-colored red patches, which indicate thinning t or Excess of Development; and Cicatricial Contractions following JUirus. Illustrated by Thirty Cases and tine Engravings. 6vo. Cloth, §3. (JO. CAMPBELL (F. R.). The Language of Medicine. 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