ttt % mtxi of ^m fork ^Atfnmtt SItbrarg f Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookongonorrOOIuys A TEXT-BOOK ON GONORRHEA AND ITS COMPLICATIONS A TEXT-BOOK ON GONORRHEA AND ITS COMPLICATIONS BY DR. GEORGES LUYS I-ATE ASSISTANT TO THE UROLOGICAI. CLINIQUE, hOpITAL LARIHOISlfeRE, PARIS PRIZEMAN OF THE FACULT^ DE M^DECINE, PARIS TRANSLATED AND EDITED EY ARTHUR FOERSTER, M.RC.S., L.R.C.P. (Lond.) LATE RESIDENT MEDICAL OFFICER, LONDON LOCK HOSPITAL WITH 200 ILLUSTRATIONS AND 3 COLOURED PLATES NEW YORK WILLIAM WOOD & COMPANY MDCCCCXIII Q. AUTHOR'S PREFACE Gonorrhea is one of the scourges of humanity which have received so far but shght attention from the general pubhc. Whilst the dangers of syphiHs are a matter of common knowledge, gonorrhea is often made hght of, and yet this disease is more common, and causes endless misery amongst the innocent. Its sequelae, which, unfortunately, are insufficiently known, are just as serious, both from the social and from the individual point of view, as those of syphihs, although they are less tragic in appearance. Gonorrhea is no benign disease which calls for jocular comment; it is a serious illness which may terminate fatally. Badly treated or insuffi- ciently cured, it produces lesions in the male which embitter his best years or his old age; and in both sexes it gives rise to systemic complications, of which those involving the joints and the heart are the most important. In fact, the gonococcus, the usual cause of the malady, does not always remain within the mucous membrane of the urethra; it enters the blood- stream more frequently than is generally believed, and thus sets up a generalized septicemia and fatal cardiac lesions, which are, unfortunately, by no means as rare as one might expect. When a man acquires an attack of gonorrhea, sensations of pain and of burning in his urethra soon acquaint him with his misfortune; but once the acute stage has passed off, he undervalues the importance of his " accident." He rapidly forgets that he is contagious, neglects his treat- ment or postpones it, and finally fails to be cured. Careless, ignorant, or guilty, he enters upon wedlock, and gives his young spouse in exchange for her virginity a poison which may cripple or kill her. The great danger at this moment is the absence of acute symptoms, and thus the unfortunate wife has no suspicion of the true nature of her illness — an illness which ruins so many young women between eighteen and twenty. It is pitiful to see the pale faces, the anxious and worn looks, the hollow eyes of these poor young women who suffer permanently from internal pains, until they submit to a surgical operation which gives them the desired relief, but also condemns them to complete steriHty. Such are the disasters brought on by gonorrhea. Its victims amongst both sexes are so numerous that it must be the duty of medical men to point out its dangers to pubHc resentment. It is one of the most frequent vi AUTHOR'S PREFACE causes of depopulation, and it is responsible for the " wrecking " of so many men, and for the sterility of so many women. Owing to the slow, but sure havoc which it causes in the individual, and to Society, gonorrhea deserves the fullest attention of medical men and of pubhc bodies. To aid and to guide them in their campaign against this plague is the object of this book. Our therapy is nowadays so perfect that it is not permissible for a medical man to allow a case of gonorrheal urethritis to go on without curing it. Modern science has made such conquests that one can say without exaggerating that there is no inflammation of the urethra which cannot be cured completely by appropriate treatment. But it should not be for- gotten that this result is only obtained by means of prolonged and pains- taking observations, and that urethroscopy alone enables us to diagnose the local lesions "with accuracy, and to apply the sovereign remedy correctly. Without the control of his eye, it is impossible for the medical man to select the best and the most efficacious treatment. It does not follow from the fact that urethroscopy is a wonderful and indispensable means of diagnosis in expert hands that it is a universal panacea for inflamed urethrae. The truth is far from this, and hence it is necessary to study the treatment of urethral inflammation in all its details. On the whole, the therapeutic measures recommended in this book have little in common with the routine treatment of former days. An experience of twelve years devoted to the study of these interesting diseases has convinced me of the absolute efficiency of certain remedies, and of their superiority over others which fortmiately have become obsolete nowadays. I have therefore avoided a tiresome enumeration of the old methods which prolonged the urethritis instead of curing it, and given a very full description of our modern accurate therapeutic measures which lead to a certain cure. This book contains twelve chapters. The history of gonorrhea I considered of interest. It shows the evolu- tion of our knowledge of the etiology and of the therapy of the disease; how gradually in the course of centuries a state of chaos and darkness was replaced by accuracy and clearness. The following chapters deal with the etiology of gonorrhea, and give a full description of the gonococcus, the usual cause of the malady. They also point out its dangers, and refer to the social struggle against gonorrhea, and to certain legal questions connected with it. As the gonococcus is not the only micro-organism capable of producing an inflammation of the urethra, a further chapter is devoted to these non- gonococcal urethrites. The basis of all rational treatment is the pathological finding, and thus a special chapter deals with the pathology of gonorrhea. AUTHOR'S PREFACE vii In the next chapter the chnical picture and the symptomatology are described. The diagnosis of urethral inflammation has received special attention, as it guides the treatment, and as the success of the latter depends on the accm'acy and completeness of the former. The following chapter gives a full description of urethroscopy, and completes the previous chapter. Without this powerful means of diagnosis, the locahzations of chronic urethritis cannot be made out, and therefore remain untreated. The numerous comphcations of gonorrhea are then reviewed, a special chapter being devoted to gonorrhea in women and children. The later two chapters, which are the most important ones, give a full description of the treatment of acute and of chronic gonorrhea. They contain the methods which have stood the tests, and lead to a certain cure if properly apphed. This book has been illustrated with special care, most of the figures being original. They are intended to render the reader famihar with the various therapeutic interventions, and to give him the impression that he is operating himself. Lastly, I have to discharge the pleasant duty of thanldng my pubhshers, Messrs. 0. Doin et Fils, for the admirable way in which they have published this book. GEOEGES LUTS. TRANSLATOR'S PREFACE In recent years a greater interest has been taken in venereal diseases, and it would seem as if the days in which it was permissible to treat these maladies with contempt and in a careless manner belonged to the past. It is being more and more reahzed that the fact of contracting a venereal disease is purely and simply a misfortune, and in itself no proof of immor- ality, calling for disapproval and punishment. It is gratifying to find leading journals, like the Times, devoting their columns occasionally to ■ important advances in venereology. Syphilis has been a good field for medical research in recent years. Valuable discoveries have followed each other in rapid succession, and thus the attention of the pubhc and of the medical profession has been concen- trated on this malady, which in the past hall-marked the majority of its victims, and could not fail to impress even the most hard-hearted. Much has been done of late for the syphihtics, and an enormous literature has sprung which, it is to be feared, is already too extensive. The other venereal diseases have thus dropped into the background, and it seems timely to bring their principal member, gonorrhea, to the front again. Its frequency and its dangers, which are dealt with in this work, would be in themselves an ample justification. There can be no doubt that its victims deserve our fullest sympathy, and that they require the same care and attention as patients suffering from other diseases, were it only for the sake of their surroundings and of their offspring. As far as " guilt " and " sin " are concerned, it would be well to cast off the cloak of hypocrisy and to adopt charitable feehngs. The cirrhotic who has dehberately ruined his health, to quote an example, and an enormous percentage of those who meet with accidents or injuries, are just as " guilty," and their lesions are to the same extent " self-inflicted " as any venereal disease. The victims of their passions suffer enough as it is. The long duration of their illness, the restrictions they have to impose upon themselves, and the knowledge of being " unclean," as Moses termed it, and of being put out of action, lead to endless mental suffering, which often inspires one with pity. To inflict upon these sufferers reHgious treatment, as some seem to ix h X TRANSLATOR'S PREFACE think fit, in preference to a proper medical tkerapy, verges on barbarism, and is not in harmony with our times. In the case of gonorrhea in particular, our medico-surgical measures are excellent and practically guarantee a cure. They appear, however, to be inadequately known, and even amongst medical men a certain uncer- tainty appears to exist, as far as the treatment of gonorrhea is concerned. This state of afTairs is not astonishing, considering that for a number of years no book has been pubhshed in the Enghsh language on this subject. It is true that several valuable works on urinary diseases have been written of late, and that they allude to gonorrhea. But these references are scanty, suitable, perhaps, for experts who do not require them. Those who are less famihar with this malady and seek detailed information will find little assistance in consulting these books. There is thus a gap in our hterature, and I have attempted to fill it by this translation of a treatise which has already made its reputation and contains all the information one could desire. Its author, Dr. Georges Luys, is a recognized authority, and so well known by his numerous writings and inventions, that all his communications deserve attention. His " Traite de la Blennorragie," of which the present volume is a translation, deals exclusively with that malady, and is the most complete book so far pubhshed on this subject. The first edition appeared only in 1912. Within a year a second edition became necessary ; an abridged Spanish translation has already been pubhshed, and a Russian version is about to appear. The text of the present Enghsh edition embodies all the additions and corrections of the second French edition, although it differs here and there from the latter. We have also been able to insert all the important new figures, owing to the efforts of my pubHshers, Messrs. Bailhere, Tindall and Cox, to whom my thanks are due for the care which they have bestowed upon this work. On the other hand, we have omitted some of those figures which appear twice in the original, and a few of minor interest. Some of our readers will regret that the references to vaccine treatment are brief; but as neither Dr. Luys nor myseK are greatly impressed by its achievements, we decided not to enlarge the paragraph relating to it. It has been the aim to lay stress upon such methods only which are reliable, and which should be employed by those whose lot it is to cure gonorrhea and to alleviate the terrible martyrdom of the sexual organs. A. FOERSTER. London, W. July, 1913. CONTENTS CHAPTER PAGE I. THE HISTORY OF GONORRHEA - - - - - 1 II. THE DANGERS OF GONORRHEA - - - - - 12 The Social Struggle against Gonoskhea - - - - 17 The Legal Aspect of Gonorrhea - - - - - 18 III. THE ETIOLOGY OF GONORRHEA - - - - - 21 The Gonococctjs - - - - - - - - 21 Frequency -------- 21 Ways in which the Contamination is brought about- - - 21 Contamination through Inert Objects - - - - - 24 Effect of Age— Gonorrhea,! Vulvitis in Little Girls - - - 25 Inllueiace of Fever - - - - - - - 25 Morphology of the Gonoooccus - - - - - - 26 Shape, Grouping, Movements - - • - - - 26 Staining Properties - - - - - - - 27 Technique of Searcihng for Gonococci - - - - 27 Examination of the Discharge and of the Filaments - - 27 Staining: Kiihne's Method; NicoUe's Method - - - 28 Double Staining - - - - - - - 29 Gram's Method ---.-- - 29 Staining of Sections - ■ - - - - - - 30 Examination under the Microscope - - - - - 30 Cultivation of the Gonococcus - - - - - 31 Coagulated Human Blood-Serum - - - - - 31 Serum-Agar - - - ^ - - - - 31 Ascites -Agar - - - - - - - - 31 Ascites Broth -------- 31 Coagulated Rabbit Serum - - - - - - 31 Pig's Serum; Wassermann's Medium - - - - - 31 Blood-Agar - 32 Henry Heiman's Medium - - - - - " - 32 Yolk of Egg Agar 32 Inoculation ..-.---- 33 The Toxin of the Gonococcus - - - - - - 33 Biology of the Gonococcus - - - - - - - 34 Relationship between Gonococcus and Meningococcus - - 34 Localization op the Gonococcus in the Human Body - - 34 Gonococcal Septicemia - - - - - - - 36 xi xii CONTENTS CHAPTER PAGE IV. INFLAMMATIONS OF THE URETHRA DUE TO OTHER CAUSES THAN THE GONOCOCCUS 39 Inflammations of the Urethra due to Common Micro -Organisms - 39 Primary Urethritis of Bacterial Origin - - - - 39 Secondary Urethritis of Bacterial Origin - - - - 40 So-called "Aseptic" Inflammations of the Urethra - - 43 Inflammations of the Urethra due to Chemicals - - - 45 Inflammations of the Urethra due to a Special Diathesis - 46 Inflammations of the Urethra due to Toxins - - - 46 Inflammations of the Urethra of Traumatic Origin - - 47 V. THE ANATOMY OF THE URETHRA, AND THE PATHOLOGY OF GONORRHEA - - - - - - - 48 The Anatomy of the Urethra - - - - - - 48 I. The Male Urethra - - - - - - - 48 Course and Different Parts - -. - - - 49 Anterior and Posterior Urethra - - - - - 49 Lumen of the Urethra - - - - - - 49 Length of the Urethra - - - - - - 53 Outer Aspect and Relations - - - - - 63 1 . Prostatic Portion - - - - - - 53 2. Membranous Portion - - - - - - 54 3. Spongy Portion - - - - - - 64 Inner Aspect - - .... . - 54 1. Prostatic Portion .... - 64 2. Membranous Portion - - - - - - 66 3. Spongy Portion - - - - - - 66 Histology of the Urethra - - - - - - 58 1. Muscular Coat - - - - - - - 68 2. Vascular Coat - - - - - - - 68 3. Mucous Coat - - - - - - - 59 A. Structure of the Mucous Membrane - - - 59 B. The Glandular Apparatus of the Urethra - - 60 1. The Glands in the Anterior Cavernous Portion - 60 2. The Prostate Gland - - - - - 62 3. Cowper's Glands - - - - - 63 II. The Female Urethra - - - - - - 66 Relations - - - - - - . - - 66 Inner Aspect - - - - - - - 66 Histology ---..--. 66 The Pathology of Gonorrhea - - - - - - 66 The Pathology of Acute Urethritis - - - - 67 The Pathology of Chronic Urethritis ♦ - - - 69 Modifications of the Urethral Epithelium - - - 70 Polypi, Caruncles, Papillomata, Condylomata - - - 76 CONTENTS xiii CHAPTER FAOB VI. THE SYMPTOMATOLOGY OP ACUTE GONORRHEA - - 78 AoiTTE Anterior Urethritis - - - - - • 78 1. Incubation Period - - - - - - - 78 2. Prodromal Symptoms - - - - - - 78 3. Florid Stage ..---.. 79 4. Period of Decline - - - - - - - 80 Acute Posterior Urethritis - - - - - - 81 Etiology --...... 81 Symptoms - - - - - - - - 82 Chronic Posterior Urethritis - - - - - - 83 Symptoms .--....- 83 Vn. THE DIAGNOSIS OF URETHRITIS - - - - - 85 Examination of the Urethral Secretions - - - - 85 1. Examination of the Discharge - - - - - 85 2. Examination of the Filaments in the Urine - - - 86 Thompson's Method - - - - - - 87 Kollmann's Method - - - - - - 88 Jadassohn-Goldberg Method - - - - - 88 Krohmeyer's Method - - - - - - 89 Lohnsteiti's Method - - - - - - 89 Wolbarst's Method - - - - - - 89 Practical Method ------- 90 Macroscopic Examination of the Filaments - - - 90 Microscopic Examination of the Filaments - - - 91 Cultivation of the Filaments - - - - - 92 Examination of the Urethra Proper - - - - - 92 1. Examination of the Meatus - - - - - 92 2. Examination of the Prepuce - - - - - 94 3. Exploratory Catheterization of the Urethra - - 94 Contra-Indications - - - - - - 94 Technique - - - - - - - 95 Results obtained by Exploratory Catheterization - - 97 Examination of the Glands connected with the Urethra - - 99 1. Exploration of Littre's Glands . - - . lOO Palpation of the Urethra ------ 100 2. Examination of Cowper's Glands - - . - 102 3. Exploration of the Prostate ----- 104 Rectal Palpation ------- 104 Expression (Milking) - - - - - - 105 Exploration by Means of the Olivary Bougie - - - 107 Exploration by Means of a Bladder Sound - ■ - 109 Urethroscopic Examination ... - - 109 Cystoscopie Examination ------ 109 4. Examination of the Seminal Vesicles - - - - 110 Palpation 'per Rectum - - ■■ • • - 110 Expression --...-. HO Urethroscopic Examination - - - - -111 xiv CONTENTS CHAPTER PAGE VII. THE DIAGNOSIS OF URETHRITIS— con^m^e^ exajvnnation of the female urethra - - - - - 111 1. Cross-Examination - - - - - - 111 2. Inspection - - - - - - - - 112 3. Palpation -----... 115 4. Examination of the Urine - - - - -116 5. Exploratory Catheterization - - - - - 116 6. Urethroscopic Examination - - - - - 116 VIII. URETHROSCOPY 117 The Importance of Urethroscopy - - - - - 117 Its Importance for ascertaining a Complete Cure - - - 119 The History of Urethroscopy ------ 121 I. Urethroscopes with External Illumination - - - 122 Urethroscopes with External Illumination attached to the Urethroscopic Tube ------ 122 Urethroscopes with External and Independent Illumination - 126 Advantages and Drawbacks of Instruments with External Illumination -...-.. 128 II. Urethroscopes with Internal Ilt.tjmination - - - 131 Luys's Urethroscope .--... 136 Special Urethroscopes for the Posterior Urethra - - 139 Personal Experiences .---.. 143 Luys's Direct Vision Cystoscope ----- 144 The Supply of Electric Current ----- 145 The Technique of Urethroscopy ----- 145 Preparation of the Instruments ----- 148 Preparation of the Patient - - . . . 150 Operative Technique - - - - - - 152 Contra- Indications - - - - - - 155 On the Use of Adrenalin in Urethroscopy - - - 156 Urethroscopy of the Urethra in Health and Disease - - 157 Urethroscopy of the Healthy Urethra - - - - 157 Urethroscopy of the Normal Anterior Urethra - - 159 Urethroscopy of the Normal Posterior Urethra - - 159 Urethroscopy of the Anterior Urethra in Disease - - 162 Soft Infiltrations - - - - - - - 164 Hard Infiltrations -----»- 166 Lesions of the Lacunae and of the Glands - - - 168 Urethroscopy of the Posterior Urethra in Disease - - 172 Urethroscopy of the Female Urethra - - - - 180 Luys's Direct Vision Cystoscope ----- 180 Technique of Direct Vision Cystoscopy - - - - 182 CONTENTS XV CHAPTER PAGE IX. THE COMPLICATIONS OF GONORRHEA - - - - 187 Local Complications --..__. 137 Phimosis and Paraphimosis ------ 187 iNGTjrsrAL Adenitis -.-.-.. igg Inflammation op the Glands op the Anterior Urethra - 189 Littritis and Folliculitis ------ 189 cowpbritis -.----.. 191 Prostatitis - - - - - - - - 194 Gonorrheal Inplammation op the Testicle - - - 198 Medical Treatment .--.-. 199 Surgical Treatment ...... 2OO Sterility Supervening upon Double Epididymo-Orchitis - - 203 Gonorrheal Vesicitlitis (Spermato-Cystitis) - - - 204 Operative Treatment of Spermato-Cystitis - - - 208 Vasotomy -...-.. 2O8 Vesiculotomy ------- 209 Vesiculectomy ...... 209 • A. Inguinal Route - - . - . 209 B. Perineal Route . - - - . 209 . C. Ischio- Rectal Route ----- 210 Catheterization of the Ejaculatory Ducts - - - 210 Indications - - - - - - - 211 Technique ---..-. 212 Gonorrheal Cystitis ------- 214 Pyelitis and Pyelo-Nephritis op Gonorrheal Origin - - 216 Retention of Urine - - - - - - - 218 General Systemic Complications .---.. 2I8 Gonorrheal Rheumatism - - - - - - 218 Arthralgia -------- 220 Hydarthrosis ----... 221 Acute Arthritis - - - - - - - 221 Polyarthritis Deformans .-.--- 221 Mfsctjlar Rheumatism -..-.. 223 Gonorrheal Synovitis - - - - - - 223 Gonorrheal Bursitis ...... 223 Gonorrheal Periostitis .---.. 224 Abscesses containing Gonococci ----- 224 Eppects op Gonorrhea upon the Skin - - . - 225 Cardiac Complications op Gonorrhea - - - - 226 Gonococcal Endocarditis ------ 226 Gonococcal Pericarditis - - - - - - 229 Gonococcal Myocarditis ------ 229 Complications appecting the Digestive System - - - 229 Gonorrhea Buccalis ...--. 230 XVI CONTENTS CHAPTER PAGE IX. THE COMPLICATIONS OP GONORRHEA— co/ifonwed Ano-Rectal Gonorrhea ...... 232 Indirect Causes ....... 232 Direct Causes ....... 233 Complications ....-.- 234 Luys's Rectoscope ...... 235 Technique -------- 237 Value of Reotoscopy in Rectal Stricture - - - 239 Complications Affecting the Respiratory Organs - - 241 Nasal Gonorrhea ------- 241 Gonococcal Pleurisy - - - - - - 241 Complications Affecting the Eye ----- 242 Exogenous Ocular Infections - . - . . 242 Endogenous Ocular Infections - ... - 244 Complications Affecting the Nervous System - - - 247 " Gonococcal Meningitis ------ 247 Neuralgia of Gonorrheal Origin ----- 247 Gonococcal Myelitis -.--.. 247 Cerebral Complications ...... 249 X. GONORRHEA IN WOMEN AND CHILDREN - - - - 250 Gonorrhea in Women - ------ 250 Gonorrheal Urethritis in the Female - - - - 252 Course ...----- 253 Para-Urethral Folliculitis ------ 253 Treatment - - - - - - - - 255 Gonorrheal Vaginitis ...... 258 Gonorrheal Metritis and Cervicitis - - - - 269 Gonorrheal Salpingo- Ovaritis - - - - - 263 Gonorrheal Peritonitis ...--- 264 GONORRHEAL BaRTHOMNITIS ------ 264 Gonorrhea in Children - - - - - - - 266 Indirect Causes ,.----- 266 Direct Causes - - - - - - - 266 Gonorrhea in Little Boys - - - - - - 267 Gonorrhea in Little Girls ------ 268 XI. THE TREATMENT OF ACUTE GONORRHEA - - - 269 1. Prophylactic Measures ...... 270 2. Antiphlogistic Treatment ..-.-- 272 3. Treatment of the Florid Stage - - - - - 275 1. Urethro- Vesical Irrigations ..... 275 Indications ....--- 276 Contra-Indications - - - - - - 276 Technique -------- 277 Local Anesthesia -..---- 280 CONTENTS xvii CHAPTER PAGE XI. THE TREATMENT OF ACUTE GO^ORURE A— continued Irrigator or Syringe ? - - - - - - 281 Should a Catheter be used ?-.--. 282 Number of Irrigations required - - - - . 283 On the Action of Potassium Permanganate ... 283 Other Drugs used for Irrigations - - . - . 284 2. Urethral Injections ...... 289 Advantages and Drawbacks - . . . . 289 Technique ----..-- 290 Drugs used for Injections ..... 290 3. Balsam Preparations ...... 292 Copaiba - - - - - - - - 293 Cubebs -----... 294 Sandalwood- Oil ------- 295 Other Preparations ...... 295 Method of giving Balsam Preparations .... 296 4. Treatment of Acute Gonorrhea by Bier's Method - - 297 4. Abortive Treatment ....... 298 1. Abortive Injections ...... 298 2. Irrigations with Permanganate- .... 301 3. Intra-Urethral Dressings ..... 303 4. Ecouvillonnage op the Urethra .... 304 5. Treatment op Acute Posterior Urethritis - - - 304 6. Sebum and Vaccine Therapy ...... 305 XII. THE TREATMENT OF CHRONIC GONORRHEA General Plan op Treatment .... The Modern Methods of treating Chronic Urethritis 1. Destruction op External Paba-Ubethral Foci 1. By Injections - - - 2. By Incision .... 3. By Means of the Galvanic Cautery 2. Urethro-Vesical Irrigations ... 309 310 311 312 312 312 312 313 3. Urethral Injections - - - - . - 313 Permanent Dressings - - - - - - 314 Combined Action of Ziac and Silver - - - 314 Action of Antiseptic Gases - ... - 315 On the Insufflation of Iodine Vapours - - - 316 4. Massage op the Glands connected with the Urethra - 317 1. Massage of Littre's Glands - - - - - 317 Indication - - - - - - - 317 Technique -..-... 317 Vibratory Massage - - - - - - 319 xviii CONTENTS CHAPTER PAGE XII. THE TREATMENT OF CHRONIC GOl^ ORBME A— continued 2. Massage of the Prostate .... 32O Indication ....--. 320 Contra-Indication ...... 32O Technique - - - - - - - 320 Combined Massage and Dilatation - - - - 321 Massage with Special Instruments - - - - 321 3. Massage of the Seminal Vesicles .... 322 Indications - - - - / - - - 322 Technique - - - - - - - 322 Normal Vesicular Contents - . - - - 323 Vesicular Contents in Disease .... 323 4. Massage of Cowper's Glands . - . - - 325 Indications ..----. 325 Technique .--.... 325 6. Dilatation of the Urethba . - - . . 326 Indication ..--..- 327 Preparation of the Patient ----- 327 1. Temporary Dilatation of the Meatus - - 327 2. Meatotomy - - - - - - 328 General Rules for Dilatating the Urethra - - - 329 Dilatation by Means of Curved Sounds - - - - 330 How many Sounds should be passed ? - - - 332 What Intervals should elapse ? - - - - 332 On the Use of Filiform Bougies - - . . 333 Dilatation by Means of Four-Bladed Dilators - - - 333 Description of KoUmann's Dilator - - - - 334 Irrigating Dilators .---.. 336 Curved Dilators ..--.. 339 Dilatation of the Posterior Urethra . . ;. . 339 Technique ..-.-.. 339 Precautions required with Far-Pushed Dilatations - - 341 Adjuvant Methods to Dilatation - . - - - 343 Complementary Urethrotomy .... 344 Electrolysis .------ 345 6. Urethroscopic Treatment - - - - - 346 1. Localized .Application of Caustics - - - - 347 Technique ..-.--- 347 Substances used ._.... 348 Indications ..----- 349 Contra-Indications ------ 349 2. Urethroscopic Treatment of Inflamed Lacunse and Follicles - 350 Indications ------- 351 Technique ------- 351 1. Glandular Electrolysis . - . . 351 2, Destruction with the Cautery - - - 353 3. Cauterization by Means of the Galvanic Cautery - - 354 Indications ...-.-- 355 Contra-Indications ------ 355 Technique ...---- 356 Untoward Effects - - - - - - 358 Results ------- 359 CONTENTS xix CHAPTER PAGE Xn. THE TREATMENT OF CHRONIC GONORRHEA— con^wwed 4. Endoscopic Surgical Incisions ----- 361 5. Curetting of Urethral Strictures . - - . 363 7. Instillations .---... 364 Indications --.--.. 364 Instrumental Outfit --..-. 365 Technique - - - - - - - 365 8. Application op Heat to the Urethral Mucous Membrane - 367 Application of Heat to the Prostate ... 368 9. Ionization Treatment --.... 369 10. Salves and Urethral Suppositories - . . . 371 Urethral Salves .-.-.. 371 Urethral Suppositories (Medicated Bougies) - - 372 11. Electrolysis of the Urethral Mucous Membrane - - 372 Indications ----... 372 Technique - - - - - - - 373 RfisuME of the Treatment of Chronic Urethritis ... 375 Index - - - - - - - - - 377 GONORRHEA CHAPTER I THE HISTORY OF GONORRHEA^ Gonorrhea is as old as mankind, and urethral discharges have, no doubt, been known at all times. In the primitive ages, before medical science had originated, the wise legislator gave legal sanction to suitable hygienic measures, and thus we find Moses laying down laws for the conduct of those who suffered from a discharge from their urethra. This oldest description of gonorrhea dates back to the fifteenth century B.C., and runs as follows (Lev. xv. 2, 3): " Speak unto the children of Israel, and say unto them. When any man hath a running issue out of his flesh, because of his issue he is unclean. " And this shall be the uncleanness in his issue : whether his flesh run with his issue, or his flesh be stopped from his issue, it is his uncleanness." In the following verses Moses adds that the uncleanness is not confined to the person of the patient. His bed, his seat, the articles he uses, and the people with whom he comes into actual contact, share his uncleanness. Moses was thus perfectly aware of the contagious nature of gonorrhea, and he desired that the patient should allow a full week to elapse after his cure before he attended to his sacrifice of atonement and resumed his social functions. Anglada 2 states that gonorrhea was one of the most important diseases which prevailed amongst the Jews, and this is not astonishing, considering their unhygienic mode of living and their sexual incontinence, of which history gives many examples. It may be mentioned, by the way, that circumcision was invented for the purpose of guarding against balano- posthitis, one of the commonest complications of gonorrhea. The first scientific document dealing with this disease was written fully twelve centuries later (300 B.C.). In the Lectures of Hippocrates, which 1 Dr. Roucayrol has made a special study of the history of gonorrhea. The facts mentioned in this chapter are largely taken from his most interesting thesis : Considera- tions Historiques sur la Blennorragie, Paris (Steinheil), 1907. 2 Anglada, Etude sur les Maladies Eteintes et les Maladies Nouvelles, Paris, 1869. 1 2 GONOKKHEA have been handed down and enlarged by his pupils, we have the first scientific observation. " No disease," says Hippocrates, " has more varied symptoms than strangury. [This is his term for acute gonorrhea, and perhaps also for cystitis.] It is most commonly found in youths and in old men. In the latter it is always more rebellious, but nobody dies from it {De Locis Affectis, c. xxix.). Its usual causes are renal suppuration, and inflam- mation of the bladder, urethra, rectum, and womb, constipation, and excessive indulgence in the pleasures of Venus. Hippocrates had dissected urethrse affected with discharge, and had, no doubt, seen polypi, for he attributed the origin of the disease to tubercles and fleshy proliferations. He therefore taught, in accordance with his ideas on inflammation, that " those suffering from tubercles and carnosities in their fvpe will get well hy suppuration and the flow of pus " — an unhappy idea which misled humanity for many centuries. All the great thinkers of those days took a keen interest in medicine, and allude to gonorrhea in their writings. Aristotle, Plato, Seneca, etc., were well acquainted with this disease, and Epicurus, the gay philosopher, suffered from it all his life. After having struggled for fourteen days against an attack of acute retention which he hoped to relieve by living in a bath, he put an end to his misery, which had been brought on by his numerous strictures, by committing suicide (Seneca, Letters 66 and 92). Celsus, who lived in the times of Augustus, was the first to attribute the discharge of gonorrhea to an ulceration of the urethra {De Medicina, lib. v.), and, influenced by Hippocrates' teaching, he said that " those whose urethrse have become the seat of little tumours are restored to health as soon as the pus is evacuated from the canal." Celsus catheterized his patients, the women as well as the men, and gave descriptions of his instruments and of his modus operandi. The beginning of the Second Century of our era is marked by two great names — Galen and Areteeus of Cappadocia. Galen is the inventor of the term " gonorrhea " (from 701^?;, semen, and pelv, to flow), his opinion being that the disease was merely an involuntary loss of sperma, unaccompanied by erection. Aretseus, on the other hand, distinguished clearly between spermatorrhea and urethral discharges in his treatise De Signis et Causis Diuturnorum Morhorum. In the chapter deahng with vesical affections, he speaks of a thick white discharge which accompanies acute cystitis. He describes this ailment at length, and attributes the sharpness of the pain to the peculiar anatomical formation of the bladder which he considers to be a " flat nerve." For the treatment of the discharge, he applied astringents to the bladder. THE HISTORY OF GONOERHEA 3 placed cooling substances in the loins, and wrapped the genitals and neigh- bouring parts in wool. He used embrocations made of rose-oil, or oil of dill, or of aromatic white wine. He was also fond of ordering poultices composed of barley flour, erymum seeds, a small amount of nitre, and sufficient honey to make a paste. Sexual abstinence and pro- longed cold baths completed these prescriptions, which were supposed to cure. Paul of Egina, in the Fourth Century, devotes a special chapter in his Surgery to paraphimosis. " Paraphimosis {7rapa(})L/iio(Ti'i)," he says, " occurs with inflammation of the privates ; when the skin is drawn back, the swollen glans can no longer receive the prepuce." In the Sixth Century, Ccelius Aurelianus {De Morhis Chronicis et Acutis) regarded purulent discharges from the urethra as a flow of watery semen, due to errors of diet, fatigue, and sexual excess. Amongst the Orientals, Susruta is one of the oldest Hindu writers on medicine. In one of his works, which was probably written long before the Ninth Century, he deals with Diseases of the Urinary Passages (Utiara St'Hana), and devotes a chapter to dysuria, for which he advises medical treatment. Rhases, in the Ninth Century, gave a fuller account of gonorrhea than his predecessors. His description of urethral discharges is not without interest, and he is the first author to point out the occurrence of hematuria in cases in which the bladder becomes involved. His treatment was chiefly antiphlogistic in the beginning. Later on he injected the urethra with honeyed water, psillum mucilage, or decoction of quince seeds, and finally he healed it with white of lead or antimony. The pain on making water was relieved by him with injections of warm vinegar, which apparently gave prompt relief, or by means of rose-water containing opium, which he injected into the bladder. He also gave large doses of the last-mentioned anodyne by the mouth (Roucayrol, loc. cit., p. 26). Mesne, in the Tenth Century, was familiar with the works of Hippocrates, and was under his influence: "All inflammatory tumours formed in the , passage and channel of the urine produce, at first, pain accompanied by strangury; then pus is formed, and as it flows the inflammatory tumours and the strangury are dispersed." Farther on he speaks of the erections which accompany the discharge. Avicenna, in his Canons, mentions retention of urine due to ulcerations of the neck of the bladder, or due to vegetations. He passed catheters on his patients, and irrigated their bladders with a silver syringe. Strangely enough, he combined this rational therapy with weird and outrageous prescriptions, such as the introduction of a flea into the meatus (Roucayrol, loc. cit., p. 30). 4 GONOEKHEA Constantinus Africanus (1015-1087) used liuman milk, oil, and barley- water, for urethral injections. Tlie excellent dietic prescriptions of tlie school of Salerno contained an aphorism which indicates a very true and useful prophylactic measure : " Post coitum si mingas Apte servabis urethras." In the Middle Ages, Roger (Thirteenth Century) taught in his Surgery that gonorrhea is characterized by pain, burning, redness, and swelling of the penis, and by difficulty in making water. His therapy was a fairly active one ; he bled his patients from the saphenous vein, and applied leeches. He also practised injections per algariam. His aim was to produce suppura- tion, because Hippocrates had said that those who have pustules in their penis get well by suppuration. He was also acquainted with gonorrheal orchitis, but did not leave any details about his treatment of this complaint. His contemporary, Gruillaume de Salicet, attributed the discharge to filth retained under the prepuce after connection with a dirty woman. He treated the ulcers formed by means of the cautery, in order to " separate the corrupt from the healthy." He stands out amongst the people of his time by being the first to study the question of prophylaxis ; he advises washings with water after every suspicious connection. Lanfranc, his pupil (Thirteenth Century), deals in his Surgery with the afostumes of the generative organs, which he attributes to hot or to cold humours. Painful erections are, in his opinion, due to the fact that " the penis is full of flatus surmounted by great pain." He treated by letting blood, on the first day from the arm, and on the second from the ankle. He forbade wine, meat, and " sweet things." He also prescribed a number of salves which he considered very wonderful. Orchitis, or " Tapostume froict," as he called it, was treated by him with suppositories. For indura- tions he had a special salve which had given him good results ; and painful erections were dealt with by anointing the penis with a special ointment, which had proved " very profitable " in his experience. He did not confine himself to curing; he also advised certain prophy- lactic measures. Those who had run the risk of contamination were recom- mended to wash with equal parts of water and of vinegar. He even went farther, and advised, on the strength of his personal experience, " to wash the part of its own urine." Gordon's LUium Medicine (Thirteenth Century) contains but rudimentary information. Gonorrhea is explained as a flow of semen, unaccompanied by pleasant sensations, which may be caused by sexual excesses or by " having sat on a cold stone " ! Gordon treated his patients by blood- THE HISTORY OF GONOERHEA 5 letting, by making them vomit, and by giving them a rose syrup. He also recommended a diet consisting of gruel, lentils, etc., and advocated bathing of the loins and of the genitals with cold water. For patients suffering from retention he ordered baths, and completed their beneficial effect by putting living or powdered fleas on the penis (Roucayrol, he. cit., p. 44). John of Gaddesden, Professor at Oxford, and a contemporary, followed in his footsteps. He also recommends prophylactic washings after every suspicious intercourse, in his book Rosa Anglica Practica MediccB. These washings were to be made with acidulated water, or with urine if no water was obtainable. Gaddesden is the first to mention suspensory bandages : Ne suspensio noceat fascondo currere materiam ad locum. Guy de Chauliac, at the end of the Fourteenth Century, took over the suspensory bandage from John of Gaddesden: "And the bandages for support shall be made in the shape of a sachet, with the truss arranged in such a way that they hold and support without causing any pain." Like Avicenna, he treated the discharge with antiphlogistics. In priapism he saw a symptom of the disease, but he described it in a special chapter, and explained it in accordance with Galen's teachings. Erections he believed to be due to a " vaporous flatus," but added that they are " also very often caused by dilatation of the arteries of the penis." He treated painful erections by means of camphor, Galen's wax salve, and by placing a sheet of lead on the organ. Following Galen and Rhases, the first step of his treatment for retention was to prescribe cantharides. Then came " baths with embrocations, plasters, salves, and lotions, which were applied to the mons Veneris, the penis, and the perineum." He also advocated Master Gordon's practice, " who gave injections and syringations into the bladder with balsams." His prescriptions were largely of a disgusting and revolting character. He believed the excreta of pigeons to be an excellent drug, and considered the application of a flea or louse to the meatus of great importance (Roucayrol, loc. cit., p. 48). Valescus of Tarentum, in the beginning of the Fifteenth Century, attrib- uted urethral discharge to intercourse with a dirty, vile, or chancrous woman, or to too frequent intercourse {Philonium PJiarmaceutium et Chirurgicum). He also held that " the sharpness of the urine leads to the formation of ulcers, if it lasts long enough," and believed it to be due to ulcerations present in the bladder andin the glans (Roucayrol, loc. cit., p. 53). Peter of Argelata speaks in his Surgery (Fifteenth Century) of pustules which break out on the penis after intercourse with diseased women, and recommends to wash the patient with water in the summer, and with urine in the winter. Restrictions in the diet, purgation, soothing applications of olive-oil, poplar-tree ointment, or barley poultice, and a salve composed 6 GONORKHBA of breadcrumbs soaked in milk and mixed witb yolk of egg, complete bis therapy, not to mention the inevitable fumigations and embrocations. About the same time Marcellus Cumanus claimed to have cured many patients by his method, which consisted of purgation, low diet, and inunc- tions with olive-oil. He also advocated to inject cow's or goat's milk, or, better still, human milk, into the urethra — an advice which he considered to be marvellous. His contemporary, Antonius Guainer, recommended, in his chapter on Retention of Urine, the introduction of a small wax bougie, or of a little sound made of silver or tin, into the urethra.' He appears to have been very familiar with this method, and is the first to mention treatment by dilatation, and thus his name deserves to be handed down to posterity. Arculanus (Fifteenth Century) laid down some extremely interesting remarks in his Treatise on Surgery. His prognosis of acute gonorrhea is. curious; he points out the gravity of the illness in the aged. He was the first to describe the properties of silver in the treatment of cystitis, and ordered irrigations of the bladder with silver. He forbade sexual inter- course, advised antiphlogistic treatment, and gave lengthy directions about the diet to be followed. In his chapter on Diflficult Micturition he gives definitions of dysuria and ischuria, the former denoting di£S.culty, the latter impossibility, of micturition. He speaks of voluntary retention caused by the pain experienced with ulcerations of the penis, and teaches that reten- tion of urine may be due to a wart, or to formation of flesh within the pipe causing " a fleshy obstruction." He recommends to investigate the origin of the retention by passing a sound, and gives some very interesting details about his instrumental outfit. Vigo's book (beginning of the Sixteenth Century) marks an important date in the history of gonorrhea. Vigo made a clear distinction between gonorrhea and syphilis. The latter disease made its first appearance in 1494, according to him. " In the year in which King Charles VIII. wished to recover the kingdom of Naples, appeared in the month of December," etc. His pupil Marianus Sanctus deals in the last part of his work De Lapide Rennum et Vesicce with the history of strictures, and mentions cases which did not even admit a sound " syringam." He advocated for their treat- ment an instrument (Fig. 1) which he appears to have invented, and which he calls " terlinum " or " rostrum arcuatum." This instrument was to be of suflB.cient length to reach the neck of the bladder, and deserves to be compared with Oberlander's dilator (Fig. 2). Rabelais, in the Sixteenth Century, was also well acquainted with gonor- rhea, and many of our readers will remember the doleful paragraph in which he refers to it : "Poor old Pantagruel fell ill, and his stomach got so out of order, that he could neither eat nor drink. And as no evil comes alone, he THE HISTORY OF GONORRHEA 7 also caught the clap, which tormented him more than you would believe. But his doctors stood by him gallantly, and with many emollient and diuretic drugs made him piss away his misfortune " (lib. ii., cap. 28). Up to this time all the authors were perfectly aware that gonorrhea and syphiHs are two distinct diseases. The confusion was started by Brassavole, whose book Examen Omnium Loch de Morbo Gallico Tractus Pig. 1, — ^Marianus Sanctus' Terlintjm ob Rostrum Arcuatum. (Roucayrol.) appeared in 1551. Like his predecessors, he dated the outbreak of syphilis back to the siege of Naples, but he considered gonorrhea to be merely a manifestation of syphilis. Alphonso Eerri wrote in 1548 a special work on strictures, which was a great improvement on the former writings on this subject. It resumes the experience which he acquired during his long professorship of surgery in Italy, and is entitled De Caruncula sive Callo quce Cervici Vescice innas- cuntur liber. Amongst the conditions which give rise to caruncles, he mentions gonorrhea. This disease may produce ulcerations anywhere in the urethra, Fig. 2. — Oberlander's Dilator. and thus caruncles may be present in any of its parts. The caruncle can be softened by means of medicines, fomentations, poultices, salves, and emollient injections. Then a bougie is passed, after it has been lubricated with " cow's butter or buffalo butter, almond, sesam, or ordinary oil, or goose or duck fat." The operator selects a suitable bougie, covers it by means of his finger with one of the substances indicated, and introduces it. Ferri warns against the use of corrosive remedies in a liquid or soft form, because they affect the healthy parts as well as the diseased focus ; and as the 8 GONOERHEA former are of a weak constitution, they would sulier. A preparation of suffi- cient hardness is required which can be applied to the caruncle without damaging any other part over which it has to pass. " One should, however, not forget," says Ferri, " that the older the caruncle, the more difficult it is to cure, and, therefore, gradually stronger remedies have to be tried if the milder ones have failed. If topics be insufficient to destroy the caruncle, one has to resort to the use of an argaly, or of a pointed and cutting sound, in order to penetrate more readily. The flow of blood caused by these instruments should not cause alarm; it is even most beneficial, providing the blood comes from the caruncle, and not from any other part. Whether this is so can always be made out easily, because one can feel if the point of the argaly or of the sound is in contact with the caruncle, in which case the operation is most successful. The subsequent flow of urine cleanses and dries the tissues, and thus leads to cicatrization, no further intervention being required." In the Sixteenth Century, Lacuna wrote a treatise on the same subject — Methodus Cognoscendi, extirpandique in VesiccB Collo Carunculas. He de- scribes bougies which melt after they have been introduced. He says that they are beyond praise, and that they consume all ulcers and carnosities without causing much pain. He also gives a list of the cases of venereal strangury which he cured with his bougies. Ambroise Fare's celebrated work Des Chaudes-fisses et Carnositez engendrees au Meat Urinal appeared in 1564. It deals mainly with syphilis, but the causes of gonorrhea are men- tioned: " The clap is due to three causes — overeating, starvation, and infection. It comes on after intercourse with a woman who has had some ulcer about her privates, some syphilitic matter." Pare thus confounded gonorrhea and syphilis, and this mistake prevailed until the beginning of the Nineteenth Century. Ambroise Pare resumed his treatment of gonorrhea as follows: " A learned doctor should be called in, and he should bleed and purge the patient, if necessary, and direct the diet." He forbade all rich food, wine, and the company of women, " even to see them in paintings or otherwise." Cold baths, as little sleep as possible, and a certain refreshing plaster which was to be applied to the loins and to the genitals, he considered useful. He recommended the use of turpentine with emphasis, as he believed it to be an excellent drug for gonorrhea. Apart from turpentine, he ordered his patients to avoid " all things which heat the blood," and violent exercise. They had to sleep on a hard bed, and to drink lemon-juice or barley-water. He alleviated the pain on micturition during the acute stage by recom- mending the patient to micturate " into a vessel containing warm milk, in which he dips his penis whilst he makes water. If no milk is at hand. THE HISTOKY OF GONOEEHEA 9 warm water shall be used instead." After the acute stage had subsided, Pare advised injections containing aromatic wine, aloes, hydromel, and absinth. For chronic urethritis he recommended urethral dressings consisting of an ointment, which was applied with a little wax candle or sound wrapped in a piece of linen. Ambroise Pare made large use of dilatation treatment for chronic inflammation of the urethra. He was the first to dwell upon the necessity of using the " biggest sounds which the patient can endure " in order to obtain a good result. Loyseau, in the Sixteenth Century, followed Ambroise Pare. He treated Henry IV. of France for stricture, and gave his royal patient great relief by introducing an ointment into his urethra by means of a bougie. The victor of Ivry was so delighted that he bought it for him, and raised him to the rank of a Count. Fabricius d'Aquapendente published in 1649 an important work in which he deals with " urethral ulcer due to gonorrhea." He was chiefly concerned with the treatment of strictures, and the same may be said of Van Helmont, Fran9ois Tolet, Van Solingen, Dionis, in the Seventeenth Century. The knowledge of the pathology of urethral inflammation made great strides under Morgagni. He was the first to show that the discharge was not caused by ulcerations in the urethra, and he put an end to the old fallacy which dated from Galen, by proving the discharge to take its origin from the urethral mucous membrane, and not from the seminal vesicles. He dis- covered the " lacunae of Morgagni," and pointed out the importance of their inflammation in chronic gonorrhea. ToCardanus(EighteenthCentury)we owe a good description of gonorrhea. He discusses acute retention under the term of " dry clap." Orchitis is, in his opinion, due to the fact that " the clap has fallen into the scrotum." Like all his contemporaries, he was unable to distinguish between gonorrhea and syphilis, and therefore treated the former with mercury, chiefly by internal administration of the perchloride. For gonorrheal epididymitis he resorted to castration. John Hunter, in the same century, was the first to undertake inocula- tion experiments for the purpose of studying the evolution of the malady. His disastrous auto-inoculation, through which he ax3quired gonorrhea and syphiHs simultaneously, led him to proclaim the identity of these two diseases, and he remained a passionate defender of this error until his death. Towards the very end of the century, in 1793, Benjamin Bell established the distinction between gonorrhea and syphilis. According to him, the former was a purely local infection caused by some special contamination which differed from syphilitic infection. 10 GONOREHEA His views were taken up in France by Bosquillon. Swediaur invented the term " blennorrhagie " (from /3X€vva, mucus), now adopted in France, and produced urethral discharges experimentally by injecting irritating chemicals, such as ammonia, into the urethra. Hernandez of Toulon undertook his famous inoculation experiments in 1812. He inoculated seventeen convicts, and demonstrated thus that inoculation of gonorrheal material produces gonorrhea, and is never followed by syphilitic lesions. The definite separation of the two diseases, however, dates from Ricord (1831), who in his lucid and vigorous writings and lectures spread the new truth. He was the first to show that the manifestations of syphilis are ushered in by the appearance of a chancre, Ricord's " accident primitif," and grouped the subsequent symptoms into " secondary " and " tertiary." He demonstrated over and over again the characteristic differences between these two diseases, and proved conclusively that an attack of gonorrhea cannot develop into syphilis. In Ricord's opinion, gonorrhea was a simple inflammation of the urethral mucous membrane which could be brought on by various ill-defined causes. His non-specific phlogogenic theory of its origin was widely accepted by his contemporaries. Rollet of Lyons, however, opposed him, and proclaimed the disease to be caused by a specific virus. He held that every case of gonorrhea owed its existence to another case of gonorrhea from which it had received the virus, which was still unknown. Whilst the war was still waging between the followers of Ricord and those of Rollet, bacteriological research had made sufiicient progress to tackle the problem. In 1872 Hallier discovered the presence of micro-organisms in the pus cells of gonorrheal discharge, and in 1879 Albert Neisser, then assistant in the Breslau Dermatological Clinique, discovered the gonococcus. To Neisser belongs, not only the credit of having discovered the specific organism, and of having described it fully and accurately, but he also proved it to be the pathogenic factor in all cases of ocular and urethral gonorrhea. Neisser's researches were confirmed by Bakei and Finkelstein, Watson- Cheyne, Haab, and others. In 1884 Bumm succeeded in making pure cul- tures of Neisser's gonococcus, and Wertheim invented a practical method of cultivation shortly afterwards. Amongst the great men associated with the study of gonorrhea, Desor- meaux deserves a special mention. As far back as 1854, the " Father of Endoscopy," as he is rightly called, realized that the treatment of urethral inflammation should be based on an exact knowledge of the lesions, and he invented for this purpose the first urethroscope. Although primitive, this THE HISTORY OF GONORRHEA 11 instrument was a remarkable invention, and represented the first step to the truly scientific treatment which we have at our disposal nowadays. Benique was the first to use the metal sounds which bear his name, for the treatment of urethral stricture. His discovery was made more than seventy years ago, and we still use his instruments. Civiale also believed in dilatation, practised and taught it. The treatment of gonorrhea, such as it was, in the middle of the Nine- teenth Century has been well summed up by Voillemier. It consisted — (1) in aborting the inflammation, if the case comes under treatment in its early stage; (2) in fighting it, once it is well established; and (3) in drying up the discharge by modifying the secreting surface by means of topics. To give a full account of all the modern work on gonorrhea in this chapter would lead to repetition. Reference to recent writers is constantly made in the following chapters. May it suflS.ce here to express our admira- tion for the great work done by the German school, headed by Professor Oberlander of Dresden. Thanks to him, the urethroscopic method has been widely adopted for the diagnosis of the foci which keep up chronic discharges, and his teachings have been made widely known through the important works of Professor Kollmann of Leipzig, and of Wossidlo and Franck of Berlin. I have devoted more than twelve years to the study of their work, and I have become a passionate partisan of their doctrines. CHAPTEH II THE DANGERS OF GONORRHEA Cases of gonorrhea are seen every day in general practice, so great is their frequency, and hence their great interest from a social point of view. Despite its apparent benignity, gonorrhea is a formidable malady because of its immediate and remote sequelae. It is a great mistake to think that " gleet," as it is usually called, is an insignificant local trouble which calls for jocular comment. One should not forget that an attack of gonorrhea may terminate in death ! Unfortunately, even medical men are to be found who regard " gleet " as a benign disease, and who are unaware of the fact that gonococci are very frequently present in these cases. It is true that these gonococci are latent, and inconvenience their owners, who enjoy towards them a relative immunity, but little, if at all; but they are virulent to others. The proof of this statement is to be found in the endless number of cases of gonorrhea which were infected by women who showed no trace of disease. In these cases one is confronted with a special adaptation of the urethral soil — with a temporary local immunity which is entirely relative. It only requires a certain amount of fatigue or sexual excess, connection during the menstrual period, or an immoderate quantity of pure wine, liqueurs, or beer, to render the soil again favourable, and to allow the gonococcus to resume its activity. There can be no question of fresh infection in these cases ; they are genuine relapses. Another very common prejudice, which is not only prevalent amongst the laity, but also amongst medical men, is the belief that only a purulent discharge, the " morning drop," is worthy of consideration, and that the disease is cured once this symptom has disappeared. This is a very serious mistake; for only too often are big, heavy filaments present in the urine after the discharge has ceased, and these filaments are apt to be carried along with the sperma during ejaculation into the genito-urinary organs of the woman. Apart from the possibility of infecting her, these filaments are a danger to the man himself. They are the products of lesions which evolve insidiously and continuously for months and months, before they become obvious in the shape of serious complications. 12 THE DANGERS OF GONORRHEA 13 Gonorrhea is thus a true social scourge which affects the individual, the family, and the community, and therefore deserves to rank with syphilis from this point of view. To begin with, it is a source of disasters to the infected individual. Strictures of the urethra and all their sequelae, double epididymo-orchitis leading to sterility, prostatitis often complicated by retention of urine, cystitis, and pyelonephritis, are some of the dangers which threaten the ignorant or careless patient. Then there are the systemic complications, which should never be lost sight of, such as gonorrheal rheumatism, which is present in 2 per cent, of all cases, periostitis, osteopathy, and muscular troubles of gonococcal origin. The cardiac, vascular, pleuro-pulmonary, peritoneal, and meningitic complications observed by so m.any authors prove conclusively the existence of a general systemic infection caused by the gonococcus. The male transmits his gonorrhea to the woman, and it has been estab- lished beyond doubt nowadays that about 70 per cent, of the bartholinites, cystites, metrites, and salpingites, met with in married women, are due to the gleet of their careless, ignorant, or unscrupulous husbands. Jullien's words^ are only too true: " Generally, morbid conditions arise which are of a persistent character, and show no tendency to cure. The generative organs become gradually involved to their whole extent ; the general health suffers; all the functions of the body become slack; the women merely drag along, and have to pay for every minute of exertion, for the shghtest error in their diet, and for a walk of any distance, with weeks of invalidity. The home is childless, there is no happiness, and this state of affairs may last for years !" The wife is an invalid or sterile, whilst the husband goes about uncon- scious of his guilt, and unaware of the fact that he is still contagious owing to the discharge which he neglected in his youth, say eight, ten, or even fifteen years previously. Ricord treated in 1840 a patient whose illness dated from the year 1800. Desormeaux attended in 1863 an officer who had not been free from urethritis since 1813. Hartmann has also had occasion to con^dnce himself of the longevity of the gonococcus : one of his patients had a chronic discharge for ten years, which had been treated without success in all the capitals of Europe. On one occasion only this patient had inter- course with a woman without a preservative : five days later she developed acute gonorrhea, characterized by violent urethritis, hemorrhagic cystitis, and metritis. Finally a double pyosalpinx supervened, which required a mutilating operation.^ How often do we not hear this doleful statement repeated by young 1 JuUien, Blennorragie et Mariage, Paris (Bailliere), 1898, p. 138. 2 Hartmann, Organes Ginito-Urinaires de l' Homme (Steinheil), 1904, p. 79. 14 GONOERHEA wives: " As a girl I was very strong and well; since my marriage my health has left me " ! An alarmingly great number of young women are confined for months, or even for years, to their bed or their sofa, and pass their days in worrying over their shattered health. The gravity of their lesions condemns them incessantly to all sorts of precautions, which may allow them to lead a life of misery for some time, but cannot cure. Their only hope is a serious operation, which deprives them of their diseased organs, and renders them sterile for ever. And those who suffer thus are not only prostitutes and ladies of easy virtue, who, as Verchere puts it, " merely run the risks of the trade," but also married women who are absolutely straight and faithful, and have nothing to reproach themselves except a mistake in the choice of their husbands. One cannot close one's eyes to the fact that very often the parents are guilty of negligence or ignorance in these instances, and that, unfortunately, also the medical adviser is not always free from the blame of having reported favourably on the fiance's health without having examined him with sufficient care. Then, again, the disease, brought into the family by the husband, may afiect the children in the form of purulent ophthalmia of the new-born, condemning these poor little creatures to complete blindness, and rendering them a burden to society. Gonorrheal urethritis, and especially vulvo- vaginitis, are not infrequently met with in little girls, chiefly amongst the poor, whose miserable hygienic conditions (lack of cleanliness, overcrowding, etc.) favour the development of this afiection. Apart from those cases of vulvo -vaginitis in which rape, criminal intercourse, etc., are responsible, there are plenty of instances in which girls of tender age were contaminated through the contact with soiled linen, infected sponges and bed clothes, or dirty thermometers,^ etc. The seriousness of this disease lies in its tenacity, and in the difficulty of eradicating it, once it has gained a footing in a family, or in a hospital, or in a school. The husband brings the germ homie, gives it to his wife, who becomes as contagious as he is — Verchere's " gonorrhea of the innocent." The pathological cycle observable is, then, one of the following: The husband seeks treatment, once he finds his disease persisting or becoming worse. When he is cured, he cohabits again with his wife, and reinfects himself. Or it is the wife who, having had since her marriage a cystitis or a severe metritis, consults a doctor and obtains relief. The first intercourse with her diseased husband leads to reinfection. Thus alternate reinfections ad infinitum take place, and it becomes impossible to Gx any date for the 1 Veil et Bayon, "Epidemie de Vulvite a Gonocoques; Transmission par un Ther- niometre," Semaine Medicale, 1904. THE DANGERS OF GONOREHEA 15 duration of tlie man's gleet or for the wife's metritis. It is not uncommon for this state of things to last ten years or longer. In cases of this type the infection is seldom acute, and rarely produces alarming symptoms. Bad cases are, however, met with, although they are very uncommon, and then they convert the honeymoon of the young couple into a gallmoon, as Callari puts it. In the vast majority of cases the infection is attenuated, or very attenu- ated even, and merely causes a urethritis or a slight metritis, which, never- theless, often renders the wife sterile. Paul Delbet has quoted two cases of this nature,^ in which the simul- taneous disinfection of husband and wife was followed by fertilization. A general outcry has been raised by all those who have studied the ques- tion, and they have pointed out with emphasis the great danger of infection connected with chronic gonorrhea. But the terrible consequences of gleet, as far as they concern married life, are inadequately known. Noeggerath,2 who was one of the first to look into the matter, maintained that in New York no less than 800 out of 1,000 husbands had suffered from gonorrhea, and that 90 per cent, of them had not been cured. Their disease, although it had become latent, remained infectious, and thus nearly all married women were infected.^ Von Schaick ^ undertook systematic researches in order to ascertain to what extent married women suffering from leucorrhea harboured gonococci, and found, amongst sixty-five women examined in the course of three years, the gonococcus seventeen times — i.e., in 26 per cent. A striking example which I had occasion to observe is the following : A young man of twenty-nine had had two attacks of gonorrhea — one when he was twenty-one, and. the second one at the age of twenty-six. On both occasions the treatment had been insufficient; but in January, 1904, he was free from discharge, as he assured me. He, however, never troubled about his water, as he did not under- stand the importance of the presence of heavy filaments in the urine, and married with a clear conscience. Six months after his marriage his wife had a profuse white discharge, which was treated with permanganate and silver nitrate douches. At the same time he noticed, to his amazement, a big flow of pus from his urethra. Injections of zinc sulphate, and cubebs taken internally removed his discharge very quickly, and this apparent cure lasted about five months. In the beginning of December, 1904, the running suddenly came on again, and now his doctor, Dr. Paul Roger, sent him to the author. On examination his discharge was found to contain typical gonococci. Under repeated irrigations with potassium permanganate the discharge disappeared rapidly and the urine became clear, but some heavy filaments were still present in the first glass. Urethroscopy was now resorted to (middle of January, 1905) after previous 1 Paul Delbet, Comptes Rendus de r Association Frangaise d'Urologie, 1902, p. 228. 2 Noeggerath, Die latente Gonorrhoe, Bonn, 1872. 3 Pierre Delbet, in Traite. de Chirurgie de Duplay-Reclus, vol. viii., p. 118, * Van Schaick, New York Medical Journal, October 30, 1897, p. 598. 16 GONOEKHEA dilatation. It was thus ascertained that the posterior urethra was healthy; but the penile urethra showed at the peno -scrotal angle a patch, about 2 centimetres in length, of typical infiltrative lesions. Methodical dilatation with KoUmann's straight dilator was now resorted to, with the result that this well-defined lesion and the heavy filaments disappeared. At the same time I examined the wife, who was eight months pregnant, and suffered from a very free white discharge. Dr. Rudaux, who attended her, had examined the secretions of her urethra, and had found gonococci. As her pregnancy did not allow more active measures, she was treated by means of vaginal douches with permanganate, and local applications to the outer surface of the cervix. A complete cure could only be effected after her confinement, when it was permissible to treat the cavity of the cervix. From the foregoing remarks a clear picture can be gained of tlie disasters which a neglected urethritis is apt to cause. It is in the interest of the public to point out these facts to its resentment. There can be no question that uncured gonorrhea is one of the most frequent causes of a declining birth-rate, that it cripples an endless number of men, and that it renders legions of women sterile. Everywhere in France and abroad the statists dwell upon the danger of a decline in the birth-rate, and the Boards of Health respond by the call: " Protect childhood !" Would it not be equally justified and to the point if one proclaimed: " Protect the future mothers " ? The public has not sufficient respect for gonorrhea; many see in it a simple cold in the pipe. They treat it with contempt, and leave its cure to time. " Gleet, that is nothing," they say, and yet the victims of neglected or unsuspected gonorrhea are countless in both sexes. It is the duty of medical men to point out these dangers. The attitude to adopt has been well outlined by Dr. Jullien, who says:^ "It is high time that this heartbreaking state of afeirs should cease. It is the duty of us doctors to start a crusade against the latent enemy which is a hundred times more terrible than syphilis, as Noeggerath rightly claimed. Let us be clear that we cannot point out too often nor too strongly the final consequences of gonorrhea. Both the working classes and the gentry should understand how it poisons the home and compromises the offspring. Let us teach them the means of recognizing this evil; let us keep them away from marriage by reason, by interest; and, above everything, let us learn to cure them. This duty is incumbent upon us both for the sake of the individual and for the benefit of society." It is not irrational, as has been done lately in America, to propose legisla- tive measures which compel all those who wish to marry to submit to a thorough medical examination.^ For further information on this subject 1 Jullien, Blennorragie et Mariage, Paris (Bailliere), 1898. 2 The State of Michigan considers all those who attempt to marry, and are suffering at the time from gonorrhea or syphilis, as criminals liable to imprisonment (up to five years), or to a fine of $500 to $1,000 (A. F.). THE DANGERS OF GONORRHEA 17 the reader may be referred to Paul Bru's interesting study, Ulnsexuee ou V Autre Avarie. One should also consider the unpleasant position of the medical man in these cases. Thus, a patient may consult him, and say: " Doctor, I am getting married in a week, and I cannot possibly put it off, as they would otherwise break of! the engagement. I should like your advice for a little trouble which I have, and which I want you to cure at once." The examina- tion shows this fiance to be contagious, and his disease to be of such a char- acter that it could not possibly be cured in the short time allotted. The doctor explains to him his condition and its dangers, and informs him that he is on the point of committing an abominable action by contaminating deliberately an innocent girl. However, he merely gets the reply: "I would not dream of giving up this marriage; it saves me from ruin. The future can look after itself." The patient thus goes away, and commits his crime, without there being any means of restraining him. Two conclusions have to be drawn from the above remarks: firstly, a certificate of health and of the completeness of the cure is indispensable before entering upon wedlock, and, secondly, the young men should be informed of the perils which await them. Not only should the necessary instruction be given in the upper forms at school, but also in the barracks and at home. They will then be in a better position to avoid the danger. The Social Struggle against Gonorrhea. We have seen above the dangers with which gonorrhea threatens both the individual and society. With reference to the campaign against this evil, two important factors deserve attention: firstly, the ignorance of the danger prevailing amongst young people, and, secondly, excessive confidence. Amongst the victims of ignorance we find firstly the sons who grew up in the bosom of their family, and know nothing about sexual life. The others, who have been to a public school, are usually full of wrong ideas, as it is extremely difficult to give proper instruction on this subject, which most masters and principals are loath to discuss. In the barracks conditions are better. In France special lectures are given in the various regiments in order to warn the soldiers against the dangers of venereal diseases. Very generally, the young man who has just acquired his first attack of gonorrhea has but vague notions of his disease. He may have heard of violent pains " like a razor," but he seldom thinks of the possibility of having been infected ; and once he realizes what has happened, he is usually hope- lessly helpless. Instead of going to a medical man, who would attend to his 2 18 GONORRHEA illness properly, and confirm the diagnosis by microscopy, he runs to the first chemist. Any drug warmly recommended is readily accepted, or else the choice is guided by advertisements seen in the daily papers or by a kind friend. This state of affairs is largely due to the deplorable fallacy that gonor- rhea is but a trifling ailment. Excessive confidence is another cardinal factor in the dissemination of the illness. Many men of sufficient knowledge and experience, who have a good general notion of venereal diseases and of their mode of dissemination, neglect the most elementary precautions at the right moment. The woman is quite healthy, they say, when they consult their doctor. But what do they know about it ? Even a medical certificate is no guarantee. After having acquired gonorrhea, a woman has obviously a few symptoms ; but they soon pass off, and the late effects are often so insignificant that she becomes convinced of her recovery, and manages to persuade her surround- ings, including her doctor, to that effect. In fact, often these women who appear to be cured are still contagious ; their virulence is dormant, but it regains its full power now and then, when circumstances are favourable, such as the periods, a strong orgasm, and temporary lack of cleanliness about the genitals. We have frequently come across cases in which young men acquired gonorrhea after several months' cohabitation, both parties being faithful to each other. An interesting example has been published by Dr. Carle of Lyons, which may be quoted:^ " A young man had attached himself to a little lady who once had suffered from gonorrhea, but had given up her former life, and he enjoyed two years of uninterrupted happiness with her. One day, as the couple were on a cycle tour in the Alps, the solitude and the bracing air revived their evil desires, which they satisfied on the spot, surrounded by magnificent scenery. There being no water near, all washings had to be omitted, and six days later the young man had a typical discharge." On other occasions the patients say that " they cannot have the clap, because their sweethearts are true to them, or because their mistress is a married woman, or because they have been to a brothel." It is obvious that the faith which underlies these statements is totally ill-founded. The Legal Aspect of Gonorrhea. As the subject of this paragraph is beyond the province of medicine, I have sought the advice of some of the most distinguished members of the Bar in Paris. Men like Henry Aubepin, Duhil, Touret-Pialat, and others, 1 M. Carle, La Blennorragie Uretrale (0. Doin), 1910, p. 12. THE DANGERS OF GONOERHEA 19 have kindly supplied me with valuable and interesting matter for this paragraph, for which I wish to tender them my best thanks. Although legal proceedings against a person who infects a healthy person with gonorrhea are just, and appeal forcibly to the mind of the public, yet there is no special law to that effect, and those in force leave a number of loopholes which allow the culprit to escape prosecution. In French law it is generally admitted as a point of law that the trans- mission of venereal disease by one consort to the other does not necessarily and of itself constitute a ground for divorce or separation. It only becomes such if it is accompanied by accessory facts and circumstances which give it the character of " cruelty."^ Such " cruelty " is present if the contaminating party did so knowingly — i.e., if he (or she) knew at the time that he (or she) was suffering from a venereal disease. " The fact of having knowingly exposed his wife (or her husband) to the dangers of contamination . . . implies undoubtedly, if it can be proved, cruelty, and is therefore a ground for an application for divorce." ^ Thus, all depends on this point: the guilty party is only punishable if he (or she) contaminated the other party knowingly. If a husband infects his wife with gonorrhea, and if it can be proved that he knew that he was ill, and that he exposed her to infection despite this knowledge, then he has committed an act of gross cruelty. His wife could under these conditions not be compelled to live with him again, as she could not have any other feelings towards him than amply justified aversion and profound contempt.^ The Gazette des Tribunaux of October 6, 1897, states definitely:"* "A wife has no right to demand a divorce because her husband gave her a venereal disease, unless it be proved that she was infected knowingly by her husband." If the contamination took place unknowingly — if the infecting party was unaware of his illness, or believed himself to be cured — then neither divorce nor separation can be granted.'^ The contamination itself is thus of little importance compared with the intention. " The mere fact of a husband having infected his wife with a venereal disease is not a sufficiently serious cruelty to justify an applica- tion for divorce or separation, providing he had reason to believe himseli cured, and providing he thus did not consider himself any longer con- tagious " (Nancy, January 26, 1901). 1 Courts : Toulouse, January 30, 1821 ; Rennes, July 14, 1866 (D. 68.2.163); Paris, April 13, 1897 (D. 97.2.137); Aubry and Rau; Demolonde, t. 4., No. 389. 2 Courts : Vouziers, July 18, 1907, Gaz. du Pal, September 24, 1907. 3 Courts: Lille, December 15, 1898. * Courts : Seine, June 4, 1897. 5 Courts : St. Quentin, January 24, 1907 {Gaz. du Pal., May 4, 1907). 20 aONORRHEA The court in Douai (January 7, 1908), and the Droit (April 11, 1908), have developed this view further: " The fact that a husband, when informed by a medical prescription of his wife's illness, shows no surprise, continues to live with her, casts no doubts upon her moral conduct, and fails to bring a counter-action when divorce proceedings are pending against him, may be interpreted as a tacit admission of his guilt, as far as the contamination which he was accused of is concerned." The infected wife must be treated as soon as possible. This duty has been clearly established by the Bordeaux. Courts : " A husband who has given his wife a venereal disease, be it even without his knowledge, is guilty of a cruelty which would be a suflB.cient ground for separation, if he sacrificed his wife's health to a false sense of shame, and failed to take the promptest measures to check the havoc of the malady " (Bordeaux, February 18, 1857). Translator's Note. — -As the legal position of those who infect others with gonorrhea is somewhat different in England, a few notes for which I am indebted to Mr. H. Morse Hewitt may here find room. Generally speaking, if a man infects a woman, or vice versa, with gonorrhea, the infected party has no legal remedy in damages, or otherwise, against the infecting party. In the case of husband and wife, there are, however, statutory enactments which have to be considered. One should imagine that the communication of gonorrhea from one consort to the other would be in itself sufficient evidence of adultery having been committed by the infecting party. But this is not so. The law-courts hold that gonorrhea (or any other venereal disease) is uncertain evidence; for, regarded strictly, such disease would be consistent with the adultery of either party, and, moreover, it would also be consistent with accidental, non-venereal transmission of the disease. It is therefore always necessary to bring special proof, supported by other facts, that adultery has been committed, if one wishes to obtain a divorce or a judicial separa- tion, as the case may be. Proof of adultery alone would suffice in the case of the husband's suit to obtain his divorce. In the case of the wife's suit, both adultery and "legal cruelty" — of which there are many kinds, the communication of a venereal disease being only one variety — have to be proved, unless, and until, the present laws be altered, as recommended by the Majority Report of the Royal Commission. In order to prove "legal cruelty" by the communication of gonorrhea, this com- munication must be shown to have been wilful. If a married man infects his wife wilfully with gonorrhea (or any other venereal disease), or vice versa, without additional marital offence, the injured party is only entitled to apply for a judicial separation, for the reason already mentioned, that the communication of a venereal disease is no proof of adultery. The courts of law cannot compel the guilty husband to have his wife treated and cured of the illness he gave her. But she may seek treatment of her own accord, and at her husband's expense ; for the medical man in attendance would be entitled to recover his fees directly from the husband, on the ground that his advice and attendance come under the designation of " necessaries " for which a husband is responsible. In the United States there is no uniform legislation concerning divorce and com- munication of a venereal disease. Each State has its own laws, and hence it is impossible to discuss this subject here. CHAPTEE III THE ETIOLOGY OF GONORRHEA Inflammation of the urethral mucous membrcme which shows itself by a discharge is always caused by some irritant which acts wpon it. In 1782 Swediaur proved experimentally tliat urethral inflammation can be produced by tlie injection of irritating chemicals. He injected ammonia into bis own urethra, with the result that he developed a violent urethritis, which in its course and in its clinical symptoms closely imitated a typical attack of acute gonorrhea. Later, Cullerier and others took up these experiments, and obtained similar results. It is nowadays well known, thanks to Neisser's discovery of the gono- coccus in 1879, that the most frequent cause of gonorrhea is a specific organism — namely, Neisser's gonococcus. One should, however, not forget that there are a number of other organisms capable of producing urethral discharges, and that this type of urethritis is very common. We will consider them later {vide Chapter IV.), and devote our attention at present to the gonococcus. The Gonococcus. This organism was discovered by Neisser in the year 1879 in discharges from the urethra. It is the best-known specific cause of gonorrhea, and is never found as a saprophyte in healthy organs. Frequency. — Gronorrhea is a very common complaint, so much so that but few men reach their prime without having had it once, or more often. It is only contracted in one way — namely, by contagion. Ways in which the Contagion is brought about. — The infection of the urethra by the gonococcus during coitus may take place in various ways. Those, for instance, who are slow run great risks, and, as Baumes tells us, also those who, without erection or connection, allow the tip of their penis to touch the external genitals or the inner surface of the upper part of the thighs of the woman, for these structures are only too often soiled with gonococcal material. Indirect contagion from one man, who has the disease, to another, 21 22 GONOKRHEA through a vagina which has escaped infection, is also possible. Diday ^ has mentioned such a case: On an excursion, six young men had successively intercourse with the same woman, who was stated to be healthy. The first actor of this scene had an inveterate attack of gonorrheal folliculitis. His immediate successor was the only one to be infected. Diday follows from this that " he had been infected by the fluid of the follicle deposited in the vagina of the woman an instant previously." Such indirect contamination is also possible if the gonococcus has been recently deposited on a mucous surface which is an unsuitable medium for ' its growth, providing the urinary meatus comes into contact with this surface. This is the mechanism of certain infections per os (vide Gonorrhea Buccalis, Chapter IX.). Gonorrheal urethritis in man is thus always derived from a gonococcal infection present in the contaminating woman at the time of intercourse. It must, however, be conceded that certain adjuvant factors, which are well summed up in Kicord's famous recipe for getting the clap, are some- times necessary. " Do you wish to get the clap ?" he used to say. " This is the way to do it: Take a lymphatic, pale, and preferably blond woman who suffers from as profuse a whitish discharge as you can find. Dine with her; begin with oysters, continue with asparagus, drink heavily white wine, cham- pagne, and liqueurs. You will be well on the way then. To expedite matters, dance together after dinner till you get hot. Then take plenty of beer, and, once the night has come on, set to work energetically; two or three connections are by no means too much — the more the better. Next morning remain in a hot bath for some time, and take a urethral injection. If you live up to this programme, and do not get ill, you must be under the special protection of a god." Excitement is thus an important predisposing factor. Amongst the various conditions which favour infection, abuse of spicy dishes, of drinks and of champagne, sexual excess, and prolonged connections, especially in a state of inebriety, deserve special mention. The lazy or " refined " intercourses, as well as those to which there is no end, are the most dangerous, and are most often followed by infection. " Oportet non morari in coitu," said Nicolas Massa : " Wise lovers are quick." Further congestive phenomena which favour infection are those which precede, accompany, or follow upon menstruation and pregnancy. Latent gonococcal infections tend to flare up under their influence, and to become virulent again. This phenomenon explains certain observations, such as the following: A woman yields successively to several men, and only contaminates one, ^ Diday, Gazette Hebdom. de Medecine et de Chirurgie, 1860, p. 727. THE ETIOLOGY OF GONORRHEA 23 whilst tlie others remain unaffected. It seems a fact that a man with whom the intercourse is " indifferent " does not elicit the particular secretion which accompanies the orgasm in woman, and that he thus has a much better chance of escaping infection than the man who " pleases," and causes a copious secretion during the height of pleasure. This profuse flow empties the infected glands, mobilizes the gonoccoci, and brings them into contact with the male urethra. How often do we not hear patients say, who come to us after they have acquired gonorrhea : " Doctor, I have a slight discharge, but I am certain that the woman from whom I got it has not got the clap " ! Such statements should be received with suspicion, once the microscope has revealed the presence of Neisser's organism ; and even if the examination of the woman fails to show any gonococci — a rare occurrence — one should suspect her, unless other sources of infection are probable {vide Chapter VII.). Others, again, still more reckless, say : " I know for certain that my sweet- heart has no disease. She is the wife, or the mistress, as the case may be, of my best friend, and there is nothing wrong with him." This, again, is a mistaken theory, which finds its explanation in the facts mentioned above. Herewith a case in point : A youth suffering from gonorrhea assured me that his mistress, the wife of his best friend, could not be ill, because her husband was free from disease. I went into the matter, and discovered the following characteristic facts : The woman was " indifferent " to her husband, and only had intercourse with him after careful douching, and she also used the douche afterwards. Her relations with my patient were, however, not " indifferent," and the two were in the habit of satisfying their desires hastily, irregularly, and without taking any precautions. This mechanism is typical for a good number of infections. The following story may also serve as example to show how little im- portance is to be attached to the statements of certain women : In September, 1909, a young man consulted me for a discharge which contained, as the microscope showed, a great number of typical gonococci. He was very astonished, and assured me that his sweetheart, to whom he had always been true, could not be ill, because she had only recently been examined by a doctor, who had certified her as having no lesions about her generative organs. I thereupon asked to be allowed to examine the lady, and she consented. The most careful search failed to reveal any lesion about the urethra, vagina, cervix, and Bartholin's glands, and I was on the point of sending her away, when I once more cross-questioned her. I now managed to extract the following information : Under normal conditions their relations had never given rise to any trouble. But once, during his mihtary service, cohabitation a ^posteriori had taken place, in order to avoid the douching, which would have been very inconvenient at the time. 24 GONORKHEA In former days site had. had. another lover, who suffered from gleet, and was addicted to this nnnatural practice. The case was thus explained ; and when I examined her rectum with my rectoscope a few days later, I found a markedly inflamed, easily bleeding mucous membrane — ^typical proctitis. As Finger^ has pointed out, a slightly alkaline medium is most suitable for the development of micro-organisms, and in particular of the gono- coccus. Under ordinary circumstances the urethral mucous membrane is bathed in an acid medium, owing to the few drops of urine which are left behind after micturition. This slight acidity, which is already sufl&cient to compromise the vitality of the spermatozoa, is neutralized by the urethral glands, which begin to secrete when erection takes place. The clear, viscous, alkaline secretion of these glands, however, not only favours the vitality of the spermatozoa, but also renders the urethral mucosa more apt to be infected by the gonococcus. As conditions which are unfavourable to infection may be mentioned : con- nection of short duration, single coitus, and immediate micturition after the act. The urethra thus becomes acid again almost at once, and is freed as far as possible from any gonococci which may be present. This practice is, by the way, well known under the somewhat vulgar term of " I'injection du zuave." Lastly, the question of constant recurrences of gonorrheal urethritis deserves attention. Formerly some doubts existed as to their production, but nowadays only two causes can be admitted for these constant reinfections of the urethra : 1. Auto-reinoculation of the urethra from a focus which has not been cured (littritis, cowperitis, prostatitis, vesiculitis, etc.). 2. Hetero-inoculation from a fresh, unknown woman, or from one's habitual consort (wife or mistress), who has been previously contaminated, and now returns her lover's or her husband's gift with interest. In cases of this latter type, the disease is usually most inveterate, and a cure is only possible if both parties allow themselves to be disinfected simultaneously. Contamination through Inert Objects. — Gonorrhea can be transmitted by soiled towels, by water which has just been used, etc. Benajmin Bell quoted the case of two students who had never had gonor- rhea, and who conceived the brilliant idea of placing a piece of gauze impregnated with gonorrheal pus between their glans and prepuce for twenty-four hours. Both acquired a balanoposthitis, and one of them an acute urethritis as well, which lasted for more than a year. The vulvo- vaginitis of little girls is often due to contact with towels, sheets, or sponges, which have been soiled by the diseased organs of others (parents, etc.). 1 Finger, in his textbook on Gonorrhea and its Complications. THE ETIOLOGY OF GONOEHHEA 25 Guiard observed a case in which a lady was infected through the nozzle of her own douche, which had been used in her absence, and without her knowledge, by her maid, who was suffering from gonorrhea. Effect of Age. — There is little doubt that age has a certain influence upon the course of gonorrhea. The old man who gets the clap is seriously exposed to complications, especiall}^ to a rapid ascending infection, involving his bladder and his kidneys. " If the pox does not care for old men, the clap is also hard on them " (Ricord). Gonorrhea Vulvitis in Little Girls. — Little girls frequently contract vulvitis, and one of the causes of their malady is the custom of taking them into the bed of their parents, which is often soiled with gonorrheal discharge. Very generally these children are badly looked after, and it is not rare to find much later in life innocent girls suffering from rebellious chronic dis- charges which contain the gonococcus, and thus reveal their origin, which lies far back. A case of this kind which has come under my personal observation is the following: In October, 1909, Professor Pozzi sent me a man of thirty-six who was in a state of despair. He had contracted gonorrhea when nineteen, had been insufficiently treated, and had never got rid of his disease. He believed, however, that the virulence ought to have subsided after a number of years, and thus he married at the age of twenty-six. Shortly afterwards his wife became ill, and she was put under the care of Professor Pozzi, who first curetted her, and later found it necessary to remove the uterus and its appendages by the abdominal route. This, however, was only part of the disaster. Their issue, a little girl, acquired gonorrheal vulvo- vaginitis at the age of eight by being taken into her parents' bed, the sheets of which were soiled with gonococcal pus. On examination, the man was found to be suffering from a chronic inflammation of Littre's glands, which had been in this condition for nineteen years, and which were certainly responsible for the illness of his wife and of his child ! On being acquainted with this truth, the unfortunate husband was in a state of frenzy, but the damage was done. Influence of Fever. — An intercurrent fever has a marked effect upon urethral discharges. Vidal de Cassis had already noted that discharges cease during attacks of rheumatism, and reappear when the joint trouble subsides. Bogdan^ quotes a case in which the gonorrheal discharge dis- appeared in pneumonia, and returned once the lungs were normal again. Guiard observed a young man who developed scarlet fever whilst he was suffering from a rebellious chronic urethritis; in this case the discharge disappeared during the fever, and remained cured. It is a matter of common knowledge that in cases of epididjnuo-orchitis which are accompanied by high fever the discharge diminishes, or even disappears for the time being. I have seen a young man who developed mumps whilst suffering from 1 Bogdan, Annates de Dermatologie, 1893, p. 253. 26 GONORRHEA gonorrhea. His temperature was very high (40° C. = 104° F.), and with the fever the discharge disappeared completely. But once the intercurrent illness had left him, the flow came on again, and had to be treated in the U3ual way. This coincidence of fever and improvement induced me to make use of heat therapeutically, and for a time I hoped to obtain a rapid general destruction of the gonococci by heat (vide Chapter XII.). But if the discharge diminishes or disappears for a time, whilst an inter- current illness produces high fever (up to 104° F.), it yet remains true that the gonococcus resists for a considerable time. Nobl^ has published five cases of gonorrhea, complicated by various febrile affections (pneumonia, pulmonary tuberculosis), in which the gonococcus was in no way influenced, as far as its virulence and resisting powers were concerned, although there was prolonged high fever of 104° F. On the other hand, Nogues has published two cases of gonorrhea in which high fever led to a spontaneous cure.^ The gonococcus can remain in the latent state for a very long time within the urethral mucous membrane. It is not rare to find patients who have had no trace of moisture about their urethra suddenly develop some local or general complication caused by the gonococcus. The Morphology of the Gonococcus. A knowledge of the gonococcus is indispensable for the clinical appre- ciation of gonorrhea. The characteristic and pathognomonic features which are essential are the following : Shape. — The gonococcus^ is not, as its name would indicate, a true coccus. Its outlines are not round, and it is always found in the diplococcus form, consisting of two parts of ovoid shape which are darker than the background, and are separated by a light line. Each member has the shape of a cofiee bean CI ^tk or of a French bean; the straight or concave surfaces ^ft ^^ are in apposition (Enschbaum's notch). The organism ^ „ ^ is 1 tt long, and 0-6 to 0-7 a wide. Fig. 3. — Gonococci mi ■ ^ (diagrammatic). Grouping. — The gonococci are always present m (After J. Courmont.) clusters and in clumps, but they never form chains. The two-and-two arrangement is always present. Movements. — These movements are not easily seen, as they are only visible in unstained preparations. One has, however, noted a slow oscillatory ^ Nobl, " Klinischer Beitrag zur Biologie der Gonokkoken," Wiener Klin. Rund- schau, 1901, Nos. 46 and 47. 2 Annates Oenito-Urinaires, 1907, p. 1288. 3 V. Marcel. See Le Gonocoque, (Thesis, Paris, 1896). THE ETIOLOGY OF GONORRHEA 27 translation movement and a rotatory movement, one of the two members of a diplococcus being on top of tbe other alternately. Lately Dr. Comandon, who has applied with such success the cinemato- graph to the study of the movements of microbes, has investigated those of the gonococcus, and found the translation movement to be limited. This organism is sluggish, and its movements are, in his opinion, simply Brownian. Its colonies only advance by their development and their increase in size. It therefore requires a considerable time for Neisser's coccus to reach the posterior urethra by its own means. This interesting fact is of capital importance: it shows the dangers of clumsy injections — how they dislodge the gonococcus from its original focus, and carry it to distant parts. Staining Properties. — The organism is readily stained by the aniline dyes, especially methylene-blue; it is Gram-negative, being easily decolorized by this method. Technique of Searching for Gonococci — Examination of the Discharge. — The simplest method is the following : By means of a platinum loop which has been passed through the flame and allowed to cool, a bead of pus is taken from the meatus, which has been previously cleansed with a piece of wool Fig. 4. — Mounted Platinum Loop for collecting the Dischaege from the Meatus. soaked in boric lotion. This bead of pus is gently squeezed out of the urethra; this precaution is of importance, because brutal squeezing is apt to injure the urethral glands. This " milking " should not only involve the tip of the penis, but the entire anterior urethra, starting at the perineum and scrotum, and working gradually forwards. The bead of pus is then spread out by means of the loop, or of an ordinary steel needle, on the surface of a slide to form a thin and even layer, and allowed to dry. This is the most satisfactory way; compression of the discharge between two slides often gives bad preparations. The smear is then fixed by passing it three times through a spirit or Bunsen flame, and is ready for staining. Microscopic Examination of the Filaments. — The fllaments contained in the urine should also be examined bacteriologically. For this purpose, the patient is asked to make water into a glass, from which one tries to recover the filaments. This fishing is often tedious and troublesome, but one finally manages to seize them with forceps or to roll them on to the platinum wire. They are then spread out on a slide. Owing to their viscous nature, they are not easily fixed, and tend to slip off. By passing a current of air over them this process can be much faciUtated. 28 GONOKEHEA These filaments are stained in the same way as the discharge. Staining. — Kiihne's carbol-methylene-blue gives the best results, and has the following formula: Absolute alcohol . . . . . . . . 10 c.c. Methylene -blue . . . . . . . . 1-5 grammes. Dissolve, and add after twenty-four hours : 5 per cent, solution of carbolic acid . . . . 100 c.c. The stain is allowed to act for a few minutes, and is then washed o& in running water. The slide is now dried and ready for examination. The whole process takes takes less than five minutes. Nicolle's Method for staining Gonococci. — Another method for staining gonococci has been devised by Nicolle:^ The pus is spread out on a slide, and rapidly dried by passing it through the flame of a lamp. The smear is then deprived of its fat by dipping it for a few seconds in a mixture of equal parts of 90 per cent, alcohol and sulphuric ether. It is then dried in the air, and a few drops of carbol-thionin are poured on to the slide. After a minute the slide is stained ; the excess of colouring matter being washed of! in running water, the preparation is dried and put under the microscope. The carbol-thionin solution used has the following formula : Saturated solution of thionin in 50 per cent, alcohol 10 c.c. 1 per cent, solution of carbolic acid . . . . 100 ,, Or one may use the following process :^ The dried slide is stained with a few drops of the following solution : Thionin solution . . . . . . . . 10 c.c. Distilled water . . . . . . . . 88 ,, Liquid phenol . . . . . . . . 2 ,, washed with water, and treated for a minute with a mixture consisting of — Saturated aqueous solution of picric acid . . . . 60 grammes. 0*1 per cent, aqueous solution of caustic soda .. 50 ,, The slide is then passed through alcohol, washed with water, dried, and examined. In specimens which are stained by this method the protoplasm of the leucocytes is straw yellow, and the nuclei are reddish-violet ; the protoplasm of the epithelial cells is pale yellow, and their nuclei are paler than those of the leucocytes. The gonococci are black, and therefore easy to recognize. Various stains in aqueous solution have been recommended (fuchsin, Bumm, Welander ; methyl-violet, Bockhardt and Wolf ; Bismarck-brown, ^ NicoUe, "Pratique des Colorations Microbiennes," Annates Pasteur, 1895, p. 964. 2 Roman von Leszynski, Ann. de Therap. de Dermatol, et de Syphil. ; Rev. Pratique des 2Ial. des Organes Genito-Urinaires, Lille, January 1, 1906, No. 12, p. 419. THE ETIOLOGY OF GONOREHEA 29 etc.). We are, however, not convinced that they present any marked advantage over Kiihne's blue. Double Staining. — 'Some authors prefer differential staining of the gonococci and the other elements. Fraenkel stains, to begin with, the leucocytes and cells with eosin, a dye which does not affect the gonococcus, and then he uses a concentrated aqueous solution of methylene-blue. The gonococci appear blue on a red background by this process. These differential staining methods are more complicated, and give prettier specimens. They are, however, of no special value, as far as diag- nosis is concerned. Gram's Method. — An experienced eye can tell very quickly if the organisms seen are gonococci or not. Beginners, however, should give preference to Gram's method, which is based on the fact that the gonococcus is decolorized by this process, whilst the other organisms retain their dye. One proceeds thus : Once the preparation has been dried and fixed, it is coloured for a few seconds with a gentian violet solution of the following formula : Gentian violet . . . . . . . . 1 gramme. Absolute alcohol . . . . . . . . 10 c.c. Dissolve, and add after twenty-four hours : 1 per cent, solution of carbolic acid . . . . 100 ,, The violet is then poured off without washing, and is replaced by an iodine solution: Iodine . . . . . . . . . . 1 gramme. Potassium iodide . . . . . . . . 2 grammes. Distilled water . . . . . . . . 200 c.c. This mixture is allowed to remain on the slide for a few seconds, being twice renewed whilst on the slide. The preparation is then decolorized in absolute alcohol, until no more violet comes away. The background is stained by means of a few drops of an alcoholic solution of eosin, which is left on for a minute, and has the following composition : Saturated solution of eosin in 95 per cent, alcohol . . 1 vol. 95 per cent, alcohol . . . . . . . . 2 vols. Then come the usual steps of washing, drying, and microscoping. The gonococci assume a pale pink by this method, and are hardly visible, whilst the ordinary organisms are dark violet. Instead of counter-staining with eosin, Bismarck-brown, according to Weinrich's formula, may be used : Warm distilled water .. .. .. ..70 c.c. Bismarck-brown . . . . . . . . 3 grammes. 96 per cent, alcohol . . . . . . . . 30 c.c. 30 GONORRHEA Staining of Sections. — ^For staining the gonococcus in sections, Wertheim adopts the following method : The section is left for three to five minutes in a saturated solution of gentian violet. It is then washed and dipped into Lugol's solution for a minute. One now decolorizes with 95 per cent, alcohol. The preparation must retain a definitely violet tint. After having transferred it to a solution of methylene-blue for a few minutes, one washes the excess of stain away, dehydrates in absolute alcohol, clears with oil, and mounts in Canada balsam. Tig. 5. — Typical Aspect of Gonococci under the Microscope. Microscopic Examination. — The gonococcus is readily seen with a mag- nification of 400 diameters. One usually uses an oil immersion lens y^ with an eyepiece No. 1, which is quite sufficient. Distribution. — The gonococci are to be found either between or within the polymorphonuclear leucocytes. This intracellular position is one of the characteristic features of the gonococcus. Some leucocytes contain only a few heaps of gonococci, whilst others are full of them, almost choked with them. The organisms never penetrate into the nucleus of a cell; they surround the nuclei, and may even touch them, but they are never within their substance. THE ETIOLOGY OF GONOREHEA 31 Number. — In pus which is definitely gonorrheal the gonococcus is found in large numbers. According to Finger, the presence of a few diplococci only, even if they be intracellular, is not conclusive evidence of gonorrheal infection. Cultivation of the Gonococcus. — The usual media, such as agar, gelatin, and broth, are not suitable for cultivating the gonococcus. Different media had therefore to be invented which fulfilled the necessary biological conditions better. ^ 1. Coagulated Human Blood-Serum. — Bumm was the first to obtain cultures of the gonococcus on this medium in 1885. He used a serum of placental origin, but the cultures were not always a success. 2. Serum-Agar. — Wertheim in 1893 prepared tubes with 2 per cent, agar, and allowed them to cool after sterilization. He then added to each tube one-half or one-third of its volume of liquid and sterile human serum, and allowed the tubes to solidify in a sloping position. The composition of his medium was as follows : Agar . . . . . . . . . . . . 2 grammes. Pepton . . . . . . . . . . 1 gramme. Sodium chloride . . . . . . . . 0*05 ,, Broth . . . . . . . . . . IQO grammes. 3. Ascites-Agar. — As it is not always easy to obtain su£Q.cient human serum, attempts have been made to replace it by the fluid removed from hydroceles, pleural effusions, or ascites, and with success. Ordinary melted agar is put into test-tubes, each tube receiving 1 c.c, and, at the moment when the agar begins to set, ^ c.c. of ascitic fluid is added to each tube. One shakes the tubes well, and allows them to set on the slope. This is an excellent method which gives well-developed cultures in twenty-four to forty-eight hours after inoculation, when incubated at 37° C. 4. Ascites Broth. — The gonococcus grows well on a mixture of equal parts of ordinary broth and ascites fluid. 5. Coagulated Rabbit Serum. — This medium has been recommended by De Christmas. 2 Unfortunately, it is diflS.cult to prepare, for technical reasons. 6. Pig's Serum : Wassermann's Medium.^ — Wassermann uses the follow- ing medium, which is said to give colonies after twenty-four hours : Pig's serum, hemoglobin -free . . . . . . 15 c.c. Water Glycerine Nutrose 3Q-35 „ 2-3 „ 80-90 centigrammes. ^ Vide Lefalher, Les Milieux de Culture du Gonocoque (Thesis, Paris, 1900). 2 Annul, d. VInst. Pasteur, 1897-1900. 3 Wassermann, Zeits.f. Hyg., 1898, vol. xxvii., p. 298. 32 aONORKHEA This mixture is shaken, boiled for twenty minutes, and then mixed with an equal part of 2 per cent, pepton containing agar which has been liquefied at 50° C. The mixture is poured into Petri dishes, and is ready for the cultivation of the gonococcus as soon as it has set. 7. Blood- Agar. — Bezan9on and G-rifion have found a very convenient medium for cultivating the gonococcus. It is composed of blood-agar, and is prepared thus :^ By means of a trocar introduced into the carotid of a rabbit, blood is abstracted, and allowed to flow into previously prepared tubes which contain melted agar, and have been kept at 50° on the water-bath. One part of blood is mixed with 2 parts of agar per tube as intimately as possible, without, however, shaking the tubes. The tubes are then placed on the slope, and allowed to cool.^ Bezan9on and Griffon's blood-agar gives characteristic colonies, and is an excellent medium which keeps the gonococci alive for several months. 8. Henry HeimarCs Medium. — Heiman^ advises to inoculate the gono- coccus on a medium composed of pleural effusion mixed with 2 per cent, agar to which 1 per cent, pepton and 0-5 per cent, salt have been added. Sterilization is obtained by discontinued heating to 65°. The liquid is kept at this temperature for six days. It is then left in the room for three days, and then again heated for three days, as before. 9. Yolk of Egg Agar.'^ — This medium is made in the following way: The yolk of a hen's egg is taken, and one adds to it three times its volume of sterilized water. This mixture is thoroughly shaken, and for every 20 grammes one adds 10 grammes of a 20 per cent, solution of sodium biphosphate and 90 grammes of 3 per cent. agar. This final mixture is put into tubes and allowed to cool. When inoculated with gonococci, and incubated at 37°, typical rich colonies develop after twenty-four to forty-eight hours. Occasionally it is of great advantage to be able to demonstrate the presence of gonococci in the urethra at a very early date — for instance, if one wishes to attempt abortive treatment, the success of which depends on its immediate application. Griffon^ has given us a method by which the presence of the gonococcus can be ascertained in less than sixteen hours. This method (Griffon's method) consists in the inoculation of a 1 Bezan9on and Grififon, " Culture du Gonocoque sur le Sang Gelose," Soc. de Biol., Jane 30, 1900. 2 Bezangon and Griffon, " Le Sang Gelose, ou Milieu de Culture pour les Microbes qui ne se developpent pas sur les Milieux Usuels," International Medical Congress, Paris, 1900. 3 Heiman, Medical Record, 1896, p. 897. * Steinschneider, Berl. Klin. Woch., 1897, p. 379. 5 Vide Annal. Genito-Urin., 1907, p. 261. THE ETIOLOGY OF GONORRHEA 33 blood-agar tube with a drop of moisture from the urethra. By means of a platinum loop which has been previously passed through the flame, one removes a little moisture from the lips of the meatus, and inoculates the blood-agar. The tube is then capped, and put into the incubator for fifteen to sixteen hours at 37°. Abundant round colonies are found in the case of a positive result. The characteristics of the colonies are : they are round, flat, glistening, transparent, and of a slight whitish or greyish-white tint. As the urethra contains no saprophytic organisms which are capable of giving such rich cultures in so short a time (fifteen to sixteen hours), this method is of the greatest diagnostic value. Moreover, it can be controlled by micro- scopic examination. Inoculation. — The inoculation of healthy urethrse with pure cultures of the gonococcus has been carried out by Bumm, Aufuso, Wertheim, Schlagen- hauser, Finger, etc. These savants succeeded in reproducing experimentally a typical gonorrhea, and proved thus conclusively the specific nature of the gonococcus. It is, however, not advisable to imitate these experiments, because the results are too positive. As evidence, the case of Ashara may be mentioned, who injected the organism which he had isolated from the blood of a patient into a willing healthy subject, with the result that the latter acquired a gonorrheal septicemia of great gravity. Bockhardt in 1882 used a fourth generation grown on gelatin, and inoculated it into the healthy urethra of a patient who was suffering from general paralysis, and about to die. A urethritis in which the gonococcus was found resulted, and ten days later, after the patient had died of pneumonia, abscesses were found post mortem in the right kidney. Inoculation of the conjunctiva of a rabbit with gonorrheal pus has been carried out successfully by Heller, the animal developing a purulent con- junctivitis. Finger infected the joints of rabbits with gonorrheal discharge, and obtained a slight inflammation of these joints. The intraperitoneal inoculation of a young rabbit is, however, the only method which gives certain results in animals. The inoculation of the urethra of an animal with gonorrheal pus has never been followed by a positive result. Such experiments have been tried on horses, dogs, monkeys, and rabbits, without success. The Toxin of the Gonocoseus. — The researches of Christmas, Wasser- mann, Nicolaysen, Schaeffer, Scholtz, have shown that the gonococcus secretes a poison which, when injected intraperitoneally into guinea-pigs or white mice, kills these animals under characteristic symptoms. According to Nicolaysen,^ the gonococcal toxin is an endotoxin. His ^ Nicolaysen, Centralhlatt f. Bakteriol., September, 18C7, No. 12, p. 305. 3 34 GONOEKHEA experiments show that the poison is contained in the body of the organism, and resists both drying and heating to 120° C. Wassermann thinks that the gonotoxin is contained in the body of the organism, and that it is set free by the death or the destruction of the coccus. Young cultures contain less toxin than those which are at least two weeks old. When applied to the urethral mucous membrane, this toxin produces a violent purulent inflammation which requires five days to subside, and differs in its clinical aspect from true gonorrhea only by the absence of the gonococcus. The urethra is not immunized by the toxin, as the experiment can be repeated several times with success. . Biology of the Gonococcus. — Neisser's organism is very susceptible to changes in the temperature. It can grow between 32° and 38° C, the optimum temperature being between 36° and 38°. Twelve hours at 39°, or six hours at 40°, are sufficient to kill it. This fact explains the dis- appearance of the discharge in patients who suffer from a fever in which the temperature rises to 40° (104° F.). Below 30° the colonies show practically no growth, which ceases completely below 20°. Below 18° the organism dies. Gonorrheal pus retains its virulence for some time at room temperature. Linen soiled with gonorrheal discharge may transmit the disease, even after a considerable time, and this is a fact of great importance. In hot water the organism is killed very rapidly. Relationship between Gonococcus and Meningococcus. — 'Pinto ^ has studied the relationship of these two organisms, which have certain morphological and physiological features in common. Their staining properties and their behaviour when cultivated also offer points of similarity. According to Pinto, the gonococcus is merely an attenuated meningo- coccus; the two organisms should be classed as two closely-allied varieties of one species. Their different pathogenic effect upon man is largely due to adaptation, each having inhabited different organs for generations and generations. Localization of the Gonococcus in the Hunlan Body. — The urethra of man contains no gonococci under normal circumstances. Although a parasite of mucous surfaces, this coccus can enter the deeper tissues, and be conveyed by the blood-streams to distant parts, thus pro- ducing metastases and a generalized infection. This condition is called gonococcal septicemia. 1 Pinto, Journal de Phys. et de Path. Oenerale, November 15, 1904, p. 1058. THE ETIOLOGY OF GONORRHEA 35 Gonococcal Septicemia. Faure-Beaulieu^ and Lautier^ have given an excellent account of gono- coccal septicemia. The latter author describes in his interesting thesis three early and uncomplicated cases of gonorrhea in which the gonococcus was present in the blood, and was cultivated by him. Apart from these typical and carefully-studied cases, there are quite a number of examples of gonococcemia which have been proved such by the examination of the blood. The micro-organism reaches the general circulation through the veins, and most often when the primary lesions involve the posterior urethra or the glands connected with it (prostate, seminal vesicles, testis). Gonococcal septicemia is seldom a pure septicemia. In most cases it produces a variety of terrible lesions, such as those of gonorrheal rheuma- tism; in others it settles upon certain organs, producing meningitis, pneu- monia, skin lesions, etc. Recovery takes place in about 70 per cent. In all fatal cases, with two exceptions, endocarditis was present, whilst in those who recovered a certain diagnosis of endocarditis could only be made in three instances. Gonococcal septicemia thus owes its gravity chiefly to the cardiac com'plications which it is apt to produce. In its manifestations, gonococcal septicemia shares the characteristics of general m.icrobic infections; i.e., it begins with fever, which may be of an intermittent, or remittent, or continuous type.^ At the same time, an eruption, composed of pinkish lenticular spots, often appears, which is not unlike that of typhoid fever. The general health is affected, but to so vari- able an extent that it does not constitute a typical symptom. Marked pallor and a sallow tint of the skin in general are constant features. General weakness and lassitude, lack of refreshing sleep, and inability to work are the rule. The relation between this state of fatigue and the gonococcus and its toxins is proved by the astonishing reUef which these patients obtain when one manages to check the discharge by means of irrigations with permanganate. Although fever is the simplest expression of generahzed gonorrhea, it is barely noticeable in ordinary uncomphcated cases. Thus, amongst twelve cases affected with acute gonorrhea which came under Nogues' observation, only one had a slight rise of temperature. Yet it is true that attacks of fever, strongly resembling those of typhoid,^ occur in general gonococcal septicemia, and that a hyperacute and hypertoxic form which 1 Marcel Faure-Beaulieu, La Septicemie Gonococcique (Thesis, Paris, 1906). 2 Lautier, De V Utilisation des Procedes de Laboratoire paar la Recherche des Gonocoques dans le Sang des Blennorragiques (Thesis, Bordeaux, 1907). 3 Vide Dieulafoy, Biill. Acad, de Med., May 18, 1909, p. 602. * Vide Dieulafoy, loc. cit. 36 GONOERHEA takes a very rapid course exists. This galloping form might very well be termed malignant gonorrhea. Dieulafoy quotes an instance which was brought to his notice by Cherrer, a military surgeon: A young soldier, sufiering from gonorrhea for a fort- night, was admitted to the Military Hospital because he felt seedy. His temperature soon rose to 38°, 39°, and even 40° C. A provisional diagnosis of typhoid fever was made, and the Widal test was done ; but the result was negative. A few days later a pleural effusion was diagnosed, and on aspira- tion a turbid fluid, full of gonococci, was withdrawn. The patient collapsed; and died soon afterwards. At the autopsy the disease was found to be generalized gonorrhea. There was no trace of any typhoid lesions. The patient had died of gonococcal septicemia; his peritoneum was inflamed, and covered with an exudate which contained gonococci. Thayer has published a similar case : A young man who had had gonorrhea for three months, was suddenly taken ill with general malaise, and fever rising to 104° F. The Widal test was negative, and thus the original diag- nosis of typhoid fever was discarded. The blood was then examined, and gonococci were cultivated from it. These examples prove clearly that the gonococcus can reach the general circulation, and they show the value of a bacteriological examination of the blood for clinching the diagnosis. For this purpose, a considerable quantity of blood (10 to 20 c.c.) should be taken during a febrile attack. The best culture media are, according to Faure-Beaulieu, the liquid media of the ascites-broth type. Faure-Beaulieu incubates these media, once they have been inoculated, for twenty-four hours, and then makes subcultures on ascites-agar. In forty-eight hours this method yields typical colonies of the gonococcus. The isolation and cultivation of the organism is, however, not easy, and even under the best conditions one meets occasionally with failures. Thus, Harris and Johnson failed to find the gonococcus on two out of five occasions on which they examined the blood of the same patient. Faure-Beaulieu was also unsuccessful in three out of four attempts under similar circumstances. It seems as if the fever did not progress in a steady, continuous manner, but that discharges of microbes into the circulation took place at odd times ; clinically, the intermittent or remittent attacks of fever would correspond to them. Courtois-SuflS.t and Beaufume^ have reported a fatal case of generalized gonorrhea in which this condition followed upon a benign intervention on the urethra, and on the repeated passing of catheters. A severe infection supervened which was characterized by multiple abscesses, and ended fatally. In all the abscesses and in the blood typical gonococci were found ^ Courtois-Saffit and Beaufume, Soc. lied, des Hopitaux de Paris, April 14, 1905. THE ETIOLOGY OF GONOEKHEA 37 — namely, in the pus taken from the right brachial and sural triceps muscles, the posterior surface of the sternum, the left thigh, and the left testicle and epididymis. As long as there are gonococci in the urethra, general infection is liable to occur. Even when the disease is confined to the anterior portion, or if it has assumed a torpid form, the local trouble may spread, and cause general havoc. This may occur spontaneously or without any cause which we are able to account for. Thevenot and Michel have pubHshed quite recently a case of hemorrhagic septicemia which came on during an attack of gonorrhea, and killed the patient. A man of thirty-one, who had been sufiering for sixteen months from a neglected attack of gonorrhea, was suddenly taken seriously ill. Apart from his bad general condition, he showed an eruption of purpura on his neck and his abdomen, and developed hemorrhages from his nose and mouth, dying shortly afterwards.^ Weitz of Hamburg had about the same time a fatal case of gonococcal septicemia, in which severe icterus, cutaneous hemorrhages, stupor, fever, and albuminuria, were observed. Cultivation of the patient's blood — a youth of nineteen — yielded typical gonococci.^ Ulmann has also met with a case of gonorrheal endocarditis which de- de loped severe jaundice when the end was near. We owe to Colombini^ the history of a remarkable case of gonococcal septicemia : A man of twenty-eight acquired gonorrhea, and was insufficiently treated. After a fortnight a bubo appeared in the left groin, which had to be incised, and with it a left epididjnuitis, which finally suppurated. The fever rose to 39*8° C, and lasted for two weeks or so. In the meantime the patient wasted away, and developed a metastatic abscess in his right parotid which required incision. The gonococcus was present in the pus from the urethra, and from the abscesses in groin, scrotum, and parotid. The blood which was taken from one of the brachial veins was found sterile on the first occasion. The second attempt yielded a culture, and with the culture of the third bleeding the urethra of another youth was successfully inoculated. In order to trace cases of gonococcal septicemia, one has recently resorted to the complement-fixation reaction, and thus established for gonorrhea a reaction similar to Wassermann's reaction for syphilis. GradwohH has made use of this serum reaction in fifty cases, following the technique indicated by Neil and Schwartz, and Wassermann's method. 1 Thevenot and Michel, Province Medicale, May 18, 1912, No. 20, p. 228. 2 Weitz, Medizin. Klinik, February 4, 1912. 3 Colombini, Centralblatt f. Balcteriol., vol. xxix.. No. 25, p. 955. * Gradwohl, American Journal of Dermatology and Genito-Urinary Diseases, June, 1 912, vol. xvi.. No. 6, pp. 294-299. 38 GONOKRHEA His conclusions are favourable, and seem to indicate that this test would be useful for the detection of latent gonococcal septicemia. The reaction only becomes positive when a posterior urethritis of three weeks' duration is present, and does not disappear when only an anterior urethritis is left. For the diagnosis of gonorrhea in the female this reaction would be of great value, as the gonococcus is often very diflS.cult to find in women; moreover, it might help in the di:fferential diagnosis of pelvic inj&ammations. The change of a positive reaction into a negative one would indicate that the patient has got rid of his disease; the clinical cure, however, precedes the serological cure, as it takes the system about thirty days to eliminate the specific bodies. CHAPTER IV INFLAMMATIONS OF THE URETHRA DUE TO OTHER CAUSES THAN THE GONOCOCCUS There are a considerable number of urethral inflammations wbicb are not caused by the gonococcus, and differ in their symptoms from ordinary gonorrhea — namely : 1. Inflammations of the urethra due to common micro-organisms. 2. Inflammations of the urethra said to be " aseptic." 3. Inflammations of the urethra due to chemicals. 4. Inflammations of the urethra due to a special diathesis. 5. Inflammations of the urethra of toxic origin. 6. Inflammations of the urethra of traumatic origin. 1. Inflammations of the Urethra due to Common Miero-Organisms. One often meets with inflammations of the urethra which are not caused by the gonococcus, and it is a great mistake to think that they are not in- fectious owing to the absence of Neisser's organism. On the contrary, these non-gonococcal urethrites are infectious, and apt to cause serious complications in the male, although they assume as a rule a torpid form in the female (slight metritis). The infectious character of these inflammations is rendered evident by the frequency with which they lead to epididymitis, prostatitis, and vesiculitis. Despite their apparent benignity, they thus deserve to be followed up, and to be treated until they are cured. The complications they expose to are sufficient argument for this line of conduct. These common non-specific urethrites of bacterial origin occur under two absolutely different conditions, which may be termed primary and secondary. 1. Primary Urethritis of Bacterial Origin is observed after intercourse with a woman who suffers from a profuse discharge, and who takes little care of her person. Janet ^ has described two instances in which the wives developed inflam- matory lesions after having married husbands who suffered from a non- 1 Janet, Annal. des Malad. des Organes Genito-Urin.. 1893. pp. 600 and 601. 39 40 GONOEEHEA specific urethritis. In their utero-vaginal secretions abundant small short bacilli were found which were identical with those present in the urethras of their husbands. I have observed several absolutely similar cases. One of them relates to a patient whose exemplary conduct was beyond suspicion. He wa^ forty-one years of age, had been married for fourteen years, and was the father of three children. After the birth of her three children, the wife had had three miscarriages, and subsequently suffered from leucorrhea. She paid no attention to her trouble, and did not even use a vaginal douche. The man had never had gonorrhea, and had also always been true to his wife since his marriage. Two months before he consulted me he developed a profuse discharge. When he came to me I examined his discharge, and found a great number of common microbes, but no gonococci. I resorted to irrigations with oxycyanide of mercury, and obtained a rapid improve- ment. A complete cure was, however, only effected after a lengthy and methodical dilatation treatment. Another interesting observation was made on a medical man. Our colleague had a urethritis of streptococcal origin, which, as he assured me, followed upon an intercourse with a woman who had suffered from erysipelas. Inflammations of the uterus and the appendages may under certain circumstances cause a urethritis, as well-authenticated examples show. Legrain-^ knew of a medical student who, after having restrained his desires for a fortnight, had connection with a woman who had been treated two months previously for a retro-uterine abscess. This intercourse was followed after twenty-four hours by an abundant greenish discharge, in which bacteriological examination revealed the presence of the Micrococcus cceruleus alhus. 2. Secondary Urethritis of Bacterial Origin. — They are very frequent, and are found in patients who have had repeated attacks of gonorrhea, and from whose urethra the gonococcus has disappeared for some time. They are often most difl&cult to cure, and require special attention. Sometimes they are kept up by a prepuce of excessive length. In cases of this kind a chronic balanoposthitis is set up, from which the organisms find their way into the urethra. I have had occasion to examine a young man who had been irrigating himself for over a year with oxycyanide of mercury. He searched every morning for his bead of pus, and sent it to a laboratory for analysis. In- variably the following reply came back: " Ordinary organisms only : staphy- lococci, streptococci . . ." This induced him to increase the number of his irrigations, and this performance went on for a year or more. When I 1 Legrain, Annul, des Malad. des Organes Oenito- Urin., August, 1888, and June, 1889. INFLAMMATIONS OF UEETHRA NOT DUE TO GONOCOCCUS 41 examined him, I found in the first glass a few very light and slender fila- ments, which contained no bacteria. His infection was confined to his meatus, and was due to common organisms. Washing the meatus with a 1 : 4000 solution of perchloride of mercury, and dusting it, as well as the balano-preputial sulcus, with an inert powder, cured him readily. Then, again, we find cases of urethritis persisting simply because the urethral epithelium has been so damaged by the gonococcus that it is com- pletely modified, and has become unable to resist the action of the conmion micro-organisms . It is well known that the normal epithelium of the urethra, which is cylindrical, has a great bactericidal power on ordinary bacteria. Once the mucous membrane loses its cylindrical cells, and has them replaced by a pavement epitheHum, its microbicidal power vanishes. This type of non-gonococcal urethritis is the most common. All those whose lot it is to treat gonorrhea should bear this point in mind. They often have to advise young men who wish to marry, and desire to get rid of their gonorrhea previously. Once a careful and conscientious treatment has removed all infection, once repeated and thorough examina- tions allow one to permit the marriage, it is well to warn them that they may develop a discharge after their marriage. This discharge is not due to gonococci which have remained latent, but to common micro-organisms. The young wife is very generally in a state of complete ignorance of sexual hygiene, and has no experience of vaginal injections. Moreover, the lacera- tions caused by defloration often form wounds, which suppurate sHghtly. Under these conditions there is sufficient microbic activity to infect the husband's weakened urethra. I have had many opportunities of verifying these statements. One case, which is of special interest, may be quoted : A young officer had had a chronic urethritis oi very long standing, which I had cured completely by means of appropriate treatment. Not only the discharge, but also all filaments, had completely disappeared. Under observation without treatment ior a month before his marriage, he never showed the slightest trace of illness, and his urine was always quite clear and free from filaments. Aiter a final complete urethro- scopic examination I gave my consent to his marriage. Only eight days after the wedding, whilst he was away on his honeymoon, anxious telegrams arrived which informed me that his discharge had reappeared, and was as bad as ever. Smear prepara- tions made by the patient came soon aiter, and allowed me to diagnose his discharge as being due to adventitious organisms. I was thus able to reassure him, and I advised him to give himself a few irrigations with mercury oxycyanide, which had the desired effect. Quite a number of books have been published on the flora of the urethra. There is thus no need for a lengthy enumeration^ of all the organisms which have been found in urethral discharges. The most important ones are — Streptococcus, Bacillus cob, pneumococcus, staphylococcus, various sarcinse, 1 Rousseau, Contribution a la Flore des Uretrites, (Paris, Pharmaceutical Thesis, 1905). 42 GONOEKHEA diphtheria bacillus, tubercle bacillus, Micrococcus fallax,^ and M. cseruleus albus (Legrain). One of the microbes most often found is a small, short, slender bacillus, arranged in chains or clusters, and present in great quantity. This organism, which, according to Finger, is a usual saprophyte of the prepuce, is met with in cases of long standing which have lasted for ages, and have been treated for a considerable period. It is practically never found in a healthy urethra which has never been infected. The accom- panying discharge contains but very few leucocytes, or none. One finds, however, the large flat cells of the urethral epithelium, either isolated or in apposition, and around and within them the bacilli (Figs. 6 and 7).^ Fig. 6. — Secondaby Infection : Numerous Small Bacilli and Epithelial Cells. (Wossidlo.) To this group may be added those urethrites which follow upon systemic infections. Legrain noted a case in which the urethritis came on after typhoid fever. The bacteriological examination revealed the presence of M. pyogenes aureus.^ Gravis and Stievenard,'^ Billoir,^ and Schmitt,^ observed urethrites following upon mumps. Moscato"^ had a patient of sixty who developed a discharge from his urethra every time he had an attack of intermittent fever, and which invariably disappeared after the attack. Dr. Morisz Porosz, of Budapest, has published an interesting paper on this subject.^ 1 Vide Geraud, "Saprophytic Uretrale Pseudo-Membraneuse," G. B. de FAss. FmnQaised'Urologie, 1907, p. 271. ^ Legrain, Thesis, Nancy, 1888. 3 Annul. Genito-Urin., 1889. ^ Bullet, de Therap., vol. xxix., p. 145. 5 Gazette Hebdom., 1859, p. 117. ^ Arch, de Med. et de Pharm. MUit., 1883. 7 /Of orgrag'nt, November, 1890. ^ Fovosz, Monatsberichtef. Urologie,Yo\.ix., 1904. INFLAMMATIONS OF UEETHRA NOT DUE TO GONOCOCCUS 43 2. So-called "Aseptic" Inflammations of the Urethra. The so-called " aseptic " inflammations of the urethra are characterized by the fact that their discharge never contains any gonococci or other micro- organisms. All one sees under the microscope is a great number of leuco- cytes and a few epithelial cells. Even if one tests the mucosa by the reaction test, .either by an injection of silver nitrate or by giving the patient plenty of beer or champagne, one finds no change in the character of the discharge. No fresh organisms appear which could be shown by the ordinary staining methods. Fig. 7. — Secondaky Infection: Organisms arranged in Chains. (Wossidlo.)i These inflammations deserve thus rightly the name " aseptic " given to them. They correspond fairly well to what is known to the layman as " echaufiement." They have been known for a long time, and have been studied by Nogues, Guiard, and others. Their pathology is, however, not clear. The following features are peculiar to them : They are always caused by excessive drink and exercise, and, above all, excessive indulgence in sexual intercourse. Connections which last long or take place at the time of the periods are especially dangerous. Their incubation, if this term may be used, is much longer than that of genuine gonorrhea; it is usually more than eight days. Sometimes three ^ Figs. 6 and 7 are taken from Wossidlo, Die Gonorrhoe des Mannes, unci Hire Komplicationen, Berlin, 1903. 44 GONOREHEA weeks elapse after the last intercourse before they appear. Tlie onset is usually torpid, and produces no painful reaction on the part of the urethral mucous membrane. The aspect of the discharge is the same as that of gonorrhea. It is, however, usually less free. It is yellowish- white or milky, but it never becomes greenish or green. Under the microscope only leucocytes, but no organisms, are seen. There is no pain worth speaking of on making water, or during an erec- tion. The urine is nearly always clear in both glasses, but it contains a greater or lesser quantity of filaments. The patient recognizes his trouble usually by the spots on his linen or by a tickling sensation in his urethra. Further inspection then shows him the scanty milky discharge. I have been able to examine, in a great number of instances, the women who were accused of being the contaminating persons . Repeated examinations never enabled me to discover any gonococci in the urethra, or in the cervix, or elsewhere. I was, however, always able to find some lesion of the genito- urinary organs. Some had a metritis, others a salpingitis, etc. A completely healthy woman has never come under my observation in these instances. A further characteristic feature of these urethrites is that they are readily cured with silver nitrate, and that they are prone to recur. I have been able to examine and to follow up a urethritis of this type in a house- surgeon, twenty-six years of age. He consulted me on May 30, 1901, for a urethritis which he had had for three weeks. His urine was clear, but there were filaments in the first glass. Micturition and erection did not give rise to any pain. A careful micro- scopic examination of his discharge showed nothing but leucocytes. He was put under the reaction test ; an injection with 1 : 1,000 silver nitrate solution was given, and he drank beer freely. Next day his discharge was less. The irrigations with silver nitrate were repeated on the next three days, with the result that the discharge and the filaments disappeared completely. At the end of June, 1901, he had no trace of any discharge, and remained well for six months. Then, on January 9, 1902, he returned with a similar discharge. He assured me that he was still with the same woman, and that he had been true to her. The intercourse which had apparently brought the discharge on again was prolonged, and took place just before her periods came on. Examination of the pus was again negative, only pus cells being found, and the same treatment produced again a rapid recovery. Some of these aseptic urethral inflammations last very long. Just as they are slow in appearing, they are reluctant to disappear, and if left to themselves they may last for ever. Usually the anterior urethra is alone affected, and the pathogenic factor seems to be located chiefly in Littre's glands of the penile portion. This is readily seen to be so if one collects the patient's urine in four glasses. The first one only contains a great number of small, light, comma-shaped fila- ments — a characteristic feature of pronounced littritis. INFLAMMATIONS OF URETHRA NOT DUE TO GONOCOCCUS 45 The best treatment for these inflammations of the urethra is silver nitrate, appHed in a 0-1 per cent, sohition as irrigations, which should be given daily with an irrigator. Once the first glass of urine has become perfectly clear, methodical dilatations are resorted to — first with curved sounds, and then with Koll- mann's four-bladed dilator. This dilatation treatment is best combined with silver nitrate irrigations, and should be continued until the meatus is perfectly dry, and until there are no more filaments in the urine. Amongst this group of " aseptic urethrites " may also be placed those secondary inflammations of the urethra which follow upon primary infec- tions of the bladder or of the kidney, or are secondary to such anatomical lesions as strictures, papillomata, polypi, and ulcerations of the urethra; chronic prostatic lesions, and those of the lacunae of Morgagni and of Littre's glands. They deserve great attention, because they are often the first symptom of an infection of the urinary organs of the utmost gravity. They are not infrequently the sign of a tuberculous urethritis which itself is a secondary manifestation of an already existing infection of the genito-urinary tract by Koch's bacillus. Tuffier and Girod have published a case of this kind, Lavaux communicated another one at the Surgical Congress in 1898, and Jamin quotes several interesting examples in his thesis. The pathological changes which give rise to the discharge are nearly always situated at the level of the prostate or of the seminal vesicles. Careful palpation of the epididymis, of the prostate, and of the seminal vesicles allows one to find nodules in one ox more of these organs, and thus to clinch the diagnosis. 3. Inflammations of the Urethra due to Chemicals. Chemical urethrites are usually caused by the injection of irritating sub- stances which produce a desquamation of the urethral epithelium, and thus open a channel of entry for saprophytic organisms. Many patients are haunted by the long duration of their discharge, and try to remedy the evil by irritating antiseptic injections, which they con- tinue daily for weeks or months. They thus themselves produce a dis- charge, which they try to get rid of by more injections, and naturally with- out success, the only way of stopping their discharge being to give up all therapy. One of the drugs which is most apt to keep up a discharge is oxycyanide of mercury. It is well to inform the patients of this fact, and to advise them, if they are using this substance, not to inject more often than once every three or four days ; otherwise their discharge may persist indefinitely. 46 GONORRHEA 4. Inflammations of the Urethra due to a Special Diathesis. This group of urethrites is exceedingly rare. Very few of the cases of urethritis recorded in the past as being due to a special diathesis can with- stand the criticism which our advanced knowledge of the disease, and our modern accurate means of diagnosis enable us to make. A " diathesis " can only be regarded as a predisposing factor ; the chief cause in these cases is always a microbic infection. The occurrence of a urethritis due to a special diathesis has been described — 1. In the case of rheumatic fever. Martineau reported in Turbur's thesis (1887) the case of a child of fourteen who suffered from subacute poly- articular rheumatism for three weeks. As long as the disease lasted, this boy had a discharge from his urethra, which disappeared with the attack. Later in life, he had three further attacks of rheumatism, and on each occa- sion he developed a profuse purulent urethral discharge. The urethritis formed thus part and parcel of his rheumatism, and its onset could be predicted as soon as the first pains were felt in the joints. 2. Arthritism, herpetism, and gout, are also held responsible for urethral inflammation by certain authors. But these cases are very doubtful. At the most, one may concede that these diatheses are predisposing. 3. According to Hamonic,^ inflammation of the urethra occurs in diabetes without infection. He observed a case of this nature in a young subject affected with glycosuria, and he noticed, to his great astonishment, that the urethritis ceased almost immediately after a suitable diet and treatment had stopped the glycosuria. In the following years the urethritis recurred each time the glycosuria came on again. Hamonic suggests two alterna- tive explanations. In some cases the diabetics have a long prepuce, under which germs develop. The stagnation of a few drops of urine favours their growth, and thus leads to an infection of the urethra. Or one must consider that the urine loaded with sugar has a direct irritant effect upon the urethral mucous membrane. At any rate, a urethritis of this kind depends upon exacerbations of the glycosuria, which therefore should be treated; and the improvement of the urethral trouble will depend upon the influence of appropriate diet and hygiene, and of arsenic and lithium alkali, upon the glycosuria. 5. Inflammations of the Urethra due to Toxms. Certain inflammations of the urethra have been noted after the intake of certain kinds of food, such as asparagus and strawberries. Schenck mentions the case of a man who could produce a discharge 1 Hamonic, "De I'Uretrite chez les Diabetiques," Ass. Fran9aise d'Urologie, 1908, p. 129. INFLAMMATIONS OF URETHRA NOT DUE TO GONOCOCCUS 47 from his urethra at will by eating cress. Harrison observed a patient who had a copious urethral discharge, which lasted five days, after having indulged freely in asparagus. The use of certain drugs is also apt to give rise to a discharge from the urethra. Cantharides inflames the whole urinary system, and thus it may lead to cystitis and urethritis. Nitrate of potash produced an intense urethritis in one of Lallemand's patients, who had taken 30 grammes (about 450 grains) of this drug. Mercier saw a similar case in which potassium iodide had been taken. The arsenical preparations have also been in- criminated (Savignac, Delacour, Saint-Philippe). 6. Inflammations of the Urethra of Traumatic Origin. A traumatic urethritis is caused by the passage or sojourn of foreign bodies in the urethra. It is common knowledge that the use of a permanent catheter is always followed by suppuration of the canal. In this group one may also include those inflammations which follow upon venereal excesses. Cases of this kind have been reported to occur from masturbation, and Ricord published the case of a doctor who, after a period of six weeks' chastity, had passed a whole day, from 10 a.m. till 7 p.m., in a state of frenzy in the company of a woman whom he loved, and who refused to yield. Three days later he had a violent and painful inflammation of his urethra. CHAPTER V THE ANATOMY OF THE URETHRA, AND THE PATHOLOGY OF GONORRHEA It is only of late that the study of gonorrhea has made great strides. For a very long time all knowledge of this disease was based on the crudest empiricism, and the treatment was purely a matter of routine. Anatomical and pathological studies were practically non-existent. Since more attention has been paid to anatomical conditions and to pathological findings, such great progress has been made that it has become possible to build up a rational and efficient therapy. A sound know- ledge of the anatomical and pathological facts is indispensable for the making of a correct diagnosis and for carrying out a sound treatment; hence the importance of this chapter. THE ANATOMY OF THE URETHRA. It is not our intention to give here a complete anatomical description of the urethra. Only those points will be mentioned which we consider essen- tial for the understanding of the persistence of " rebellious gleet," and of certain methods of treatment. I. The Male Urethra. The urethra is the channel through which, in both sexes, the urine passes from the bladder, where it has been stored, to the outside. In the male the urethra extends from the neck of the bladder to the tip of the glans penis; into it open the ejaculatory ducts, and thus it also acts as channel for the sperma. Course. — The urethra describes, on its way from the neck of the bladder to the root of the penis, a curve with a concavity directed upwards and forwards. In front of the symphysis pubis it bends down, and runs along the under-surface of the penis. The urethra thus describes two curves, which form together an italic S. Of these two curves, only the posterior one is permanent; the other one disappears when the penis is raised — e.g.^ 48 THE ANATOMY OF THE UKETHRA 49 during erection. The urethra then only has one curve, the concavity of which is directed forwards and upwards. Its Different Parts. — Examination of a median vertical section of the pelvis shows that the most posterior portion of the urethra is almost com- pletely surrounded by the prostate gland. Below the prostate the channel is free for about 10 to 12 millimetres, and perforates the middle aponeurosis of the perineum. Farther forward the urethra enters the upper surface of a column of erectile tissue, which forms a protecting sheath for it. This structure is termed the " corpus spongiosum " ; the urethra runs in it up to its termination. Owing to this anatomical arrangement, the urethra can be divided into three portions : a prostatic, a membranous, and a spongy portion. Anterior and Posterior Urethra. — For clinical and pathological purposes — which are alone of importance to us — the spongy portion, which extends from the tip of the penis to the inferior part of the perineum, is usually called the anterior urethra. The remainder, comprising the prostatic and mem- branous portions, is the posterior urethra. This terminology is due to Gruyon, who established its clinical importance. For practical purposes we thus recognize two parts, which are separated from each other at the membranous portion: an anterior urethra, com- prising the canal in front of the membranous sphincter; and a posterior urethra, comprising the part behind the sphincter. This distinction is based upon anatomical, physiological, and develop- mental considerations. Picard, in 1885, and others have shown that the posterior urethra is formed solely from the genito-urinary sinus, whilst the anterior urethra is derived from a long bud which is an offshoot from the anterior wall of the cloaca. This " anlage " gradually develops into a long gutter which finally closes, and thus forms the anterior urethra. The membranous sphincter thus forms the barrier between the anterior urethra, which is in free communication with the outside, and the posterior urethra, of which the secretions readily flow back into the bladder. It has been shown on an endless number of occasions that liquids which are injected under moderate pressure into the anterior urethra by means of an ordinary syringe do not travel beyond the bulb, and that a considerable pressure is required to force the barrier formed by the membranous sphincter. Thus, all secretions formed in front of the sphincter flow out of the urethra through the meatus, whilst those of the posterior urethra regurgitate into the bladder. Lumen of the Urethra. — The lumen of the urethra varies in its different parts. The meatus is situated at the tip of the glans, and is formed by two lateral lips which are joined by two commissures — an inferior and a superior. 4 50 GONOKRHEA These commissures are often membranous, either in their upper or in their lower portions.^ Normally, the meatus is directed forwards, but it is, perhaps, more often found to be directed slightly downwards. Its shape varies with different individuals, so much so that it is impossible to describe a typically normal shape. 12. Fig. 8. — The Male Urethra, seen in a Median Vertical Section through THE Body. (After L. Testut.) 1, Symphysis pubis; 2, pre-vesical space; 3, abdominal wall; 4, bladder; 5, urachus: 6, §eminal vesicle and vas deferens; 7, prostate; 8, Santorini's venous plexus; 9, sphincter of the bladder ; 10, suspensory ligament of the penis ; 11, flaccid penis ; 12, penis during erection; 13, glans; 14, bulb of the urethra; 15, cul-de-sac of the bulb. a, Prostatic urethra ; h, membranous urethra ; c, spongy urethra. Not infrequently the meatus has several orifices, of which the upper one (or ones) is usually imperforate. The lowest of these openings is always the most important ; it is the one which constitutes the orifice of the urethra. In all cases of this kind a more or less marked degree of hypospadias is present. The meatus is the narrowest and the least extensible portion of the 1 Pasteau, " Les Differentes Formes du Meat Urina'ire chez I'Homme," Annal. des Mai. Genito-Urin., April, 1897. THE ANATOMY OF THE UKETHRA 51 — 3 urethra. In a healthy organ it is therefore the most difficult part to overcome. Hence it becomes necessary in many cases to split the meatus in order to be able to introduce a sound of sufficient size ; or, at any rate, one has to resort to a temporary dilatation of the meatus with appropriate instruments. It should, however, be remembered that it is impossible to widen the lumen of the meatus to any marked degree by mere dilatation. Immediately behind the meatal narrowing the lumen of the urethra widens out into the fossa navicularis, which is about 20 to 2 o millimetres long, and is limited behind by the necJc of the fossa navicularis. At this second narrowing a sound is again apt to stop. This arrangement is therefore not without practical importance, and it is advisable, in cases of congenital atresia of the meatus, not only to open this structure by meatotomy, but also to in- clude the fossa navicularis and its neck in the operation. The cavernous portion is uniform and cylindrical, and has, for practical purposes, the same width in its entire length. It ends in a fusiform enlarge- ment — ^the hulb — which is the widest part of the urethra. In it instruments which so far fitted the urethral walls tightly, lose all contact with them. The wide bulbous portion is limited behind by the mem- branous isthmus. The lumen of the membranous portion is practically uniform. Once the urethra has passed the uro-genital diaphragm, it widens out into another fusiform enlargement. The greatest width of this enlargement is situated at the level of the verumontanum. The urethra then becomes narrower again, a further constriction being found immediately in front of the opening of the bladder. To resume : The urethra presents four narrow points: (1) The meatus; Fig. 9. — The Lumen of the Ubethba, seen IN A Sagittal Section. (After L. Testut.) 1, Bladder; 2, cul-de-sac of the bulb; 3, neck of the bladder ; 4, prostatic widenmg ; 5, narrowmg at the membranous portion; 6, neck of the bulb; 7, penile narrowing; 8, fossa navicularis ; 9, meatus. 52 GONORRHEA 14 CROULEflAS Fig. 10. — The Prostate in Sagittal Section. Section through a Congealed Subject, passing slightly to the Left of the Middle Line; the Figure SHOWS the Right Half of the Section. (After L. Testut.) 1, Symphysis pubis; 2, bladder, with its neck 2'; 3, anterior ligament of the bladder;. 4, umbilico-prevesical fascia of Faraboeuf ; 5, prevesical space ; 6, rectum; 7, recto- vesical fold of peritoneum, containing a loop of small intestine; 8, prostate; 9, veru- montanum ; 10, left ejaculatory duct cut obliquely ; 1 1, right vas deferens ; 12, middle aponeurosis of the perineum, with Guthrie's muscle; 13, prostato-peritoneal fascia ;. 14, anus; 15, external sphincter of the rectum; 16, Cowper's gland; 17, bulb of the urethra; 18, spongy urethra; 19, corpus cavernosum; 20, suspensory ligament of the penis; 21, deep dorsal vein of the penis; 22, Santorini's venous plexus;. 23, perineum; 24, scrotum. (2) the far end, or neck, of the fossa navicularis ; (3) the membranous isthmus ;. (4) the vesical orifice. To these constrictions correspond five fusiform enlargements: (1) The fossa navicularis; (2) the cavernous portion; (3) the bulb; (4) the membranous portion; (5) the prostatic portion. Of the four narrow points, the first two are the most inelastic; the two- THE ANATOMY OF THE URETHRA 53 latter are easily dilated. Of the five spindles, the first one is only slightly dilatable, whilst the third can be widened with the greatest ease. Length. — In the adult the urethra measures about 16 centimetres, of which 2-5 belong to the prostatic portion, 1-5 to the membranous, and 12-0 to the spongy. Fig. 11.— The Urethra opened AiiONG its Upper Surface, and spread out in Order to show THE Details of its Inferior and Lateral Surfaces. (After L. Testut.) A, Prostatic portion ; B, membranous portion ; C, spongy portion. 1, Verumontanum, with the orifices of the ejaculatory ducts; 2, frenum of the verumontanum; 3, pros- tate, with, 3', the prostatic glandules situated on the an tero -superior aspect of the urethra; 4, sec- tion through the unstriped sphincter; 5, section through the striped sphincter ; 6, wall of the mem- branous portion ; 7, Cowper's glands, with, 7', the orifices of their ducts; 8, bulb; 9, longitudinal folds of the bulbous and membranous portions of the urethra ; 10, posterior wall of the spongy ure- thra; 11, roots of the corpora cavernosa; 12, sep- tum between the corpora cavernosa, along which the urethra has been opened; 12', orifice, or lacuna, through which the meshes of the two cor- pora cavernosa intercommunicate; 13, termina- tion of the corpus cavernosum m an excavation in the glans; 13', fibrous septum separating corpus cavernosum from glans ; 14, section through the anterior partof the corpus cavernosum; 15, glans ; 16, fossa navicularis, with, 17, the two halves of Guerin's valve; 18, lacmise of Morgagni; 19, meatus. Outer Aspect and Relations. — 1. Prostatic Urethra. — The prostatic urethra begins im- mediately at the neck of the bladder, and traverses the substance of the prostate gland at the junction of its anterior one-fifth with its posterior four- fifbhs. The prostatic urethra is in relation : in front, with the venous plexus of Santorini and the symphysis pubis ; on each side, with the fascia covering the levator ani muscle and the levator ani ; behind, with the rectum and the prostato-peritoneal fascia of DenonvilHers. The two ejaculatory ducts enter the prostatic urethra from behind. 54 GONOREHEA Above, the prostatic portion is directly continuous witli the neck of the bladder, and below, it joins the membranous urethra. 2. Membranous Urethra. — The membranous urethra passes through the middle perineal aponeurosis, which adheres to its walls. This aponeurosis is thus one of its means of fixation. The relations of this portion are : in front, the symphysis pubis; behind, the rectum. Above, it is continuous with the prostatic portion, and below, it unites with the bulb. The membranous urethra is close to the skin, from which it is separated by unimpor- tant structures only. It was for this reason that surgeons used to approach the bladder through it in former days. 3. Spongy Urethra. — The spongy urethra is surrounded in almost its entire length by an erectile sheath, the " corpus spongiosum," from which its name is derived. It runs in an angular groove formed by the apposition of the two corpora cavernosa. At its posterior extremity the corpus spongio- sum expands to form a bulb; in front, it swells out into the glans. This portion of the urethra is the longest, and may be divided into a ferineal, scrotal, penile, and balanic part for purposes of description. The perineo-scrotal portion is in relation laterally with the two ischio- pubic rami, which are each covered by their corpus cavernosum and the corresponding ischio-cavernosus mus- cle. It is accompanied by the secretory ducts of Cowper's glands. Below, the spongy urethra is covered by skin, subcutaneous tissue, the superficial fascia of the perineum, and the bulbo-cavernosus muscle. The penile part occupies the inferior aspect of the penis. Inner Aspect. — The interior of the urethra varies in its different portions, which therefore are described separately. 1. Prostatic Urethra. — On the posterior wall of the prostatic urethra is an oblong elevation which occupies its middle. This structure is always well marked, and is called the verumontanum. The verumontanum is usually 12 to 14 millimetres long and 1 millimetre Fig. 12. — Front View of the Veru- montanum. (The Inferior Wall OF THE Urethra has been STRAIGHTENED OUT.) (After L. Testut.) 1, Bladder; 2, urethra; 3, prostate; 4 verumontanum; 5, frenum of the verumontanum; 6, urethral crest; 7, utriculus, or sinus pocularis; 8, orifices of the ejaculatory ducts ; 9, prostatic fossette; 10, openings of the prostatic glands (prostatic sinus). THE ANATOMY OF THE URETHRA 55 broad. Its posterior end terminates by a number of folds which run back to the vesical orifice, and form the frenum of the verumontanum. Behind the verumontanum one usually finds a more or less marked de- pression; this is the 'prostatic fossette, into which the ducts of the middle lobe of the prostate open {vide Chapter VIII.). The anterior extremity of the verumontanum is prolonged forwards by a fold, called the urethral crest, which ends in the membranous urethra after bifurcation. The base of the verumontanum forms part of the urethral wall, from which it is an offshoot. Its apex presents a slit running in an antero-posterior direction, which occupies the middle line, and leads to a small cul-de-sac — ^the prostatic Fig. 13. — Transverse Sections through the Verumontanum : A, Through the Highest Portion, behind the Chief Excretory Ducts of the Prostate; B, Immediately Above the Orifices of the Utriculus and the Orifices of the Ejaculatory Ducts; C, Below, and in Front of, the Orifices of the Ejaculatory Ducts. (After Henle, modified, from L. Testut.) I, Central column of the verumontanum; 2, cavernous tissue; 3, urethral mucous membrane; 4, utriculus; 5, 5', ejaculatory ducts. utriculus, or sinus pocularis. This utriculus is developed from the inferior extremity of Miiller's ducts, and therefore represents embryologically the male vagina, and not the male uterus, as "Weber taught. To the right and left of the utriculus are the openings of the ejaculatory ducts, which pour the sperma into the urethra. On each side, the verumontanum is limited by a depression running in an antero-posterior direction. These lateral grooves of the verumonta- num contain a number of openings for the bulk of the prostatic gland ducts. Structure of the Verumontanum. — The verumontanum is composed of erectile tissue which is supported by a central column of elastic and muscular tissue. It is covered in by the urethral mucous membrane, which shows at 56 GONOEKHEA its level a few fine folds, thus allowing for adaptation to variations in the volume of the verumontanum. The latter, which is traversed by the ejaculatory ducts, is an erectile organ. It becomes turgid during erection, and thus causes the ejaculatory orifices to gape. At the same time it shuts ofi the part in immediate proximity of the bladder, and thus plays an important role in preventing the flow of urine, or micturition, during erection. 2. Membranous Urethra. — The membranous urethra presents, normally, on its inferior wall a series of longitudinal folds which continue the urethral crest, and are finally lost in the cul-de-sac of the bulb. On its walls the openings of Littre's glands are visible. 3. Spongy Urethra. — In the spongy urethra we find — (1) The Orifices of Cowper's Glands. — They are two in number, and are situated on the inferior wall, to each side of the middle line in the lower part of the bulb. (2) The LacuncB of Morgagni. — They were discovered by Morgagni in 1706. They are arranged in linear series, and are of various sizes. Morgagni described large ones, or foramina, and small ones, or foraminula. Sappey added an intermediate type. The large ones are found along the middle line on the upper surface. They are constant. The intermediate and small ones are usually on the lateral surfaces. As a rule there is no lacuna on the lower surface. The small lacunse are only a few millimetres deep ; the large ones extend often for a considerable distance (6 to 7 millimetres) submucously. Their fundus is directed backwards towards the bladder, and is usually simple; but sometimes one meets with a double or triple pouch. One lacuna, which is practically constant, is situated 1 to 2 centimetres behind the meatus. It is larger than the others, and has been specially described by Guerin; hence the name valve of Guerin for the fold of mucous membrane, and sinus of Guerin for the pouch formed by it. In the course of my personal researches on the anatomy of the normal Fig. 14. — The Ubethba, opened in the middle Line along its Inferior Surface, in Order to SHOW THE Details of ITS Upper Wall. (Partly after Jarjavay.) 1, Upper angle of meatus, with, 1', its right lip; 2, fossa navicularis; 3, probe entering the sinus of Guerin; 4, lateral bor- ders of the urethra, with, 4', the lateral foraminula ; 4", median foramina; 5, large lacunae of Mor- gagni, or foramina; 6, sec- tion through the corpus spongiosum ; 7, prepuce drawn back; 8, section through the integuments ; 9, glans. THE ANATOMY OF THE URETHRA 57 urethral mucous membrane, I have been struck by the number and by the importance of Morgagni's lacunce. These little pouches, which are entirely formed by invaginations of the mucosa, are of variable depth. The deepest and most constant one is GuerirCs valve, which is situated in the balanic portion, about 1 to 2 centimetres from the meatus. If one spreads out a urethra, after having slit it up on its under surface along the middle line, these lacunae become easily accessible, and can be explored with a probe. One often finds, then, not only one large lacuna, but as many as three, or even four, in the penile region, and all of them are similar in structure and size to Guerin's valve. Fig. 15, which has been drawn from nature, shows the anatomical disposition in a man of forty-five ; small quantities of suet were injected into the lacunae in order to show their size and how they gape. I have investigated fourteen cases, varying in age from seventeen to seventy-five years. Only one of them (a man of fifty-five) had a completely smooth mucosa and no lacunse. In one case only a solitary lacuna was present, which was situated in the middle of the penile, and not in the balanic part (man of sixty-eight). On four occasions two large lacunae were found — one in the balanic part (Gruerin's valve), and one in the penile (men of thirty-four, forty-five, forty- eight, fifty). Three valves were found six times, one of them in the balanic portion (Guerin's valve), and the two others in a row in the penile part (men of seven- teen, twenty-eight, thirty-nine, fifty-four, sixty, sixty-five). Two cases had four valves spread along the penile urethra (men of fifty- eight and seventy-five). The depth of these lacunae varied from 5 to 12 millimetres. They are, however, sometimes still larger; Cruveilher, for instance, met with some which were 27 millimetres deep. At all events, the structure of these lacunae, which reminds one of a pigeon's nest, is responsible for the important role which they play both in Fig. 15. — Longititdin-al Section of THE Penis. Normal aspect of the upper surface of the penile urethra, with its lacunae of Morgagni and Littre's glands. 58 GONOERHEA acute and chronic gonorrhea. They are regular hampers in the bottom of which the gonococcus can live for a long time, and in which the organism is sheltered against irrigations or injections. The fluid simply passes over these lacunee, but does not enter them. When, during an attack of gonorrhea, a lacuna or a group of Littre's glands becomes infected, the inflammation leads to their obstruction. . As has been well shown by Keersmaecker and Verhoogen,^ the mouths of these glands, or the orifice of the lacuna, are gradually obliterated, and thus the gonococci are shut off. A regular little cyst is formed as the gland expands. This cyst may either remain closed or it may burst partially into the urethra. In both instances it remains a hotbed for germs, in which they are not dis- turbed by any irrigations or injections. Histologically there is no difference between the walls of these lacunse and the urethral mucosa. They are not true glands, but merely depressions in the latter. HISTOLOGY OF THE URETHRA. The walls of the urethra are formed by three concentric coats, which are, from without inwards : 1. The muscular coat. 2. The vascular coat. 3. The mucous coat. 1. Muscular Coat. — The muscular coat is composed of unstriped muscle fibres which are arranged in two layers — an internal longitudinal one, and an external, which is circular. The longitudinal fibres are the continuation of the plexiform layer of the musculature of the bladder; they are well marked in the prostatic region, and gradually become fewer and fewer, there being less in the membranous portion, and still less in the spongy part. The circular fibres are well developed in the posterior urethra, which they sur- round at its commencement, forming a large ring — the unstriped s'phincter of the bladder. In the normal state this sphincter keeps the bladder closed, owing to its tonic contraction. It also occludes the part of the urethra behind the ejaculatory ducts, and thus compels the sperma to travel down the urethra instead of flowing back into the bladder. Apart from these unstriped fibres, there are a number of muscles of voluntary contraction: the bulbo-cavernosus^ Guthrie's muscle, Wilson's muscle, and the sphincter urethrse. 2. Vascular Coat. — This layer is thin, and ill-defined in the prostatic and membranous portions. It is, however, well marked in the spongy urethra, where it forms a kind of bed for this latter structure. This vascular forma- tion — ^the corpus sjyongiosum — ^is analogous to the corpora cavernosa, and 1 De Keersmaecker and Verhoogen, L'Urethrite Chronique d'Origine Gonococcique, Bruxelles, 1898. THE ANATOMY OF THE URETHRA 59 participates in the phenomenon of erection. Histologically, it is composed of numerous venous cavities which vary in size, and anastomose freely. 3. Mucous Coat. — The urethral mucosa lines the canal in its whole course. During life its colour is uniformly red, as can iDe easily seen by means of the urethroscope. G-enerally speaking, the mucosa is smooth and presents a uniform lustre. It is rather thin and soft, despite its great elasticity. It is thus capable of resisting traction and distension well, but it is easily damaged and perforated by a metal instrument. It presents, for descriptive purposes : A. A structure of its own. B. A system of glands connected with it. A. Structure of the Urethral Mucous Membrajste. Thickness. — The thickness of the urethral mucosa varies shghtly in its difierent parts. It is comparatively thick in the prostatic portion — 0-3 millimetre — and tapers in the membranous portion to 0'2 millimetre. Histology. — Two layers can be made out : 1. An epithelial layer, 60 to 80 fjL thick, which is com- posed in its most superficial part by two rows of cylin- drical cells. The deeper part is formed by replacement cells, which are polygonal or ovoid. 2. A connective - tissue layer, or stroma, which con- sists of a tough laminar connective tissue, containing a great number of elastic fibres. These elastic fibres form a network which pro- jects between the muscular fibres, and extends into the meshes of the erectile tissue. This arrangement strengthens the mucosa, and prevents the different layers from separating. In the region of the glans the stroma shows well-developed papillae; behind the fossa navicularis these papillse are rudimentary. Fig. 16. — Histologicax, Aspect of the Urethral Mucous Membraxe (400 Diameters ). (After Lichtenberg. ) G, Glandular sinus ; L, leucocytes penetrating ir.to the mucosa. 60 GONOEKHEA B. The Glandular Apparatus op the Urethral Mucous Membrane. In early embryonic life the urethral mucous membrane is quite smooth. About the third month of intra-uterine existence solid epithelial buds are formed on the deep surface of the epithelial layer, and penetrate into the stroma, thus giving rise to various glands, which may be grouped under three headings: 1. The glands of the anterior, cavernous portion of the urethra. 2. The prostate gland. 3. Cowper's glands. The urethra is thus well suppHed with glands, which are destined to lubricate the epithelium, and to protect it, by means of their secretions, against the irritant effect of the urine. A copious flow of the mucus which they produce takes place during erection. 1. The Glands of the Anterior, Cavernous Portion of the Urethra. These glands are of three different types, which have been well studied by Lichtenberg of Heidelberg •} 1. Tubo- Alveolar Subepithelial Glands. — These glands are deeply sunk into the tissues, and are fixed between the meshes of the corpus spongiosum. Their young forms are often intra-epithelial, and communicate with the lumen of the urethra by a very narrow duct. Most authors classify them as cysts, and one finds them described in the literature as " follicles." They are usually considered to consist of degenerated epithelium which has been separated off from the lumen of the urethra. Lichtenberg holds that they are progressive formations which are free during the stage of development in the deep part of the epithelium, but remain small and keep in contact with the epithelium — hence their sub- epithelial position. Occasionally they increase to such an extent that they rise to the level of the mucous membrane, and then they communicate freely with its lumen. They represent imperfect glands of Littre. 2. Depressions of Glandular Shape.— Their structure is irregular. They are covered by an epithelium which is similar to that of the former group, but they are more developed, and exist as true mucous glands in other vertebrates. 3. Submucous Glands. — These glands are superficial, and bulge into the submucous part of the mucosa. They are visible if one examines the mucous membrane with a lens. In the spongy part they are noteworthy on account of their situation; they are partly covered in by muscle fibres. Littre was 1 Lichtenberg, Beitrdge zur Histologie, Mikroshopischen Anatomic, und EntwicUungs- gescMchte des Urogenital Kanals de Mannes und seiner Druesen, Wiesbaden, 1906. THE ANATOMY OF THE URETHRA 61 the first to describe them, in 1706. As their orifices are in the midst of erec- tile tissue, they secrete a considerable amount of mucus during erection. In the prostatic portion Littre's glands are few and rudimentary. They are scattered in the membranous urethra, and present in great numbers in the spongy. They occupy chiefly the upper and lateral surfaces. On the lower surface there are but very few. Their ducts, which vary in length according to the more or less superficial position of the glands, open either directly on the surface of the mucous membrane or into the pouches of the lacunae of Morgagni, Histologically, they are composed of a thin membrane and a prismatic epithelium. They secrete a clear, transparent mucus which reaches the Fig. 17. — Histological Aspect of the Urethral Mucosa in the Cavernoits Region (155 Diameters). (After Lichtenberg.) E, Epithelial cells : L, leucocytes entering the mucosa ; G, glandular sinus ; V, bloodvessels. urethra through their ducts. The latter are directed obliquely towards the meatus, and vary in length from a few millimetres to 2 centimetres. Ob- struction of a duct is sufficient to form within the urethral wall a focus which discharges its contents only on and off into the urethra, and will keep up a chronic urethritis. These glands thus are of considerable importance. When infected, they are, together with the lacunse of Morgagni, hotbeds for micro-organisms. They are closed by a plug of mucus, and discharge their contents intermittently into the urethra. The organisms within them defy all irrigations, injections, and instillations, as the fluids used fail to reach these recesses. It is thus easily understood that a focus of this nature may give rise to 62 GONORKHEA a series of reinfections which drive the patient and his surgeon to despair, and to repeated recurrences, even when a properly-conducted irrigation treat- ment seemed to be on the point of curing the discharge from the urethra. 2. The Prostate. The prostate is a gland which belongs physiologically to the sexual ■organs. It is conical in shape, and is situated just below the bladder, above the middle perineal aponeurosis, behind the symphysis pubis, and in front of the rectal ampulla. Through it runs the urethra from above downwards, with a forward slope. It is also traversed by the two ejaculatory ducts. Anatomically, the prostate consists of two lateral lobes — a right and a left one — and of an intermediate portion — ^the so-called middle lobe. 9^ Fig. 18. — Histological Aspect of the Urethral Mucous Membrane in the Cavernous Portion (200 Diameters). (After LicMenberg.) G, Glandular sinus; gl, subepithelial tubo-alveolar glands; V, bloodvessels. Structure. — One distinguishes a stroma and a gland substance. The former consists of a mixture of connective tissue and unstriped muscle fibres. Its outer surface is in relation with the walls of the prostatic fossa. Its inner surface sends out septa which radiate towards the centre of the organ, where they form a mass of lesser density — ^the central nucleus. Through the various partitions so formed, the interior is divided into a number of small spaces which are occupied by the glandular substance. The individual prostatic glands, about thirty to forty in number, are arranged in a radiating fashion around the urethra. Their excretory ducts open on the free surface of the urethral mucous membrane by small round openings which are readily seen with a magnifying-glass. THE ANATOMY OF THE URETHRA 63 The glandular elements are composed of a dense stroma of connective tissue which is lined with the secreting epithelium. Under normal conditions the prostatic secretion is only excreted during ejaculation, and mixes immediately with the sperma. 3. Cowper's Glands. Cowper's glands are small round- ish masses situated behind the base of the bulb, in the angular space formed by it and the membranous portion of the urethra. Their size varies from that of a bean to that of a small hazelnut. They are enclosed in the middle aponeurosis of the perineum. Structure. — Cowper's glands be- long to the grape type of glands, and consist of lobules and acini. The walls of the latter are formed by a single row of pyramidal cells. Their excre- tory ducts join, and form one single Fig. 19. — The Pbostatic Utriculus, SEEN IN A Sagittal Section through THE Prostate. (After L. Testut.) 1, Bladder, with, 1', its neck; 2, urethra; 3, prostate; 4, verumontanum ; 5, utric- ulus ; 6, seminal vesicle ; 7, vas deferens (a probe, introduced into this duct, is seen to appear in the urethra slightly to the outer side of the utriculus). Fig. 20.— The Posterior Part op the Urethra, as seen after a Median Longitudinal Incision oe its Anterior Wall. (After L. Testut.) 1, Neck of the bladder; 2, section through prostate and urethral sphincters ; 3, sec- tion through the membranous urethra; 4, section through the spongy urethra; 4', bulb ; 5 and 5', the two corpora caver- nosa; 6, verumontanum, with, 6', the orifice of the utriculus ; 7, posterior wall of the urethra ; 8, ejaculatory ducts, with, 8', their orifices; 9, Cowper's glands; 10, their ducts (dissected out on the right side); 10', orifice of the duct of Cowper's gland; 11, longitudinal folds of the ure- thral mucosa; 12, cul-de-sac of the bulb; 13, neck of the bulb. 64 GONOERHEA duct which, passes through the inferior layer of the middle aponeurosis of the perineum, and enters the substance of the bulb. In this way, the duct on either side of the urethra reaches its under-surface, which it follows as far as the anterior part of the cul-de-sac of the bulb. Here it perforates the urethra and opens into its lumen. Each gland of Cowper has thus a duct of relatively considerable length (30 to 40 millimetres). The secretion of Cowper's glands is a transparent, viscous fluid, contain- ing albumin. As in the case of the prostate and of the seminal vesicles, these glands discharge their contents at the time of ejaculation, and thus supply the sperma with one of its elements. 8 25 18 16 19 Fig. 21. — Sagittal Section through a Congealed Subject (Vikgin of Twenty- four, Natural Size), comprising the Urethra, the Vulva, and the Vagina. (After L. Testut.) 1, Symphysis pubis; 2, suspensory ligament of the clitoris; 3, corpus cavernosum clitoridis; 4, anterior extremity of the clitoris (glans); 5, its prepuce; 6, dorsal vein of the clitoris; 7, intermediate venous plexus between clitoris and bulb; 8 and 8', anterior and posterior walls of the bladder; 9, neck of the bladder; 10, urethra; 11, external sphincter of the urethra; 12, urinary meatus; 13, labium minus; 14, labium ma jus ; 15, vestibule ; 16, inferior orifice of the vagina ; 17 and 17', anterior and posterior columns of the vagina; 18, vaginal tubercle; 19, hymen; 20, external sphincter ani ; 20', constrictor cunni ; 21, those fibres of the latter muscle which are situated between urethra and clitoris; 22, fossa navicularis; 23, fourchette; 24, vesico-uterine fold of peritoneum; 25, prevesical space. THE ANATOMY OF THE URETHRA 65 II. The Female Urethra. The urethra of woman is much shorter than the male urethra, and only has one function — namely, to act as a channel for the urine. Its average length is 35 millimetres. Its width is generally 7 to 8 milli- metres ; but it can be dilated with ease, and there is no difficulty in passing sounds 10 or 12 milli- metres thick. Certain surgeons, like Simon of Heidelberg, have prac- tised dilatations up to 20 millimetres, and Reli- quet went as far as 30 millimetres. The course of the female urethra is directed obliquely downwards and forwards; it describes a slight curve, the con- cavity of which looks up- wards and forwards. Relations. — Behind, the female urethra rests on the anterior vaginal GDevy Fig. 22 wail, to which it is ad- herent. In front of it is the venous plexus of Santorini, the constrictor cunni muscle, and the symphysis pubis. Its lateral relations are the venous plexus of ■The Feihale Urethra, seek from the Front. (After L. Testut.) The anterior wall of the urethra has been incised along the middle line, and the urethra has been spread out. 1, Bladder, with its neck, 1'; 2, urethra, with its longi- tudinal folds and glandular orifices ; 3, urethral crest ; 4, muscular coat of the urethra ; 5, external sphincter of the urethra ; 6, urinary meatus ; 7, vaginal tubercle ; 8, vagina; 9, labia minora; 10, clitoris, with, 11, its prepuce. Santorini, Wilson's mus- cle, the middle aponeurosis of the perineum, Gruthrie's muscle, the constrictor cunni, and the root of the corpora cavernosa clitoridis. Its upper opening corresponds to the anterior angle of the trigone of the bladder. Its lower orifice is the urinary meatus, which is the narrowest and least dilatable part of the canal. It is placed immediately behind the clitoris, and immediately in front of a protrusion called the " vaginal tubercle," the termination of the anterior column of the vagina. Inner Aspect. — A certain number of little folds run along the urethra from behind forwards. Apart from them, the urethral mucous membrane pre- 5 66 GONOEEHEA sents a number of little openings which correspond partly to the lacunae of Morgagni, and partly to the orifices of the urethral glands. Histology. — The female urethra has two coats, an outer muscular coat, and an inner mucous coat. The former is composed of two layers of un- striped muscle fibres. The longitudinal muscle fibres are just external to the mucous coat, whilst the circular ones, which are the more superficial, form in the region of the neck of the bladder a large ring — the unstriped sphincter. This musculature is reinforced by striped fibres which form the sphincter of voluntary contraction. The mucosa consists also of two layers: (1) A stroma, containing a great number of elastic fibres; and (2) an epithelium, formed by two or three rows of polyhedrical cells. The glands are less numerous than in the male, and are nearly all located in the anterior portion. The region in the immediate neighbourhood of the sphincter is practically free from glands. The great number of urethroscopic examinations which I have carried out on women has shown me the arrangement just described to be constant. It is therefore permissible, from this point of view, to distinguish an anterior and a posterior urethra, just as in the case of man. The female posterior urethra is essentially muscular, covered by a smooth mucous membrane, whilst the anterior one is essentially glandular. The infection of its glands by the gonococcus is the chief cause of the long duration of gonorrhea in woman. THE PATHOLOGY OF GONORRHEA. Before describing the lesions which the use of the urethroscope has allowed us to discover in chronic gonorrhea, a short resume of our present knowledge of its pathology may here be given, as it is only in this way that these lesions can be understood. Histological and urethroscopical researches complete each other, and they should go hand in hand. The pathological changes in chronic urethritis are clearly visible during life by means of the urethroscope, but they become invisible to the naked eye after death, because the local congestion and edema vanishes with the cessation of life. In the following we will consider the infection from its very beginning, from the moment the gonococcus enters the urethra up to the remotest lesions which it produces. The cases of acute gonorrhea in which a post-mortem examination has been made, are scarce. Thanks to Finger, who inoculated moribunds with gonorrhea, detailed examinations of the urethra thirty-six and forty-eight hours after the infection have been made, and we thus have an account of the lesions present at that stage. Amongst the other authors who have studied the morbid histology of THE PATHOLOGY OF GONORRHEA 67 gonorrhea, the important works of Dinklers and Finger, Oberlander and Neelsen, Oberlander and Kollmann, Baraban, Wassermann and Halle, Bumm, Tonton, Jadassohn, Fabry, Rosinsky, Wossidlo, Motz, and others, should be mentioned. These researches complete each other, and give a complete insight into the activity of the gonococcus within the urethral mucous membrane. The Pathology of Acute Urethritis. Once the gonococcus has fixed itself on a point of the urethral mucous membrane, it develops on the surface of the epithelial layer. After a very short time, however, it tends to enter the deeper tissues. In the case of a cylindrical epithelium, this penetration takes place readily, less so if the epithelium is of the flat pavement type. The cylindrical epithelium is thus a very favourable soil. This fact has been well pointed out by Finger, and it explains certain peculiarities of gonorrhea infection. It is a matter of common knowledge — and all specialists have frequently occasion to corroborate it — ^that the gonococci penetrate into a normal urethra which has never been infected, and has a healthy cylindrical epi- thelium, much more easily and readily than into one which has been infected some time or other. This fact explains why abortive treatment by means of immediate irrigations is much more often a failure in fresh cases than in subsequent attacks. One of the consequences of gonorrheal infection of the urethra is destruction of the cylindrical epithelium, and its replacement by pavement epithelium. After a couple of attacks, the urethra has undergone such modifications as to become a bad soil for the gonococcus. The organism finds it difficult to penetrate into the epithehum, and thus the chances of a well-conducted abortive treatment proving successful are infinitely greater. On the average, thi rty-six hours elapse before the gonococcus penetrates into the depth of the urethral mucosa. This period during which the organism remains on the surface is free from symptoms, and is termed the incubation 'period. When the gonococcus enters the epithelium, it passes between the superficial cells wherever there is least resistance. It thus ad- vances as far as the subepithelial connective tissue, and this fact is of the utmost importance therapeutically. The migration of the gonococcus is accompanied by an intense reaction on the part of the tissues, which finds its expression in a severe inflammation which appears usually on the third day. This reaction is an attempt on the part of the body to defend itself against the invasion by a pathogenic irritant, and is characterized by a pronounced diapedesis of leucocytes. These cells leave in large numbers the walls of their capillaries, which are dilated, and advance towards the cocci. The result of the ensuing struggle is the purulent discharge. 68 GONOEEHEA To schematize, we observe tlie following: On one hand, the gonococci penetrate into the mucous membrane, and on the other hand, the leucocytes leave their bloodvessels and attack the invaders. In the struggle which now takes place within the mucosa, the white cells engulf the organisms; but they are killed, and their corpses, laden with the organisms, are brought to the surface of the mucous membrane, and discharged into the lumen of the urethra, thus giving rise to the flow of pus from the meatus. The urethral mucous membrane is thus a true battle-field, and it will be easily seen that it has to suffer to a considerable extent. It is damaged, not only by the cocci as they penetrate into it, but also by the leucocytes as they pass into the interstices from within outwards. The injured epithelium undergoes mucous degeneration, peels off in flakes, and disappears in places, leaving a denuded mucous surface. Soon after, the inflammation leads to the mucosa being occupied by em- bryonic cells. This infiltration is limited in some cases to the superficial layers only; in others it involves the mucosa in its entire thickness. This latter structure is then roughened, thickened, and inelastic, and bleeds readily. Or, again, the inflammation may extend still farther; the sub- epithelial connective tissue is infiltrated with embryonic cells, and this process may spread to the corpora cavernosa and affect their trabeculsB. The network of the corpora cavernosa begins to swell and to undergo infiltra- tion; phlebitis supervenes, and there is also some endo- and peri-arteritis. The dilated capillaries are full of polymorphonuclear leucocytes. The lym- phatics may also be implicated ; the lymphatic glands become enlarged and painful, and may even suppurate. The urethral glands (Morgagni's lacunae and Littre's glands) have their share in the inflammatory process, and this is of the utmost importance, owing to the role which inflammation of these structures . plays in chronic gonorrhea. The gonococci are present around the glands. They are not actually on the epithelium which lines the glandular lacunae, but they are within the leucocytes which cover it. They remain between the cells which line the excretory ducts of Littre's glands, the acini of which contain but leucocytes. The inner surfaces of the gland ducts undergo partial desquama- tion, and are then invaded by leucocytes. Finally they become the seat of an abundant cell proliferation ; the duct walls thus become thickened and infiltrated with embryonic cells. Around the glands this process spreads and may reach the corpora cavernosa. The infection of the urethral glands terminates either by sclerosis, or by the obliteration of the ducts, or by their transformation into cysts. We have so far only considered, from the pathological point of view, the infection inasmuch as it is a downward spreading process. We will now turn our attention to its extension on the surface. THE PATHOLOGY OF GONORRHEA 69 From the fossa navicularis, where it begins, the gonorrheal inflammation spreads backwards to a variable extent, according to the virulence of the infection, the constitution of the patient, and the treatment applied, which is of the greatest importance in this respect. If the infection stops in front of the membranous sphincter, we speak of an anterior urethritis ; if it passes beyond that muscle, a posterior urethritis is present. The involvement of the posterior urethra occurs in 60 or 70 per cent, of all cases (Finger, Jadassohn). A posterior urethritis is always more serious, owing to the possibility of complications arising, such as prostatitis, vesiculitis, cowperitis, pyelonephritis, etc. The Pathology of Chronic Urethritis. After a few weeks (usually about the third), the acute stage of gonorrhea has passed its climax. The number of gonococci diminishes; the phago- FiG. 23. cytosis is less active ; the embryonic infiltrations are resorbed ; the vascular changes become less evident, and the destroyed epithelium is gradually Fig. 24. — Superficial Infiltbation of the Urethea : Proliferated Cylindrical Epithelium. (Motz.) regenerated. The process of repair begins. It becomes effectual about the fifth or sixth week by the formation of a pavement epithelium composed 70 GONORRHEA of several strata. In no instance do the epithelial cells reassume the char- acter of a cylindrical epithelium. When this proliferation of embryonic tissue is too active, the foundation for future stenoses and strictures of the urethra is laid. Fig. 25. — Superficial Infiltration of the Urethra : Stratified Cylindrical Epithelium, covered by a Layer of Pavement Epithelium. (Motz.) This replacement of the cylindrical epithelial cells by pavement epi- thelium is the rule in gonorrhea. The epithelium thus becomes finally a kind of tough skin which is less permeable to antiseptics than the normal one, and has lost its suppleness. A restitutio ad integrum is thus impossible, and all cases of chronic gonor- rhea which are neglected invariably develop strictures. Lastly, the gonococci which were present in the depth of the tissues and in the caverns of the glands, disappear about the sixth week. This for- tunate issue is, however, by no means the rule ; usually all the organisms do Fig. 26. — Superficial Infiltration of the Urethra : Epithelial Lining composed OF Many Layers of Pavement and of Cylindrical Epithelium. (Motz.) not disappear. A number of them remain somewhere in the tissues or in the glands, and keep up the inflammation of the mucous membrane. The urethritis then becomes chronic. Changes in the Urethral Epithelium. — In chronic urethritis, the first effect of the inflammation on the epithelium is the stratification of the cylindrical epithelium, which may show as many as seven or eight layers. THE PATHOLOGY OF GONORRHEA 71 The second stage is the evolution of the epithelium towards keratiniza- tion. The urethra is covered with a great number of epithelial layers, partly of the cylindrical and partly of the pavement type. Gradually this Fig. 27. — Superficial Infiltration of the Urethra. The Epithelium is KERATINIZED. (Motz.) condition changes, until a number of flat, keratinized epithelial strata are formed which have the greatest analogy with those of the skin. The mucosa thus loses its permeability to a very great extent; drugs applied to it for a short time cannot reach its deeper layers, and therefore remain ineffective. l "^ ■ .' * vsS'5 ■--<;>- -■ .t'„i Fig. 28. — Chronic Urethritis, Epithelium almost Normal : Superficial and Deep Infiltrations; Urethral Adenitis.^ (Motz.) The result of this pathological process is " that most chronic infiltrations are protected by a thick shell which is almost impermeable to chemicals. This is the true reason why it is so difficult to disinfect these superficial 1 " Adenitis " means here, and in the following figures, " inflammation of the glands of the urethra " (A. F.). 72 GONOEKHEA infiltrations, whicli sometimes last twenty or thirty years, as the autopsies on patients who died from stricture show." ^ The chorion also takes part in the inflammation, and is infiltrated with leucocytes and embryonic cells. These embryonic elements form fibrous tissue which ultimately assumes the character of a true cicatrix. The lacunsB of Morgagni also participate. They begin to swell, and their orifices take the shape of crater-like elevations. At a later stage, sclerosis Fig. 29. — Chkonic Ukethritis : Stbatified CyIiINDRIcal Epithelium; Super- ficial Embryonic Ikpiltrations; Adenitis. (Motz.) supervenes: in some cases the lacunae retract, atrophy, and disappear; in others their orifice becomes obstructed, and they become filled with cellular debris, and are converted into cysts which appear on the surface of the mucous membrane as whitish nodules. Less often they suppurate, and give rise to peri-urethral abscesses and fistulse. It is around the glands of Littre that the infiltrative lesions are most marked. Several forms are met with : either the glandular secretion increases, and the glands become swollen; or little cysts, filled with a colloid material, are formed; or the cell proliferation loosens the cylindrical epithelium, destroys the sinus, and fills the gland with epithelial debris; or, lastly, the 1 Motz, Annul, des Malad. des Organes Genito-Urin., 1903, p 419. THE PATHOLOGY OF GONORRHEA 73 surrounding fibrosis strangulates the glands, as it becomes harder, and contracts, and thus causes them to disappear gradually. Thus, Littre's glands are liable to three difierent changes : 1. The periglandular infiltrations lead to a modification in the epithelium which lines the duct of the gland. This epithelial degeneration is similar to the one on the surface of the mucosa, and is characterized by cell prolifera- tion and the formation of pavement epithelium. The gland thus ceases to secrete, and its acini are soon filled with epithelial neo -formations. Fig. 30. — Chronic Glandular Urethritis : Stratified Cylindrical Epithelium covered by several layers of pavement epithelium; mucosa and sub- MUCOSA CURED; ADENITIS. (Motz.) 2. The periglandular infiltration retracts, and thus gradually compresses the acini. In this case the alteration of the glandular epithelium is purely passive; it undergoes slowly complete destruction, strangulated by the contracting fibrous tissue around it. 3. The glands are shut ofi from the lumen of the urethra, and are con- verted into cysts. If these cysts become the seat of an acute inflammation, they tend to suppurate and to give rise to follicular abscesses. The urethral glands thus play an important role in gonorrheal inflamma- tion; they are largely responsible for the deplorable tenacity of certain urethrites. In the glandular culs-de-sac the gonococcus finds shelter, even when the surface of the mucosa in general has become normal again, and thus it gives rise to repeated recrudescences of the illness. Under the influence of the same factors which produce congestion, either generally or locally, the 74 GONOREHEA glandular secretion increases suddenly, and carries the cocci again to the surface of the mucosa. The peri-urethral erectile tissue and the corpora cavernosa may be invaded by the same changes as the mucous membrane. The inflammatory process takes a similar course. At first numerous round cells invade the corpora cavernosa; then connective-tissue fibres appear; and finally hard retracted bands are formed, which are often the beginning of a stricture. In the above pages the primary and secondary changes which are found in the anterior urethra have been described. A few further remarks on the posterior urethra may be useful. The two common phases of inflammation are also met with in the posterior urethra. They take a similar course : at first there is cell proliferation, and Fig. 31. — Chronic Superficial and Deep Urethritis: Keratinized Epithelium; Superficial Embryonic Infiltrations; Urethral Adenitis. (Motz.) especially desquamation of the cylindrical epithelium; then regeneration takes place, and conversion of the cylindrical epithelium into pavement epithelium. The anatomical conditions, however, modify this process to a certain extent. In the membranous urethra the sphincter causes the mucosa to fissure owing to its energetic contractions. Thus, more or less deep rhagades, which present a red base and bleed easily, are formed in many cases. These ulcerations heal by cicatrization, and tend to narrow the lumen; hence the great frequency of strictures in this region. In the prostatic region the infiltration distorts the mucous membrane. The fibrous tissue formed compresses, and finally obliterates, the orifices of THE PATHOLOGY OF GONORRHEA 75 the ejaculatory ducts. The latter are also often infiltrated, and their walls become rigid and gape. The prostatic glandules become the seat of a muco-purulent or purulent catarrh, or even undergo, as a result of periglandular infiltration, necrosis and destruction.^ The inflammatory process may not extend beyond the superficial layers of the subepithelial tissue, but it is more common for the inflammation to reach the deeper structures, and this extension of the inflammation takes place chiefly along the glands and their excretory ducts. Sometimes, only the orifice of an ejaculatory duct is involved. In cases of this kind the opening becomes sclerosed and narrowed ; hence the shooting pain felt by certain patients during ejaculation, when the sperma is on the Fig. 32. — Deep Chronic Urethritis : Keratinized Epithelium; Sclerosis of Mucosa and Submucosa; Deep Infiltrations; Adenitis. (Motz.) point of passing the narrowed orifice of the duct. Moreover, these rigid ejaculatory ducts close the seminal vesicles incompletely, and thus sperma- torrhea is not infrequent in chronic urethritis. The epithelium of the prostatic glands also undergoes changes, of which two types may be distinguished : Either the glands are filled with atrophied and desquamated epithelium, in which case the prostatic secretion is copious, white, opaque, and contains an excessive amount of epithelial elements ; or they are filled with polymor- phonuclear leucocytes, and secrete freely a thick yellowish mass — pus indicative of prostatitis. ^ De Keersmaecker and Verhoogen, UUretrite. Chronique d'Origine Gonococcique, Bruxelles (Lamertin), 1898. 76 GONORRHEA Urethral Polypi. Gonorrhea lias an incontestable influence on tlie formation of polypi in the nrethra. Polypi may develop as an immediate result of the inflamma- tion which leads to hypertrophy of the papillse ; or they may arise at a later period subsequently to the formation of strictures. Oberlander,^ Gregoire,^ and Burckhardt,^ have devoted special studies to them, and Dr. A. Pelletier has published a very interesting paper^ on this subject. Fig. 33. — Polypi of the Neck of the Bladder in a Woman (Typical Case DRAWN FROM NaTTJEE). According to Burckhardt, four varieties of polypi are found : 1. Caruncles. — These are small vascular tumours with a more or less well-defined pedicle, which are chiefly found in women. They resemble a raspberry in aspect, and are most common about the meatus. Owing to 1 Oberlander, " Ueber die papillomatose Schleimhautentziindung der inannlichen Harnrohre," Viertdjah. f. Dermat. und Syph., 1887; Lehrbuch der Urethroscopie, 1893. 2 Gregoire, " Les Polypes de I'Uretre chez la Femme." Ann. des Mai. des Org. Genito-Urin., 1904, p. 321. 3 Burckhardt, " Die Verletzungen und Chirurgischen Erkrankungen der Harnrohre," Handbuch der Urologie, 1906, vol. iii., p. 267 (Die Neubildungen der Harnrohre). ^ Albert Pelletier, " Les Polypes de I'Uretre," La Clinique, 1911, p. 260. THE PATHOLOGY OF GONORRHEA 77 their great vascularity, they bleed readily. Histologically, these tumours are composed mainly of numerous dilated bloodvessels covered by a pave- ment epithelium of moderate thickness. 2. Papillomata. — They can be distinguished with the naked eye owing to the presence of papillae. Microscopically, they are formed by a thick layer of pavement epithelium; their long axis is occupied by bloodvessels. 3. Condylomata. — These tumours have the naked-eye appearance of little cock's combs. Microscopically, they have a very thick epithelial lining which is supported by a compact stroma which is comparatively poor in cells and bloodvessels. 4. Glandular and Mucous Polypi. — These growths owe their origin to a hypertrophy of the glandular culs-de-sac of the mucous membrane. Their stroma, which is covered by several layers of epithelial cells, is composed of loose tissue, and contains numerous glands. I have seen a polypus of this type in a doctor who consulted me in 1910. By means of my urethroscope I discovered it in the region of the prostate, and removed it with a pair of cutting forceps. The histological examination made by Dr. Chenot showed it to be an " adenoma " which owed its origin, in all probability, to a previous attack of gonorrhea which had set up a chronic irritation of the prostatic cells. CHAPTER VI THE SYMPTOMATOLOGY OF ACUTE GONORRHEA The membranous sphincter of the urethra is a well-defined boundary which the gonococcus usually respects. In front of it, we have the anterior urethra ; behind it, is the posterior urethra. When the gonorrheal infection reaches this latter portion of the urethra, peculiar and special symptoms appear which are characteristic. Aeute Anterior Urethritis. Acute anterior urethritis has several stages, viz. : 1. A Period of Incubation. — In most cases the time of incubation varies from three to five days. Sometimes it is shorter (twenty -four hours or less) ; in other instances it is longer (seven to eight days). An incubation period which lasts more than a fortnight is quite exceptional. The cases in which the discharge comes on at so late a date are usually not due to a fresh infection; they are sudden exacerbations of a gonococcal infection which has been present for a considerable time. 2. Prodromal Symptoms. — One observes {a) Local Symptoms, such as redness of the lips of the meatus, which are stuck together. Between two micturitions a slightly greyish and sticky drop is formed, which on micro- scopic examination is found to consist of epithelial cells of the pavement type, a few leucocytes, and a few gonococci. If the patient makes water into several glasses, the first one contains turbid urine, laden with heavy flakes, whilst the remainder are clear. (6) Functional Symptoms. — The first symptom is a sensation of tingling and slight pricking, which comes and goes suddenly, "as if a fly were settling down " (Diday). (c) General Symptoms. — They are characterized by a certain depression, fatigue, and loss of appetite. 3. Florid Stage — (a) Local Symptoms. — The inflammatory phenomena appear rapidly, after twenty-four to forty-eight hours. The skin of the penis and the prepuce are red and oedematous.^ The latter is covered with excoriations, and often cannot be drawn back (inflammatory phimosis). 78 THE SYMPTOMATOLOGY OF ACUTE GONORRHEA 79 Under the skin of the penis the inflamed lymphatics become visible as cords running along the dorsum. The glans is red, inflamed, and covered with small ulcers, which sometimes " shine like a ripe cherry " (Hunter). The lips of the meatus, which reflect the condition of the urethral mucous membrane " in the same way as the tongue is the mirror of the alimentary canal " (Diday), are red, edematous, and often excoriated. There is a certain degree of ectropion. A profuse flow of pus sets in — a regular " incontinence of pus," as Forgue puts it. The inflamed urethra is like a thick rope to the touch, and very tender. On palpation a number of Httle nodules of the size of millet-grains are felt along its under-surf ace ; they are inflamed glands of Littre. The discharge becomes thicker, creamy, yellow, and purulent. Towards the end of the first week it assumes a more greenish tint, and produces the characteristic spots on the linen. In the centre of these stains is a thick purulent zone, surrounded by a lighter halo which corresponds to the serous constituent of the discharge. The flow is always greatest in the morning, because the patient micturates but little, if at all, during the night. In the daytime the urethra is frequently cleansed by making water. The reaction of the discharge is alkaline. (&) Functional Symptoms. — At this stage appears the characteristic symptom of pain. Those affected with gonorrhea suffer during micturition, during erection, and during ejaculation. The pain on making water is more or less pronounced; occasionally it is unbearable. Some patients feel as if they were " passing a red-hot iron," or as if they had " razors in their pipe." The severity of the pain depends to a large extent on the suddenness with which the flow of urine dilates the inflamed passage. In most cases the pain is sharp, shooting, or burning. This last-mentioned character has left a lasting impression on the French mind; hence the popular term of " chaudepisse " for gonorrhea. The patients usually dread the act of micturition, and delay it as much as possible, and eventually they proceed with the utmost caution. The seat of the pain on making water varies; it is usually located all along the penile portion ; occasionally it is the perineum which feels " heavy." Owing to the swelling of the mucous membrane, the lumen of the urethra is narrowed, and thus a certain mechanical diflS.culty in making water is produced. The stream is smaller, thin, split, and sometimes resembles a spray. In the very acute cases the patients micturate drop by drop. In a few rare instances a certain degree of retention is present, which is partly due to the swelling of the mucosa, and partly to spasm of the mem- branous region. At this stage the patient is constantly troubled, when he lies down, by erections which result from the congestion of the parts in the horizontal position, the warmth of the bed, or from lascivious dreams or his 80 GONOERHEA compulsory abstinence. These erections are usually accompanied by sbarp pains, because the mucous membrane loses its elasticity, and its dilatability when it is inflamed. The patient tries to rid himself from these erections by getting up, or by putting cold compresses on his penis, and ultimately succeeds ; but as soon as he returns to his bed, he is in as bad a plight as before. When these erections are followed by pollutions (so-called " wet- dreams "), the ejaculations give rise to intense pain; they may even lead to slight Assuring of the mucosa. In this way the slight hemorrhages occur which one meets with. They often cause the pus and the sperma to be blood- stained, a condition which has been decorated with the name " Russian clap." As the elasticity of the mucosa is diminished, the latter cannot follow the expansion of the corpora cavernosa during erection, and thus the penis becomes distorted. In slight cases, only the glans is bent, but in severer cases the entire penis becomes arched. This condition is known as chorda venerea, or chordee, and is said by many authorities to be due to the con- traction of the longitudinal unstriped muscle fibres of the urethral sub- mucous tissues. The pain of chordee has led some ignorant patients to seek relief by placing their erect distorted penis on a firm flat support, and attempting to straighten it by hammering it into shape with their fist. This deplorable practice is apt to be followed by serious accidents ; the urethra ruptures at some point or other, and it may bleed so furiously that death takes place, as in the case recorded by Voillemier. Moreover, extravasation of urine, sepsis, and traumatic stricture, are apt to supervene. (c) General Symptoms. — The troubles mentioned are accompanied by general systemic disturbances, such as slight chills, lassitude, loss of appetite, fatigue, and an earthy pallor. Slight fever up to 38° C. (100-4° P.) is also not uncommon. The gonococcus produces a general intoxication of the body which is characterized by pallor, loss of appetite, wasting, headache, and a typical anemia.^ In many instances these systemic troubles are insignificant, and a good number of patients " drip " calmly for fifteen to thirty days, without showing much worry or anxiety. The acute stage of gonorrheal inflammation reaches its height about the middle or the end of the third week, after which improvement sets in, if there are no complications. 4. Period of Decline. — After twelve to fourteen days the symptoms become less marked. The inflammation of the glans and of the meatus diminishes progressively; the walls of the urethra become supple again, and gradually regain their normal aspect. Micturition and erection cease to be 1 Vide Chapter III., Gonococcal Septicemia. THE SYMPTOMATOLOGY OF ACUTE GONORRHEA 81 accompanied by pain. The microscopic examination shows fewer and fewer gonococci and pns cells, whilst more and more epithelial cells are found, especially of the pavement type. The urine becomes clearer, and finally only the first glass contains a few filaments. The usual duration of an acute anterior urethritis is about five to six weeks. Recurrences are frequent. They are due to the numerous recesses in the mucosa in which the gonococci lodge themselves, and remain latent for a considerable time. A spontaneous cure is very rare. As a rule inflammatory areas are left which keep up a chronic urethritis. The course of the malady is largely influenced by the age of the patient. In old people there is a marked tendency for the disease to spread rapidly to the bladder and to the kidneys. There is a great variety of different clinical types, but they are not sufficiently definite and distinct to deserve individual descriptions. The phase of decline is of variable length. It may last two or three weeks, but it has no definite limit, as all depends on the observance of the necessary hygienic measures and on the treatment. Carelessness and a misdirected therapy invariably prolong the course of the disease. Acute Posterior Urethritis. Inflammation of the posterior urethra is an infinitely more formidable illness than anterior urethritis, owing to the complications which may arise^ such as cystitis, epididymitis, prostatitis, and vesiculitis. These troubles are very common, and, as the posterior urethra is affected in almost 80 per cent, of all cases, an early diagnosis of this inflammation is imperative. Etiology of Posterior Urethritis. — Some authors, like Heissler,^ have maintained that the posterior urethra is always involved during an attack of gonorrhea. This view, however, appears to be exaggerated, and there is very little doubt that in a considerable number of cases the anterior urethra is alone affected. There are many causes for the spreading backwards of the gonorrheal infection to the posterior urethra. In some cases this appears to occur spontaneously without any therapeutic interference. But there is practically always a definite cause for the invasion of the posterior urethra by the gonococcus, and one can find it, if one takes the trouble to look for it. General or local fatigue, such as excessive drinking, coitus, prolonged erections, and violent exercise (long walks, cycling, riding), are responsible in certain cases ; in others the fault is to be found in neglecting to keep the parts clean. But the principal cause for the onset of a posterior urethritis is the practice of giving injections into the anterior urethra by means of a small 1 Heissler, Arch. f. Dermitolog. und Syphilis, 1891, vol. xxiii., p. 765. 82 GONOEKHEA syringe. This dangerous custom should be given up for good. An energetic patient has only to inject a certain amount of fluid, pushing the piston as far as it will go, and to keep his urethra closed at the same time ; the walls of the canal are then under tension, and the fluid tends to seek an outlet. Finally the membranous sphincter yields, and the liquid, which is full of gonococci, enters the posterior urethra, and infects it with the pus from the anterior part. Another important cause is a clumsily and hadly given urethro-vesical irrigation. In nearly every instance the first irrigations do not enter the posterior urethra easily, unless the patient is an habitue. The membranous sphincter contracts, and keeps the liquid back. The gonococci are thus driven into the posterior limit of the anterior urethra, and settle down there, as no flow of antiseptic fluid removes them immediately. As we shall see later on, in the chapter on Treatment, a well-given urethro-vesical irrigation is the best safeguard against the onset of a posterior urethritis. It is just as beneficial as a clumsy irrigation is harmful. Another common cause for the development of a posterior urethritis is the untimely passing of a catheter — for instance, if it is carried out without urgent need, and without sufficient previous disinfection of the anterior urethra. At all events, it is absolutely necessary to diagnose a posterior urethritis at the earliest possible moment. Under immediate and proper treatment this trouble tends to heal rapidly, and without any further damage ; but it is prone to cause a number of serious complications if neglected. A patient who consents to stay in bed from the beginning of his gonorrhea on, who commits no carelessness and no therapeutic error, has the greatest possible chance, if not the certainty, of escaping an infection of his posterior urethra. Symptoms of Acute Posterior Urethritis. — Posterior urethritis comes on during the first or second week of acute gonorrhea. Its onset is insidious, so much so that most patients are unaware of their trouble ; but it is just this benign character of the symptoms which should attract the attention of the surgeon. The cardinal symptoms of this condition are the following : 1. The Small Amount of Discharge visible at the Meatus. — ^When the posterior urethra becomes infected during an ordinary attack of gonorrhea, one frequently finds that the discharge suddenly diminishes considerably in a day or so. The patient is usually very pleased when he notices this apparent improvement. One should, however, not share his joy, and keep a careful watch over his posterior urethra, which is in danger. 2. The Turbidity of the Urine. — All four glasses are turbid if the patient makes water into four glasses. This sign is extremely important, for it is the first clue to the diagnosis of a posterior infection if the case has been THE SYMPTOMATOLOGY OF ACUTE GONOERHEA 83 treated with permanganate irrigations. It should be a hard-and-fast rule to examine the urine of all patients who are treated with urethro-vesical irrigations every day by the four-glass method. 3. The Frequency of Micturition. — This functional symptom is not present in the beginning, but it comes on soon. Its causation is not so much the injfiammation of the posterior urethra as that of the neck of the bladder. There is vesical tenesmus ; the micturitions become imperative and irresistible. The patient has to make water every ten or five minutes, quite irrespectively of the amount of urine contained in the bladder. 4. Pain. — The pain assumes almost at once the character of the pain observed in cystitis, and is marked by its intensity at the end of micturition. Apart from these four cardinal symptoms, there are others which should not escape a careful observer's notice. " Wet-dreams " become frequent owing to the implication of the verumontanum in the inflammation. Slight terminal hematuria is also found occasionally. Lastly, the general health is impaired. The patient, who so far may have been very well in himself, feels tried, worn out, and complains of loss of appetite. His eyes are hollow and surrounded by dark rings. A curious and characteristic pallor is seldom wanting; the patient is, and feels, a wreck. When these symptoms are present, a surgical examination becomes urgent; the prostate should be examined by palpation fer rectum. In the early moments of acute posterior urethritis this exploration gives but little information or none ; but after a couple of days it is nearly always possible to make out a painful, doughy spot in the prostate, or a general enlargement of the organ. The prostate is thus of the greatest importance in the pathology of posterior urethritis. The same is true for the seminal vesicles, which should always be examined, and any change in them should be noted. Chronic Posterior Urethritis. Symptoms. — The symptoms which characterize a lesion of the posterior urethra in chronic urethritis are generally not well known, and often escape the notice of the patient, as they are usually trifling, and as the discharge is reduced to a minimum, a slight moisture. The chief signs are the following: 1. The Filaments in the Urine. — When the patient makes water into four glasses, heavy filaments are constantly found, chiefly in the first and fourth glasses. 2. The Pains. — The pains complained of by the patients are usually vague, unpleasant sensations about the urogenital region. In slight cases complaint is made of an indefinite heavy feeling about the " back of the pipe," or the patient has a sensation of heat, or tickling, or of the presence of a weight, or foreign body, in his posterior urethra. On other occasions the patients claim that their urethra burns, especially when they make water. 84 GONOEEHEA These different sensations are mainly present at tlie moment of, or at the end of, micturition, but they may be permanent. Neuralgic pains shooting about the perineum, the groin, and the testicles, are also complained of, even when there is not the slightest evidence of epididymitis. They sometimes radiate to the loins, the sacral region, the upper part of the thigh, or the whole pelvis, and worry the patient when he is sitting down, and more so when he walks, or rides on horseback. 3. Neurasthenic Troubles. — ^Patients who have lesions in their posterior urethra are nearly always neurasthenics; they suffer from " sexual neuras- thenia." Pains in the region of the kidneys, headache, vertigo, feelings of anxiety and of fainting are their lot, and the indefinite character of their trouble leads them to go from one doctor to another. Very often the true nature of their illness is not detected for a long time. This neurasthenia ultimately culminates in sexual impotence ; the erections are incomplete, and lead to nothing satisfactory, and finally the patients become hypochondriacs on a sexual basis. 4. Ejaculatory Troubles. — There are four different varieties which one meets with — ^namely : {a) Loss of Semen may occur, especially when the patient empties his bowels, or there is spermatorrhea or prostatorrhea at the end of micturition, or frequent " wet-dreams," or premature ejaculations — ejaculatio ante fortas, as somebody has termed them — may be complained of. (&) Pain during Ejaculation. — In some cases the voluptuous sensation during coitus is lost; in others an intense pain is felt at the height of the orgasm. Definite pathological conditions, which have been carefully studied, underlie these symptoms. There is atresia of the orifices of the ejaculatory ducts in these cases. The ducts have lost their suppleness; they have become rigid, and their lumen is narrowed by the formation of strictures. When the sperma is vigorously sent through them during ejaculation, they cannot dilate properly under the pressure, and thus give rise to pain. (c) Bloodstained Ejaculations. — Chronic lesions in the posterior urethra are always to be expected when a patient complains that his sperma is blood- stained. The latter may be definitely red, in which case a simultaneous inflammation of the seminal vesicles is probable, or it may be simply streaked with blood, in which case lesions of the verumontanum are likely to be present. Xiastly, retrograde ejaculations are sometimes noted. Instead of being expelled in the normal way outside the body, the sperma runs backwards into the bladder, which it leaves subsequently mixed with urine. {d) Repeated Attacks of Epididymitis. — This is another equally character- istic symptom of chronic posterior urethritis. Sometimes the epididymitis recurs at variable intervals in the same testis ; in other instances both sides are affected alternately, a condition known as orchite a bascule. CHAPTER VII THE DIAGNOSIS OF URETHRITIS The diagnosis of urethral inflammation is of the utmost importance. On its correctness and completeness depends the choice of treatment, and one may say without exaggeration that a rational and well-planned therapy invariably leads to a certain and permanent cure. The surgeon should therefore direct all his efforts towards a good diagnosis, and for this purpose he should keep all the principal symptoms which we are -about to describe carefully in mind. He should consider — 1. The urethral secretions. 2. The walls of the urethra proper. 3. The glands connected with the urethra. 1. Examination of the Urethral Secretions. It is a mistake to confine oneself to the examination of the purulent discharge which appears at the meatus. It is essential to investigate also the secretions which remain in the canal for a certain time, and are only expelled during micturition — namely, the filaments. One has therefore to examine — 1. The urethral discharge proper. 2. The filaments found in the urine. 1. Examination of the Discharge. — First of all one has to satisfy oneself that the discharge complained of really comes from the urethra, and not from a neglected or unsuspected balanoposthitis. Individuals who suffer from phimosis, very often develop under their long and tight foreskin, which permanently covers their glans, an ulcer, or a chancre, or warts. These conditions are apt to give rise to a discharge, which could easily be diagnosed wrongly, and be mistaken for a discharge from the urethra.^ Then there are patients who are addicted to the practice of injecting antiseptic solutions into their urethra in order to cure the gonorrhea which they believe themselves to be suffering from. All they achieve is to set up 85 86 GONORKHEA a chemical urethritis which could easily have been avoided had a properly conducted medical examination been made. As to the discharge itself, one has to ascertain, in the first place, if it is continuous, and if it shows itself again within an hour or an haK-hour after having made water — a characteristic feature of a still evolving attack of acute gonorrhea — or, if there is but a drop, rather pointing to an inflam- mation of a chronic nature. Then, again, one has to consider if the discharge is present during the day or only in the morning, in which latter case one has to deal with a true " gleet." Is the discharge so scanty that it only just forms a little scab or crust over the lips of the meatus, causing it to be sticky ? The colour of the discharge should also be noted. It may be white, or yellow, or green, or greyish, or opalescent, or clear like glycerine. Every one of these tints bears a definite relation to the amount of pus cells contained in the discharge. Its consistence is also of importance. Is it uniform, " laudable," pus, or is it flaky ? Is it viscous and slimy, and does it stain the linen ? Not infrequently the discharge is represented solely by a drop of clear fluid, like water, and is only visible in the morning. During the day the lips of the meatus are only slightly stuck together. This condition corresponds to Diday's " mucous oozing," or urorrhea. A discharge of this kind contains but very few epithelial elements ; occasionally, also, a small number of odd bacteria are found, but never any pus cells. 2. Examination of the Filaments in the Urine. — A painstaking examina- tion of the filaments found in the urine, and their differentiation, are of the greatest importance, and should never be omitted. By examining the filaments methodically, an experienced eye can at once establish the basis of his diagnosis. One is thus also enabled to control the result of a methodical treatment, and to tell approximately — although not with certainty — ^whether the patient is cured or not. To satisfy oneself that the patient's meatus is no longer sticky, and that he has no sign of a discharge, is not sufficient for giving him a clean bill of health. It is, amongst other further precautions, absolutely essential to ascertain that there are no filaments in the urine. To act diflerently means running the risk of serious miscalculations, of which the least dangerous one would be to see the patient return a few days after his supposed cure, with a recurrence of his discharge, or with an epididymo- orchitis, or with some other complication. It is best to examine the first urine which the patient passes in the morning ; but in practice this cannot always be carried out, and it is sufficient in most cases to test a specimen which is obtained three to four hours after the last micturition. THE DIAGNOSIS OF UEETHRITIS 87 If the urine is turbid, it is one's first duty to ascertain tliat this turbidity is not due to the precipitation of salts, chiefly phosphates, in an alkahne urine. For this purpose a few drops of acetic acid are poured into the turbid urine ; if phosphates be present, they are immediately dissolved, and the urine becomes clear. The omission of this test is apt to lead to serious mistakes. In order to differentiate the various filaments found in the urine according to their origin, a number of methods have been devised, which we will rapidly review here. Thompson's Method. — Thompson's method is very simple, but also very inaccurate. It consists in making the patient pass his water into two glasses only. The first glass is supposed to represent the condition of the anterior urethra, and the second one that of the posterior urethra. If we exclude all patients who suffer from renal or vesical lesions which give rise to turbid urine and to special symptoms, and only consider cases of urethritis, then three groups of cases can be distinguished : 1. Both glasses are turbid. 2. The first one is turbid, the second one clear. 3. Both glasses are clear ; but there are filaments, in one or in both. Each of these different groups has a different signification. The first two (turbid urine) indicate diffuse acute or recent superficial lesions. In the first instance the urethritis is a total one ; in the second group the anterior urethra is alone affected. The third alternative is the most common (clear urine with filaments), and means practically always a localized chronic lesion. But to distinguish between lesions of the anterior and of the posterior urethra in this case is extremely diflS.cult. Thompson's two-glass method is based on the purely theoretical assump- tion that the external sphincter of the bladder divides the urethra anatomic- ally, and physiologically into two distinct portions. This muscle is supposed to form so impassable a barrier that all secretions which are formed in the anterior urethra are at once driven towards the meatus, whilst those of the posterior portion flow back into the bladder and mix with the urine. This view is more theoretical than practical, for common experience tells that, in the overwhelming majority of cases, the filaments are found in the first glass whether they come from the anterior or from the posterior urethra. The first stream of urine drives them out of the meatus, and thus they fall into the first glass, so much so that there is no need for the second glass to contain any filaments at all. 88 GONOEEHEA Thompson's metliod is thus quite useless for accurate work. Supposing the patient passes very little urine into the first glass, less than necessary for washing away all the filaments, the latter are then found in the second glass, even if they originated in the anterior urethra. Again, in cases of obvious posterior urethritis, pus and debris may be present in the first glass, whilst the second one is quite clear, owing to the fact that the first lot of urine sufficed to cleanse the urethra completely. In cases of this kind a wrong diagnosis would be made with certainty were one to rely upon this method. However, one must admit that a posterior urethritis is usually present when big and heavy filaments are found in the second glass. A control by other methods of investigation is, however, always required (cross-examina- tion of the patient in order to ascertain if he has suffered from cystitis or epi- didymitis, and, still more important, examination of the prostate "per rectum). Kollmann's Method. — Professor Kollmann of Leipzig has devised a five-glass method which safeguards against the errors of Thompson's process. The examination is best carried out in the early morning, before the patient has made his first water. His anterior urethra is washed out with a syringe, or through a soft sound passed as far as the bulb, the patient standing upright, and great care being taken to irrigate slowly, and not to force the sphincter. The washings are all collected in th^ first glass as long as filaments come away. When the irrigation fluid is returned quite clear, a result which is only obt^ained after | to 1 litre has been used, it is collected in the second glass, which is kept as evidence that the anterior urethra has been thoroughly washed. The patient then makes water into the other three glasses. If one of them contains filaments, or if the urine is turbid, the phosphates having been eliminated, then the posterior urethra must be aflected. If, on the other hand, neither turbidity nor filaments are present, whilst the fkst glass (containing the washings) is full of filaments, the anterior urethra is alone diseased. Kollmann's five-glass method is absolutely accurate when applied with care. Young of Baltimore has developed this method into a seven-glass process. He first washes the anterior urethra: first glass. The patient compresses his urethra at the root of the penis, and the washings are con- tinued until they are returned perfectly clear : second glass. A glass tube is now inserted as far as the bulb, and one irrigates again until no more fila- ments come away ; these washings are the third and fourth glasses. The patient then empties his bladder into the fifth, sixth, and seventh glasses. The Jadassohn-Goldberg Method.' — The anterior urethra is washed care- fully with a syringe until the washings return quite clear. These washings contain, of course, the secretions of the anterior urethra only. THE DIAGNOSIS OF URETHRITIS 89 The patient then makes water into two glasses, and any pus or purulent debris found in them necessarily comes from the posterior urethra. This method allows one to distinguish clearly between the secretions of the anterior urethra and those of the posterior urethra ; but it does not allow one to differentiate between those of the posterior urethra and those of the bladder. The same criticism applies to Krohmeyer's method, which we will consider next. Krohmeyer's Method. — Krohmeyer injects or instils 4 or 5 c.c. of a O'l per cent, solution of methylene-blue into the anterior urethra, and allows this fluid to be retained for a few minutes. The patient then makes water into several glasses. Any filaments stained blue are derived from the anterior urethra, whilst those of the posterior urethra are colourless. Lohnstein's method is very similar. Lohnstein's Method. — Before the first lot of urine has been passed in the morning, a 0-5 per cent, solution of potassium ferrocyanide is injected into the anterior urethra until the fluid comes out clear. Great care must be taken not to force the sphincter. All traces of ferrocyanide are then washed away. That this has been achieved can be controlled by the addition of a few drops of perchloride of iron solution to the washings, as they are returned. Any trace of ferro- cyanide would be revealed by the appearance of a characteristic colour (Prussian blue). When it is certain that the washings have removed all the reagent, the patient makes water into three glasses, which are inspected for filaments. To each glass a little perchloride of iron is added, and should give no colour. A blue colour would indicate that some of the ferrocyanide has passed into the posterior urethra. In this way the correctness of the technique can be controlled. None of these methods permit of a rigorous distinction between the secretions of the posterior urethra and those of the bladder or those of the prostate. This differentiation is possible by means of Wolbarst's method. Wolbarst's Method.-"- — Four glasses are required, and one proceeds as follows : 1. The anterior urethra is carefully washed, and the washings are col- lected in the first glass; they represent the condition of the anterior urethra. 2. A soft catheter is passed into the bladder, and the pure vesical urine is collected in the second glass. 3. The bladder is now washed until the fluid returns clear. It is then filled with water, and the catheter is withdrawn. The anterior urethra and the bladder are now thoroughly clean. 4. The patient now passes some of the fluid which had been injected 1 Abr. L. Wolbarst, of New York, Medical Record, April 21, 1906, p. 627. 90 GONOERHEA into his bladder into a third glass ; this lot contains anv secretions which may come from the posterior urethra. In this way the secretions from the three parts of the lower urinary passages are separated. 5. The prostate is massaged, and the patient makes water into the fourth glass, the contents of which represent the prostate. The author of this process has never found it to fail, and he considers its indications to be absolutely accurate. There is no doubt that these various methods are of great assistance in complex cases which require special accuracy, but for ordinary purposes they are too tedious and too complicated. The Practical Method. — ^In most cases it is sufficient to ask the patient to make water into four glasses. One can thus differentiate with sufficient accuracy the lesions of the anterior urethra from those of the posterior. If the contents of the first glass failed to cleanse the anterior urethra, those of the second, and a fortiori those of the third, will do so ; and if the fourth glass contains heavy flakes, whilst the second and third do not, or only contain a few, then the diagnosis of posterior urethritis is certain. This simple method is sufficiently accurate. The differentiation between the anterior and the posterior urethra is effected in this method by the second and third glasses. The types most commonly observed are the following : TFirst glass clear or turbid, with heavy if. . , . I. ' filaments; second, third, and fourth UM^^erior^ urethritis or [ glasses clear, without filaments. J [ posterior urethritis. fFirst glass clear or turbid, with heavy ^ J J J filaments; second and third glasses I clear, without filaments; fourth glass 1^ clear or turbid, with heavy filaments. f First glass clear, with a few heavy fila-^ ments; second and third glasses clear, with a few or no filaments; fourth glass turbid, with heavy filaments. J Anterior urethritis and I posterior urethritis. III. . J Posterior urethritis I chiefly. Macroscopical Examination of the Filaments. — ^The filaments vary in character, and should be examined carefully. Sometimes they are very long, mucous, viscous, and, above all, light. They float in the urine, and rise to the surface. They signify irritation, swperficial congestion, rather than a deeply-situated lesion, and are commonly found in the first glass, if the case has been treated with permanganate irrigations. These are the light or mucous filaments. In other cases the filaments are thick, heavy, and sinJc rabidly to the bottom of the glass. They always contain pus cells, and are indicative of a still progressing lesion ; they are the dangerous filaments. If they are only THE DIAGNOSIS OF URETHRITIS 91 found in the first glass, tlie anterior urethra alone is likely to be affected. If they are present in the last one or two glasses, and have the shape of thick crumbs, they denote a lesion of the posterior urethra. Between these two extreme types of filaments many intermediate varieties occur, but one has only to wait a few moments to see them behave in one of the two ways described. Again, the filaments may be comma-shaped. According to Fiirbringer and Finger, these special filaments are derived from the glandular elements of the prostate, which are moulded upon them, and these authorities hold that their presence is an urgent indication to explore the prostate per rectum. This view is perfectly correct, but there are also other comma-shaped fila- ments which are less well known, and which differ not only in their aspect, but also in their origin, from them. These filaments resemble a well-made comma or a well-shaped crescent. They are slender, and contrast by their lightness with the heavier and thicker prostatic filaments. Moreover, they are only found in the first glass. They are often present in large numbers, and are of great im- portance, because they are an almost infallible sign of an inflammation of Littre's glands. These characteristic filaments origin- FiG. 34, — Suspended in the Urine: Small, Light, Typical " Comma -shaped" Filaments, INDICATING Lesions oe Littre's Glands. ate, without any doubt, in the glands of Littre which are found in the penile urethra. Whenever this diagnosis can be controlled by means of the urethroscope, one sees that the orifices of these glands are inflamed {vide Coloured Plate III., Figs. 1, 2, 3, 4); and palpation always reveals in these cases small nodules of the size of a millet-grain or hempseed along the under- surface of the urethra {vide p. 100). Lastly there is the therapeutic proof. Under a rational and well-conducted treatment of Littre's glands, these characteristic filaments disappear as the littritis subsides. Microscopical Examination of the Filaments. — This examination is essential whenever it is impossible to examine the discharge. One is thus enabled to distinguish the microbic elements which come from the balano-preputial sulcus and from the meatus, and are not present .92 GONOERHEA in the urethra. In the latter case there are no organisms in the filaments, even if the microscope had shown them in the discharge collected from the meatus. The technique is very simple. With a platinum loop which has been passed through the flame, one or two filaments are removed from the urine and placed on a slide, which is then dried in a current of air, and fixed by being passed rapidly through a Bunsen flame three times. It is then stained by one of the methods described in Chapter III. and examined. Cultivation of the Filaments. — ^When there is no discharge, it is very often important to know if the filaments are quite sterile. This is, for instance, the case if the patient wishes to marry. It is then advisable to cultivate these filaments ; one can use the ordinary media for this purpose (agar, gelatin, or broth), but it is preferable to inoculate them on special media, such as blood-agar (Bezan9on and Griffon's medium). 2. Examination of the Urethra Proper. The examination of the urethra proper consists chiefly in the study of its walls. It should always be preceded by the inspection of the meatus and of the prepuce. We therefore have to consider — 1. The examination of the meatus. 2. The examination of the prepuce. 3. The exploratory catheterization of the urethra. 1. Examination of the Meatus. The meatus requires careful inspection ; in the same way as the tongue is the mirror of the stomach, the meatus is " the mirror of the urethral mucous membrane." Red, hyperemic, and edematous lips of the meatus allow one to suspect an acute and recent inflammation of the canal. On the other hand, if the lips are bluish, almost dry, or scabbed over, or stuck together, a chronic condition is more likely to be present. One should also note if the shape of the meatus is normal or not, if there is epispadias or hypospadias, and if diverticula which so often harbour gonococci are present. The para-urethral ducts should be sought for carefully in the neighbour- hood of meatus and frenum. Their exploration is greatly facilitated by the use of a small urethral speculum and of a small probe with which they can be catheterized. These flstulse and para-urethral ducts are often responsible for the THE DIAGNOSIS OF UEETHRITIS 93 non-success of uretliro-vesical irrigations witli antiseptic solutions ; the latter simply pass over them without entering them. The diverticula which are visible on the outside have been well described by Janet. ^ They are relatively easy to treat. Those which are situated inside the lumen of the urethra are only observable with the aid of the urethroscope. The former variety, which may be termed " external," often opens by means of a tiny orifice which is in no proportion to the length of its tract- Fig. 35.— Small Urethral Speculum for examining the Meatus. It should be explored with a stylet ending in a sharp point, and not with a soft bougie, because the latter lacks the necessary resistance. Another common bulwark of micro-organisms is to be found in this region — namely, Tyson's glands. When these para-urethral ducts are infected, they can only be treated successfully and cured in one way : by opening them up in their whole length. The second variety, the internal fistulae, is common. These fistulae are readily seen with the urethroscope, and demand the same treatment as the external variety. Fig. 36. — Small Stylet for exploring the Para-Urethral Ducts. One should not restrict the examination of the meatus to inspecting it in the closed condition. The lips should be seized between thumb and index, and be separated. One is thus often able to make interesting dis- coveries. For instance, a youth who was sent to me by Dr. Barbier showed nothing abnormal on ordinary inspection, but when I separated the lips of his meatus, two polypous masses, analogous to those found on the glans, pro- jected, and showed us that he was suffering from a polypous urethritis. 1 Janet, " Les Repaires Microbiens de I'Uretre," Annal. des Mai. des Organes Qenito-Urin., 1902, p. 897. 94 GONOKKHEA 2. Examination of the Peepuce. The prepuce should be drawn back completely for examination. The balano-preputial sulcus is cleansed with swabs and carefully inspected. One's attention should not be confined to its state of inflammation; but one should also look for abnormal or inflamed orifices, such as the openings of Tyson's glands, already alluded to. The length of the prepuce has also to be considered ; a prepuce of excessive length favours balanoposthitis, and often keeps up a chronic urethritis for a considerable time. 3. EXPLOEATORY CaTHETEEIZATION OF THE UeETHRA. The exploratory catheterization of the urethra is carried out with special bougies which have an olivary end, as shown in Fig. 37. They should be of sufficient length to reach the bladder, and of such rigidity that they do not curl up at the slightest obstacle. On the other hand, they should adapt themselves easily to the curves of the urethra, and have such a diameter Fig. 37. — Explobatory Olivary Bougie. that they are not in actual contact with its walls. The terminal olive forms a marked projection where it joins the stem of the instrument, a kind of heel. The sizes of the various olives are measured by means of a special gauge^ {vide Fig. 38). Contra-Indications against Instrumental Examination of the Urethra. — One should never introduce an instrument into the urethra without having examined the urine previously, which should be passed into several glasses. This precaution allows one to avoid serious troubles, because the passing of 1 The gauge used is the ordinary French scale, and is graduated in thirds of a millimetre. Thus, No. 1 is J millimetre thick, No. 12 equals 4 millimetres, etc. In addition to this " filiere Charriere," there is the " fili^re Guyon," which is graduated in sixths of a millimetre. This scale was introduced by the late Professor Guyon, and is generally used for dilators and other metal instruments. The equivalence of the two scales is easily calculated. Guyon's odd numbers have no equivalent in the Charriere scale. His even numbers are the double of the corresponding numbers of the ordinary gauge ; thus, 40 Guyon equals 20 Charriere, etc. For genito-urmary work the French scales are preferable to the English catheter gauge, as Mr. Reginald Harrison pointed out long ago (Surgical Disorders of the Urinary Organs, J. and A. Churchill, 1893). I have therefore thought it undesirable to compli- cate the text by giving the approximate English equivalents. Where reference is made to Guyon's scale, a G has been added (A. F.). THE DIAGNOSIS OF URETHRITIS 95 instruments is apt to lead to complications when the urethra is acutely inflamed. For instance, if the posterior urethra be healthy, whilst the anterior portion is inflamed, an instrument can easily convey organisms from the latter to the former, and thus infect it. In practice one should therefore be guided by the principle that a patient whose first glass of urine is turbid should not be treated with instru- ments, even if the second one be clear. In a case of this kind, diffuse and recent superficial lesions are present, which hasty and untimely manipulations would probably aggravate. When the urine is clear, and contains but filaments — i.e., when the lesions are localized — then, and only then, can instrumental examination of the urethra be carried out without any risk. Technique. — For a urethra which one has never explored before, it is best to take an exploratory bougie (No. 18). The meatus and the anterior Fig. 38. — French Catheter Scale (Filiere Charribre). urethra are washed, and it is wise to allow a little boric solution to run into the bladder from an irrigator. A catheter should not be used in filling the bladder. The lubricated exploratory bougie is then placed against the meatus with the right hand, whilst the left one stretches the penis somewhat. The olivary end is then gently passed into the meatus by means of a slight rotatory movement, and pushed onwards. In a healthy urethra the instru- ment advances without diflS.culty, and without causing any pain, until the membranous urethra is reached. Here the olive meets with an obstacle which is physiological, and is present in every urethra. It is indispensable to inform the patient of this fact. By so doing one saves him the surprise of an unexpected, disagreeable, and painful sensation, and enables him to assist matters by trying to relax his sphincter, as if he were about to make water, or by letting himself go, taking deep breaths, as if he were fast asleep. In most cases the sphincter is thus overcome; the instrument passes over the prostate and enters the bladder, where it becomes freely movable. 96 GONORRHEA But before it glides past the neck of the bladder tbe olive always gives a little " jerk," as Lallemand pointed out as far back as 1836. This is due to the presence of the verumontanum, which projects into the lumen of the urethra, and thus forms a slight obstacle. Normally this structure is almost void of sensation, but when it is chronically inflamed it occasionally becomes exceedingly tender. The passage of an instrument is then horribly painful, and throws the patient into the position of opisthotonos as long as the instrument remains in contact with his verumontanum. In cases of chronic posterior urethritis, and in nervous subjects, one also meets with instances FiG. 39. — Exploratory Catheterization op the Urethra. in which the bougie will not pass; the sphincter is firmly contracted, in a state of spasm, although the patients may do their best to assist the intervention. When such spasm is present, the following simple remedy may be tried : One presses the bougie gently against the sphincter with the right hand, whilst the left hand draws the penis upwards. By this means one prevents the olive from being caught in a fold of mucous membrane instead of the sphincter. This procedure is often of no avail, and the sphincter remains so tightly contracted that nothing can pass. Then one may try a thin, more rigid bougie, which may take the sphincter by surprise and pass it. This method is often successful, and allows one to pass the olivary bougies subsequently. Or one may anesthetize the sphincter with stovain. For this purpose, THE DIAGNOSIS OF URETHRITIS 97 either an instillation of a few drops of a 1 per cent, solution is made just in front of the sphincter, or the anterior urethra is filled with 10 c.c. of this solution, which is allowed to act for a few minutes. Lastly, another means consists in passing a large metal sound (No. 40 G or No. 42 G). This last method is as a rule the most likely one to prove successful. In one of my cases, for instance, the patient, a young man of twenty-seven, had a chronic urethritis, and was able to pass his water without any diffi- culty. His sphincter, however, contracted firmly every time an instrument came into touch with it. First a filiform bougie was stopped, and the spasm of the sphincter was accompanied by spasmodic contractions of his right femoral triceps. Then instillations of cocain proved useless. Finally a sound was introduced; it passed easily along the anterior urethra, but as soon as it reached the sphincter the patient had a seizure, which compelled me to remove the instrument speedily. However, a second attempt was made, after he had quieted down, and this time the sound entered with the greatest ease. Fig. 40. — Curved Metal Sound (Benique with Guyon's Curve). At all events the membranous sphincter is a fixed and precious landmark which allows one to locate any abnormal sensations which may be felt whilst the exploratory catheter is being passed. For further precision one should use the touch. The relief formed by the olive should be felt through the integuments, and this is easy if one moves the instrument gently to and fro. In this way a lesion can be accurately located. Generally speaking, exploration of the urethra by means of the olivary bougie is most useful. This instrument is really a continuation of the palpating finger; it allows one to feel any changes in the lumen of the passage, and to locate the lesions present fairly accurately. Results obtained by the Exploratory Catheterization of the Urethra. — 1. This method of examination is especially useful in chronic urethritis. The patches of induration and of infiltration which develop in the course of this affection are detected by the olivary bougie, and hence the suitable treatment is indicated. Some of these patches are almost imperceptible, the so-called wide strictures, and should always be looked for with great care. It is often 7