COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00034630 'MM mmmmm^ RC87/ L3S intijeCitptJfilmgork College of ^fjpsficians; anb burgeons: i^ibrarp ■^-:?i. Bi^^Bii^^HL^ f.,1 ^Jp^l^ / ^,^><^^^«4-•; (0^/^;f The Surgical Diseases of the Genito-Urinary Tract VENEREAL AND SEXUAL DISEASES A TEXT-BOOK FOR STUDENTS AND PRACTITIONERS G. FRANK LYDSTON, M.D. Professor of the Surgical Diseases of the Genito-Urinary Organs and Syphilology in the MEmcAi, De- partment OF the State University of Illinois (the Chicago College of Physicians and Surgeons^ : Professor of Criminal Anthropology in the Kent College op Law; Scrgeon-in-Chief to the Genito-Urinary Department of the West-side Dispensary : Late Major and Surgeon, U. S. V.; Fellow of the Chicago Academy of Medicine: Fellow OF THE American Academy of Political and Social Science ; Dele- gate from the United States to the International Con- gress for the Prevention of Syphilis and the Venereal Diseases held at Brussels, Belgium, September o, 1S99 ; etc. Illustrated witb 235 Ettgravittds Philadelphia, New York, Chicago THE F. A. DAVIS COMPANY, PUBLISHERS 1899 COPYRIGHT. 1S99, BY THE F. A. DAVIS COMPANY. I Registered at St.itioners' Hall. London, Eng.] Philadelphia, Pa., U. S. A. : The Medical Bulletin Printing-house, 1914-16 Cherry Street. TO FESSENDEN N. OTIS, In Token of Appreciatiox of His OEroixAL Research and Practical Clinical Observations, avhich Have Been the Basis of the Best Work that Genito-Urinary Surgery Has Thus Far Accomplished in America, AND AS A Testimonial of Personal Gratitude and Esteem from His Old-Time Hospital Interne, this Volume is Affectionately Inscribed by THE AUTHOR. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgicaldiseasesOOIyds PREFACE. In view of the cordial manner in which my various contributions to the subjects embraced in this volume have been received by the profession^ I have felt that the publication of a more comprehensive treatise hardly requires either apology or explanation. I have embraced the opportunity herein afforded me for airing a few heresies of my own, in juxtaposition with as much of the accepted and standard teachings as it is practicable to present in a work chiefly designed for the student and general practitioner rather than the specialist; but this may be pardoned. Ko attempt has been made to cover the literature of the various subjects comprised in this vol- ume. The endeavor has been to give a practical survey of the field of genito- urinary and venereal diseases, following as closely as practicable the plan of my course of lectures on the subject delivered in the Medical Depart- ment of the University of Illinois. aC^^^^L&T,*^ Reliance Building, Chicago, September 1, 1899. (V) CONTE>s"TS. PAET I. General PEiisrciPLES of Genito-Ukinaey, Sexual, and Venereal Pathology and Therapeutics. CHAPTER I. PAGE Genito-Urinaiy and Sexual Hygiene 1 CHAPTER 11. Urinalysis in its Surgical Relations 10 CHAPTER III. Hematuria 34 CHAPTER IV. The Bacteriologic Relations of Genito-Urinary Infections and Secondary Infec- tions and Toxemias of Urinary Origin 46 CHAPTER V. General Morbid Phenomena Incidental to the Surgery of the Genito-Urinary Organs 54 PAET II. NON- VENEREAL DISEASES OF THE PeNIS. CHAPTER VI. Anatomy and Physiology, Anomalous Formations, Traumatisms, Acute and Chronic Inflammations, Neoplasms, and Amputation of the Penis 69 CHAPTER VII. Diseases of the Skin and Quasimucous Mambrane of the Penis 80 PAET III. Diseases of the Urethra and Gonorrhea. CHAPTER VIII. Diseases of the Male Urethra: Anatomy and Physiology; Traumatisms; Foreign Bodies and Tumors of the Urethra 94 CHAPTER IX. Urethritis and Gonorrhea ■. 116 (Yii) Vni CONTENTS. CHAPTER X. PAGE Gonorrhea in the Female 163 CHAPTER XL Stricture of the Urethra 172 PAET IV. Chanckoid axd Bubo ajs^d their Complications. CHAPTER XII. Chancroid 265 CHAPTER XIII. Venereal Adenitis, or Bubo 308 PART Y. Syphilis. CHAPTER XIY. Syphilis 332 CHAPTER XV. Methods of Acquiring Syphilis — Varieties and Treatment of Chancre — Primary Syphilitic Adenopathy 363 CHAPTER XVI. General Infection of Syphilis 376 CHAPTER XVII. Early Brain and Xerve Syphilis 398 CHAPTER XVIII. The Period of Sequels, or So-Called Tertiary Syphilis 417 CHAPTER XIX. Congenital Syphilis — Acquired Syphilis in Children 4.55 CHAPTER XX. Treatment of Syphilis 469 PAET YI. Diseases Affecting Sexual Physiology. CHAPTER XXI. Aberrant and Imperfect Differentiation of Sex 515 CONTEN'TS. IX CHAPTER XXII. PAGE Diseases of the Sexual Function and Instinct 524 CHAPTER XXIII. Aberrations of the Sexual Instinct 529 CHAPTER XXIV. Satyriasis, Xymphomania, Masturbation, Sexual Excess, and Unphysiologic Coitus 544 CHAPTER XXV. Impotence and Sterility 568 CHAPTER XXVI. Spermatorrhea 602 PAET VII. Diseases of the Peostate and Seminal Vesicles. CHAPTER XXVII. Diseases of the Prostate 624 CHAPTER XXVIII. Chronic Prostatic Inflammation and Suppuration 663 CHAPTER XXIX. Tuberculosis of the Prostate. Cancer of the Prostate. Calculus of the Prostate . . 675 CHAPTER XXX. Hypertrophy of the Prostate 686 CHAPTER XXXI. Diseases of the Seminal Vesicles 728 PART VIII. Diseases of the Urinary Bladder. CHAPTER XXXII. Diseases of the Urinary Bladder 732 CHAPTER XXXIII. Neoplasms of the Bladder and Vesical Tuberculosis 757 CHAPTER XXXIV. Urinary Calculus 776 CHAPTER XXXV. Neuroses of the Bladder 830 X -CONTENTS. PAET IX. Surgical Affections of the Kidney and Ureter. CHAPTER XXXVI. page Surgical Affections of the Kidney 842 CHAPTER XXXVII. Surgical Aflfections of the Kidney (Continued) 878 CHAPTER XXXVIII. Diseases of the Ureter 907 PAET X. Diseases of the Testis and Spermatic Cord. CHAPTER XXXIX. Diseases of the Scrotum, Testis, and Spermatic Cord 916 CHAPTER XL. Hydrocele 928 • CHAPTER XLI. Inflammatory Affections of the Testis 941 CHAPTER XLII. Neoplasms of the Testis 969 CHAPTER XLIII. Varicocele 985 Appendix 1000 Index 1003 LIST OF ILLUSTEATIONS. FIG. PAGE. 1. Ammonium-urate crystals 17 2. iJrie-acid crystals 19 3. Calcium-oxalate crystals 20 4. Triple-phosjjhate crystals 21 5. Morning urine in a spermatorrheic 32 6. Section of the penis at about its middle 69 7. Buck's fascia 72 8. "Osseous" degeneration of the penis 75 9. Penile epithelioma. Vegetating form 76 10. Operation for phimosis 82 11. Venereal vegetations 92 12. Simple penile papillomata 93 13. The fossa navicularis 94 14. Showing lacuna magna 95 15. Diagrammatic section of perineum, showing arrangement of the triangular ligament 96 16. Dissection of perineum, showing relation of bulb of urethra to the triangu- lar ligament 97 17. Dissection of perineum, showing deeper parts in their relation to the urethra 97 18. Normal curve of urethra 98 19. Bell's curve, showing relation of English, American, and Benique sounds to it, and comparative length of beaks 98 20. Case of. hypospadias (pseudohermaphroditism) 100 21. Case of hypospadias with marked feminine physique 101 22. Operation for hypospadias 102 23. Case of simple epispadias 1 03 24. Dolbeau's operation 104 25. Dolbeau's operation, flaps in position 105 26. Formation of glans urethra 106 27. Formation of penile urethra 106 28. Flaps sutured in position 107 29. Formation of preputial graft 107 30. Preputial graft 108 31. Closure of posterior urethral defect 108 32. Closure of posterior urethral defect 109 33. Alligator urethral forceps 112 34. Adenomata of the urethra 113 35. Adenoma of the urethra 114 36. Gonococci in lu'ethral pus 123 37. Periurethral phlegmon 130 38. Lydston's urethral irrigator 137 39. Proper form of urethral syringe 145 40. Chronic granular urethritis 151 41. Guyon's bulbous "bougie exploratrice" 153 42. Lamp for direct electric illumination of the urethra 153 43. Endoscope 154 44. Author's endoscopic tubes 154 45. Cupped sound for urethral medication 155 46. Brown's urethral speculum 156 47. Author's syringe for deep injection 157 48. Oberlaender's dilator (straight) 159 49. Oberlaender's dilator with deep curve 159 50. Gonorrheal inflammation of the left vulvo-vaginal gland 169 51. Showing the manner in which urethral coarctation and spasm oppose the entrance and withdrawal of a bulbous bougie 174 52. Linear stricture 184 53. Bridle stricture 185 54. Annular stricture 186 (xi) Xll LIST OF ILLUSTEAT10X5. FIG. PAGE. 5.5. Tortuous multiple stricture 187 56. Multiple stricture, penile and deep, showing varying caliber 188 57. Casts of alleged normal lu-ethras, showing points of contraction 196 58. Dilation and trabeculation of prostatic urethra, secondary to close bulbo- membranous stricture 198 59. Showing extreme dilation of proximal side of genito-iu'iuary tract iu stricture of long standing 200 60. Otis's urethrometer . 206 61. ileatotome 207 62. Otis exploring bulbs 209 63. French scale for measuring urethral instruments 219 64. Dlive-tipped soft bougie 225 65. Soft straight catheters 225 66. Screw-tipped guides 225 67. Bank's whalebone bougies 226 68. Correct curve for instruments 226 69. Author's urethral sounds 227 70. Firsi position in introducing a sound 231 71. Second position in introducmg a sound 232 72. Third position 233 73. Fourth and final position 234 74. False passage in stricture 235 75. Maisonneuve's urethrotome 239 76. Tne Otis dilating urethrotome 240 77. Condition of urethra fifteen years after operation of dilating urethrotomy. . 243 78. Gouley's catheter staff and guide 244 79. Filiform bougies 245 80. Tunneled sound 245 81. Deep urethrotomy 246 82. Author's perineal drainage-tube 247 83. Shirted cannula 248 84. Multiple urinary fistulas from deep stricture 258 85. Szymanowski's urethroplasty for penile urinary fistula 259 86. Szymanowski's urethroplasty for penile urinary fistula 259 S7. Szymanowski's urethroplasty for penile urinary fistula 259 88. Szymanowski's urethroplasty for penile urinary fistula 259 89. Szymanowski s operation for large penile fistula 260 90. Xelaton's operation for penile fistula 261 91. Xelaton's operation for penile fistula 262 92. Clark's operation for penile fistula: first step 262 93. Clark s operation for penile fistula : second st«p 263 93ff. Section of chancroid showing Ducrey-Unna streptobacillus in the tissues. . 266 94. Multiple chancroid in the female 280 95. Multiple chancroids in the male 282 96. Chronic chancroid of right labia 284 97. Extensive destruction of the genitals, permeum, and ischio-rectal fossas from chancroid in an old syphilitic 285 98. Double chancroidic bubo after spontaneous evacuation 311 99. Phagedenic bubo 316 100. Case of hereditary syphilis diagnosed as and treated for leprosy 333 101. Plantar leprosy, resembling syphilis 334 102. Mixed type of leprosy simulating syphflis 335 103. Chancre of upper lip.* " 366 1Q4. Hard chancre in the fossa glandis 368 105. Papular syphilide 385 106. Papulo-squamous syphilide 386 107. Pustulo-ulcerous syphilide 387 108. Ulcerating gumma 395 109. Ulcerous late syphilide 419 110. Squamous syphilide — so-called syphilitic psoriasis — of palms 430 111. Early scjuamous syphilide — so-called syphilitic psoriasis — of palms 431 112. Early circinate syphilide 434 113. Circinate syphilide 435 114. Ulcerous late syphilide 436 115. Secondary circinate syphilide 437 LIST OF ILLUSTEATIO>N^S. Xlll FIG. PAGE. 116. Dactylitis syphilitica 449 117. Dactylitis syphilitica with absorption of bone 4.50 118. Showing cranial hyperostoses from tertiary syphilis 4,52 119. Showing osteoporosis and carious destruction of frontal region from ter- tiary syphilis 4.53 120. Aberrant psychosexual differentiation with imperfect physical differentia- tion 516 121. Pseudohermaphroditism 518 122. Aberrant genitosexual differentiation (hypospadiac) .520 123. Pseudohermaphroditism ,521 124. Author's insulated prostatic electrode 592 125. Microscopic appearance of normal human semen 607 126. Spermuria 611 127. Conventional illustration of the anatomic relations of the parts about the base of the bladder 625 128. Showing the internal anatomic relations of the bladder, urethra, and pros- tate 626 129. Midsection of prostatic urethra 629 130. Prostato-vesical calculus 684 .131. An example of greatly-enlarged prostate, mainly due to fibrous tumors. . . . 693 132. Pedimculated '"middle lobe"' obstructing catheter 694 133. Enlargement of "middle lobe"' 695 134. Adenomatous tumor from left lobe of prostate 696 135. Enlargement of the lateral lobes 697 136. Hypertrophy, fasciculation, and sacculation of vesical walls 700 137. Small phosphatic calculi 704 138. Exploring sound for diagiiosing condition of vesical neck 706 139- Olive-tipped flexible catheter 708 140. ■Jacc{ue"s soft catheter 708 141. The catheter coude 709 142. Metallic catheter with prostatic curve 709 143. Catheter coiide with prostatic curve 710 144. Routes for vesical j^uncture 712 145. Hunter McGuire's suprapubic-fistula stem 721 146. Rongeur forceps for prostatectomy and similar intravesical work 721 147. Saw-tooth scissors for intravesical work 722 148. Author's perineal drainage-tube 723 149. Bottini-Freudenberg electroprostatome 727 1,50. Method of suturing bladder 736 151. Wood's method. Outline of flaps 738 152. The same after insertion of sutures 738 153. Simple papilloma of the bladder 757 154. Vesical fibropapilloma 758 155. Histology of filaments of papilloma of the bladder 759 1.56. Myxosarcoma 761 157. Vesical epithelioma 763 158. Carcinoma of bladder 764 159. Bladder containing medullary cancer complicated by two calculi 765 160. Nitze-Leiter cystoscope 765 161. Sacculation of bladder 769 162. Sacculation of bladder, showing sac cut open 769 163. Principal varieties of urinary calculi 781 164. Calculus formed around a hair-pin, the ends of which ai-e visible 782 165. Handle of a tooth-brush, covered with calcareous deposit, found in a young girl's bladder 783 166. Ovoid calculus formed around a bean 784 167. Cluster-calculus formed around a head of wheat 785 168. Thompson's searcher for stone 786 169. Sounding for stone above pubes 787 170. Sounding for stone in the has-fond 787 171. Sounding for encysted calculus 788 172. Modified Bigelow' lithotrite 795 173. Clover's evacuating apparatus and tubes 795 . 174. English method of seizing the stone in lithotrity 796 175. French method of seizing the stone in lithotrity 798 xiv LIST OF ILLUSTEATIOXS. FIG. PAGE. 176. Chismore's lithotrite 802 177. Chismore's percussor for fracturing calc-uli 803 178. Chismore's washing bottle and tube 803 179. Clover's crutch 811 180. Position of patient and line of incision in lateral lithotomy 812 181. Lithotomy-staff 813 182. Probe-pointed straight lithotomy-knife 813 183. Probe-pointed curA'ed lithotomy-scalpel 813 184. Conventional diagram of the perineum and the incisions in lateral lithot- omy 814 185. Lateral lithotomy with a curved staff 815 186. The bony pelvis m its relations to perineal lithotomy 816 187. Incision in the prostate in lateral lithotomy 817 188. Broad-grooved lithotomy-director 817 189. Combined lithotomy-scoop and lithotomy-director 818 190. Lithotomy-forceps: double cuiTcd 818 191. Lithotomy-forceps: single curved 819 192. Irregular calculi removed by suprapubic section 828 193. Single median kidney lying below bifurcation of the aorta 843 194. Horseshoe kidney 844. 195. Renal calculus removed in the author's case of hepato-nephrolithotomy . . . . 854 196. Calculus imbedded in lower portion of renal pelvis 855 197. Enormous segmented renal calculus, natural size 857 198. Enormous renal calculus, reduced: segments separated, showing facets. . . . 858 199. Calculous pyelonephritis, with destruction of renal tissue 862 200. Histology of acute interstitial nephritis with disseminated abscesses 876 201. Hydronephrotic kidney without much enlargement 879 202. Tuberculous pyelonephritis 886 203. Harris's device for collecting urine from the ureters separately 889 204. Harris's device for collecting urine from the ureters separately 890 204o. Harris's device for collecting urine from the ureters separately 890 205. Van Hook's method of anastomosis of the divided ureter 910 206. The Kelly method of exploring the ureters in the female 913 207. Ureteral catheter in position 914 208. Dissection of testis 917 209. Elephantiasis scroti 921 210. Hematocele of the tunica vaginalis 925 211. Vertical section of simple hydrocele 929 212. Double hydrocele of tunica vaginalis 930 213. Encysted hydrocele of the testis 931 214. Tapping a hydrocele 932 215. Hydrocele complicated by hernia 935 216. Encysted hydrocele of cord 939 217. Benign fungus of testis 944 218. Acute epididymitis 953 219. Strapping the testis 964 220. Gumma of testis surrounded by sclerosis 971 221. Disseminated tuberculosis of the body of the testis 974 222. Tuberculosis of the epididymis 975 223. Cancer of right testis " 978 224. Encephaloid of testis 979 225. Section of cancer of testis, showing fibrous stroma and alveoli filled with epithelial cells 980 226. Monocystic testis 981 227. Multicvstic degeneration of testis. . 982 228. Enormous pendulous scrotum from varicocele 987 229. Dissection of varicocele 988 230. Eeverdin needle for varicocele 994 231. Large varicocele, seven years after ablation of scrotum, showing recurrence. 996 232. Ablation of the scrotum with Horteloup's clamp 997 233. Henry's clamp for scrotal resection 998 PART I. GENEEAL PEINCIPLES OF GENITO-URIKARY, SEXUAL, AND VENEEEAL PATHOLOGY AND THEEAPEUTICS. CHAPTEE I. Genito-Urinaey and Sexual Hygiexe. As a preliminary to tlie special study of genito-urinary and sexual diseases, the consideration of certain basic principles bearing upon their pathology, symptomatology, and treatment is of the greatest importance. Success or failure in this department of medical and surgical science is often determined by the degTee of intelligence displayed by the surgeon in the comprehension and application of these principles. In a general way^ what will be said upon this topic applies to both sexes. Any qualifica- tion necessitated by certain anatomic and physiologic differences in the male and female sexual organs will not interfere with the clinical application of the various principles involved from a general stand-point. The first topic for consideration in natural order is the hygiene of the organs involved in the performance of the urinary and sexual functions. The most important point, especially in the male, is the state of the urinary secretion. Normal urine is more or less acid, the physiologic degree of acidity being difficult to determine. It varies greatly with the individual and under different conditions. Much depends upon the diet, the amount of physical exercise taken, and the state of the genito-urinary organs. Even normally- acid urine is more or less irritating to the mucous membrane in all acute inflammatory affections of the genito-urinary apparatus, irritation increas- ing pari passu with acidity. It is the correction of acidity, therefore, that chiefly demands attention. In every case of genito-urinary disease, in- volving irritation or inflammation of the mucous membrane, the first indi- cation is to neutralize acidity of the urine, even to make it slightly alkaline, if possible, by internal medication, regulation of diet, and attention to vicarious elimination of the products of retrograde tissue-metamorphosis. Neutral or faintly-alkaline urine is relatively bland, and much less irritating to the inflamed miTcous membrane than the normal secretion. A peculiar fact bearing upon the irritating properties of the urine in inflammations (1) 2 GEXITO-UEIXAEY AXD SEXUAL HYGIENE. of the geuito-urinary tract is that, even in certain clironic cases of cystitis in which the voided urine is strongly ammoniacal, alkaline remedies are beneficial. The acid urine, as it trickles down from the renal cortex, irri- tates the mucous membrane of the renal pelvis and ureter; the excessive secretion of mucus thereby induced enters the bladder and produces fer- mentation of the vesical urine, resulting in ammoniacal decomposition. Thus, the primary source of the irritation may be acid urine, though the fluid as voided from the bladder may be distinctly alkaline. Eemedies that lessen acidity are likely to allay the irritation and inflam- mation. There are various drugs that neutralize urinary acidity, the best of these being the citrate and acetate of potassium. These combinations of alkaline salts Avith vegetable acids are especially useful in surgical diseases of the genito-urinary organs. They should be given in large and frequent doses. They are usually given in doses that are much too small to be serv- iceable. Pure water is equal if not superior to any of the various drugs recom- mended as diuretics and urinary diluents. Various mineral waters — good, bad, and indifferent — are highly extolled for their action in urinary affec- tions, but, while many of them doubtless are valuable, they are all expensive and in no wise superior to distilled water taken in large quantity. When the element of faith in simple water is lacking, some natural mineral water with a high-sounding name is likely to inspire the patient with confidence. Under these circumstances he will probably be willing to take enough water to be beneficial. Certain of the manufactured mineral waters are valuable. Those containing lithia in considerable amount are among the best of these. ^ The urine is often excessively irritating because of its admixture with bacteria and their products. Bacteriuria, as will be seen in the chapter on urinary bacteriology, is a very important factor in genito-urinary pathology. Even in cases where irritation is obviously due to ammoniacal urine, bacterial evolution is the fons origo of the existing pathologic condition. It will be seen, therefore, that urinary antisepsis is a desideratum in such eases. Urinary antisepsis may be accomplished in two ways, viz.: by remedies administered per orem and by irrigations of the bladder with anti- septic solutions. The most efficient urinary antiseptics for internal adminis- tration-are, in the order of their efficiency, oil of eucalyptus, cystogen, boric acid, salol, and guaiacol. The best combination is, in the author's opinion, the oil of eucalj'ptus and salol, in 10-minim and lO-grain doses, respectively. This is best administered in capsule. There are no contra-indi cations for its use save possibly gastric sensitiveness. For local antisepsis, boric acid, carbolic acid, biborate of soda, creolin, and mercury bichlorid are the most reliable remedies. The principal ob- ^ The Garrod Spa, manufactured by the Enno Sander Company, is one of the best of the artificial lithia-waters. DIET IX GEXITO-UEIXAKY DISEASE. 3 stacle to the apiDlication of local measures is the extreme sensitiveness of the vesical neck and the mechanic disturbance necessarily attendant npon irri- gation, however it may be practiced. Another important consideration in reducing acidity of urine is atten- tion to diet. It is probable that few patients can subsist on a non-nitrog- enous diet for any length of time without causing a greater or less degree of alkalinity of urine. The value of a vegetable diet, therefore, is self- evident. It should be remembered, however, that certain vegetables are objec- tionable as imparting irritating priiiciples to the urine. Thus, rhubarb and tomatoes contain oxalic acid and are especially injurious iii inflammations of the urinary tract. Asparagus is also open to impeachment. Acid fruits, also, are generally to be interdicted. The ideal diet, although not entirely non-nitrogenous, is Ijread and milk. Milk is mildly alkaline in reaction, and if taken in large quantities, providing the patient abstains from meat, produces a neutral or faintly- alkaline urine. It also dilutes and adds to the watery constituents of the urine. The best practice in all inflammatory troubles of the genito-urinary tract is to confine the patient to a diet of which milk is the basis. The author has treated experimentally many cases of acute gonorrhea by an exclusive diet of bread and milk and the administration of the acetate of potassium. With no other remedies than these the inflammatory symptoms have promptly subsided. Such a j^lan of treatment is the only safe one in the majority of eases of sharply-acute urethritis in the early stages. Anti- septics and astringents, with or without balsams, will quite likely become necessary in a certain proportion of cases, after the acute symptoms have begun to subside, but, as a rule, it is not Avise to adopt treatment that is in the least degree stimulating for the first week or two after the beginning of urethritis. It is probable that if all patients with acute inflammation of the bladder or urethra were treated with a bread-and-milk diet, conjoined with rest and simple diluent remedies, they would almost invariably do well. The frequency of complications and sequels would certainly be reduced to a minimurn and their severity greatly diminished. Chronic cases some- times recover completely after suspension of all astringent and balsamic preparations, the patient subsisting for a few weeks entirely upon bread and milk. The question of tobacco and stimulants is of vital importance in the general management of genito-urinary and venereal diseases. In a large proportion of cases the patient's remissness in this respect is a serious obstacle to successful treatment. Both tobacco and liquor tend to produce an irritable condition of the nervous system as well as irritation of the mucous membranes. Alcohol, being eliminated largely by the kidneys, is especially irritating to the genito-urinary tract. It also has an especially exciting effect upon the sexual organs. 4 GEXITO-UEIXAEY AXD SEXUAL HYGIEXE. AA'ith reference to the action of tobacco, the author believes that it has a pronounced deleterious effect upon the genito-urinary tract. Patients with inflammatory affections of the urethra;, prostate, bladder, and kidneys certainly do better when they abstain from tobacco. In syphilis, as will be noted later, the evil effects of both tobacco and alcohol are not only familiar, but readily explicable. Certain varieties of alcoholic beverages are particularly open to im- peachment as regards their deleterious action upon the genito-urinary tract. Beer, champagne, and such wines as port and Burgundy are worse in this respect than a pure article of whisky or brandy, although the latter is bad enough. In general, it may be said that abstinence from alcohol and to- bacco is the key-note of success in the management of a large proportion of cases of genito-urinary disease. Tea and coffee are usually to be inter- dicted in acute affections of the genito-urinary tract. Another vital point is the condition of the skin and bowels. If these eliminative areas do not functionate properly, the kidneys must necessarily be called upon to act vicariously, the resultant increase in urinary solids making the urine much more irritating. A primary indication, therefore, is to increase the secretion of the skin, thus removing a certain amount of waste-material that would otherwise make the urine extremely acid. This is especially necessary with patients of a rheumatic or gouty diathesis, who usually eat and drink to excess. The skin and bowels may be stimulated by very simple remedies. The Turkish bath is useful in increasing sudoriparous secretion and elimination, and, in lieu of it, ordinary hot baths are quite efficient, while such simple laxatives as compound licorice powder or any of the saline laxative mineral waters are usually suflficient to keep the bowels active. In referring to the value of hot baths in the special class of morbid conditions coming within the province of this Avork. their use in the venereal diseases is worthy of special consideration. Frecjuent general hot baths in syphilis are an essential feature of its rational therapeutics. Hot sitz-baths are of great value in chancroid, bubo, gonorrhea, and all simple inflammatory affections of the genitals and their environs. It is very important to avoid chilling of the body, particularly the lower limbs, in all affections of the genito-urinary tract. Exposure is often responsible for aggravation of inflammation and the intercurrence of com- plications. An equable temperature of the skin is a sine qua non in the management of chronic genito-urinary affections in old men and in renal diseases at all ages and in both sexes. Chilling of the general surface is always dangerous in renal disease. Local chilling — as of the lumbar, hypo- gastric, and perineal regions — is especially to be avoided. The most important of all indications in the treatment of inflamma- tory troubles of the genito-urinary organs is the maintenance of perfect rest. Indeed, the neutralization of urinarv aciditv is reallv one element in BEST IN GEXITO-rEIXAEY DISEASE. -J promoting rest of the inflamed mucous membrane, Just as truly as avoidance of dust is an important factor in resting an inflamed eye. With the majority of persons suffering from such diseases, rest, in the strict sense of the term, is a difficult thing to secure. Patients do not, or will not, understand its importance. They expect to be cured while going about attending to busi- ness and social duties. In deference to professional routine, and a desire to retain the patient, the surgeon is usually compelled to treat his cases as best he may while the patient is on his feet and actively exercising when he really should be completely at rest, even to the extent of going to bed for a week or ten days. It is, of course, not alwaj^s absolutely necessary or practicable for him to lie in bed, but such a course is certainly indicated in the majority of cases. The snrgeon should at least instruct the patient to keep as quiet as possible and, so far as he can, to avoid walking and unnecessary muscnlar exercise during the existence of acute inflammation. Physical rest is obviously easier to secure in women with genito-urinary and sexual disorders than in men. In cases of inflammation of the prostate or bladder it is often absolutely necessary to order the patient to bed for a greater or less length of time. The author has seen cases of bpth acute and chronic prostatitis that had been treated in every conceivable Avay without benefit completely recover after two or three months in bed. One case in particular was that of a physician sufl^ering from a prostatitis of five or six months' standing. He had been treated by nearly all known methods at the hands of a number of competent physicians without apparent benefit. He was ordered to bed, with instructions to keep perfectly quiet. The treatment consisted entirely of alkaline reiuedies and counter-irritation of the perineum, with an ex- clusive diet of bread and milk. This course was persisted in for several months, resulting in complete recovery. Confinement to bed compels com- plete rest — something Avhich it is not practicable to accomplish in any other way. It must be remembered that a patient can hardly move — he certainly cannot take a step — without irritating the inflamed prostate and bladder. The prostate in cases of acute inflammation is sometimes the size of a small orange; under such circumstances the slightest motion of the thighs will cause mechanically more or less pain and irritation. Then, too, the erect posture tends to cause congestion and irritation of tbe inflamed organ, with resultant enhancement of inflaiumation. The necessity of physical rest is not all that must be impressed upon the patient's mind; an attempt should be made to secure sexual rest as well. This is, of necessity, diflficult of accomplishment. A patient with a broken leg is compelled to take rest, — indeed, he cannot move without being pun- ished for his indiscretion, — the injured limb being securely bound in splints, rendering movement of the affected part well-nigh impossible. A patient sufl^ering from pneumonia has his chest incased in hot poultices or the ice-pack, insuring rest for the inflamed lung. Even in genito-urinary dis- 6 GEXITO-URIXAEY AXD SEXUAL HYGIEXE. eases physical rest is comparatively easy to secure; the patient may often be kept in Ijed so long as the physician deems necessary. Unfortunately, hoAvever, it is not so easy to keep the patient's thoughts diverted from his sexual organs, which, unlike a fractured leg or inflamed lung, may he irri- tated hy psychic stimuli. Many morbid conditions of the sexual apparatus are due to reflex sexual irritation through psychic impressions. Very often the patient reads a great deal of literature of a more or less erotic nature, or allows his mind to dwell upon sexual affairs: and as a consequence the sexual organs are never at rest. It is probable, moreover, that every conti- nent man suffers more or less from sexual starvation. The male sex is not alone in respect to sexual craving; women some- times suffer from the same difficulty. Quite recently a young woman con- sulted the author for this trouble. She stated that she was annoyed con- tinually by sexual excitement. She was undoubtedly virtuous, intelligent, well educated and refined, and suspicious of the existence of some obscure uterine trouble that might account for her ailment. She was averse to examination, but Avas probably suff'ering from some inflammatory affection of the uterus or ovaries, causiu'ii' reflex excitement: i.e., sexual hyperesthesia. She stated that she was greatly annoyed by peculiar, quivering sensations about the uterus attended In* emissions of fluid of some kind occurring daily. As is well known, women do not have true emission during inter- course, the seeming emission feeing an excessive secretion of the mucus that normally lubricates the genital tract. This mucus constituted the so-called "emissions" in this instance. Such cases demonstrate that sexual starvation is met with in both sexes, though Avomen are not so likely as men to under- stand the situation. A great many females thus affected realize that they are ailing, but, being essentially jnire-minded. do not ascribe their troubles to the real source — sexual starvation. Hysteria, melancholia, hypochondria, and other nervous conditions in women may result reflexly from irritation of the sexual apparatus. Irritation of the uterus and ovaries may be due to that instinctive jiliysiologic craving with which every normal womafi, however pure, is endowed. The use of the term '"sexual starvation" may be criticised adversely: so it might be well to call attention to the fact that sexual affinity itself has been asserted by biologists to be a refinement of hunger, which is the real foundation of sexual desire. Hysteria, melancholia, and hyjiochondria in the male are more often met with as a consequence of irritation of the sexual organs, and especially the prostate, than is generally recognized. Ungratified sexual desire is quite often responsible for such nervous affections in men. The necessity for a proper performance of the sexual function may not be recognized l)y the individual most concerned, yet it exists in every adult human being who is nnrnially constituted. Xo man or woman at adult age is in perfect physiologic condition until the sexual function is naturally EEGULATIOX OF THE SEXUAL FU^X'TIOX. 7 and regularly iDerformed. It is not merely the sexual act, the orgasm and discharge of semen in the male, or the orgasm and reception of semen in the female, that is essential to the relief of sexual starvation, but there should rightfully be a physiologic purpose in the performance of the procreative function. This is not usually accomplished save in the matrimonial state. The sexual appetite of the average man diminishes after a variable period of normal, regular gratification, and lie no longer gives himself special con- cern regarding his sexual function; in fact, he concerns himself no more than he does about the function of his bowels or bladder. He lives con- tentedh', as regards his sexual organs, and fulfills his matrimonial obliga- tions in a quite perfunctory fashion. . Modern society, unfortunately, imposes conditions that make sexual excitement without gratification very common. The methods of dancing at present in vogue are responsible for this to a certain degree. The inti- mate contact of the sexes that dancing permits, associated with the emo- tional effect of music, cannot fail to produce more or less erotism in certain susceptible individuals. Pure-mindedness is not always a safe-guard, for physiologic law is likely to be more potent than psychic purity. Sexual stimulation and erotic excitement by no means necessarily require sexual thought as their basis. The most unfortunate feature of it all is that society offers less induce- ment to matrimony than formerly. The average young man of to-day Justly considers matrimony a too expensive luxury. In the case of women the matrimonial problem is still more difficult. They are debarred by social custom from taking the initiative. Taken all in all. intelligent physicians and sociologists alike are united in the belief that the existing conventional extramatrimonial relations of the sexes are not physiologic, however moral they may be. Literature of a romantic and erotic character is often even Avorse than dancing sometimes is in its pernicious effects upon the sexual system. Especially is this true of individuals at about the age of puberty. There are ways and means to prevent, or at least limit, the injurious effects caused by sexual stimulation without gratification; fornication, how- ever, is not one of them. The fear of evil consequences alone makes such a course decidedly unphysiologic. Masturbation only serves to make matters physically worse, irrespective of its demoralizing effects. The best moral educator for young men is, in the author's opinion, the gymnasium. The resultant physical improvement might seem likely to in- crease sexual activity. Such is not the case, however. The most vigorous individual is not always the most amorous. The man who studies very hard, or is engaged in an intellectual occupation that fosters an excitable state of the nervous system and exaggerates nervous sensibility and emotionalism, is likely to be more intemperate in his sexual relations than the hard-work- ing laborer. It will be noticed, however, that the laboring man is generally 8 GENITO-UEIXARY AND SEXUAL HYGIEXE. the one who has the most children. The individual who most frequently seeks sexual gratification is not usually distinguished by either the number or good health of his progeny. He who is most temperate sexually is usually best fitted for procreation, because, from a sexual point of view, most ener- getic. Frequent intercourse causes decided deterioration in the quantity and fructifying quality of the semen. This is well known to stock-breeders. It is a cardinal rule that overexcitement of any function will cause loss of power. It is quite generally known that the males of the Orient become impotent earlier than other men because of excessive indulgence of their sensual appetites, conjoined with a life of indolence and ease. The youth who indulges in sexual intercourse most frequently is the one who will be most likely to become impotent or sterile at middle age. This holds true with all peoples the world over. The surgeon is very often consulted by men approaching middle age who complain that they cannot indulge their sexual appetite as frequently as formerly, and ask for remedies where- with to whip up the jaded function. To such patients he should say: "You are paying for your early excesses, and cannot expect to perform the sexual act so often as you did when but eighteen or twenty 3^ears old. The magazine is almost exhausted." This answer may not satisfy the pa- tient, perhajDS, but it is certainly conscientious. A great many patients complain of real or imaginary sexual exhaustion, spermatorrhea, or prema- ture old age, and if the surgeon does not understand the physiologic con- ditions involved, he certainly cannot manage such cases satisfactorily. As already stated, we may alleviate sexual irritability and excessive desire through the physical system, by giving the patient some occupation that will necessitate muscular exercise, diverting his superfluous nervous energy in the direction of his muscles. He may also be benefited through the medium of the mind. He should be kept occupied with something that will serve to divert his thoughts from the sexual organs. Literature of an erotic or prurient nature and female society of a doubtful character should be forbidden. Good literature and the society of refined women are, how- ever, a sine qua non. In many instances sedative and anaphrodisiac remedies are of great service. If marriage be practicable and the patient has no organic disease, it is well to advise it, irrespective of the patient's confidence in his ability to perform the matrimonial act. Impotency in the average young man is a myth. He is generally capable of exhibiting as much sexual prowess as will ever be required of him legitimately. As a rule, to which there are few exceptions, marriage is permissible providing the sexual organs are normally developed and objectively sound and the patient is otherwise healthy. Caution should be exercised in advising matrimony, however. It is quite the fashion for physicians to prescribe matrimony for the cure of pathologic conditions in the male, with a total disregard for the interests of the female party to the prescrip- MAKKIAGE AS A EEMEDY. \) tion. The custom of prescribing virgins for Avorn-out roues and men suifer- ing from physical ills, infectious or otherwise — conditions for which the patient is himself alone responsible — is more popular than it should be. Pure women should not be considered as remedial agents to be prescribed solely with regard to the interests of the consumer — of which more anon. With reference to the results of matrimony under proper conditions, it is safe to say that the average sufferer from more or less imaginary sexual woes is not likely to have any cause for complaint after marriage, so far as his sexual function is concerned. CHAPTER II. UrIXALYSIS IX ITS SUEGICAL PiELATIOXS. The various standard treatises upon genito-urinarv diseases devote but little attention to the special characters of the urine in the various dis- eases coming under the observation of the surgeon. Such attention as is given to urinalysis from a surgical stand-point is merely incidental to the description of the diseases of the genito-urinary tract, and is very meagre. This seems somewhat strange, too, in view of the important information that may often be obtained from a careful study of the urine in different surgical diseases, parti ctdarly those involving the genito-urinary organs. It seems fitting, therefore, in a work of this kind, that a chapter should be devoted to the special consideration of urinalysis in its surgical relations. The technic of urinary chemistry and microscopy is, of course, beyond the province of this work. Maceoscopic Study of the Ueixe. — It is desirable for the surgeon to so familiarize himself with the gross physical characters of the urine voided in different diseases that he can form a fairly accurate estimate of the condition of the genito-urinary organs without an exhaustive chemic and microscopic examination. To pursue accurate investigations in the minidice of urinah'sis, considerable technic knowledge of analytic chemistry and of the science of microscopy is necessary; but, for the application of pathologico-chemic facts and the main features of urinary microscopy to the diagnosis of genito-urinary diseases, a moderate degree of familiarity with microscopic and chemic technic is amply sufficient. Todd has wisely said that, '•'Although it is clearly a duty not to neglect any means of observation and investigation, it is desirable that we should be as little as possible dependent upon means that are not always at hand, and which it does not fall to the lot of every eye and hand to use with equal readiness and skill." The greatest of modern pathologists. Professor Yirchow, has expressed himself in a somewhat similar manner as regards what he has aptly termed "naked-eye pathology." The experience of most practical pathologists is corroborative of the assertion of this eminent authority that microscopic characters may often be anticipated by a con- scientious and expert macroscopic examination. It is not the author's intention to take up the subject of urinalysis in detail, nor, indeed, in general, excepting in so far as it applies more or less directly to surgical diseases. Quantity of Urine.- — The quantity of urine varies greatly even in health, the amount excreted being dependent upon a number of circumstances. The urine varies considerablv in amount with the season of the vear, being (10) PEOPORTIOX OF UEIXAEY SOLIDS. 11 most abimdant during the winter months. This variation is due to the decreased activity of the skin in cold weather. The weather also modifies the chemic properties of the urine; thus, in summer the raprd and profuse excretion of fluid by the skin not only diminishes the amount excreted by the kidneys, but, 2^<^^"'' passu with this diminution in quantity, we note, under normal circumstances, an increase in the proportionate amount of excreted solids. The cj[uantity of urine is obviously modified by the character of the food and drink. A^egetable diet, which contains a large proportion of fluid in its composition, produces a larger excretion of urine than does purely animal food. The amount of fluid ingested necessarily modifies the quantity of urine more than any other circumstance. Tlie condition of the bowels is also of great imjjortance. A patient with diarrhea is likely to excrete urine in scanty amount. This is well illustrated in Asiatic cholera, in which complete suppression of urine eventually occurs, being explicable, at least in part, by the rapid removal of fluid from the blood by the bowel-evacua- tions. The condition of the kidneys modifies the quantity of urine as well as its proportion of solids. Much depends upon the condition of the nervous system, vasomotor disturbances being productive of an increase or decrease, as the case may be, in the amount of excreted urine. Thus, we have a con- dition of hydruria, or excessive amount of watery secretion from the kidneys, in cases of diabetes insipidus, in which the daily urinary flow may amount to from 7000 to 10.000 cubic centimeters, the specific gravity being very often as low as 1002. Persons of highly nervous or hysteric temperament are not infrequently affected by this condition. It is a not uncommon experience for those who are subjected to mental strain or anxiety, or to the emotions of anger or fright, to have an enormous increase in the quantity of urine. Students undergoing the ordeal of examination are quite apt to be affected by hydruria. The term hydruria is properly applied only to that form of excessive urinary secretion in which there is a marked increase of fluid with a co-existent diminution of solids. When the increase of water is attended with an increase in the amount of urinary solids from exagger- ated tissue-metabolism, the condition is properly termed polyuria. Proportion of Urinary Solids. — The proportion of solids contained in the urinary fluid is modified by the same influences as those affecting the quantity of the excreted fluid, and is a vital point in the study of genito- urinary diseases. A very simple method of determining approximately the amount of solids in the urine is given by Flint. The specific gravity of the urine is to be taken, and between 1010 and 1030 it will be found that the last two figures of the specific gravity represent tolerably accurately the number of grains of solids excreted in each ounce of the fiuid. By ascertaining the total number of ounces excreted in the twenty-four hours we can readily 12 TKIXALYSIS IN ITS SURGICAL EELATIOXS. determine;, with sufficient accuracy for most practical purposes, the total amount of solids excreted. This is important as showing whether the kid- neys are performing their functions sufficiently well to obviate the danger of uremia in certain diseases/ In making this estimate of the quantity of solids excreted it is necessary to take into consideration the quantity and quality of the food and drink. The determination of the amount of solids excreted during the twenty-four hours may be a ver}^ important considera- tion in connection with operations upon the genito-urinary organs. Indeed, it may influence us either to avoid or ^Derform an o^Deration in cases in which the amount of albumin is of negative importance. Diet and exercise modify the amount of solids very markedly. Thus, a diet of highl3'-nitrogenized food increases the amount of solids, and par- ticularly urea, to a marked degree, causing a condition described by Fuller as haruria, with a large increase in the total amount of urinary solids. Urine of this character is very concentrated, and urates are usually deposited. This condition of the urine characterizes the systemic condition termed by Murchison Utliemia. This state of the blood bears an intimate relation to urinar}^ calculus, and various irritative and inflammatory affections of the genito-urinary tract. The late Andrew Clark described a condition known as renal inadequacy, in which there is a notable deficiency in the amount of urea excreted, without marked or constant change in the amount of fluid passed. He failed to show, however, whether this condition depends upon insufficient renal action or upon deficient tissue-metabolism. Either condition may be effective in its causation, and it is safe to assume the possi- bility of a combination of both. The quantity of urine and the proportion of fluid and solid ingredients are two of the most important points to be considered in connection with the various surgical affections of the genito- urinary tract. If perfectl}' familiar with the conditions that modify the composition and amomit of the urine, the surgeon will have a distinct advantage in the management of these diseases. Thus, in diseases of a cal- culous or inflammatory character it is obviously desirable to increase so far as possible the proportion of urinary fluid, and decrease the amount of solids, without interfering with the elimination by the system of those substances usually taken care of by the kidneys. This may be accomplished by diet, rest or modification of exercise, hot baths, the administration of large quan- tities of fluid, and various diuretic remedies. Another important consideration is the condition of the digestive ap- paratus, for if the functions of the stomach and liver be impaired there will be present in the urine more or less crude products of tissue-metabolism. Thus, instead of a comjDlete metamorphosis of proteids the termination of which should be the production of urea, there is likely to occur, as a result ^ The term "uremia"' is used conventionally. It is beginning to be known that urea is a trivial factor in urinary toxemia. It is something of a '"bugaboo." SPECIFIC GKAVITY, COLOK, AND ODOE OF THE URIXE. 13 of imperfect preparation of the food by the digestive apparatus, a cessation of the process midway, with resulting formation of uric or lithic acid. This is one of the establislied causes of lithemia. The degree to which imperfect oxidation may contribute to this state of affairs is a matter of controversy. It is to be remembered in this connection, however, — and seemingly many writers upon the subject fail to appreciate this fact, — that excessive quan- tity and imperfect preparation for assimilation of certain food-elements are not the only circumstances upon which lithemia depends, for there may be a normal proportion and perfect preparation of proteids by the digestive apparatus which fails of its object because of defective tissue-metabolism. Behind this defective chemism lie nervous perturbations as yet undefined, modifying the nervous influences that preside over tissue-nutrition and the various glandular functions. It is necessary, therefore, in considering the ways and means of lessen- ing the irritating properties of the urine, to take into consideration the amount and quality of the food, the activity of those physiochemic changes the function of which is the final disposition of the nutrient pabulum, and the condition of the nervous system. This question is of more importance to the surgeon than is evident upon superficial observation, as will be seen in connection with the subject of urinary calculi. Specific Gravity, Color, and Odor of the Urine. — These qualities are in- terdependent and vary considerably, being dependent upon the same cir- cumstances as those affecting the quantity of the fluid and its proportion of solids. Urine containing a large proportion of solids has a high color, as a rule, with high specific gravity. The urine of hydruria is pale and limpid, and of low specific gravity. This is seen in some cases of surgical and granu- lar kidney. The urine of lithemic or gouty subjects is of high color and high specific gravity. Urine of low specific gravity has comparatively little odor. Xormal urine has a peculiar aromatic smell that grows strong and pungent pari passu with an increase in its proportion of solids. Various diseases and the ingestion of certain drugs modify the properties of the urine just de- scribed. Blood and pus modify the odor to a certain extent, and necessarily modify the color in proportion to the amount of these substances present. Carbolic acid, the preparations of iodin, santonin, and methyl-blue, taken internally, modify the color of the urine. Certain articles of diet also modify it. Asparagus gives a peculiarly-offensive odor and dark color to the urine. Diuretics of various kinds increase the proportion of water and consequently lessen the pungency of the urine and cause it to become paler. In a general way, the urine may be said to be irritating in proportion to its height of color and degree of pungency. In a large number of observations upon subjects for life-insurance examinations the author has noted that the recent ingestion of malt liquor causes a marked diminution in the specific gravity and an increase in quan- tity of the urine greater than could possibly result from the mere addition 14 UEIXALYSIS IX ITS SURGICAL RELATIONS. of an extra amount of fluid. So closely associated are the recent ingestion of malt liquor and an abnormally low specific gravity of the urine that, when the fluid has a specific gravity of less than 1015 (and 1010 is fre- quent), the author immediately suspects that the applicant has recently been drinking beer. In the majority of instances this suspicion is verified upon inquiry. There is an apparent inconsistency in this observation. Malt liquor is especially irritating to the genito-urinary tract. The rapid passage of the fluid elements of the beer through the blood and kidneys is associated with an injurious stimulation incidental to the alcohol it con- tains. Later on, the excessive nutriment contained in the beer, especially the proteids, interferes Avith tissue-metabolism and makes the urine heavy. Beer also deranges the function of the liver, which adds to the sum-total of urinary perturbation by disturbing assimilation. Copaiba, cubebs, sandal- wood, and turpentine — drugs that bear an important relation to genito- urinary surgery — markedly modify the odor of the urine. Xormal urine has an odor, sui generis, that has been described as aromatic. L'rine con- taining a volatile alkali from decomposition emits a strong ammoniacal odor. AVhen it contains a fixed alkali, however, the odor is faint and dis- agreeable, something like the urine of the herbivora. Urine containing phosphates, especially of lime, speedily decomposes and has a very offen- sive odor. Eeadion of the Urine. — The reaction of normal urine varies consider- ably at dilferent periods of the day. Tlie urine of fasting is generally quite acid, becoming neutral or perhaps faintly alkaline a short time after the ingestion of food. Bence Jones explains this diminution in the acidity of the urine by the abstraction of acid from the circulation for the supply of the gastric juice. Eoberts, however, is inclined to regard the cbange from acid to alkaline as due to the introduction of alkaline bases from the freshly- digested food into the blood. The reaction of the urine is markedly modi- fied by the quality and quantity of the food, by exercise, and by various diseases of the genito-urinary tract. Excessive ingestion of proteids greatly increases its acidity; a vegetable diet makes it alkaline. Chronic inflam- matory diseases of the urinary organs usually produce alkalinity of the urine. Thus, in chronic prostatic and vesical disease the reaction may be strongly alkaline, with a decided odor of ammonia. Strongly-acid urine deposits urates upon cooling, while alkaline urine deposits phosphates. It is sometimes desirable to differentiate the alkalinity due to volatile alkali dependent on ammoniacal decomposition from that due to a fixed alkali (potassium or sodium). This is readily done by observing the behavior of red litmus-paper that has been dipped in the urine and allowed to dry. The blue color produced by ammoniacal urine disappears as the paper dries, while in the case of the fixed alkali it persists. Transparency of the Urine. — The clearness of the urine is an important consideration. Urine, though dark, may be perfectly clear, while light TEANSPAKENCY OF THE L'EI^'E. 15 urine, on the other hand, may be perfectly opaque, according to the amount of extraneous matter or urinary deposits present. Opaque urine may be very light or very dark. When of a light color it contains either earthy phosphates, mucus, or pus, singly or combined. Mucus is more apt to form a distinct cloud in the urine than pus, which, from its higher specific gravity, sinks to the bottom of the vessel. This, however, depends some- what upon the character and origin of the pus. For example: in pyelitis the pus is powdery and easily diffused throughout the fluid, while in cystitis or abscess emptying into the bladder it forms a more distinct layer. Puru- lent urine may, however, be completely opaque, with a distinct, thick, yel- lowish layer of corpuscles at the bottom. When urine is turbid from either mucus, pus, or salts, it should be filtered before a critical examination is made. When the urine is dark and opaque it may contain blood or bile. Carbolic-acid, chlorate-of-potassium, or creasote poisoning makes the urine very dark and o|)aque. Chlorate of potassium in poisonous doses imparts in some instances an almost black color to the urine, due to hemoglobinuria. Any drug that is capable of producing renal irritation and inflammation may produce hemoglobinuria or hematuria. Certain diathetic states, such as scurvy, have a similar effect. Santonin has a most peculiar effect on the urine. A single dose usually imparts a bright-yellow color, lasting several days. If the urine is alkaline, the color is blood-red. The addition of ammonia also turns the urine red, where santonin has been taken. x\sso- ciated with the peculiar coloration of the urine, santonin also causes marked vesical irritation. Santonin in its passage through the circulation is eon- verted into xanthopsin — this produces the change in the color of the urine. Turbidity of the urine often indicates disease of the genito-urinary tract where no subjective symptoms of disease exist. Attention has been called to the relation of bacteria of various forms to more or less marked turbidity of the urine. Bacteria of various forms may be found in the urine in cases in which there are no definite symp- toms of organic disease. The micrococcus ureae, vibrios, rod-like bacteria, and spirilla are apt to be met with.^ As many as six different varieties of bacteria have been found in a single specimen within three hours after micturition. Urine that is turbid when voided, and is not cleared on fil- tration, generally contains bacteria. Independently of bacteria, turbidity of the urine is apt to indicate an unhealthy state of the mucous membrane, that may be the result of old organic disease or of present slight disturbance which may later on become sufficiently marked to attract attention and require treatment. Bacteria may be implanted upon the vesical mucosa by septic catheterization, pro- ducing a mild degree of irritation with resultant formation of mucus, ^ Very active motile bacteria may be present in the urine, which, clinically at least, have no especial pathologic significance. 16 UKIK'ALYSIS I^^ ITS SUEGICAL EELATIOXS. which condition is capable, under favorable circumstances, of progressing to true chronic inflammation. In making observations upon the lines above indicated, great care is necessary to maintain perfect cleanliness in our manipulations of the urine. When the subject of bacteriuria was in its infancy, the author had an experience bearing upon this point that was very instructive as showing how rapidly the urine could become turbid after evacuation. In making life-insurance examinations the applicant was requested to void urine into a large-mouthed bottle, from which a sample was taken for examination. This bottle was thoroughly rinsed with cold water — which under the cir- cumstances was considered sufficient for cleansing — before and after use on each occasion. It had been observed for some time that in quite a pro- portion of instances the urine was not perfectly clear when inspected shortly after it was voided, and upon microscopic examination of a few of the specimens they were found to be swarming with bacteria. It was noticed that when the urine was examined immediately after its discharge it was clear and did not contain bacteria. The explanation was finally found to be a slight accumulation of urinary sediment upon the sides and bottom of the bottle that rinsing with cold water had been insufficient to remove. In this sediment bacteria had thrived and waxed fat, and when healthy urine was voided into the bottle they soon began to multiply very rapidly. Frequent scalding of the vessel after the discovery of this fact obviated further difficulty, as can be readily understood in the light of our more recent knowledge of the subject. Foam upon the Urine. — Persistent foam upon the urine — i.e., foam remaining upon its surface for half an hour or more — is an indication, as a rule, of either albumin or bile, or both. Mucus in considerable amount is also productive of persistent foam. This suggests in a general way a catarrhal state of the mucous membrane of the urethra, bladder, or pelvis of the kidney, or structural renal disease, and is a point well worth remembering. Gross Characters of Urinary Sediments. — It is very useful to be able to form a general estimate of the character of urinary deposits from their macroscopic appearance. Sediments occur in the urine very frequently, and may be deposited before its evacuation from the bladder. This is often the case in certain forms of kidney and vesical disease. On the other hand, deposits may appear only after the fluid has stood for a variable time. The various substances constituting urinary sediments may be insoluble in the urine primarily, or they may be soluble only in the warm fluid, rapidly precipitating when it becomes cool. Still other sediments result from chemic changes occurring with greater or less rapidity after the evacuation of the fluid. A deposit of a fawn color and of more or less powdery consistence, unless mixed with mucus, appearing in the cold urine, but dissolving when URINARY SEDIMENTS. 17 heated, consists of urates of sodinm or ammoniiim, or both. Cystin is an- other, but much rarer, deposit of a similar color, not dissolved by heat, and only slowly acted upon by alkalies. A heavy, red, sandy deposit at the bottom of the vessel is composed of uric acid. This is dissolved both by nitric acid and alkalies. Blood-corpuscles may form a reddish deposit at the bottom of the fluid, the peculiar color giving some idea of the char- acter of the deposit. A whitish deposit not soluble in the heated urine, and often deposited by heating previously clear urine, is composed of the earthy salts — triple phosphates, phosphate of lime, and oxalate of lime. The oxalate of lime and phosphates are difiEerentiated by adding acetic acid, the latter deposit clearing up, while the former does not. A creamy-white, ropy, or flocculent sediment is probably mucus; a yellow deposit forming a sort of jelly with liquor potassse is usually composed of pus or muco-pus. Long, whitish strings or filaments — tripper-fdden — often occur as a con- sequence of stricture or chronic urethritis. The various urinary deposits require special consideration. Fig. 1. — Ammonium-urate crystals. Ur^ea is one of the most important substances for our consideration in connection with the excreted solids of the urine. It does not occur alone in the form of deposits because of its extreme solubility. The quantity of urea excreted during twenty-four hours is the best criterion of the excretory activity of the kidneys, and is important in its relations to both medicine and surgery. If in any particular case the amount of urea excreted has been determined, the surgeon is in a position to decide whether the patient is in danger of so-called uremia or not. This question demands most care- ful consideration in connection with operations upon and diseases of the genito-urinary tract. ^ Urea represents the ultimate product of tissue-metabolism, its amount ^ It is to be remembered, however, that, although urea is a very imjiortant lu'inary solid, it normally represents chiefly muscle-waste, and its amount is not necessarily regulated by the condition of the kidneys. When produced in small amount its excretion is likewise small. 18 UEIXALYSIS IN ITS SUEGICAL KELATIOXS. depending (1) upon the amount of proteids ingested, (2) upon the actiyity of physiochemic transformation of proteids after digestion and absorption, (3) upon the actual amount of waste of the fixed tissues, and (4) upon the degree of functional activity of the kidneys. In all diseases in which fever is a symptom the excretion of urea is increased. Diseases of the liver modify the amount of urea, inasmuch as it is the organ in which the physiochemic changes resulting in the forma- tion of urea are most energetic. In hepatic abscess, and in cancer of the liver, a notable diminution of urea is observable. The various forms of surgical disease of the kidney itself generally cause a diminution in the excretion of urea. For ordinary purposes it is not necessary to resort to the intricacies of quantitative urinalysis to determine with sufficient accuracy for practical purposes the amount of excreted urea. If the total quantity of urine be normal or nearly so, and the specific gravity of the urine is not appreciably lowered, it may be inferred, if sugar is not present, that a sufficient amount of urea is being excreted to fulfill the needs of the economy. If the specific gravity is low, but there is a compensating increase in the total amount of excreted urea, we are also justified in believing that there is no imminent danger of toxemia. Due consideration must, hoAvever, be given to the amount of fluid ingested, and the amount and quality of the food. Uric acid was formerly thought to be the characteristic element in the composition of urinary calculi; hence it was called lithic acid. Since its discovery, more than one hundred years ago, it has been shown to bear an important relation to gout, and incidentally it has been demonstrated that a gouty or lithic condition of the blood is the foundation of many cases of urinary calculi. Garrod in particular has dwelt upon the association of uricemia and gout, and has shown that an excess of uric acid is present in the blood during an attack of that disease. Uric acid has been described as a midproduct of tissue-metabolism. It is the result of imperfect oxidation of those nitrogenized elements of the food which should be converted, on the one hand, into substances ready for assimilation by the tissues, and, on the other, into urea. Uric acid bears an important relation to the surgical affections of the genito- urinary tract, the severity of all inflammatory affections being to a certain extent dependent upon its amount, not only in the urine, but in the blood — not that the acidity of the urine is dependent upon uric acid, but because urine containing an excess of this substance is heavy and irritating by virtue of the mechanic effects of the uric-acid crystals themselves. The intimate association of uric acid and the urates with urinary calculus is familiar to every practical physician and surgeon. The close association of uricemia with gout is well illustrated by the fact that the so-called gouty deposits, or tophi, which occur in the joints, the cartilages of the ear, and in the tubuli recti of the kidney are com- UEINAEY SEDIMENTS. 19 posed of sodium urate. Uric acid requires for its solution about 15,000 parts of water, in this respect differing markedly from urea, which is very- soluble. Thus, when the urine is very concentrated, and the amount of water much below the normal standard, the deposition of uric acid is likely to occur. Uric acid and the urates may vary in quantity by modifications of diet. Uric acid, when deposited in the urine in a free state, resembles brick-dust or red pepper. Oxalic acid in the urine in the form of calcium oxalate — oxaluria — has given rise to considerable controversy regarding its origin. It has been generally held that oxalate of calcium as a urinary deposit is a derivative of the decomposition of uric acid after its formation, thus implying that the crystals of oxalate of lime signify only an excess of uric acid. It has been assumed by those who accept this view that oxalic acid {i.e., oxalate of lime) bears the same relation to uric acid that uric acid does to urea. This hypothesis implies that the process of oxidization if stopped at a cer- tain point produces oxalic acid; a little further on, uric acid; and, when Fig. 2. — Uric-acid crystals. perfected, urea.- Per contra, in order to obtain oxalic acid from uric acid it is necessary to oxidize it more completely. The determination of the precise conditions producing oxalic acid in the tissues is necessarily a very difficult matter. In spite of all the theories that have been advanced, it can only be said that an excess of oxalic acid in the blood — oxalemia — and of calcium oxalate in the urine result from certain undetermined per- versions and modifications of tissue-metabolism. A &mall quantity of oxalic acid is present normally in the blood, and is discoverable in the form of calcium oxalate in the urine as a consequence of numerous circumstances. Thus, its presence may be due to: 1. Inges- tion of an excessive quantity of food-substances containing calcium oxalate, — e.g., certain vegetable matters, such as rhubarb, tomatoes, turnips, and onions, rhubarb containing a large quantity of this substance. 2. Imper- fect oxidation of starchy and fatty food-materials, which before their final transformation into HoO and CO, pass through transformations in which they present themselves as organic acids: i.e., oxalic, lactic, butyric, and glycocholic acid. 3. Increase in the physiochemic activity of the 20 t'EIXALYSIS IX ITS SUEGICAL EELATIOXS. tissues. This involves the question of exercise and hypermetabolism of tissue cliie to certain nervous influences. 4. It has been asserted that oxalate of lime may be derived from the mucus of the genito-urinary mucosa. The only way that this could occur would be through urinary decomposi- tion excited by the mucus. This theory of the origin of oxalic acid, although advanced by an excellent authority (Meckel), is evidently purely theoretic. 5. An excess of acids in the blood and tissues as a result of buty- ric and lactic fermentation in the alimentary canal. These substances being absorbed, are not completely oxidized or transformed into C0„, and, as a consequence, the midiDrodiict, oxalic acid, is formed. The presence of oxalic acid has been claimed by certain observers to hear a certain relation to diabetes. Thus, Cantani asserts that he has noticed an alternation of calcium oxalate and sugar in the urine. Fiir- bringer discovered oxalic acid in the sputum of a patient suffering from diabetes mellitus. The excretion of oxalic acid in the urine has received considerable at- tention. When present in excess it has been supposed to signify perturba- Jk0.^O Fig. 3. — Calcium-oxalate crystals. tion of tissue-waste, and has been described as a distinct disease — oxaluria. While the presence of the crystals of oxalate of lime in the urine may unquestionably produce irritation of the mucous membrane of the genito- urinary tract, with frequent micturition and pain in the back, the author believes that the importance of the substance has been greatly overesti- mated. It is hardly fair to ascribe a severe pain in the back, accompanied by an excess of calcium oxalate in the urine, to irritation produced by the crystals in all cases, for the relation of cause and effect is difficult to demonstrate. Such diagnoses are apt to lead to a confusion of propter and post: in other words, the pain and oxaluria may both be dependent upon actual renal disturbance or upon nervous derangement. Calcium oxalate is associated with one form of urinary calculus (the mulberry) which is composed almost or quite entirely of that substance. Pronounced oxaluria is usually associated with digestive disturbance and nervous depression. Phosphoric acid in the form of the phosphates is a frequent and im- portant urinary deposit. Triple phosphates — ammonio-magnesian phos- GLYCOSUEIA AS A SYMPTOM OF GENITO-UKIXARY DISEASE. 21 phates — are most frequent^, and calcium phosphate the rarest form. The normal acidity of the urine is dependent upon the biphosphate, or acid phosphate, of soda. Phosphates are not deposited so long as the urine remains acid, but immediately it becomes alkaline a deposit occurs, whether the phosphoric acid in the urine be in excess or not. The principal surgical importance of the phosphates is their relation to urinary calculus, hyper- trophy of the prostate, chronic cystitis, and pyelitis. Whenever the urine decomposes as a consequence of an excess of mucus or from prolonged retention, a deposit of phosphates occurs. If a foreign body be present, this deposition of phosphates occurs about it, and eventually solidifies, forming a calculus about the nucleus; thus, it may form about a small quantity of uric acid or calcium oxalate that has come down from the kidney, a clot of mucus, or a foreign body introduced into the bladder from without. The addition of an acid to phosphatic urine clears it up immediately. Xaniliic oxid, or i-anthin, presents itself in the urine as a very rare Fig. 4. — Triple-phosphate crystals. form of urinary calculus. Cases have been reported by Langenbeck and Bence Jones. Such cases have been seen in young subjects.^ Glycosuria as a Symptom of Genito-Ueixaey Disease. — In an article published some time since the author called attention to glycosuria as an occasional result of the reflex irritation incidental to surgical diseases of the genito-urinary tract, especially phimosis and stricture.- The follow- ing cases are illustrative of this exceedingly interesting and important point: Case 1. — E. B., male, aged 7 years, had been afflicted with glycosuria — which had been diagnosed as diabetes mellitus — for some seven months. During this time ^ It is probable that xanthin and its derivatives bear a more important relation to urinary toxemia than is generally supposed— more important, perhaps, than urea. The coloring matter of the urine and the potassium salts are also important factors in urinary toxemia. ^ Western Medical Review, October, 1897. 23 UEINALYSIS IN ITS SUEGICAL EELATIONS. the child had been under the care of several exceptionally-competent medical men, and had seemed at times to be improving under treatment. The sugar in the urine had, however, at no time wholly disappeared, and at the time the author was con- sulted the glycosuria was more marked than it had been for several months — this in spite of careful treatment and an antidiabetic diet. There were practically no suggestions to offer regarding the medical treatment of the case, and the child's parents were so infornied. Some improvement, however^ resulted under the con- tinuance of the treatment to which the case had already been subjected, but the glycosuria not only did not disappear, but relapsed from time to time after apparently marked improvement. The possible etiologic relation of genital irritation to the glycosuria was not at first suspected. The father of the patient, however, finally called attention to the fact that the child appeared to be troubled with irritation about the penis. Examination showed an adherent prepuce and balanitis. Circumcision was soon followed by improvement in the condition of the urine, and within two months the glycosuria had completely disappeared and the patient was entirely well, there being no recurrence of the diabetic symptoms during the year that the child was subse- quently under observation. Case 2. — A second very similar case came under the author's care some months later. A boy, 15 years of age, had manifested diabetic symptoms for about three months. Bulimia and thirst were especially marked, and the quantity of urine greatly increased. With the case previously recorded in mind, possible sources of reflex genital iri'itation were at once looked for. A stenosed and adherent prepuce and a greatly- contracted meatus were found. These conditions were corrected and the patient put upon arsenite of bromin and the regulation diet. The ease rapidly improved, and four months later the last trace of sugar had disappeared from the urine. The patient has since remained perfectly well, and, as over two years have elapsed with- out recurrence of glycosuria, the cure is probably permanent. The pertinence of the foregoing clinical observations may be questioned on the ground that the ordinary dietetic and medicinal measures of treat- ment were em^Dloyed. Considering, however, the rapid and fatal course of diabetes in young children, in spite of the best of treatment, the assumption is warrantable that the genito-urinary irritation bore a causal relation to the diabetes in these cases. The result of the surgical treatment Avould seem to corroborate this view. The following case in an adult is quite suggestive: — Case 3. — A man, aged 30, consulted the author regarding an irritable stricture of the deep urethra. Urinalysis showed marked glycosuria. There were no diabetic symptoms of a general character. After the irritability of the stricture had been allayed by suitable treatment, dilation was begun and successfully carried out. As the local difficulty improved the glycosuria gradually diminished and finally dis- appeared. A year later there had been no recun-ence. M, L, Harris has furnished the author with notes of a case that is perti- nent to the foregoing clinical observations: — Case 4. — A man, 35 years of age, had had gonorrhoea some years before coming under observation. When first seen the patient had been receiving treatment for diabetes mellitus for some time. He presented the usual symptoms. The urine was highly saccharin and passed in large amount. Thirst excessive and bulimia marked. No particular degree of emaciation. Pain and difficulty in urination developed and ORGANIZED DEPOSITS. 23 the patient was referred for surgical treatment. Urethral exploration revealed a very sensitive, rather soft stricture of the membranous urethra, which admitted Xo. 12 French. The stricture yielded easily to gradual dilation, and with the disappear- ance of the stricture all traces of sugar disappeared from the urine, as well as all symptoms of the diabetes. Oeganized Deposits — Chaeactee of the TJeine in Special Con- ditions. — Albumin in the urine, whether associated with the ordinary forms of nephritis or not, is quite constant in certain surgical diseases of the genito-urinary tract. For practical purposes urinary albumin may be divided into serum-albumin and pus-albumin. It is important to difEer- entiate the two, for there is a wide variation in prognosis according to the origin of the albumin. On the one hand, the albumin is due to renal disease of a serious and probably incurable character, while, upon the other, its presence depends upon the presence in the urine of certain inflammatory products of local disease. It is impossible to difEerentiate the two forms of albumin by simple chemic examination. When there is no renal disease the case may be diagnosed negatively by the constant absence of casts of the urinary tubuli and upon the symptoms and clinical history of the case. If, on the other hand, acute or chronic suppurative disease of the genito- urinary tract co-exists with morbus Brightii, it is difhcult to determine the precise amount of albumin dependent upon each cause. We must be guided, to a certain extent, by the amount of excreted solids, which is a criterion of the functional activity of the kidneys, and the specific gravity of the urine after all pus has been removed. In the majority of instances in which pus is present a fair estimate of the condition of the kidneys may be formed by decanting the supernatant fluid from the purulent deposit, and after filtration subjecting it to chemic examination. When the pus is dependent upon inflammation of the bladder or urethra, these parts may be thoroughly freed from pus by irrigation, after which a small quantity of urine is allowed to accumulate and then withdrawn and examined. The difference, or otherwise, in the amount of albumin in the first and last specimens is a fair criterion of the condition of the kidneys. Albumin may be found in the urine in surgical kidney with or with- out co-existent pyelitis, in cystitis, vesical cysts, enlarged prostate, gonor- rhea, gleet, and hemorrhage from any portion of the genito-urinary tract. Albumin is likely to be found in that peculiar form of renal disease secondary to prolonged and wasting suppurative processes in various por- tions of the body, particularly those involving the bones, of which caries of the spine and hip-joint are familiar examples. This is associated with a similar lardaceous deposit in the liver, and perhaps other viscera, and is known as the amyloid, or waxy, kidney. It is to be considered as a sur- gical affection of the kidney — although not amenable to surgical methods of relief — because of its occurrence as a secondary feature of surgical dis- eases elsewhere than in the genito-urinarv tract. Whenever albumin is 24 UKINALYSIS IN ITS SUEGICAL EELATIONS. present in the urine and no tube-casts can be found, after repeated exami- nations with the microscope, it is reasonable to suppose that the secreting structure of the kidney is free from serious disease — from the surgeon's stand-point, at least. Blood is found in the urine in a number of distinct and separate affections of the genito-urinary tract. The various conditions giving rise to its presence will be discussed in detail in a su.bsequent special chapter on hematuria. In a general way its origin may be: — 1. Local disease or injury of any portion- of the genito-urinary mucous membrane: for example, external traumatism, laceration by a passing cal- culus or the movements of a large vesical calculus, renal hyperemia, acute Bright's disease, drugs, parasitic disease, cancer, sarcoma, and tuber- culosis. 2. Peculiar conditions of depravity or disorganization of the blood: such, for example, as is met with in scorbutus, purpura hemorrhagica, per- nicious malarial infection, and typhus fever. 3. Perturbation of the capillary circulation of the renal tissue, such as is sometimes met with in simple intermittent fever, or as a result of certain peculiar impressions made through the emotions upon the vaso- motor filaments of the sympathetic. 4. And, most rarely, simple passive hyperemia incident to obstructive cardiac lesion. There is obviously no constancy in the amount of blood present in the urine in hematuria. The color of the urine varies from a slight foggy or smoky hue to one closely approximating pure blood. In some cases the blood is fluid, while in others coagula of greater or less size are present, this feature varying with the activity and source of the hemorrhage. The amount of blood necessary to give a decided red or black color to the urine varies somewhat. Much depends upon the degree of freshness of the blood and upon the depth of the color of the urine prior to its admixture Avith the blood. In some cases a very slight hemorrhage from any part of the genito-urinary tract imparts an intensely-red color to the urine. Ralfe has made some practical experiments respecting this point. He remarks as follows: — In some of the experiments I made in 1873 at the laboratory of Charing Cross Hospital, and published in the Lancet, I found that only 1 part of blood gave a decided smoky tint to 1500 parts of normal urine, while 1 part in 500 gave a briglit- cherry color. Considerable hemorrhages, therefore, are best judged by the amount of coagula rather than by mere intensity of color. In some instances blood is present in the urine in its normal or formed condition, blood-corpuscles being recognizable microscopically — hematuria. Less frequently the corpuscles are disorganized, nothing but their coloring matter being present— hemoglobinuria or hematinuria. In general, the former condition is indicative of a distinct solution of continuity of some OEGANIZED DEPOSITS. 25 portion of the genito-iirinary tract, the blood being nsnally of normal com- position and consistency; while in the latter there may be no solution of continuity in the genito-nrinary mncous membrane, but aplasticity and dis- organization of the blood, permitting the fluid to transude freely through the walls of the capillary blood-vessels and appear in the urine. If the blood-corpuscles escape under such circumstances, they are of such low vitality that they are easily broken down and quickly disappear. Bile in the urine is of importance only in relation to those diseases of the liver which are amenable to surgical interference: for example, hepatic abscess and some cases of biliary calculi. Chyle in the urine (chyluria) is a very rare phenomenon. In such cases the urine has much the appearance of milk, sometimes jnixed with blood. After the urine has stood for some time a Jelly-like clot forms. The presence of chyle in such cases is probably due to a lesion of some kind affecting the renal lymphatic capillaries. A few recorded cases of chronic chyluria have been found to depend upon the presence of the Filaria sanguinis hominis: a rare and peculiar form of ^^arasite. The admixture of fatty material with the urine sometimes gives an appearance resembling chyluria. Ealfe reports a case of this kind occur- ring in a patient dying of acute diabetic coma (acetonemia). Fibrin never appears in the urine excepting as a secondary condition in chyluria, in which it forms the jelly-like clot already alluded to, and in hematuria, in which disease casts of various portions of the urinary tract are often found. Mucus appears in normal urine, sometimes immediately, and almost always within a few hours after it has been voided. It forms in little clouds that finally settle to the bottom of the vessel. Under the microscope we find in these cloudy deposits epithelial cells, mucus-corpuscles, and coagula of mucus. In urine from the female there may be an admixture of blood, mucus, and pus-corpuscles from the vagina, dependent upon a combination of menstrual fluid and leucorrheal secretion. The urinary mucus is increased in amount by different diseases of the genito-urinary tract. For example, in vesical catarrh its amount is a fair, but not accu- rate, criterion of the condition of the genito-urinary mucous membrane. In some instances mucus presents itself in the form of longitudinal strias resembling hyaline casts, but distinguished from the latter by their irregu- lar outline and their comparatively greater breadth and branched form. Mucus may be removed from the urine by adding to the cold fluid acetic acid, — which separates the mucus in the form of a flaky deposit, — followed by filtration, which clears the urine completely. Turbidity resulting from boiling consists either of albumin or phosphates; the addition of nitric acid increases the turbidity in the case of the former, and clears the urine in the case of the latter. Pyuria. — Pus-corpuscles are found in the urine in chronic inflamma- 36 UEINALYSIS IN ITS SIJKGICAL EELATIONS. tion of the genito-urinary mucosa. It is ordinarily impossible to dis- tinguish them microscopically from the mucus-corpuscle or chyle-corpuscle. According to Peyer, "single pus-corpuscles" occur in almost every urine, especially that of women; but as a matter of fact, the corpuscles described by Peyer are simply mucus-corpuscles. The clinical features of each par- ticular case must be taken into consideration in the differentiation of pus and mucus, as the microscope alone will not serve to distinguish them. Whenever the form of corpuscle presented by mucus and pus occurs in large numbers in the urine, the presence of pus may be inferred. Pus is invariably an indication of acute or chronic inflammation of some portion of the genito-urinary system. Pus-corpuscles are about double the size of blood-corpuscles, are opaque and finely granular, this granular appearance serving to conceal their nuclei, which, however, become visible on the addition of acetic acid. The pus-corpuscles may be crenated or notched in appearance. When the urine is strongly ammoniacal, they dissolve to a certain extent and coalesce into a mass, losing their form, so that the microscope shows only their nuclei. When urine containing pus is freshly voided, the pus-corpuscles may present under the microscope the peculiar ameboid movement of the leucocyte. Blood-corpuscles appear under the microscope usually in the form of pale-reddish or amber-colored, biconcave disks. Their form varies according to the manner in which they lie in the visual field. When they lie upon edge they have a sort of biscuit form, but when lying upon their flat surfaces they present a dark center with a lighter areola about it, and are apparently round or nearly so. When they remain in the urine for a long time, and particularly if the urine becomes ammoniacal, they become paler and more globular, and finally are completely dissolved, liberating their pigment. Epithelium is usually found in normal urine, and is indicative of the same changes as occur in the stratum corneum of the skin, viz.: the shedding of effete epithelium. This shedding of epithelium is not abundant under normal circumstances. In the presence of disease, however, it is increased, and we therefore find, in cases in which there is an abundance of muco-pus or pus, an increased quantity of epithelium the form of which depends upon the site of the morbid process. In case of inflammation of the renal tubuli and urethra the epithelial cells are rounded. The epi- thelial cells from the vagina and bladder are of the pavement variety, often hexagonal in form, nucleated, and not to be differentiated from each other. Caudate epithelium originates usually in the renal pelvis; this form of epi- thelium is sometimes spindle-shaped. In some instances of severe inflam- mation about the neck of the bladder caudate epithelial cells are exfoliated. Thus, Peyer describes a case in which a large quantity of caudate epithelium was thrown ofl after cauterization of the deep urethra. Casts in the urine bear a more important relation to the medical dis- eases of the kidney than to those of a strictly surgical character. We CLINICAL FEATURES OP THE UEIXE IN VARIOUS DISEASES. 27 may, however, find them in nephritis secondary to surgical diseases of the genito-nrinary tract and in renal hemorrhage. They may appear in the form of epithelial cylinders, consisting of an exfoliation en masse of the epithelial lining of the renal tubuli. Hyaline cylinders or granular casts may be met with, according to the form and stage of the morbid change in the secretory structure of the kidney. Blood-casts and fibrin-casts occur as a consequence of renal hemorrhage.^ Clinical Features of the Urine in Various Diseases. — The con- dition of the urine in the special diseases of the genito-urinary tract is what most concerns the surgeon. Injuries of the urethra, prostate, bladder, kidney, and testis may give rise to blood in the urine. Hematuria from these accidents will be de- scribed in detail in connection with the special discussion of that subject. The appearance of the urine necessarily varies according to the amount of hemorrhage and its location. When the hemorrhage is from the urethra the blood is apt to appear in the form of a long, pencil-shaped coagulum, the discharge of which is followed by a flow of fluid blood. The bulk of the blood appears in the first portion of the urine, the midportion being comparatively clear, but a certain amount of almost pure blood being ex- truded at the end of the act of micturition as it is forced out of the injured part by the contraction of the cut-off and accelerator-urinee muscles. The blood in these cases is quite dark in the coagulum, but is of a bright arterial hue as admixed with the urine and following the act of micturition. When the prostate is involved, the amount of blood in the urine may be small and escape in the form of a fusiform clot, or there may be consider- able blood diffused throughout the fluid. In such cases, also, the con- traction of the cut-off muscle squeezes out a certain quantity of nearly pure blood at the end of the act of micturition. Hemorrhage from the bladder may give rise to clots in the urine, sometimes of considerable size, and where the hemorrhage forms a coagulum in the bladder this will, when broken up, give rise to a large amount of dehris of coagulated blood. When the urine is voided soon after the occurrence of the vesical hemorrhage, its color is comparatively bright, but when it remains in the bladder for a considerable time it becomes darker in color. When the kidneys are in- volved, the blood is apt to be uniformly diffused through the urine and to impart a quite dark, smoky color. The urine may be perfectly opaque in any case of genito-urinary hemorrhage, this being entirely dependent upon the amount of blood. The special points in differential diagnosis of the source of the hemor- rhage will be discussed in the chapter on hematuria. ^The intimate relation of casts to muscular and cardiac overstrain, and to transitory vicarious renal strain from exposure to cold or rapid temperature fall, is a new and fertile field opened up by the centrifuge. 28 UEINALYSIS IN ITS SUEGICAL EELATIONS. Blood may apjDear in the urine as a consequence of tranma of the testicle. This form of hematuria is very rare, excepting as following the emission of bloody semen occurring under such circumstances, or in cases of seminal vesiculitis with semino-vesicular hemorrhage attending emission. Acute urethritis gives rise to pus and blood in the urine, the latter being sometimes in considerable amount. For exam^Dle, in cases in which severe chordee exists and accidental or intentional rupture occurs, the blood is present in abundant quantity, and chemic tests develop the presence of albumin. There is usually, also, a considerable admixture of pavement- epithelium. Chronic urethritis causes certain peculiar appearances that are worthy of consideration. In some cases the chronic inflammation is localized at some particular point in the urethra, possibly behind an organic stricture. In such cases we have the appearance of the so-called gonorrheal or urethral threads: tripper-fdden. These consist of little thready filaments floating about in the urine when freshly voided, and sinking to the bottom when the fluid is allowed to stand. They are composed of mucus and epithelium rolled up. In some cases complicated by spermatorrhea, or after an emis- sion, spermatozoa will be found mingled with these threads. Free epi- thelium and pus-corpuscles are also present in some cases in considerable quantity. Gonococci are often found, and are of special significance. When the neck of the bladder is involved we find caudate epithelium mixed with the pus-corpuscles and thready filaments. In some instances of chronic urethritis a small plug of mucus of a gTayish-white color may be found in the morning urine. This consists of the accumulated secretion of the night, and forms at the meatus. Acute vesical inflammation, causes the appearance of hexagonal and caudate pavement-cells in the urine. These are mixed with an abundance of pus-corpuscles and more or less blood-corpuscles. On standing, these materials form at the bottom of the fluid a grayish-white or reddish-brown deposit. The reaction of the urine in such cases is acid, unless the condi- tion is an acute exacerbation of chronic vesical inflammation or the result of prolonged retention of urine from some special cause. Thus, Peyer has an excellent plate representing the appearance of the urine in a case of acute vesical inflammation, with alkaline reaction, occurring in a lying-in woman whose bladder had been paralyzed by the application of forceps, as a consequence of which catheterization became necessary. Such cases are only explicable by the entrance of bacteria into the bladder via a filthy catheter. This authority states, however, that, although acute vesical catarrh is attended by acid urine and usually bacteria are absent, yet they may be present in spite of the acidity. Chronic catarrh of the nech of the Madder often occurs without active symptoms of infiammation. In such cases the urine is acid and contains small flakes of mucus and epithelium, resembling, somewhat, urethral CLINICAL FEATUEES OF THE UEINE IK" VAEIOUS DISEASES. 29 threads. The character of the epithelium distinguishes these flakes from the latter, for, instead of being round, the epithelium is of the pavement (hexagonal and caudate) variety. In these cases the nrine is apt to be highly acid if there is any obstruction or retention. It usually occurs in gouty patients, and the specific gravity is apt to be high. In addition to the flaky material we have mucus-corpuscles and perhaps a few blood-cor- puscles. If bacteria are introduced from without by means of a dirty catheter or other instrument, the reaction of the urine speedily becomes alkaline, and we have definite symptoms of inflammation; in such cases we find more or less blood, pus, epithelium, and perhaps phosphates. These materials form in large quantity in chronic obstructive disease of the genito-urinary tract. In some cases of chronic vesical inflammation there are evidences of a morbid condition of the mucous membrane in the form of pus, blood, and epithelial cells, and yet the urine will be acid. This is explained by Peyer upon the hypothesis that a large amount of acid urine coming down from the kidneys is sufficient to neutralize vesical alkalinity, or, indeed, to make the urine acid, if it be voided speedily after its entrance into the bladder. The singular feature of such cases is the fact that the latter part of the urine — i.e., the portion that may be drawn off by the catheter from behind the obstruction, residual urine — is of alkaline re- action. The same phenomenon may occur in sacculation of the bladder. Stone in the bladder and enlarged prostate impart to the urine the character- istics of an exaggerated form of vesical inflammation, pus, blood, various forms of bacteria, and phosphates being present in abundance and the urine strongly alkaline. Pyelitis does not give rise to conditions of the urine that are pathog- nomonic of their origin, particularly if, as is frequently the case, vesical inflammation co-exists, either as a secondary or primary condition. As will be seen later on, inflammation of the bladder may, by simple extension, result in pyelitis; while, on the other hand, the irritating products of in- flammation of the pelvis of the kidney may secondarily induce vesical in- flammation. There is a form of pyelitis, however, resembling simple chronic catarrh of the bladder, occurring frequently in gouty patients, in which uneasiness in the region of the kidneys in combination with the appearance of more or less muco-pus and the characteristic caudate cells of the renal pelvis in the urine, enables us to diagnose the case with some positiveness. In such cases, however, if the neck of the bladder becomes implicated, the caudate cells lose their significance. We have in pyelitis, pus, blood, and epithelium in the urine. The pus is inclined to be of a powdery consistency and to be more finely dis- seminated throughout the nrine than in chronic vesical infiammation. It is apt to be of a greenish color, from admixture with hematin. The author has recently seen a case in which an exacerbation of pyelitis occurred in a young man who suffered from stricture and vesical catarrh, during 30 ITEINALYSIS IX ITS SURGICAL EELATIOXS. the progress of malarial fever. In this case the urine had a most peculiar greenish hue, very similar to what might have been expected from the ad- mixture of vegetable matter. These special features of pyelitic urine un- fortunately lose much of their significance from the frequent co-existence of vesical complications. Abscesses in the vicinity of , and discharging into, the genito-urinarij tract give rise to pyuria. In such cases the profuseness of the purulent deposit in the urine and its close resemblance to the pus discharged from abscesses in other situations should lead to a suspicion of the condition present, but even in cases in which the marked clinical features of the case should serve as a guide to a correct diagnosis, the source of the pus is frequently overlooked. Thus, the author has recently seen a case success- fully operated for abscess secondary to disease of the hip- joint which had discharged into the bladder. The cause of the pus in the urine in this case had been overlooked by several competent surgeons. A case was recently referred to the author, of a woman who suffered from chronic inflammation of the bladder with discharge of an immense quantity of pus in the urine. This ease upon investigation proved to be one of pelvic cellulitis with resulting abscess that had opened into the bladder. Suprapubic cystotomy with proper drainage resulted in the clos- ure of the vesical opening of the abscess. The case passed from under observation before the suprapubic fistula had completely healed. In one of the author's earlier cases a vaginal cystotomy was successfully performed. In another instance the presence of severe vesical inflammation and an abundance of pus in the urine following acute pelvic symptoms, demon- strated the intravesical rupture of a pelvic abscess from periuterine infection. Fortunately in this case complete recovery occurred under antiseptic vesical irrigations. Various neoplastic formations in the genito-urinary tract cause the ap- pearance of certain characteristic materials in the urine. Thus, we may have in various forms of malignant disease the appearance of characteristic cells or even small particles of the growth itself. The cells of vesical cancer are quite large; nucleated, the nucleus being often multiple; and are not unlike, in some respects, the ciliated cells characteristic of the mucous membrane of the pelvis of the kidney; hence care should be taken not to confound the two. In villous cancer small filamentary particles are found in the urine, these particles or loops being covered Avith delicate epithelium. They may appear in the urine spontaneously or at a variable period after the introduction of instruments. Aside from these characteristic features of malignant growths of the genito-urinary tract, we have in the urine^ of such cases the characteristic products of secondary inflammation of the ^ Microscopic examination of the urine is notoriously unreliable, on the average, in vesical neoplasms. CLIXICAL FEATURES OF THE TEIXE IX VARIOUS DISEASES. 31 bladder or pelvis of the kidney, as the ease may be, from irritation or obstruction. In hydatid tumors the hooklets of the echinococcus will be found coincidently with the periodic rupture of the cyst; the urine containing these hooklets, being diluted by the fluid contents of the hydatid growth, is of low specific gravity and very pale, unless blood be present, as may be the case from rupture of the sac. Surgical Jcidney imparts certain peculiarities to the urine. Thus, it is apt to be increased in quantity, with marked diminution of the specific gravity. Erichsen records a case in which the patient passed five pints of urine daily of a specific gravity of 1.003. In such cases a' low grade of chronic interstitial nephritis secondary to urinary obstruction with dila- tion of the kidney is to be suspected. The quantity of albumin in such a specimen of urine is either very small or nil. A few hyaline casts may be found, and possibly no renal epithelium whatever. The excretion of urea is usually sufficient for the needs of economy, the relatively low specific gravity being compensated for by the large quantity of excreted fluid. It is to be remembered, in this connection, that, as already stated, the amount of urea may be small, yet may represent the total amount formed in the system by the retrograde metamorphosis of nitrogenized material. In surgical kidney, complicated by purulent inflammation either of the renal pelvis or bladder, there is apt to be nothing characteristic shown by urinalysis. Acute nephritis concerns the surgeon only as a possible consequence of operative interference with the genito-urinary tract. Upon the super- vention of this condition the urine becomes scanty in amount, and in ex- treme cases finally suppressed. Such fluid as is voided is of a dark color^ smoky in appearance from admixture with blood, and of high specific gravity. It contains blood-casts, renal epithelium, a relatively large amount of albumin, and epithelium from the renal tubuli in the form of casts and also free in the fluid. Caudate epithelium from the pelvis of the kidney is also usually to be found. Spermatorrhea gives rise to the presence of mucoid material and sper- matozoa in the urine. In many cases there is a relatively large quantity of mucus from hypersecretion by the prostatic follicles. In some instances prostatic catarrh alone will give rise to quite a quantity of mucus without spermatozoa. In the majority of instances of this condition, however, more or less semen is present, probably because of the patulous condition of the mouths of the ejaculatory ducts and an overdistended condition of the vesiculce seminales as a result of reflex irritation of the nerves of sexual sensi- bility produced by prostatic disease. The presence of spermatic elements in the urine does not necessarily indicate spermatorrhea. Thus, the morning urine may contain semen as a consequence of prolonged erection, pollution, or intercourse during the 32 UBIKALYSIS IX ITS SUEGICAL EELATIQXS. night. The next act of urination following prolonged sexual excitement brings away with the Yoided urine in most instances a large quantity of mucus secreted by the prostate^ Cowper's glands, and urethral follicles, and in some instances a small amount of semen. Peyer states that he has found in certain cases of sexual excess and masturbation no spermatozoa, nothing being present except a few muciis- cells and epithelial cells, and in some instances a large number of beautiful, little, coffin-shaped and pointed crystals of phosphate of lime. In such instances he claims the urine is acid, but the mucous sediment is alkaline. He states that he has been able to diagnose positively from this condition of the urine masturbation in young men who had at first jDositively denied Fig. 5. — Morning urine in a spermatorrheic. it. The accuracy of his deductions from what seems to have been an accidentally correct diagnosis is questionable, especially as practically all youths masturbate. Spermatic elements may be found in the urine in certain cases of cerebral and spinal disease. Genito-urinary iuberculosis does not always yield reliable diagnostic signs in the urine. In the case of renal tuberculosis the urine presents the same features as in calculous pyelitis, which, indeed, may be a complica- tion. Pus and epithelial cells, and sometimes small particles of caseous material, are met with. The bacillus tuberculosis is, of course, pathog- nomonic when found, but it is often undiscoverable, even where unequivo- cal tuberculosis exists. The same statement holds good in tuberculosis of CLINICAL FEATUEES OF THE UKINE IX VAEIOUS DISEASES. 33 the ureter, bladder, prostate, seminal vesicles, testis, and urethra. The characteristic bacilli in the urine are conclusive when detected, but their absence in nowise militates against the existence of tuberculosis. Often enough, bacilli are absent from the urine in the early stages of genito- urinary tuberculosis, yet appear in abundance later on, when tissue- necrosis occurs. CHAPTEE III. Hematueia. The presence of formed or disorganized blood-elements in the urine is one of the most important of the objective evidences of genito-urinary disease. So important is it in its general relations to the surgery of the genito-urinary tract that it merits special consideration, more particularly because it is a prominent symptomatic condition common to a number of important affections of the genito-urinary organs. Although blood in the urine is not an essential disease, and is always symptomatic, it must be remembered that we are sometimes unable to recognize the precise patho- logic condition upon which it depends. Quantity of Blood Present. — The quantity of blood voided in different conditions varies from an amount merely sufficient to produce slight smoki- ness of the urine to nearly pure blood. In a general way, the urine discharged in hematuria dependent upon morbid constitutional states is darker in color than in cases in which it is due to disease of a purely local character affecting the mucous membrane of the genito-urinary tract. It may also be stated that, the nearer the seat of hemorrhage is to the vesical neck, the more vivid the color of the urine. Appearance of the Urine. — The appearance of the urine varies con- siderably according to the source of the blood, the amount present, and the length of time that has elapsed since its discharge. Varieties. — The differences in the characters of the blood present in the urine have warranted a division of cases of hematuria into (a) hematuria pure and simple and (&) hemoglohifiuria. In the former the blood-corpuscles exist intact in the urine, while in the latter they are not perceptible micro- scopically, the discoloration of the urine being due to disorganization of the blood-cells and liberation of their hemoglobin, or blood-pigment. Obviously the pathologic conditions producing hematuria are more likely to be of an essentially benignant character than those in which, as a result of profound hematopoietic disturbance, the blood in the urine is disorganized when voided. Diagnosis. — The diagnosis of hematuria is often easily determined from the gross appearances of the urine, but in obscure cases the micro- scope is necessary for the detection of the blood-corpuscles. In hemo- globinuria the corpuscles being broken down and only blood-pigment present, the spectroscope may be necessary to determine the presence of blood. There are several chemic tests that are both simple and practical. A very popular one is known as Day's test. This consists in adding a few drops of alcoholic solution of guaiac to the suspected liquid, followed by (34) ETIOLOGY OF HEMATUEIA. 35 a small quantity of ethereal solution of hydrogen peroxid. If blood be present a blue color results. The ordinary spirit of turpentine, with the addition of a little tincture of guaiac, also gives a decided blue tint to bloody urine. The diagnosis of hematuria having been completed, our in- vestigations have but just begun, for it remains to determine the source of the blood, and in many cases this is a difficult matter. Etiology. — The causes of hematuria are numerous. The condition may be due to certain general or constitutional conditions affecting the composition of the blood and the integrity of the capillary blood-vessels, as in scurvy and purpura hemorrhagica, the result in such cases being hemoglobinuria. It is most frequently due, however, to local disease of some portion of the genito-urinary tract or to injury of the mucous mem- brane produced by the presence or passage of urinary calculi. Diseases of the kidney — such as acute congestion or inflammation, cancer of the kidney, rupture of the kidney from traumatism, pyelitis, calculus, reflex renal hy- peremia; acute inflammation of kidney, ureter, and bladder from poison- ing by chlorate of potassium, cantharides, turpentine, or carbolic acid — are among the principal causes of hematuria. Hematuria following the paroxysmal pain produced by calculus of the kidney, ureter, or bladder is very common. When the hemorrhage is due to renal disease, epithelial or blood-casts may be found by the microscope, these clearing up the diagnosis. This means of diagnosis is greatly facilitated by the fact that, if the blood- cells are intact when they enter the urine, they are preserved for some time and do not readily lose either their shape or pigment. In scurvy, purpura hemorrhagica, malaria, and sometimes in septicemia the kidney is the seat of hemorrhage. It may be, however, that in some cases of these conditions the hemorrhage originates in the bladder itself. In some cases the entire urinary tract appears to be involved. Among the general causes of hematuria, and especially hemoglobinuria, malarial infection holds a prominent place. This form is sometimes inter- mittent or paroxysmal in character, and may or may not be associated with symptoms of ordinary malarial disease, although it most often succeeds more or less prolonged malarial infection and is usually attended by so typic and so violent malarial symptoms that there is little difficulty in diagnosis. Such cases of hematuria are very frequently seen in malarious districts. This sometimes occurs in a malignant form that rapidly destroys life. This form bears a strong resemblance to yellow fever. Active and passive hyperemia of the kidney and acute diffuse or acute hemorrhagic nephritis often cause hematuria. These conditions are transitory: i.e., the patient either dies promptly, or, what is more probable, recovers. The condition may end in chronic nephritis, in which event the hematuria disappears. There is a form of hematuria, prevalent in tropic countries, that is produced by a parasite — the Bilharzia hcematolia, so named after its 36 HEilATUElA. discoverer, Theodor Bilharz — in "«-hich both the kidney and prostate are affected by the jDarasite, both organs consequently contributing to the blood in the urine. Diseases of the bladder may cause hematuria, the conditions giving rise to it being congestion, inflammation, vesical calculus, villous tumor, traumatism, and simple or malignant ulceration; rupture of the bladder, pathologic or traiimatic, is also occasionally a cause. Diseases of the pros- tate, such as congestion, hypertrophy, inflammation and ulceration, simple or malignant, may also cause the disease. Passive congestion of the pros- tate and bladder may result from hepatic congestion and obstruction and give rise to blood in the urine. It is sometimes the result of congestion of the prostatic plexus associated with straining efforts at defecation inci- dental to inflamed hemorrhoids. Urethral trauma, simple or specific urethritis, and organic stricture may give rise to urethral hemorrhage which may or may not produce hematuria. Tlie determination of the source of urinary hemorrhage is a very im- portant matter. As a general rule, careful exploration of the urethra, blad- der, and rectum, with a careful analysis of the urine with reference to the existence of renal disease, is necessary to determine the source of the hemorrhage. This examination of the urine involves microscopic as well as macroscopic and chemic tests. The origin of many cases of hematuria may be revealed by thorough study of the history and constitutional con- dition of the patient. Much may be learned from the gross appearance of the iirine. When the hemorrhage is renal the urine is smoky and the blood is uniformly diffused through it: blood and epithelial casts are usu- ally to be found by microscopic examination. When the hemorrhage is vesical or prostatic, the first urine discharged is usually clear, the last few drops being bloody and sometimes composed of nearly pure blood, being always wholly or in part of a bright, arterial hue. In prostatic hemor- rhage the first urine expelled is apt to contain a clot or clots presenting the general contour and size of the prostatic sinus. This is by no means exceptional. Under such circumstances the blood-coagulum is dark and quite firm, and little or no pure blood is visible until the act of urination is nearly completed. "When the hemorrhage is urethral, blood is likely to escape independently of the act of urination, and is always washed away with the first gush of urine, the last portion being clear unless the hemor- rhage be profuse. In addition to these special features, symptoms referable to disease of the particular organ involved are usually present. In some cases it may be necessary to wash out the bladder with warm water through a catheter, thus removing the blood. If the next few drams of urine are bloody, the hemorrhage is probably renal. The cystoscope is often suc- cessful in the detection of the source of hemorrhage during the intermissiou of hemorrhage. In some cases it is possible to determine whether one or both kidnevs are involved in the bleedins: bv studvins: the urine as it flows ETIOLOGY OF HEMATURIA. 37 from the ureters into the bladder with the cystoscope or Harris's instru- ment. When all diagnostic means are inetiectual an exploratory incision of the bladder is demanded, and, if the cause be discovered, it should be removed at the same operation if possible. The diagnostic significance of blood in the urine is succinctly stated by Ealfe as follows: — 1. Hematuria. — The character of the hemorrhage, together with the general and special symptoms, is usually sufficient to indicate the part of the genito-urinary tract from whence it is derived. Thus, (a) acute nephritis; smoky -to dark-brown urine persistent for some days, with granular and bloody casts and excess of albumin. (h) Renal calculus: often deejj red from excess of blood, increased by movement, and passing off rapidly if the patient is kept quiet in bed; so that only a few blood- corpuscles can be seen in the urine. Generally accompanied by or immediately follow- ing a severe attack of colic; retraction of testicle on side affected, (c) Vesical cal- culus: hemorrhage generally follows undue movement, especially jolting; bladder symptoms prominent; detection of stone in bladder by sound, (d) Cancer of kidney: hematuria very abundant with large coagula, and repeated at irregular intervals; generally tumor in loin, (e) Cancer of bladder: frequent and profuse hemorrhage; cancer-cells in urine (?); pain referable to bladder, and a tumor may be discovered with sound, (f) Morbid conditions of the blood: hemorrhage often profuse, but rarely attended with formation of clots; general constitutional symptoms manifest, (g) Intermittent hematuria: the blood passes at irregular intervals, and is generally associated with a considerable quantity of albumin and a definite rise of temperature. In this case there is a history of ague, if that disease has disappeared. It is some- times associated with intermittent chyluria or gout. 2. Hematinueia (Hemoglobinuria). — In this case only the coloring matter of the blood is present; no blood-corpuscles, or only a few, are to be found. The attacks come on in paroxysms, attended with a chill and generally pain, with some degree of nausea and slight jaundice. The urine has a port-wine color, and is usually passed clear; on standing it deposits a granular sediment consisting of a few tube- casts (fibrinous cylinders), epithelium, and crystals of calcium oxalate. In some cases crystals of hematin ha^-e been observed. Certain peculiarities as regards the time of appearance of the hemor- rhage, as regards the act of micturition, and certain peculiarities of forma- tion of the coagula passed are apt to lead to a fairly-accurate knowledge of the location of the hemorrhage. In this connection the author recalls several instances of nephritic calculus in which small casts of the ureter, strongly resembling angle- worms, were passed some hours after the onset of the colic. Where there is any question as to the diagnosis, the appearance of such clots is im- portant as showing that the ureter, or the kidney which it drains, is the site of the hemorrhage-yielding lesion. The blood may be detected quite readily by the microscope in cases in which it is not completely disorganized. In the latter event, however, the spectroscope may become necessary. In the case of malignant growths, the assertion that cancer-cells are to be found in the urine is not justified by the facts in most cases. It is more likely to occur — from masses of the 38 HEMATURIA. growth becoming detached — where the growth is in the bladder^ prostate, or urethra, than when the kidney alone is atfected. In the latter condition the patient dies, worn out by repeated hemorrhages and cachexia, long before the mass could break down. Cases of idiopathic hematuria occur in which the hemorrhage is ap- jDarently the essential disease and neither the source nor the cause is dis- coverable; cases 'of this kind are described by Van Buren and Keyes and others. The author has seen several cases where there apparently existed no adequate cause for the hemorrhage, which speedily disappeared with little or no treatment without apparent injury to the patient. Overheating and extreme fatigue have appeared to bear a causal relation to some of the cases observed. It seems logical to attribute such cases to vasomotor dis- turbance of the renal circulation. The condition of passive congestion of the prostate, to which allusion has already been made, is a more frequent cause of hematuria than has been supposed. The author has observed several cases of this kind. The following cases are of considerable interest in an illustrative Avay: — Case 1. — A young man, about 25 years of age, was referred by his family physician for the relief of urethral hemorrhage, which had occurred almost daily for six months. The doctor liad susi>ected stricture, but as he had succeeded in passing a No. 15 English sound, he concluded that some disease of a more serious character existed. A history of several attacks of gonorrhea was elicited, but further than this nothing had ever occurred that might have accounted for the hemorrhage. The blood escaped in the morning with great regularity, and was occasionally observed at other times during the day, especially if violent exercise had been indulged in. A fusiform clot generally escaped with the first gush of urine, the remainder of the flow being only slightly tinged with blood. Constipation had been a prominent symptom, and several internal hemorrhoids had formed before the hematuria appeared. Micturi- tion was rather frequent, but not excessively so, as the patient was compelled to rise at night. Nocturnal emissions frequently occurred, and for several months there had been a slight gleety discharge from the urethra. The general health was only fair, digestion being disturbed the greater part of the time. On examination with the urethrometer, a stricture of large caliber was found in the penile urethra about one and a half inches from the meatus, and a slight organic contraction could be detected at the bulbo-membranous junction. Exploration of these strictures did not produce hemorrhage. The prostate was distinctly enlarged and soft, but not tender to pressure or the passage of sounds. Firm pressure upon the perineum, however, produced a sense of tension and fullness. As a preliminary to' medical treatment, meatotomy was performed and the penile stricture cut to a caliber of 30 French, the deep stricture being treated by gradual dilation. Internal medication consisted chiefly in remedies to relieve hepatic congestion in combination with ergot and bromid of potassium. Counter-irritation to the perineum and cold sitz-baths composed the remainder of the treatment. Improvement was rapid, the hemorrhage ceasing at the end of the first week and the other symptoms disappearing very soon thereafter. The possible rela- tion of reflex hyperemia of the prostate incidental to the penile stricture to the hematuria is at once obvious in such cases. Case 2. — A gentleman, 32 years of age, had been treated for slight stricture, the urethra having been dilated to about No. 20 French, Avhen he stopped treatment. Some time thereafter, while suffering from an attack of constipation attended by EENAL AND IDIOPATHIC HEMATUEIA. 39 hemorrhoids, he noticed a small amount of blood in the urine. This recurred daily, and gradually became a source of great annoyance, although there was at no time any great loss of blood nor any pain, either during micturition or at other times. Upon examination a stricture of moderately-large caliber was found at three inches from the meatus. This did not bleed on exploration. The prostate was moder- ately enlarged and there were slight internal hemorrhoids. The treatment of this patient was precisely like that of the preceding case, with the exception that the fluid extract of hamamelis, in small doses, was substituted for the ergot. A cure was effected in six weeks. Case 3. — This patient, a healthy-looking man 43 years of age, had never been ill until about three months previously, and had never contracted any venereal disease. At the time mentioned he had strained his back and perineum slightly in a bowling contest, and shortly thereafter began to be troubled with constipation, slight hemor- rhoids, and hematuria. The blood had increased in quantity until the urine was very largely mixed with blood, fusiform clots being occasionally observed during urination. Aside from the worry consequent upon the hematuria, the patient was still perfectly well; appetite, sleep, and strength were unimpaired; and there was no pain. For some unaccountable reason, several physicians had pronounced the case Bright's disease, and had treated it accordingly. The symptoms appeared to warrant a diagnosis of hemorrhage from the prostate and vesical neck, this being determined by the absence of pain and general symptoms, the shape of the clots, the absence of vesical irritability and urethral disease, the absence of tenderness on pressure upon the hypogastrium and perineum, the occurrence of hemorrhage in the morning, chiefly after stool, and the absence of blood-casts and other evidences of renal disease. Ergot, turpentine, and cholagogues, with the citrate of potassium in Vichy water, and a bread-and-milk diet constituted the treatment of this case, and was per- fectly successful, a cure being affected in about three weeks. When we consider the intimate association of the hemorrhoidal and prostatic plexuses in their relation to the neck of the bladder, prostate, and anus, and the close relation of this venous net-work with the portal circu- lation via the mesenteric veins, such cases are hardly surprising. Con- sidering the frequenc}^ with which a greater or less amount of urethral obstruction is superadded to simple constipation, thus necessitating more or less straining during micturition, it would, indeed, be remarkable if such cases were not occasionally seen. Case 4.^ — Apparently idiopathic hematuria. A boy, 12 years of age, was referred for marked hematuria that had appeared at each act of micturition for three or four weeks. Careful questioning elicited no history of injuiy or vesical irritation. Examination failed to detect any local cause for the hemorrhage, the bladder being carefully searched for stone. Cystoscopy was unsatisfactory. Under restricted diet, ergot, salines, and rest in bed the condition disappeared within a Aveek. The patient has been under observation ever since, a period of five years, and has had no recur- rence of the trouble and no disturbance referable to the urinary organs. There is a form of hematuria, of undoubted renal origin, in which even operative exploration of the particular kidney proved by the cysto- scope to be the source of the hemorrhage is productive of negative results. In a case of the author's there were many points suggestive of renal calculus, a probable diagnosis of which was made. The hematuria had been 40 ■ HEMATTJEIA. almost constant for months and^ in conjunction with the pain, had pro- duced marked anemia and emaciation. The patient, a woman of 30, was willing to submit to any operation, however tentative, for a possible chance of relief. The suspected kidney on exposure was found to be larger than the average normal organ and dis- tinctly congested; but, after free nephrotomy, no stone nor any condition suggestive of malignant or tubercular disease was found. Cessation of both hemorrhage and pain followed the operation. M. L. Harris has recently published eighteen cases of a similar nature, collected from the literature, the two following being his own^: — Case 1.— Male, aged 51; Ameriean; occupation, street-car conductor; of good habits; with no venereal history; had always been strong and healthy. In Febru- ary, 1895, without previous illness or injury, he began passing blood in the urine. As there were absolutely no subjective symptoms, he paid little attention to it, but continued at his work. After some three months he had gradually become so weak from loss of blood that he was unable to perform his full day's work, and it was for this weakness that he sought advice on April 27, 1895. There were no symptoms referable to the urinary organs. Had he not observed the dark color of the urine he would not have suspected any urinary trouble. Physical examination failed to reveal anything abnormal about any of the viscera. There was no renal tenderness, nor could either kidney be felt. An examination of the bladder, prostate, and urethra was nega- tive. The urine was dark brown in color, cloudy, acid, 1018 to 1025 sp. gr. Small amount of albumin; no sugar. The microscope showed numerous red blood-cells, ^^ith a few leucocytes, no casts, and no epithelial cells. The urine was repeatedly exam- ined during the next few weeks, but nothing abnormal was found except blood. There was no elevation of temperature nor unusual acceleration of pulse. He was not a "bleeder," and had never had hemorrhages before. With these facts before us, a satisfactory diagnosis was difficult to make. The hemorrhage was undoubtedly renal in origin. Eenal calculus was excluded on account of the uniform, unchangeable character of the hematuria, and the total absence of pain. Tuberculosis was excluded on account of absence of temperature-elevation and pus in the urine. Malignant growth seemed most probable, although no tumor could be felt, and the prolonged uinterrupted character of the hemorrhage was unusual. A diagnosis was, therefore, withheld. The patient was placed at rest, and the usual hemostatic remedies given. This line of treatment was followed a few weeks, without the slightest apparent improvement. This plan was then discontinued, and, while con- sidering the advisability of exploring the kidneys, he was placed on general tonics, with forced nourishment. He began to improve at once. The blood rapidly diminished in amount, and by June 5, 1895, he was able to resume his occupation. In a few days more the urine was entirely free from blood. Some two and a half years have now elapsed. He has been at work constantly since then, and a few days ago reported that he felt perfectly well, and has had no recurrence of the hematuria. Case 2. — Male, aged 50 years; American; married; occupation, farmer. Family history negative. Has always enjoyed good health. He thinks he had "malarial fevei-" eighteen years ago, but not since. He has never drank to any extent, but has used tobacco freely. Has never been subject to hemorrhage of any kind. No family history of hemophilia. Has had no venereal disease. The present trouble began about three years ago, when he noticed, accidentally, that his urine was quite dark in color. ^Philadelphia Medical Journal, March 19, 1898. EENAL HEMATUEIA WITHOUT LESION. 41 At first this was not constant, the urine varying in color, being at times quite clear, again very dark. He consulted, a physician, who found blood in the urine. The blood in the urine gradually became more constant, until, for something more than a year past, there has been no time when it has been free from blood. It has been uniformly of a muddy, dark-brown color. During all this time there have been no symptoms referable to the urinary tract; in fact, nothing to direct attention to the urinary organs, except the blood in the urine. Appetite has been good and bowels regular. He had suffered somewhat mentally, fearing some serious condition, owing to the per- sistence of the hematuria. He had likewise noticed, during the past few months, that he was becoming perceptibly weaker. He was unable to do a full day's work, and found he gave out much sooner than formerly. He had lost 8 pounds during the year, his present weight being 145 pounds. His mucous membranes were rather pale, the pulse regular and about 70 to 75; temperature, 98.6°; the heart, lungs, and the hepatic and splenic areas normal. The kidneys could not be felt, nor was there any tenderness about them. In the rectum Avas found a small superficial ulcer about twelve millimeters in diameter. The urethra was of normal caliber throughout. Thorough examination of the bladder by sounds, irrigation, etc., was entirely negative. Upon cystoscopic examination, the blood was easily seen issuing from the left ureter, the urine issuing from the right ureter being perfectly clear. The amount of urine in twenty-four hours was 32 ounces; the color, very dark brown and cloudy; the reaction, acid; sp. gr., 1030. It contained no sugar and but a small amount of albumin. The microscope showed very abundant red blood-cells, few leucocytes, no casts, no epithelial cells. Repeated microscopic examinations were made of the centrifuged urine, extending over a period of several days, but no casts or epithelial elements were ever found. Blood-cells were always abundant. In considering the diagnosis we were at once directed to the left kidney as the source of the hemorrhage. Renal calculus was excluded by the long persistence and constancy of the hemorrhage, the fact that it was not increased by exercise or jolting, nor diminished by repose and recumbency, and the total absence of all pain. Tuber- culosis was excluded by the absence of pus and tubercle bacilli from the urine, and the absence of elevation of temperature (carefully recorded for several days). Malig- nancy could, in all probability, be excluded, owing to the absence of a tumor, which we would expect to be present before the end of three years. We were thus reduced to one of two conditions: hemorrhage from an angioma of the pelvis or the kidney — which was not likely, owing to the uniformity and constancy of the hemorrhage— or so-called angioneurotic hematuria or renal hemorrhage without known pathologic change — the most probable diagnosis. Medicinal treatment being ineffectual, it was decided to explore the kidney. The left kidney was therefore cut down and found to be normal in location, size, external appearance, and consistency. It Avas then slit open freely along the convex border, opening widely the pelvis. The fibrous capsule was easily detachable ; the cut surface, as well as the pelvis, so far as could be determined by sight and touch, were normal. In fact, the most careful examination within and without failed to discover the slightest abnormality about the kidney. It is much to be regretted that a portion was not excised for microscopic examination. The incision in the kidney was sutured with catgut, and the wound closed. On the first day after the operation the urine was still bloody; on the second, much clearer; on the third, quite bloody again; thereafter it became rapidly clearer, and by the end of the first week no more blood could be found with the microscope. Recovery Avas without incident. The man left the hospital nine- teen days after the operation. Not a trace of albumin or blood could be found in the urine. The patient Avas much relieved, mentally, by the cessation of his trouble. He Avas last heard from six months after the operation, in first-class condition, Avithout recurrence of hematuria. 42 HEilATUEIA. Harris remarks upon liis cases as follows: — These two cases are of particular interest owing to their negative points, there being absolutely no svmptoms except the hematuria, with its resultant anemia and general weakness. That there was no marked or serious lesion of the kidneys is evi- dent from the fact that both patients permanently recovered. When Klemperer read his article "Ueber Xierenblutungen bei gesunden Xieren"' (Deutsche mediciirische WocJienschrift, X05. 9 and 10, 1897) before the Society of Internal Medicine in Berlin, in December, 1896, he was criticised by some for the use of the term "healthy kidneys." It was considered that a kidney permitting the constant escape of blood from it must be looked upon as pathologic. In defense of this point Klemperer cited numerous instances of vicarious menstruation and of hemorrhage from different organs of "bleeders" in whom no pathologic condition of the bleeding organs could be deter- mined; but more important still, as bearing directly upon the subject, he presented reports of cases wherein the most careful macroscopic and microscopic examination by competent observers of kidneys removed for uncontrollable hemorrhage had failed to detect the slight-est pathologic change. Others have met with similar eases, and, acting upon the suggestions of Klemperer, Elb collected all the cases he could find in the literature up to 1896, and published them in his dissertation. These cases were eight in number. Harris succeeded in collecting the histories of eighteen cases, includ- ing his own. His comments upon them constitute a most yaluahle addition to the literature of hematuria, and are herewith presented in full: — We have here 18 cases, including my own, or, if we exclude one which was probably tuberculous, in which there was found a small contracted, dense, tough kidney, we have 16 cases of persistent, severe renal hematuria. Avithout perceptible lesions of the kidneys. As to sex, there are 7 males and 9 females. The ages range from 19 to 54. In all cases the hematuria began without known cause in individuals in apparent health, and was usually discovered accidentally, no symptoms haA'ing directed attention to the urinary organs. The urine contained no abnormal constituents, except the red and white blood-cells and albumin corresponding to the amount of blood present. It will thus be seen that the diagnosis must at present rest mostly upon negative findings, or diagnosis by exclusion. We miss the casts and renal epithelium of nephritis in the urine; the tubercle bacilli, other micro-organisms, pus, crystals, sand, or gravel of infective inflammations, calculi, etc.; there were no enlargements of the kidney or unusual groups of cells in the lu-ine as in malignant tumors, no constitutional symptoms of uremic or septic intoxication — in fact, as stated, the findings were nega- tive, with the exception of the hematuria and its resulting anemia. Concerning the etiology and pathology of the condition, little that is definite can be said. Could an accurate analysis be made of the cases here reported, it is quite jjrobable that not all of them would be found due to the same cause ; still there is sufficient similarity in the cases to warrant placing them in a class by themselves until more definite knowledge may possibly lead to further classification. I cannot agree with Klemperer in considering these kidneys as healthy. A kidney that permits the escape of blood for weeks or months, or even years, cannot be looked upon as normal, notwithstanding the fact that no definite lesions have so far been discovered. To bridge over this lack of knowledge the influence of the nervous system has been called in to explain these cases. It is thus sought to explain the sudden appear- ance of the hematuria following excitement, or the equally sudden cessation of the EEXAL HEMATUEIA WITHOUT LESION. 43 bleeding folloAving different acts supposed to produce some impression upon the nervous centers. Klemperer uses the term "angione.urotic hematuria" in these cases. Without denying the possibility of the nervous system's influencing these cases, it appears to me that there is one fact which strongly militates against the acceptance of the neurotic theoi-y as the main element, namely: in all of the cases where the fact was determined, 16 of the 18 cases (in 2 cases not determined), but one kidney was affected. This, to my mind, must indicate some local condition. Any influence from nerve- centers upon organs so mutually and reciprocally related as are the kidneys would most certainly affect both organs, unless there existed some local determining con- ditions. The fact that simple nephrotomy has almost uniformly been followed by im- mediate cessation of the bleeding, is no proof against local disease. In a ease in which very small, contracted, hard, dense kidney was foimd, complete recovery followed simple nephrotomy, and continued until the patient's death, some seven or eight years later. In one case of renal tuberculosis, with severe hematuria, simple nephrotomy was followed by cessation of the bleeding for 18 months. Harrison has shown that in some eases of acute nephritis, with marked albuminuria and scanty secretion, the urine has lost its albumin and regained its normal flow almost immediately after simple nephrotomy or acupuncture. In these cases it must be acknowledged that definite pathologic conditions were at least symptomatically cui*ed by simple nephrot- omy. In all of the 18 cases here recorded simple nephrotomy was done. Of these, 1 died. Of the 10 recoveries, 9 Avere completely relieved of the hematutda. In 1, in which the kidney was exposed, but not cut into, no benefit followed. In 5 cases nephrectomy was done ; 1 of these died. It was the case which had not been benefited by the exposure of the kidney some two years before. The 4 recoveries Avere all permanently relieved. Of the remaining 3 cases, 1 recovered under tonics and nourish- ment, 1 under cold baths, and 1 following cystotomy for the purpose of catheterizing the iireters. In closing, while the number of cases is too small to warrant any definite con- clusions, I think the following statements are justified: — 1. There is a condition of renal hematuria not due to the usually-accepted causes, namely: acute nephritis, calciili, tuberculosis, septic infection, malignant and non- malignant new formations, hemophilia, injuries, malaria, intoxications, etc. 2. There is probably in these cases a local lesion in the kidney which may be strongly influenced by the nervous system. 3. With our present knowledge we are unable to state what the pathologic changes are. 4. These cases have not been benefited by the usual hemostatic remedies. 0. After a reasonable trial of other methods of treatment, including tonics, cold baths, etc., if unsuccessful, simple nephrotomy should be performed. 6. Owing to the almost uniform success of simple nephrotomy, primary nephrec- tomy should never be performed. The author is inclined to the vasomotor theory of the origin of the interesting class of cases jnst described, the more especially as such an explanation best harmonizes with the condition found in the single case in which he has had the opportunity of inspecting the kidney. As Harris says, the nervous correlation of the two kidneys is most intimate; but it does not therefore follow that both organs are necessarily involved simultaneously in vasomotor perturbations; if so, this physio-pathologic phenomenon is peculiar to the kidney alone of all the tissues and organs 44 HEMATUEIA. of the body. It is possible that irritation produced by a crystallizing out of the solid matters of the urine, short of an amount necessary to form a distinct calculus, may be localized in a single kidney, causing hematuria. This is consistent with the known clinical fact that definite calculi are often limited to a single kidney. It is by no means impossible that sup- posedly idiopathic renal hematuria is sometimes a concomitant of what may be termed the precalculous stage of renal lithiasis. Another possibility is that the hemorrhage is significant of the precancerous stage of malignant disease. The author desires to call special attention to a class of cases in which hematuria of prostatic origin is the first symptom of prostato-vesical tuber- culosis. In one ease of this kind, at present under his care, the hema- turia disappeared under treatment, but vesical symptoms developed after a time, and the tell-tale bacilli were found in large numbers in the urine. TeeatmejSTT. — The treatment of hematuria necessarily involves the proper management of its causal conditions when they are discoverable. Morbid constitutional conditions require correction, but it would be hardly proper, in this connection, to dwell upon the treatment of purpiu-a hemor- rhagica and scurvy, as they properly belong to another department of medi- cine. It is also unnecessary to give the minutice of treatment of the various local causes of hematuria, inasmuch as it would only be a duplication of what will be said in the special discussion of these diseases. In a general way, inflammation of the kidneys, prostate, or bladder requires hot baths, the application of leeches and hot fomentations, and the administration of saline cathartics and alkaline diuretics. Gallic acid, matico, ergot, or tur- pentine, in combination with any of the various demulcents that will be mentioned later on, are indicated in cases where hemorrhage is alarming In inflammatory conditions hemorrhage, as a rule, should not be checked. The author especially desires to extol turpentine in the internal treatment of hematuria. It may be given in emulsion; 10 minims to the dram, and repeated every three hours, with due regard to possible strangury. If passive congestion or hyperemia of any portion of the genito-urinary tract exists, the portal sj^stem requires relief by mercurial cathartics, and the local blood-supply must be regulated by the administration of ergot and hama- melis. The diet should be restricted as nearly as possible to the regimen alluded to in the chapter on genito-urinary hygiene. As a rule, catheter- ism should be avoided, especially if the urethra, prostate, or vesical neck be the source of the hemorrhage. Sometimes, however, the bladder becomes so completely filled with coagula as to present a strong resemblance to the gravid uterus. In such cases the fluid portion of the blood and urine should be drawn off and the coagula washed away with a double-current catheter, .a mild alkaline solution being best for this purpose. A digestive solution of pepsin and hydrochloric acid has been recommended for the purpose of dissolving vesical clots, and has been claimed to be very effica- TKEATMEXT OF HEMATUEIA. 45 cious. It may be necessary, after removal of the clots, to attempt local hemostasis by means of hot water or astringent irrigations. Antipyrin in 10-per-cent. solution is very valuable for this purpose. In no case should undue haste be exhibited in the attempt to evacuate clots, as it is desirable, where possible, to wait until the hemorrhage has subsided. If decomposi- tion of the clot occurs, antiseptic irrigation is necessary. In such cases, also, the administration of eucalyptus, boric acid, salicylic acid, creasote, salol, or guaiacol may assist in maintaining an aseptic condition of the contents of the bladder. Great care should always be taken to maintain asepsis in vesical manipulations in hematuria. Superadded infection is a very serious matter. The litholapaxy evacuating-tube is often serviceable in removing clots. Cases of vesical hematuria occasionally occur in which hemorrhage is so severe and uncontrollable that suprapubic cystotomy and packing the bladder with iodoform gauze are demanded. Drainage-tubes may be used, although not usually necessary. They should be passed down to the vicinity of the ureteral orifices, the gauze being packed around them. The indications for the treatment of cases of hematuria dependent upon passive congestion of the prostate and vesical neck are quite simple, as may be seen by the cases of that condition that have been described. They consist chiefly in the relief of venous obstruction by laxatives, espe- cially such as act upon the liver, and the removal of urethral contractures by operation or dilation. Eemedies, such as ergot and hamamelis, which act upon non-striated muscular fiber are quite essential, but of secondary importance. The sexual function always requires a certain amount of con- sideration, and the diet should be restricted to as unstimulating a regimen as possible. Neutralization of the urine should, of course, be accomplished as a matter of routine. With respect to the sexual function, the author has experienced one fatal case of hematuria coming on ten days after a perineal urethrotomy, in which sexual excitement and resultant hyperemia had much to do with the unfortunate result. Such cases emphasize the necessity of sexual continence, psychic as well as physical, in all conditions of the lower portion of the sexual tract characterized by hematuria. CHAPTER IV. The Bacteeiologic Eelatioxs of Gexito- Ueixaey Ixfections and Secoxdaet Ixfectioxs axd Toxemias of Ueixaey Oeigix. MoDEEN bacteriologic research has shed much light upon many ohscnre points in genito-urinary pathology. Many of the phenomena of disease affecting the urinary tract, or secondary to such local disease, have been solved within recent years by the discovery of the relation of pathogenic organisms to them, and no text-book upon genito-urinary diseases can be considered comprehensive without a general resume of the most important facts in genito-urinary germ-pathology. In presenting these more recent developments in the study of genito-urinary disease, the author does not desire to be understood as claiming that recent discoveries of the important relation of pathogenic organisms to both primary and secondary pathologic conditions of the genito-urinary tract justify sweeping away, as if they were so much rubbish, the clinical observations and pathologic deductions of past generations of surgeons. Their observant eyes, well-trained fingers, and logical minds were often productive of material so valuable that we can only regret that their methods of study and observation were not sup- plemented by the microscope. Urinary toxemia is unquestionably the most important of all etiologic factors in its relations to the general accidents of genito-urinary pathology and practice. The composition of the normal urine per se and the absorp- tion of that fluid have nothing to do with the resulting pathologic proc- esses, which are invariably due to an alteration of the composition of the urine through the medium of micro-organisms of various kinds. The pre- cise character of these micro-organisms has by no means been definitely settled. That the ordinary bacteria of decomposition have much to do with urinary toxemia is probable, and some modern researches tend to show the existence of a special type of micro-organism in decomposing urine. The particular product of urinary decomposition that possesses general pathogenic properties has elicited much discussion. That the ammonia developed in decomposing urine produces general toxemia is no longer believed; that it may produce local pathologic changes within certain limits is admitted, but only in so far as it acts as an irritant of greater or less intensity. It cannot be positively stated that any particular chemic com- pound is the cause of the toxemic conditions resulting from genito-urinary disease, injury, or operation, although we are warranted in assuming that such compounds are the principal etiologic factors in such conditions. Eeasoning by analogy, we are, perhaps, safe in the inference that they are toxins similar to, if not identic with, the ptomains and leucomains of (46) SEPTIC ABSOEPTION. 47 which we now hear so much. The function, then, of microbial organisms in toxemias of g^enito-urinary origin woukl seem to be, in general, of an indirect character, it being the product of the micro-organisms, and not the germs, 'per se, that produces the difficulty. There are, of course, cases of infection that are unquestionably due to special types of micro-organisms — ordinary septic microbes playing an important role. In considering the relation of septic absorption to the general febrile accidents of genito-urinary practice it must be remembered that the ab- sorptive power of the intact vesical mucosa is very slight, while, as experi- ments have shown, that of the normal urethral mucous membrane is very great. Absorption of toxic materials by the unbroken urethral mucous mem- brane readily occurs.^ Earely, if ever, does the intact epithelium of the vesical mucosa absorb toxic or other materials, even when they have re- mained in the interior of the bladder for a prolonged period. It is probable that absorption by the lymphatics bears a very important relation to the septic infection that sometimes results from genito-urinary operations. A striking analogy is found in the metro-lymphangitis that so often constitutes a starting-point for general septic infection in the puer- perium. Personally the author is inclined to attribute relatively greater importance to absorption by the venous channels than to that by the lym- phatics in some cases of general infection from the genito-urinary organs; still, it must be acknowledged that the septic infection may take its point of departure in a septic lymphangitis. Other things being equal, it would be natural to expect absorption by the veins to result in general septic infection more quickly than in the case of absorption by the lymphatics. A point that it is well to bear in mind is the fact that absorption by means of the veins is, perhaps, not necessarily followed by a thrombophlebitis. Eapid general septic intoxication with a fatal result may possibly occur before thrombophlebitis has time to develop. Eegarding the presence of a specific type of micro-organism as a cause of urinary infection, a number of varieties of microbes have been observed by various investigators in pathologic urine and in surgical lesions of the kidneys. It is not surprising that the immortal pioneer in bacteriology, Pasteur, should have suspected the truth regarding urinary infection nearly twenty-five years ago. As early as 1875 he publicly expressed the opinion that pathogenic microbes accidentally introduced into the bladder were the cause of urinary infection. During a discussion by the Parisian Academy, he said: — If I had the honor to be a surgeon I would never introduce an instrument into a patient's bladder without having observed the most rigid precautions to avoid the introduction of germs from the external atmosphere. ' Certain accidents with cocain used as a urethral anesthetic show this rather too emphatically. 48 EELATIOX OF BACTEEIOLOGY TO GEXITO-rEIXAKT DISEASE. All the various conditions embraced under the term surgical kidney — save the results of backward pressure pure and simple — are unquestion- ably the result of infection from the more external portions of the genito- urinary tract. Ascending nephritis has been shown by Klebs, Virchow, and others to be due to parasitic infection. The microbes, after entering the bladder, ascend along the ureters, infect the pelves of the kidneys, and even penetrate into the secreting structure itself. According to Lan- cereaux, renal abscesses under such circumstances contain the same microbes that are found in pathologic urine. Microbes have been found by many investigators in pyelonephritis, these organisms being in some instances bacteria and in others micrococci. The streptococcus pyogenes has been found in conjunction with various other forms of microbes, both bacteria and micrococci, the staphylococcus pyogenes being especially frequent. A point of interest regarding the relation of bacterial infection to genito-urinary disease is the occurrence of descending infection of the kid- ney, ureter, and bladder. It has been shown that pathogenic germs may attack primarily the glandular structure of the kidney, and that subse- quently either these germs or their ^jroducts produce infection of the more external portions of the genito-urinary tract: e.g., a cystitis may result from a primary septic nephritis acquired by infection through the medium of the general circulation. It has been demonstrated that certain circulatory disturbances of the genito-urinary tract afford an invitation for germ- infection. Thus, Heubner ligated temporarily the vesical arteries; he then released the vessels and observed that the influx of blood was fol- lowed by coagulation-necrosis and thickening of the bladder-walls. He then found that if coincidently with the removal of the constriction of the circulation he injected pathogenic organisms into the blood, septic cystitis and gangrene of the vesical mucosa resulted. Guyon performed similar experiments upon the kidneys with a similar result, as regards both the effect of the circulatory disturbance and the locus minoris resistentioe afforded pathogenic organisms subsequently entering the kidney by means of the general circulation. In 1886 Bumm reported eight cases of puerperal cystitis in which he found a micrococcus common to all that, according to Halle, was probably the staphylococcus aureus. Clado, in 1887, isolated from pathologic urine a bacillus that he described as a septic form of bacterium of the bladder. He experimented upon animals with this bacillus and produced, by its in- troduction into the bladder, cystitis. Injection of the same micro-organism into the peritoneum resulted in the death of the animal. In three cases of urinary fever this author found in two living patients the same bacillus in blood drawn from the liver, and in one autopsy he found the same organism in the blood. Other experimenters have isolated from pathologic urine micro-organisms which, injected into animals, produce nephritis. Halle, who has written what is possibly the most comprehensive article upon MICKOBES IN UEINE. 49 urinary infection, has made some very interesting observations. In 1887 this author published the very interesting case upon which he first formu- lated his theory of urinary infection.^ The patient was affected by imper- meable stricture with intense cystitis, and presented, after each attempt at forcible catheterism, violent febrile complications that finally resulted in death. The purulent urine collected and cultivated during life fur- nished a pure culture of a known liquefying bacterium. At the autopsy this same bacterium was found in a condition of purity in the urine of the renal pelvis, the parenchyma of the kidney, and in miliary abscesses in the renal structure. It was also found in the general blood-circulation and in the liver. This bacterium injected into the peritoneum of a monkey caused speedy death by general infection. The bacterium in this case was subsequently recognized as identical with the germ isolated from urine by Clado. In 1888 Albarran and Halle published an elaborate bacteriologic study of a case of urinary infection observed in the Hopital Necker, with numerous experiments upon animals.^ These authors observed this bac- terium in 47 out of 50 examinations of pathologic urine. In 35 urines, studied by culture, 15 contained this bacterium in a condition of purity; in 20 other cases it was associated with other micro-organisms. In 19 autopsies, made immediately after death, the pelvis of the kidney contained this bacterium in 18 cases. It was also found unassociated with other bacteria in the pus of a case of pyonephrosis removed by incision. It was found in 3 cases of periurethral urinary abscess and in 14 cases of infectious nephritis. In 2 cases of acute febrile infection an early autopsy showed this organism in the blood, the liver, and the spleen in a condition of purity. In 6 cases of fatal urinary fever of slow development culture of the blood in the large vessels, made immediately after death, in 4 cases yielded this bacterium in a condition of purity. With this organism the authors pro- duced (1) cystitis in animals by injecting it into the bladder after ligature of the veins, (2) fatal general infection by inoculation in the serous cavities, (3) localized suppuration by inoculation of the cellular tissue, and (4) sup- purative pyelonephritis with renal abscess by injection into the ureter after ligature. It would be a work of supererogation to present all of the con- clusive experiments made by the foregoing experimenters. It is interesting to note the marked pyogenic properties of the microbe discovered by Albarran and Halle. Krogius^ discovered a peculiar microbe in purulent ammoniacal urine. In ten specimens of urine this author isolated in three instances a micro- organism quite different from that described by Albarran and Halle, both ^ Halle: Bulletin de la Societe Anatomique, October, 1887. -Albarran et Halle: "Xote siir une Bacterie pyogene et sur son rule dans I'infection urinaire." Academy of Medicine. August 21, 1888. ^Krcigius: Society de Biologie. Julv 23. 1890. 50 EELATIOX OF BACTERIOLOGY TO GEXITO-rEINAEY DISEASE. in the method of its formation, its size, and its coloring properties. The inoculation of this bacillus in the cellular tissue, veins, and peritoneum of the rabbit killed the animal verj^ speedily in some instances; in others at a later period. At the point of inoculation the bacillus produced edema and gangrene of the cellular tissue, but no suppuration. Sterilized cultures were not so active. This bacillus Krogius termed the urohaciUus lique- faciens septicus. The researches of this author have been supported and confirmed by others since his original discovery. As illustrative of the many types of germs that have been found in pathologic urine taken from twenty-nine cases of cystitis, Eovsing's studies were very interesting. These comprised twelve species of microbes, includ- ing some varieties with which we are already familiar, such as the hacillus tuberculosis; staphylococcus albus, citreus, and aureus; and new varieties to which he applied the names of streptococcus urece pyogenes, coccohacillus, urece pyogenes, diplococcus urece pyogenes, micrococcus urece pyogenes flavus, and four other varieties, which, as Halle remarks, are nothing but the four preceding forms deprived of their properties of pathogenesis. Experi- ments upon animals showed the pathogenic properties of these various microbes. The point of greatest interest is the fact that recent investigations have shown many of the pyogenic microbes found in the genito-urinary tract to be practically identic with the lucteriurn coli commune. Krogius found among seventeen specimens of pathologic urine in the fluid taken from the twelve eases an organism that he recognized as identic with pyo- genic bacteria and also with the bacterium cuti commune. In eleven cases this bacillus was present in pure culture. He afterward found this organ- ism in secondary suppurative processes of the kidney, and also in the parenchyma of the spleen. Its pyogenic properties were proved by experi- mentation upon animals. ■ It is unnecessary to go into full details confirmatory of the important relation of microbial infection to the local and general toxemias dependent upon pathologic conditions of the genito-urinary apparatus. A few general considerations are, however, essential: — That the gonococcus is an important factor in genito-urinary infection has been proved beyond the possibility of dispute. That it is so important a factor as Neisser, Bumm, and others assert is possibly open to question — open to question at least in this respect: that, if it be claimed that without the gonococcus there is no infection of the urethral mucous membrane or of the mucous membrane of the female genitalia, too much is claimed for that micrb-organism, and too little respect is shown for other micro-organ- isms that thrive in the female genital tract and which may, under certain circumstances, assume pathogenic properties. It is the author's belief that, through evolutionary changes, what may be termed the normal micro- organisms of the female generative apparatus may undergo transformations THE GOXOCOCCUS AS A FACTOE. 51 and assume new and pathogenic properties not only capable of exciting urethral inflammation in the male, but under favorable circumstances — such as are afforded by the traumatism incidental to parturition — of infecting the female herself. There is one point that has probably puzzled others as well as the author. Granting that gonorrhea and its congeners have their origin in filthy, unhealthy states of the female genitalia, it remains to account for the origin of the gonococcus. Is there any organism, normally found in the female genital apparatus, that may undergo transformation and assume the properties that we know to be peculiar to the gonococcus? Ur is the starting-point really in the genital apparatus of the male, the female genitalia acting merely as the culture-bed for the evolution of the special germ? There is something very strildng in the close similarity of the gonococcus and the normal urethral coccus. The question is an open one whether the gonococcus is not really a derivative of urethral and vaginal cocci; in other words, whether the differences existing between the urethral coccus and the gonococcus — such differences, for example, as variation in their culture-media and properties of pathogenesis — might not be accounted for by evolutionary changes in these innocuous cocci. The special proper- ties of the gonococcus would be no argument against this possibility, for, with evolutionary changes of form and adaptation to the new environment afforded by a suppurative inflammation of the urethra, it is not illogical to assume that the acquirement of new and aj^parently specific properties might result. Even in cases of urethritis that are distinctly gonococcal in origin, or, rather, in which gonococci are present in great numbers, we are confronted with a mixed infection. The periurethral phlegmons and aljscesses, the lymphangitis, the prostatic suppurations, the acute cystitis and acute inflammations of the kidney, and in women the peritonitis that occurs in the course of gonorrhea, are due, not to infection with the gono- coccus per se, but to other germs that are associated with it. Gonococci, even in typic gonorrhea, rarely exist independently of common pyogenic microbes, certainly not after the first few days. In the joint, muscle, ten- don, and other serious complications of gonorrhea, other germs than gono- cocci — or the products of other germs — are usually responsible for the condition.^ There is no more typically mixed infection than that of gonorrhea. It may be stated, in this connection, that pus from periurethral ab- scesses following gonorrhea has been inoculated upon the urethral mucous membrane with a negative result. Ehrmann, of Vienna, has introduced pus from an unopened periurethral abscess into a blind sac of mucous mem- brane in a healthy hypospadiac without effect. The introduction of this ^ The author expressed this opinion with a full knowledge of the fact that gonococci have been discovered in some of these secondary infections. 52 EELATIOX OF BACTEEIOLOGY TO GEXITO-UEIXAEY DISEASE. pus into the urethra of the same individual caused only a slight follicular inflammation that disapjjeared in a few days/ If the non-existence of a specific gonorrheal cystitis be established, it will certainly greatly modify the existing views regarding this much- dreaded complication of gonorrhea. Even prior to the discovery of the gonococcus it was supposed that gonorrheal cystitis was due to specific infection: i.e., to the specific ''poison" of the gonorrheal process. Since the discovery of the gonococcus it has been supposed that this germ was the exciting cause of complicating cystitis. Dumesnil,^ however, denies that there is such a thing as specific gonorrheal cystitis. He claims that when gonococci are found in the urine they are accidental ingrafts upon the infectious process, having entered the bladder along with the purulent products of the urethral inflammation. They are not, according to him, new products developed from true specific inflammation of the vesical mucosa. It is conceivable that in women urethral or vaginal pus often gets into the bladder in this manner, but, as a matter of fact, so-called gonorrheal cystitis is relatively quite rare in women. Dumesnil claims to have deter- mined by recent researches that gonococci produce no alteration in the com- position of urine, cystitis with ammoniacal urine never being produced by these germs. He claims, moreover, that the constant contact of the urine either renders the gonococci harmless or kills them completely. Eegarding the evolutionary theory of the origin of the local venereal diseases, — which will be again alluded to in connection with those affec- tions, there is one fact that seems to the author to be of paramount impor- tance, viz.: if we accept the theory of evolution as applying to the higher types of animal and vegetable life, we must necessarily accept it as applying to germ-life, the difference being that, while, in the case of the higher animal and vegetable types as we see them at the present day, differentiation and adaptation to environment are going on slowly if at all, they are progressing in a most marked degree in the lower forms of life — to such a degree that a distinct variation in toxic properties, if not in physical form, is naturally to be expected. One thing is certain, viz.: if we accept the laws of evolution as appMng to the host — i.e., the animal infected — we must, nolens volens. also accept it as applying to the parasite: i.e., the microbe. We certainly produce evolutionary changes in the germ, so far at least as its vital properties are concerned,, in an artificial environment of our own creation in the laboratorj', and it would seem that, if it were not that a natural law of evolution governs micro-organisms — which law prevails much more powerfully in its natural habitat than in our culture-tubes — Ave would ^ Such results as these, however, are merely suggestive. The discharge of a periurethral abscess into the urethra is quite generally followed by a fresh urethritis. The mixed character of the infection works both ways. - Virchow's Archiv. vol. cxxvi, 1891. EVOLUTION OF GENITO-UKIXAEY IXFECTIOXS. 53 have absolutely no experimental control over such organisms. The only alternative of this theory is the view of a special creation of perfectly de- veloped and unvaryingly typic forms, and this is certainly incompatible with the present status of biology. A point of considerable importance, bearing upon the multiplicity of forms discovered by different observers in various infectious genito-urinary processes, and bearing more particularly upon the close similarity of several forms of microbes thus discovered, is the fact that the physical characteristics of a germ are not an accurate cri- terion of its special qualities of infectiousness. Germs, the form and alleged pathogenic properties of which are precisely similar, have been found in several very dissimilar pathologic processes, suggesting that a metamor- phosis of the germ may occur by virtue of which it acquires a variation in its properties of infectiousness without necessarily undergoing any change in physical conformation. There is much that has been said in the foregoing general survey of genito-urinary. infection that is theoretic, but a theory based upon known laws and harmonizing with known facts contains more of the elements of progress than a passive scientific agnosticism associated with a mass of crude and imperfectly assimilated clinical and experimental observations — "bricks without straw" — that signify nothing and produce nothing save chaos in the minds of those who develop them. CHAPTEE Y. General Morbid Phexomexa Ixcidextal to the Surgery OF THE GeXITO-UeINARY OeGAXS. Urinary or Urethral Fever. — This is an omnibus term applied to certain morbid phenomena that occasionally result from operations upon, or diseases of, the genito-urinary tract. These phenomena frequently follow surgical maneuvers that are apparently of trivial importance; indeed, a slight operation, such as simple dilation of the urethra, may produce seri- ous results even where severe operations are well borne. There is. great discrepancy in the opinions of various authorities re- garding the pathology of the polymorphous disturbances known by the various terms of urethral, urinary, and urine- fevers. This is because these terms are applied hap-hazard to several distinct types of morbid phenomena, as is clearly shown by a careful survey of the clinical facts. The term urethral fever has been made to cover a series of widely- var^ang conditions. The term urine-fever, suggested by Eeginald Harri- son, is perhaps the most accurate as applied to a certain type of cases, but is fallacious because suggestive only of one etiologic factor. Harrison is of opinion that the so-called urethral fever is invariably due to morbid changes in the urine at the site of injury, developing toxic materials, which, when absorbed into the circulation, are always injurious and often fatal. Whatever its etiology may be, the various phases of this complex affection constitute the principal danger of operations or injuries of the genito- urinary tract. The term urethral fever has been made to include conditions bearing no relation to each other, save that they have the same point of departure, viz.: disease or injury of the genito-urinary tract. Surgical shock, uremia, nervous manifestations, and sepsis following genito-urinary operations are entirely different conditions. They may exist in varying combinations, it is true, but this does not justify an omnibus nomenclature. Cases in which death results shortly after sounding, and classic septemia following genito-urinary operations, differ widely and should not be included under any general head. Bacteriologic research has proved many of the cases hitherto described as urethral fever to be due to germ-infection, or the absorption of germ-products. This should, and may eventually, govern their nomenclature. Etiologically, so-called urethral fever embraces the following forms of morbid phenomena, capable of demonstration in typic cases. One may merge into the other; all are secondary to genito-urinary operations, chronic disease, or injury. (54) URIXARY OR URETHRAL FEYER. 55 1. The first and simplest form is nervous rigor not succeeded hy fever, following shortly after ojDerations or injury. It is probably due to slight shock, with resultant peripheral vasomotor disturbance. 2. Traumatic or surgical fever (ferment-fever), due to excessive reac- tion from shock — perverted metabolism — in combination with decomposi- tion of fibrin ferments. This is likely to be modified by a varying degree of septic infection. 3. Toxemia foUoiving severe shoch with resultant perverted elaboration of the urinary secretion and the formation of organic poisons similar to the vegetable alkaloids. Associated with this is reflex inhibition of the renal function with uremia and perversion of general tissue-metabolism. This is the typic urinary fever. It is sometimes complicated by convulsions. 4. Septemia, or sapremia, which may be speedily fatal, or merge into general pus-infection with circumscribed and diffuse suppurations in various parts. The latter may supervene without the characteristic phenomena of ordinary sepsis. 5. Typic pus-infection, due to pyogenic microbes of various forms. (). Chronic urinary fever (chronic urinary toxemia) attendant upon long-standing obstructive urinar}' disease. 7. Cases of mixed type combining in varying degrees various elements of the preceding types of disease. If the foregoing classification be clinically or even pathologically justi- fiable, the variation of opinion regarding the pathology of urinary fever is not surprising. There must be some explanation for the fact that one authority claims that these varying phenomena are invariably septic, another that they are due to ammoniacal decomposition of urine and absorption of the products, another that they are due to simple uremia, and last, but not least, that they are clue to obscure changes in the urinary secretion and the formation of new, and as yet unisolated, toxic compounds. It is evident to every practical surgeon that none of these causes is sufficient to explain all of the cases of so-called urethral fever. Simple absorption of healthy urine will not produce injury. It has been shown that normal urine will not even produce suppuration when injected hypodermically. Decomposed urine, however, has most powerful propensities for evil; in fact, there is hardly any organic substance that is so destructive to cellular tissue. Ex- perience with cases of urinary extravasation substantiates this. There is a close resemblance between the effects of extravasation of decomposing urine and those of the poisons of erysipelas, dissecting wounds, and even the bite of venomous reptiles, as regards their effects upon connective tissue. It is obvious that in all cases of injury or operations of the urinary organs there is great danger of septic infection. The site of the injury is usually such that free drainage is impossible; decomposing urine is usually present, producing more or less wide-spread death of connective and cellular 56 GENEEAL PHE^^OMEXA IN GEXITO-rEINARY SUEGEEY. tissue, and there always prevail the conditions of heat and moisture. Such an environment is peculiarly favorable to the development of the germs upon which septemia and its congeners depend. ISTone of the pathologic views thus far advanced will, when taken alone, explain the fatalities occasionally resulting from the introduction of a smooth sound. ^ It is worthy of note that a simple straight cut in the urethra — as in' internal urethrotomy — often produces less shock than stretching the sensitive stricture by bougies. Irritable, sensitive, con- tractured tissues in any situation are always more safely and comfortably dealt with by complete division than by repeated attempts at stretching. The benefits of gradual dilatation in stricture depend upon (1) me- chanic distension; (2) reactionary hyperemia, with increased local tissue- change. The activity of the lymphatics and veins is increased, and ab- sorption is very rapid. If the tissues be extraordinarily sensitive or if toxic principles from decomposing urine or ordinary septic materials be present at the site of the stricture or behind it, dilation must necessarily produce, first, a degree of nervous shock dependent upon the susceptibility of the individual and the roughness of manipulation; second, a varying degree of absorption of morbific materials. The lymphatics and veins, unfortu- nately, do not discriminate between poisonous and non-poisonous sub- stances; they therefore take up the poisonous materials simultaneously with the products of retrograde tissue-change and thereby infect the general sys- tem. The relation of organic and functional renal disturbance to so-called urethral fever is most intimate. No case of long-standing obstructive dis- ease of the genito-urinary tract is unaccompanied by functional aberration of the kidneys. In a large proportion of cases organic changes finally occur. This is to be anticipated and given serious consideration. The im- mediate effects may not be marked, because of vicarious elimination by the skin and bowels: constituting the means by which the system accomodates itself to imperfect elimination of the constituents of urine. There are few persons whose bodily sewage is perfect, and, if the kidneys perform their functions imperfectly, this condition of imperfect sewage assumes vital im- portance. When genito-urinary operations produce shock, reflex renal hyperemia is apt to result. This causes a strain upon the renal circulation that its impaired condition cannot withstand. As a result, its functions are completely inhibited and uremia follows. To those familiar with nerve-physiology in its more intimate relations to visceral functions, the association of reflex irritation and renal aberra- tion should not be surprising, yet this particular phase of neuro]3athology is seldom accorded the prominence it deserves. Many interesting examples ^ Recent writers — germ-aiid-toxin mad — ignore all of the old-fashioned, but accurate, clinical obsei-^-ations of these cases. EELATION OF EENAL DISEASE TO UEIXAKY FEYEE. 57 of urinary suppression from reflex inhibition of the renal function have been observed. Peyrani has shown that the sympathetic nerves have a remarkable influence over the secretion of urine, galvanization of these nerves increas- ing the amount of urine and urea, while section of them causes both urine and urea to sink to a minimum. There is abundant proof of the relation of renal disturbances — and especially albuminuria — to reflex irritation. Eenal aberration is most liable to occur from operations in certain special regions — notably the abdomen and genito-urinary organs. This is explained by the intimate relation of the sympathetic ganglia (through their visceral filaments of distribution) with the nervous supply of these regions. Nowhere are the cerebro-spinal and sympathetic systems more closely associated. This being understood, it is not remarkable that injuries of these parts should cause reflex dis- turbance of correlated organs, even though distant. The functions and physiologic integrity of the abdominal and pelvic viscera are dominated by the solar plexus, the kidneys being intimately associated with the other organs through the renal plexus, the component parts of which are fila- ments from the solar and aortic plexuses, semilunar ganglia, and lesser splanchnic nerves. Passing into the renal substance from the renal plexus are some fifteen or twenty nerve-filaments with numerous associated ganglia accompanying the arteries. The multitudinous distribution of these filaments to the parenchyma and blood-vessels of the kidneys has been well described b)'' Holbrook. The renal nerve-tissues are principally non- medullated, sometimes surrounding the arteries in immense numbers; en- circling them around, above, and below; freely branching, bifurcating, and supplying all of the neighboring structure with numerous delicate fibrils; a plexus encircling every tubule; supplying the connective tissue extending into the layer known as the memhrana propria, and even piercing this structure and penetrating into the epithelia and the cement-substance between them. The nerves also give off delicate ramifications to the afferent blood-vessels, entering the vascular tufts and producing a delicate plexus around the capillaries. The distribution of nerves is richer in the con- voluted and narrow tubules than in the straight collecting tubes. Eeasoning from the foregoing anatomic facts, it is easy to understand how irritations of the abdominal and pelvic viscera or genito-urinary organs may be reflected to, and produce morbific changes in, the kidneys. Hardly a case of genito-urinary disease, perhaps, runs its course without a certain degree of this refiex impression. The result depends chiefly upon the organic state of the kidneys; if this be bad, speedy death may result. All operative manipulations of the genito-urinary tract are liable to concuss, so to speak, the renal nerve-supply: i.e., are likely to bring a reflex strain upon the blood-vessels, disturbing, secondarily, the nutrition of the kidneys. Autogenesis in its relations to the development of certain constitutional 58 GENERAL PHENOMENA IX GEXITO-UEIXAEY SURGEKY. conditions demands more attention than is usually accorded it. and it is probable that physioehemic researches in this direction will in future shed new light upon many diseases the etiology of which is now obsctire. Among the modern writers who have given attention to the morbid results of perverted physiologic chemistry, Benjamin Ward Eichardson is, perhaps, the most prominent. It is to the researches of this author that we are indebted for the most widely accepted theory of the pathology of rheuma- tism. It is probable that perverted tissue-metabolism bears a causal relation to the typic cases of urethral fever. This perverted physiochemism may l)e readily brought about by stirgical shock, and is especially marked in glandu- lar tissues. We know quite well that mental emotions of various kinds and those impressions upon the nervous system that result in shock may produce marked changes in the various physiologic secretions, consisting of increased or diminished flow or obscure cliemic changes of composition; thus, various nervous impressions may cause increase or decrease of saliva, lacteal secretion, gastro-intestinal secretions, urine, and the menstrual flow. A familiar illustration of the chemic effect of emotions upon physio- logic secretions is the change in the quality of the lacteal secretion induced by fright, anger, or grief. This change, although occult and incapable of demonstration by microscopic or chemic research, is very pronounced in its morbid eff'ects upon the child, cholera infantum of a most fatal character being a frequent sequel to the emotion of anger in the mother. Precisely what this change in chemic composition may be is an open question, but it is possibly a species of decomposition resulting in the formation of a poison analogous to the "tyrotoxicon" discovered by Vaughn in impure cows" milk. It is well known that great care is necessary on the part of those who sup- ply milk for the use of infants to prevent fatigue and various sources of excitement in the cows from which it is taken. Sexual excitement in the cow catises changes in the milk that may render it unfit for human food. If the changes alluded to occur in one secretion, it is probable that all of the physiologic secretions are susceptible to them. In the case of the saliva, for example, the emotion of anger may ^jossibly cause the de- velopment of toxic principles in that secretion that explain the serious re- sidts which so often ensue from the bite of an enrasfecl human being. The difficulty of proving this theory in the present state of our knowl- edge of physiologic chemistry is obvious. In the case of the urine the influence of surgical shock may he in- ferred to consist in the development of organic poisons — toxins — in that secretion. These may be considered to be hypothetically analogous to the ptomains and leucomains found in both dead and living bodies, and which so closely resemble the vegetable alkaloids, particularly nicotin. brucin, and strychnin. Eeginald Harrison also believes that such compounds may de- velop in the urine, under certain circumstances. The toxemia resulting PEKYERTED METABOLISM IX UKIXAEY FEVEE. 59 from snch changes will perhaps explain some of the otherwise ohscure and mysterious cases of death following the simple introduction of a sound. It is a noteworthy fact, in this connection, that in many cases it is not until the urine comes in contact with a urethral wound tliat chill or febrile action result. Thus, if an operation-wound he made in the anterior urethra no disturbance may result ifntil the patient urinates for the first time after operation. AAlien the urine is diverted from the wound by the insertion of a vesical drain through the perineum, urinary fever does not result, as a rule.^ In some cases the development of uremia or toxemia is very gradual, coming on only after successive operations upon the genito-urinary tract. The poisonous materials may accumulate in the system for some time and their presence fail to manifest itself until the system, so to speak, is sur- charged with them and ready for an explosion, when a previously well- tolerated and comparatively slight irritation of the genito-urinary appa- ratus will he sufficient to develop serious results.- The following case illustrates the point just made: — Case. — A competent surgeon of this city i^erformed urethrotomy upon an appar- ently healthy young man 28 years of age. The stricture was located about three- fourths of an inch posterior to the meatus and" was divided under cocain without diffi- culty or pain. Each subsequent operation of dilation was preceded by the injec- tion of 4-per-cent. solution of cocain, the quantity used being about 2 fluidrams. A week after the urethrotomy the patient complained of nervousness and insomnia, which was not considered important. On the ninth day an attempt was made to per- form the usual operation of sounding and injection of cocain, the patient meanwhile lying on an ordinaiy surgical chair. The surgeon left the patient for a moment to procure a sound and give the cocain an opportunity to act. He was called back in about a minute by the patient, who complained of dizziness and immediately fell back in the chair in convulsions. Assistance was called, stimulants were given, and the galvanic current used, but without avail, the patient dying within five minutes. At the post-mortem a thorough examination of all the vital organs was made, but everything was found perfectly healthy, with the exception of the kidneys, which were extremely congested, presenting a bluish appear- ance similar to that of the spleen. This fatal result was evidently not attributable to the cocain, but due to the sudden explosion of poisonous- materials that had been gradually accumulating in the s)'stem as a con- sequence of inhibition of the renal functions and the metabolic action of slight surgical shock upon the tissues. This toxemia gradually increased and finally became so severe that comparatively slight irritation was suffi- cient to precipitate a nervous explosion. The irritation was afforded by ^ HaiTison insists on this point much too emphatically. Some cases develop chill immediately after sounding, and before urine has been passed. = The late Sir Andrew Clark also suggested that '-'catheter-fever'^ might be due to some nutritive disturbance produced by reflex nervous influences. 60 GENERAL PHENOMENA IN GENITO-URINARY SURGERY. the mechanic effect of the injection of cocain, and it is probable that the introduction of simple water would have had a similar effect. The analog-y to an epileptic seizure at once suggests itself. The danger of development of urinary fever is directly proportionate to the depth of traumatic and surgical injuries of the urethra, — i.e., to their distance from the meatus. Those situated in the pendulous portion are not, as a rule, very dangerous as compared with those that occur in the fixed or deep portion. This is easily explained: the nerve-supply of the deep urethra is much more liberal and sensitive, the cellular tissue more abun- dant, and the opportunities for drainage much less favorable than in the pendulous portion. Decomposing urine is not so likely to remain behind a stricture in the pendulous portion, because of simple gravity and the fact that such strictures are usually of large caliber. Urinary extravasation in the pendulous urethra is not apt to produce serious danger to life; the connective tissue in this situation is very sparse and the extravasated fluid is likely to be detected before it has burrowed back into the perineum. The relation of germ-infection and absorption of the products of germ- evolution to the septic varieties of so-called urethral fever is a most im- portant one. This is proved by the researches of investigators whose testi- mony is unimpeachable. The clinical features of the various morbid general phenomena that may result from surgical manipulations of the genito-urinary tract demand special consideration: — The nervous form of the disease usually appears in patients of an im- pressionable constitution: i.e., those who present a decided neuropathic tendency. Its occurrence may often be anticipated from the patient's be- havior under instrumentation. He may have nausea, perhaps vomiting, slight rigors, partial or complete orgasm, or more or less complete syncope as the instrument penetrates the deep urethra. Such patients are likely to develop, as a rule, a sharp chill within twenty-four hours after urethral operations or injuries. This lasts for a variable time, is rarely prolonged, and when it passes off leaves the patient about as well as before, with the exception, perhaps, of more or less mental depression. Earely, indeed, there may be a slight amount of fever or sweating. The chill may come on within a very few minutes after the operation. The traumatic form is the most common. This is ushered in by a sharp chill, usually within twenty-four hours after operations or injuries of the genito-urinary tract, and is followed by sharp fever succeeded by sweating. The disturbance either passes off after a single paroxysm, or is followed by a period of general malaise, with perhaps a recurrence of the paroxysms for several days. In these latter cases there is present in all probability a slightly septic element. Typic urine-fever — the most frequent variety — may or may not be attended by a violent chill coming on within twelve to thirty-six hours. VARIETIES OF URINARY FEVER. 61 There are marked prostration, violent vomiting and diarrhea, coldness of the skin, — succeeded later on by more or less febrile movement of tempera- ture, if the patient survives, — with suppression of urine, merging in a very short time in fatal cases into coma of an apparently uremic type. The author describes the coma as of "apparently uremic type" because, accord- ing to the theory advanced regarding the action of shock upon the urine, there is probably present in many cases a toxic element that is independent of ordinary uremia. This condition may develop gradually, manifesting itself by a sudden explosion in the form of convulsions, as illustrated by the fatal case that has just been related. 8&ptemic fever of genito-urinary origin usually begins by slight (but sometimes very severe) chill; this is followed by fever of varying degree of severity. The infection may be very acute, the patient sinking into a typhoid condition, or becoming comatose and dying within from two to ten days. Again, the condition may be subacute, merging into general pus-infection, known familiarly as pyemia. In the latter event the patient finally succumbs to the slow development of circumscribed or diffuse puru- lent deposits in the joints, viscera, and other structures of the body, due to infection with pyogenic microbes and their products. The chronic form of urine-fever is a chronic condition of toxemia and nervous irritation produced by long-continued obstructive and inflamma- tory affections of the genito-urinary tract. This condition of toxemia and general nervous irritation is not generally recognized, but is very important in its relations to chronic genito-urinary disease. It exists in the majority of cases of organic stricture of long standing, in old men with prostatic hypertrophy, in tumors of the bladder, in chronic cystitis from any cause, and in pyelitis, especially the variety due to nephritic calculi. Patients suffering with these affections have a tendency to mild hectic fever; flushing of the face with slight elevation of temperature, perhaps followed by a certain degree of perspiration, is quite common; nervous irritability is espe- cially marked. Indeed, there are few conditions that are productive of so much mental depression and irascibility as chronic diseases of the genito- urinary tract. The sufferer from vesical calculus, prostatic hypertrophy, or stricture is apt to be unreasonably morose and irritable. More or less obscure rheumatic or neuralgic pains in various situations may also be present. After prolonged retention of urine from any cause the majority of patients suffer for a few days or weeks from more or less elevation of temperature. The different general canditions that have been outlined are probably mainly due to toxemia dependent upon (a) imperfect elimination of the products of retrograde tissue-metamorphosis; (b) a greater or less degree of absorption of morbific materials, — i.e., pseudo-alkaloid germ-products, — produced by inflammation and the decomposition of residual urine behind the site of obstruction. It will be observed that many patients suffering 62 GENERAL PHENOMENA IN GENITO-URINARY SURGEEY. from clironic obstructive genito-iirinary disease do not realize how ill they are until the local disease has been removed or at least greatly improved; they then find that slight disturbances to which they had paid comparatively little attention and which they had not in the least attributed to their urinary trouble have disappeared. This is due, in great measure, to the removal of reflex nervous irritation, but, more than this, to the fact that the constant absorption of poisonous materials from the site of disease has been stopped. Tlie mia'ed form of so-caUed urethral fever- is not so distinct an entity as the preceding varieties. There are relatively few cases that cannot be assigned to one or the other of the varieties of disturbance already described. Cases occasionally occur, however, in which there exists in varying pro- portions evidence of both septic or pus absorption and uremia, Avith pos- sibly a tendency to disturbance of the nervous functions. A clinical differ- entiation might, in such cases, be impracticable. It is obvious, from the foregoing survey of clinical and pathologic facts, that the range of cases which can justly be designated as urethral, urine, or urinary fever is rather limited. Those cases resulting from sep- temia and surgical shock certainly cannot consistently be so classified. It has been the author's experience that patients suffering from paludal poisoning are especially apt to develop chill, and often fever, after genito- .urinary manipulations. In cases in which a general anesthetic is given, it is always well to in- quire into the responsibility of the anesthetic per se. The anesthetic is often a direct cause of renal disaster following genito-urinary operations. Ether is far more dangerous than chloroform in this respect. If this were gen- erdly understood, chloroform would be far more popular than at present. Chloroform kills in such an unmistakable fashion that he who runs may read, and never fails to receive due credit for accidents. Ether, however, while permitting the patient to get off the operating-table, often destroys life several days later by acute renal congestion, or, perchance, acute nephritis. Urinary chill and fever are infrequently met with unless there is a lesion of the mucous membrane, showing that the cause in a large proportion of the cases in which evil results from genito-urinary operations is absorption of some toxic material. Xo matter Avhat view he may take of the etiology of the various forms of urinary fever, the surgeon is always confronted by three possible elements of pathogenesis in such cases: (1) an impression of a purely nervous char- acter, (2) toxemia due to absorption of septic materials, and (3) toxemia pro- duced by retention in the blood of the products of retrograde tissue- metamorphosis incidental to inhibition of the renal function of the kid- neys, which, in lieu of a better term, we call uremia. These pathologic factors, as already noted, may exist singly or combined. TREATMENT OF URINARY FEVER. 63 Treatment. — The principal measures of treatment of the morbid phe- nomena following genito-urinary operations are of a prophylactic character for, unfortunately, the marked forms of the disease — i.e., the septic and uremic varieties — are seldom recovered from. The principal feature of prophylaxis should consist of strict attention to the principles of genito- urinary hygiene. If the functions of the kidney are stimulated by alkaline diuretics, and the skin and bowels kept in an active condition, thus afford- ing vicarious relief to the kidney, the patient is placed in the best possible condition to avoid the accidents and complications that have been described. In addition to these measures, antiseptics should be given internally prior to operations. Of these, boric acid, cystogen, diuretin, and salol are among the most popular. The author's preference is for the oil of eucalyptus in doses of 10 minims. Salicylic acid or, preferably, salicylate of soda is also serviceable. Local antisepsis in cases of chronic bladder and prostatic disease is, of course, essential. It can be best accomplished by irrigation with mild anti- septic solutions, such as carbolic acid, sodium biborate or boric acid, potas- sium permanganate, and mercury bichlorid. Operations upon cases com- plicated by structural renal disease should be avoided if possible. Where operation is unavoidable the surgeon should not only be very careful in his manipulations, but should lay the unfavorable features of the case frankly before the patient and his friends. Immediately prior to operative inter- ference, in eases of serious import, particular attention should be paid to the function of the kidneys and local antisepsis. The patient should be put to bed and kept perfectly quiet, and put upon a milk diet with moderate doses of quinin, 3 to 5 grains thrice daily, for a week or ten days previous to the operation. Various drugs have been recommended for administration just before or at the time of urinary manipulations or operations. Quinin and mor- pliin in 10- and ^/^-grain doses, respectively, are popular remedies and un- questionably have a proj)hylactic effect by increasing the resisting power of the nervous system, thus lessening liability to shock. Jaborandi is also rec- ommended for this purpose, and inasmuch as its physiologic action is such that it must necessarily relieve strain upon the kidney, the drug would appear to be one of our most philosophic remedies. Hypodermic injections of ^/g to ^/g grain of pilocarpin muriate may be given instead of the fluid extract of jaborandi. Should uremia supervene, this method of adminis- tration is absolutely essential. The milder cases of general disturbance (the nervous and traumatic forms) are rarely fatal, but may possibly merge into the severer types, and consequently demand attention. The administration of opium and jabo- randi, with, perhaps (in the traumatic form), aconite or veratrum viride, constitutes the 'best treatment at our command. When uremia occurs, attention should first be directed to the vicarious 64 GEISTERAL PHENOMEXA IN GEiv'ITO-URIX ARY SUEGEEY. elimination of urea. Valuable time must not be wasted in attempting to restore the function of the kidneys immediately after the supervention of uremia, particularly if coma develops. Pilocarpin given hypodermically is effective in inducing perspiration, even when the patient is comatose, and should be given freely. The bowels should be moved by croton-oil, 2 or 3 drops of which in combination with 5 or 6 drops of olive-oil, may be placed upon the back of the tongue. If the patient is able to swallow, elaterium in the dose of from Vs to Vs grain is preferable to all other hydragogic cathartics. Hot baths should be given and dry or wet cups applied over the region of the kidneys. Digitalis and saline diuretics may be given internally after the emergency is over, but it is bad practice to attempt to accomplish anything by diuretics before vicarious elimination of urea has been attended to. It is also questionable whether stimulation of the renal function is safe practice before an attempt at derivation has been made. Urethral irrigations with solutions of mercury biehlorid, 1 in 20,000, before and after manipulations of the canal, will usually prevent septic infection after genito-urinary manipulations. Modern measures to insure asepsis of urethral instruments constitute an important means of prophylaxis of sepsis. Before being used the asep- tized sounds and other instruments should be carefully warmed, and luljri- cated with some antiseptic substance; they should also be perfectly smooth. Metallic instruments are more liable to produce chill and subsequent manifestations of urinary fever than are the soft varieties. The probable explanation is that soft instruments are used in comparatively small sizes and their introduction is so easy that it would be a bungling operator indeed who could succeed in producing injury; whereas even in skilled hands the use of the steel sound or metallic catheter is likely to produce a relatively marked disturbance both of normal and pathologic mucous mem- brane. When septemia or pyemia develops despite all precautions, very little can be done, as a rule, beyond supporting the vital powers by free stimula- tion, a fatal result being almost inevitable. An attempt to avert a fatal result should, however, be made, by incision and drainage where practicable, and, if the case is clearly septic, a free incision at the site of the stricture, or cystotomy in cases of bladder and prostatic trouble, is the proper re- course. The management of chronic urinary toxemia consists in local antisepsis by irrigation and prompt removal of the organic conditions upon which the gradual and constant septic infection depends. Whenever it is found that there is a tendency to serious disturbance after each operation of dilation in stricture, whatever type the morbid phe- nomena may assume, some more radical measure must be substituted for the sound. Urethrotomy is far safer than attempts at dilation in such cases. Perineal section and drainage is often followed bv no disaa-reeable TREATMENT OF UEINAEY EEVEE. 65 symptoms in deep stricture in which every effort at dilation is followed by alarming symptoms. Nervous manifestations attendant upon the introduction of a sound and bearing a certain relation to so-called urethral fever are so frequently seen that they are worthy of special consideration, though necessitating repeti- tion of points embraced in the preceding general discussion. Some indi- viduals of a nervous temperament are characterized by extreme hyperes- thesia of the urethral mucous membrane, notably of its prostatic portion. The nerves of sexual sensibility are apparently involved in the hyperes- thesia, and are a factor in the causation of the direct and reflex nervous results of instrumentation. Shivering, a sense of impending syncope, cold perspiration, and perhaps nausea are not infrequently noted during the passage of instruments into the bladder. These symptoms commonly begin as soon as the instrument enters the membranous urethra, increasing as the vesical neck is approached. They usually pass off immediately, but may recur, constituting the nervous form of so-called urethral fever already described. The precise cause of these nervous manifestations is not clear. They are probabl}^ often due primarily to an impressionable nervous system associated with timidity. They may, however, occur in individuals of strong consti- tution and undoubted courage. It is nevertheless certain that fear has much to do with the causation of such nervous phenomena in many in- stances. The author has observed that severe pain and spasm usually occur in individuals who have a dread of the treatment; in such patients consider- able depression following simple operations is by no means unusual. It is well to remember, in this connection, the intimate association of the nervous supply of the genito-urinary tract — and particularly the parts about the neck of the bladder and prostate — with the sympathetic ganglia. Eelatively-slight disturbances of these parts produce, in some individuals, most profound and depressing disturbance of the sympathetic nervous system, as shown by various perturbations of the vital functions. The modus operandi of such disturbances is probably through a reflex impression made upon the sympathetic ganglia by irritation of the nerves of sexual and general sensibility supplied to the parts involved. Conversely, it will be found that stimulation of this region, within certain limits, has a decidedly stimulating and even tonic effect upon the general system. There are many nervous disturbances that are purely reflex, referable to irritations of the sexual apparatus independently of pre-existing inflammation. It is a noteworthy fact that inflammation about the neck of the bladder and pros- tate are attended by more marked constitutional depression than similar morbid conditions, of greater magnitude, located elsewhere. This is only explicable upon the theory of a profound reflex impression produced upon the sympathetic via irritation of the involved nervous supply. Eelatively-pronounced nervous disturbance from slight operations is 66 GEXEKAL PHEXOMEXA IX GEXITO-UEIXAEY SUECtEEY. also observed when tissues and organs correlated to tlie prostate and vesical neck are involved. Injuries of and' operations upon the testes, anus, and rectum are striking examples of this rule. Urinary fever — and even minor nervous disturbances — rarely occurs in women, in Avhom the urethra is relatively insensitive. Aji additional factor in their immunity is the fact that the seat of sexual sensibility is not located in this portion of the female anatomy. Erichsen states that he has only once seen symptoms of urethral chill in the female. This was in the case of a strong and healthy young married lady, who had a stricture of the urethral orifice which he dilated by a two-bladed dilator. Twenty hours after the operation she had three most intense rigors, followed by profuse sweating.^ It is obvious that the danger of general infection from urethral dis- ease is more marked in the male: the greater extent of surface and more numerous glands as compared with the female urethra constitute an all- important factor in favoring sepsis. The female urethra is rarely subject to lesions that conduce to general infection. In cases of apparent urethral chill in the female it is wise to look for coincidental pathogenic factors independent of the urethral status, and bearing no especial relation to the operative procedures that are seemingly responsible for the rigor or fever. Hysteria and malaria are important pathologic possibilities for considera- tion in this connection. The author's experience with urethral chill in the female comprises a single case, in which a severe rigor followed shortly after cystoscopy. A slight convulsion, without elevation of temperature, suc- ceeded the chill. In this case the apparentl3^-serious disturbance was prob- ably hysteric. The author was, to a certain extent, responsible for the hys- teric outbreak, having discoursed somewhat didactically before the patient on urethral chill for the edification of the assistants during the operation. Liability to nervous and febrile disturbances following instrumentation of the urethra is greatly modified by the location of the morbid condition that is under treatment. Dilation of stricture in any part of the urethra may produce such phenomena, but they are most frequent after operation upon strictures in the deep portion, not because — as has been stated by some — this part is most commonly strictured, but because it is more closely associated with the nerves of sexual sensibility and the filaments supplied by the sympathetic. In the deep urethra also we are most likely to have dangerously-septic states of the mucous membrane and its environs. Drain- age is notoriously imperfect in this location; hence urine is quite likely to pocket behind an obstruction. The same is true of pathologic secretions. The deeper parts of the urethra being richly endowed with absorbents as contrasted with the penile portion, relatively greater danger of sepsis is to be inferred. ^ "Science and Art of Surgery." CAEE AS A PKOPHYLACTIC FACTOR. 67 Erichsen reports a case in wliieli fatal chill followed incision and dilation of the meatus. Keflex inhibition of the function of the kidneys produced by nervous shock was the probable explanation. Strictures at the meatus often produce serious nervous disturbance, reflex spasm, and vesical troubles, and it is conceivable that an operation upon this sensitive part might have a very profound effect upon the nervous system in some cases: an effect resulting in reflex hyperemia of the kidneys with complete inhibi- tion of their functions and consequent uremia. This succeeds the purely nervous manifestations induced by the operation. It is doubtful, however, if such a serious result could occur from me- atotomy unless the kidneys were extensively diseased. An exception might possibly be made of highly-neurotic individuals in whom grave shock may be produced by very trivial operations. Still, death from pure and uncom- plicated shock is not frequent in any class of surgical accidents or operations. It is to be remembered that, as already stated, a condition of chronic urinary toxemia underlies many of the cases of rigor and fever following instrumentation of the urethra. The nervous system under such circum- stances is in a perpetual state of irritability, and it is only necessary for some slight shock to occur to precipitate a nervous crisis, such as fatal convulsions. This shock is afforded in some instances by even the most delicate manipulations of the canal. The occurrence of the various symptoms which have been described may be prevented, in a large proportion of cases, by gentleness in manipu- lation, and a careful study of the condition of the case at the time of each instrumentation. Like other accidents occurring in the course of dilation of the urethra, much may be done in the way of prophylaxis by careful observation of the exigencies of each particular case. Eoutinism is likety to be attended by annoying or even disastrous results. It is not at all surprising that cases of urethral fever arise in the practice of sur- geons who, regardless of the effects of previous instrumentations and the local and general conditions prevailing at the time of operation, dilate all cases of stricture in a routine fashion every second or third day. The condition of the stricture itself as regards irritability has much to do with the development of nervous manifestations after dilation. Given a highly- irritable state of the contracted tissue, a primarily-susceptible nervous organization, and chronic uremia, in combination with unskillful attempts at instrumentation, urethral chill — and perhaps fever — is almost inevitable. The administration of anodynes; the preliminary use of hot baths, diaphoretics, and other derivative and eliminative measures of treatment; with the careful application of cocain in mild solution and moderate quan- tity at the time of the operation, are very useful in the prevention of dis- agreeable nervous results. The remedies that are generally recognized as valuable in the pre- vention of urethral chill have already been mentioned. It is noteworthy 68 GENEEAL PHENOMENA IN GENITO-UEINAET SUEGEEY. that they are all remedies which act selectively, so to speak, upon the nervous mechanism. Where the operation of dilation produces severe shock, it may be necessary to administer hot toddy or some other form of stimulant. Wine of coca is beneficial to patients of a very impressionable nervous tempera- ment. Eegarding the possibility of nervous manifestations from dilation, the surgeon should never introduce instruments with the patient in the stand- ing posture until tolerance on the part of the nervous system has been ac- quired. It is a very unpleasant thing to have a patient fall upon the floor in a dead faint while an instrument is being introduced: an accident that occasionally happens. Extreme sensibility of the urethra, and incidently of the nervous system, are often observed where the urethra has not been previously explored. This local and general hyperesthesia soon becomes blunted, as a rule, by the local and constitutional effects of instrumentation. It will be found, after a few seances, that operations are well tolerated. In some exceptional cases, however, the urethra remains permanently intoler- ant of instruments, and, no matter how long the treatment may be con- tinued, severe spasm, nervous shock, and perhaps rigors will be produced hy instrumentation. PART 11. NON- VENEREAL DISEASES OF THE PENIS. CHAPTER VI. Anatomy and Physiology, Anomalous Formations, Traumatisms, Acute and Chronic Inflammations, Neoplasms, and Amputation OP THE Penis. The first subject that demands consideration in the special study of the diseases of the male genito-urinary organs is naturally the various patho- logic conditions affecting the organ of generation. Anatomy and Physiology op the Penis. — The penis is designed chiefly for the performance of the reproductive function. The urine is as readily expelled after removal of the penis as when the organ is intact. In the average perfectly-formed adult the quiescent penis measures from 2 to 4 ^/a inches in length, this measurement varying with emotional excitement and increasing imder sexual stimulus to from 5 to 7 inches. The size of the Fig. 6. — Section of the penis at about its middle. (After Cruveilhier.) flaccid organ is no criterion of its dimensions when ready for the act of copulation, the organ in some instances being disproportionately large when erect. On the other hand, a comparatively large penis may increase very little in size during erection. The organ may be divided into three portions: The base, or root; the body; and the anterior expanded extremity, or glans. The base of the penis is closely attached to the pubic rami by two strong fibrous processes known as the crura; it is attached to the front of the pubic symphysis by a fibrous membrane, the suspensory ligament of the penis. The body is composed of three portions: two above, the corpora cavernosa, and one below, the corpus spongiosum. The latter contains the urethra. These three bodies are bound together by a firm fascia to be subsequently described (Buck's fascia), each body having also a special fibrous envelope. (69) 70 KOX-TEXEEEAL DISEASES OF THE PENIS. The corpora cavernosa form the major part of the erectile tissues of the penis; they are situated side by side and united by fibrous tissue. Tliey resemble two cylindrical tubes, the septum between which is imperfect and permits the passage of blood from one to the other. The interior of each is trabeculated^ the spaces thus formed being continually filled with blood. I'pon the walls of these spaces ramify the small arteries that con- stitute the most important part of the erectile tissue. These arteries are curled peculiarly^ being termed, from their resemblance to a helix or coil, the helicine arteries. The septum between the two bodies is termed the septum pectmiforme, from its resemblance to the teeth of a comb. The fibrous investment of the corpora cavernosa is so dense and strong that it is capable of supporting the weight of the entire body. The free com- munication between the interior of the cavernous bodies permits equable enlargement of the jDenis under sexual excitement. Erection is said by most authorities to be due to practically passive congestion produced by compression of the dorsal vein of the penis by a special muscle — the erector penis — with consequent venous obstruction and distension. This, however, is not a sufficient explanation, else it would be practicable to produce a vigorous erection by constricting the root of the organ. Erection is due to active reflex hyperemia produced by dilation of the tortuous helicine arteries under the stimulus of sexual excitement. The phenomena of erection are, in many respects, analogous to the hyperemia of the skin produced by psychic impressions popularly known as blushing. The vascular phenomena in both are produced by a reflex impression upon the vasomotor filaments of the sympathetic. The venous congestion accom- panying erection results from obstruction produced by the pressure of the distended arterioles. The corpora cavernosa begin posteriorly just in front of the ischial tuberosities, passing upward and forward upon either side and joining in the median line. Xear their junction each cavernous body presents a slight enlargement: the hulb of the corpus cavernosum. The corpora caver- nosa terminates anteriorly in a conic extremity adapted to a concavity upon the posterior surface of the glans. The corpus spongiosum contains the urethra, and is situated in the median line beneath the corpora cavernosa. It commences posteriorly, just in front of the deep fascia of the perineum, in a rounded bulb, the iulb of the corpus spongiosum, and terminates anteriorly in another expansion, the glan^ penis. The posterior surface of the glans is concave, fitting accurately the conic extremity of the corpora cavernosa, there being, however, no vascular connection. The glans is conic in shape, somewhat flattened above; at its anterior extremity is the meatus urinarius. The base of the glans presents a circular projecting border, the corona glandis, behind which is a furrow, the fossa glandis. Upon the corona and in the fossa are found a considerable number of sebaceous Eclands. the glands of ANATOMY OF THE PEXIS. 71 Tyson, or glandulce odoriferce. These secrete a sebaceous matter, the smegma preputii, which is of highly-nitrogenized composition and readily decomposes, developing a very offensive and characteristic odor. The function of the glans penis is probably to afford a soft and deli- cate expansion for the exquisitely sensitive filaments of the nerves of sexual sensibility. The arteries of the penis are derived from the internal pudic. Each corpus cavernosum has a separate artery, the artery of the corpus caver- nosum, and also small branches from the dorsal artery of the penis. Special arteries — the arteries of the bulb — supplied by the internal pudic to the corpus spongiosum, are very important in their surgical relations. The lymphatics of the penis consist of two sets: superficial and deep. The superficial terminate in the inguinal, the deep in the pelvic glands. The nerves of the penis are branches of the internal pudic nerve and hypogastric plexus. Upon the glans a few Pacinian bodies are found in connection with the nervous filaments. The hulh of the corpus spongiosum is a factor in the expulsion of the final drops of urine in micturition and of semen in copulation. It is surrounded by comparatively-strong muscular fibers. The prostate, levator ani, and deep urethral muscles force the fluid into the bulbous urethra; the accelerator-urince muscle then impels the fluid by a peculiar undulatory motion forward to the meatus. When this action of the accelerator is in- hibited, as is often the case in organic stricture, the final drops of urine are retained, subsequently dribbling away and soiling the patient's clothing. Sterility may be thus caused, extrusion of semen being incomplete. The three bodies comprising the penis are bound firmly together by a proper fibrous sheath. This is a very important structure in its surgical relations. It was first accurately described by Gurdon Buck. Buch's fascia is really the deep layer of the superficial fascia of the perineum which, curving under the transversus perinei muscles, becomes blended with the anterior layer of the triangular ligament. In this con- nection it should be borne in mind that the so-called special fascias are really not separate and distinct entities. They consist of areas of the gen- eral fascia of the body, which, by virtue of certain physiologic relations with the parts they invest, or because of their surgical relations to various pathologic conditions, have seemed to merit special description. Thus, the intercolumnar fascia is simply the deep layer of the superficial fascia which assumes an important position because it covers the external inguinal ring and is attached to its pillars or columns. The cribriform fascia is merely a part of the deep layer of the general fascia of the thigh, investing the saphenous opening and perforated by the saphenous vein. Buck's fascia rises from the linea alba and pubic symphysis, where it is continuous with a triangular fibrous structure known as the suspensory liga- ment of the penis. It spreads out laterally upon the corpora cavernosa and 72 NON-VENEREAL DISEASES OF THE PENIS. extends forward over their conic extremity, becoming attached to the under surface of the glans. After encircling the corpora cavernosa Bnck's fascia splits into two layers that inclose the corpus spongiosum. It is attached laterally to the rami of the pubes. This peculiar arrangement prevents burrowing of infiltrated urine or pus, so long as the fascia is intact, excepting in one direction,- — above, — where, as shown by Eichet, it is blended with the general abdominal fascia. A large collection of fluid is, therefore, likely to burrow upward into the subcutaneous tissue of the abdo- men, passing outward along Poupart's ligainent into the groin. The fascia rarely yields laterally, permitting infiltration of fluid into the cellular tissue of the thighs. Fig. 7. — Buck's fascia. (After Gurdon Buck.) Tlie integument of the penis resembles, in general, that of the rest of the body. It has, however, a peculiar tendency to pigmentation, and is very loose, there being little areolar tissue beneath it. It is attached firmly to the neck of the glans, being folded over that structure to form the prepuce. The prepuce is necessarily composed of two layers: internal and external. The internal layer, being protected and moist, forms a quasimucous mem- brane. On the under surface of the prepuce is a small, cord-like structure that attaches the internal layer to the under surface of the glans; this is termed the frenum preputii, and contains a small artery, which, if cut or eroded by ulceration, sometimes gives rise to considerable hemorrhage. TEAUMATISMS OF THE PENIS. 73 Anomalous Foemations of the Penis. — Congenital anomalies of the penis are rare and seldom demand surgical interference. Variations in the dimensions of the organ are of no surgical importance. Double penis has been observed, but is so rare that it is a curiosity. Van Buren mentions a single case coming under his observation in which two distinct male organs of normal size and apparently perfect formation were situated side by side, each being attached at its base to the symphysis pubis. One of the organs, the right, was the larger. There was either a double urethra or a diverticulum from the urethra that opened in the perineum behind the scrotum. The meatus in the left organ was impervious. Sexual desire, erection, and emission were apparently normal. The individual was effeminate, as is likely to be the case in congenital malformations of the male sexual organs. Double penis corresponds to the uterus bicornis and double vagina occasionally seen in the female. Cases have been recorded of congenital absence of the penis, the scrotum and testes being perfectly developed and the urethra represented by a rectal opening. This arrangement is similar to that which exists normally in birds. Van Buren and Keyes,^ quoting from Nelaton and Groschler, admit the existence of such cases. More recent writers have also reported cases of the kind. Injuries of the Penis. — Traumatism of the penis is relatively infre- quent, it being quite difficult to injure the organ accidentally. Eupture of the cavernous bodies, more often of the corpus spongiosum, has been seen. Violent attempts at coitus, especially in the presence of chordee, may pro- duce it. A few cases of fracture of the penis produced in this manner have been reported. Bruises of the penis are liable to give rise to considerable ecchymosis, sometimes to extensive extravasation of blood, because of the relatively large size of the blood-vessels, notably the veins, and the extreme looseness of the areolar tissue, which offers little resistance to the diffusion of fluid. Wounds of the penis are sometimes produced by self-mutilation. The insane, especially those suffering from masturbatory melancholia, not in- frequently deliberately injure their sexual organs. Female jealousy is occasionally responsible for wounds of the penis. The author recalls two cases of wounds inflicted by women. In one case the woman claimed to have been defending herself from an attempted outrage. In the other case a man suffered complete amputation of the penis by his jealous wife. Another instance of injury of the penis that came under the author's obser- vation was peculiar. A boatman was set upon while in the act of urinating behind a building by a huge dog and suffered considerable mutilation of the penis. The dangers of injury to the penis are hemorrhage, inflammation, ab- ^ "Surgical Diseases of the Genito-Urinary Organs.' 74 NON-YENEEEAL DISEASES OF THE PENIS. scess, septic infection from decomposition of extravasated bloody urinary infiltration, gangrene, fistula, and subsequent deformity of the organ. Tkeatment. — Contusions of the organ warrant little interference. Complete rest, with either the cold-water coil or ice-bags to limit extravasa- tion and inflammation, is essential. Incision of the contused tissues should be avoided, else infection, with resultant extensive suppuration and perhaps septic processes, may ensue. In some cases the penis may, with advantage, be encircled by adhesive straps to prevent further extravasation and promote absorption of the effused blood. Clean cuts upon the surface of the organ should be sutured with fine catgut, horsehair, or silk sutures, after which the cold-water coil should be applied. Cold is necessary to prevent reopen- ing of the wound during erection, with consequent hemorrhage and slow healing. The extreme heat of the sexual organs, and the reflex tendency to erection incidental to irritations about the penis, are among the principal obstacles to be overcome in the surgery of the part. When there is inflltration of urine free antiseptic incision is an urgent necessity. In cases of fracture of the corpora cavernosa the passage of a gum catheter of moderate size into the bladder has been recommended. The instrument should be anchored and the penis compressed upon it with adhesive straps, the cold coil being applied over all. If extravasation of blood is so extensive that gangrene seems imminent, tension should be relieved by aseptic aspiration or puncture. Cases have been recorded in which gangrene following injury necessitated amputation of the organ. Diseases of the Body of the Penis. — Simple acute inflammation of the corpora cavernosa is but rarely seen; it may, however, result from in- juries. Chronic inflammation is also rare; and its causes are very obscure. In some few recorded instances it has been attributed to syphilis. It is readily conceivable that a syphilitic deposit may occur either in the erectile tissue or fibrous envelope of the cavernous bodies. This may excite proliferation of connective tissue, producing thickening of the corpora cavernosa. As a consequence, impairment of elasticity results and erection is apt to be de- fective. This condition appeared in one of the author's cases several weeks after operation for stricture by a competent surgeon. There was a perma- nent lateral deviation of the organ during erections. This patient, how- ever, was suffering from late secondary syphilis, and it would be difficult to determine what influence the constitutional disease had over the morbid condition following urethrotomy. In some instances calcific material is de- posited at the seat of the chronic inflammation, giving rise to a peculiar condition that has been erroneously termed ossiflcation of the penis. In other instances the fibrous deposit becomes pseudocartilaginous. The plates of cartilaginous or calcific material may be readily felt through the superly- ing tissues. In some instances they are localized and of small dimensions, in others encircling the greater portion of the circumference of the corpora CAVERNOSITIS. 75 cavernosa. It has been asserted that deposits resulting from chronic cav- ernous inflammation are apt to move from the original location, in some instances gradually advancing to the root of the penis. The author's experi- ence has apparently confirmed this. Gout seems to bear a very important etiologic relation to chronic cavernositis. What relation long-forgotten traumatism may bear to it is an open question. We must not overlook the possible analogy of stricture's following old-time trauma and urethritis. The author has met with two cases in which inflammation of the corpora cavernosa developed as a complication of chronic urethritis and stricture. In one case there was marked lateral deviation of the penis during erection; several plaques of induration were discernible. Eecovery ensued Fig. 8. — "Osseous" degeneration of the penis. (After Demarquay.) after some months of urethral treatment conjoined with the faradic current and massage. The conditions described are of importance only as regards their psychic results and possible interference with erection. Keyes has recorded several interesting cases of chronic circumscribed inflammation of the erectile tissue of the corpora cavernosa. The author's personal experience comprises four uncomplicated cases. The treatment of cavernositis offers very little hope of success in most instances. The only cases susceptible to remedial measures are those of unequivocal syphilitic deposit prior to fibroconnective-tissue deposit and those dependent upon chronic urethritis. In three of the author's typic cases no improvement resulted from treatment. In one, however, in which there was a history of possible syph- ilis, large and increasing doses of iodide of potassium, with local inunctions 76 iN'OX-YENEKEAL DISEASES OF THE PEXIS. of mercury^ reduced the induration to a considerable extent^ but did not remove it entirely. Antilitliic remedies are always in order in view of a possible gouty origin. Counter-irritation seems to be of little or no service. Electricity may possibly afford some benefit, although, its use in this affection has not been satisfactory thus far. Electrolysis is worse than useless. Inflammaiion of the corpus spongiosum is by no means rare, but it occurs chiefly as a complication of gonorrhea and stricture, and will be described in connection with those affections. Chordee, as will be seen later, is an example of acute inflammation affecting the spongy body of the penis, and in certain exceptional instances chronic chordee illustrates the effects of chronic inflammation of this structure. Fig. 9. — Penile epithelioma. Vegetating form. (After White and Martin.) Xew Growths of the Pexis. — Tumors of various kinds occur upon the penis; nearly all the simpler varieties of tumor may be met with. They are, however, relatively rare, malignant growths being, perhaps, more fre- quent. Tumors of a cystic, fibroid, lipomatous, telangiectatic, or nevoid character have been observed. Cancer of the penis usually occurs in the form of epithelioma, other varieties being exceedingly rare. Sarcoma has been noted in young subjects as a more or less remote result of trauma. This form of malignant growth develops very rapidlj^, speedily infects the neighboring glands and soon produces death by exhaustion, with or Avithout general dissemination. Epithelioma may invade either the mucous membrane of the glans or the integument of the orsfan.. It affects men above middle age. as a rule. EPITHELIOMA OF THE PEXIS. 77 The author, however, has met with a case in a young man, 28 years of age, in whom epithelioma developed on the site of an indurated chancre and after several operations eventually resulted fatally. The diagnosis in this case was verified by the microscope. The disease is often mistaken in its in- cipiency for a late syphilitic lesion. The speedy involvement of the inguinal and femoral glands and the use of the microscope readily makes the diag- nosis clear. Early syphilis is not likely to lead to diagnostic errors. The disease runs a course similar to that of epithelioma elsewhere, the average duration of the disease being from one to two years. Death finally results from exhaustion and general disturbance of nutrition. In some cases the disease attacks secondarily the testicle and spermatic cord; in rare instances the prostate and bladder are involved. A case of this kind has occurred in the author's experience: — • Case. — The patient was a man about 45 years of age, epithelioma of the glans penis having existed for some months. The disease had progressed very rapidly, and at the time of examination the tumor was the size of a small orange Amputation of the penis was advised and consented to. The growth soon recurred after operation and speedily involved the greater part of the scrotum and the perineal portion of the urethra. By the time the patient consented to a second operation the disease had extended along the spermatic cord and invaded the inguinal canal. Micturition had become very difficult, and it was impossible to pass an instrument into the bladder without producing free bleeding. Urination after instrumentation was attended hj the discharge of portions of what was evidently a secondary growth in and about the prostate and vesical neck, evidence of which was afforded by digital examination per rectum. The obstruction to micturition continuing, the patient submitted to an operation for the removal of so much of the disease as might be necessary for the purpose of freeing the urethra from obstruction, it being evidently impracticable to entirely remove the growth. It was found necessary to excise the perineal portion of the penis as low down as the junction of the crura. As much healthy urethra as possible was preserved. This was everted and stitched to the margins of the wound. The tunica vaginalis was found to be involved in the growth and a portion of it was dissected away with the scrotum, the dissection being carried upward into the inguinal canal for some distance. The patient soon recovered from the operation, although the kidneys, as shown by the condition of the urine, were evidently markedly diseased. Death occurred from uremia some eight weeks later, the wound having healed and urination having been comparatively free since the operation. At the autopsy the bladder and prostate were found to be extensively involved. The kidneys were the seat of chronic parenchymatous inflammation. Epithelioma of the penis usually develops upon the mucous membrane as a small ulceration or excoriation that subsequently becomes indurated and slowly invades the surrounding tissues. It may appear in the form of a small scaly patch which, when removed, reveals at first an excoriated, and later on an ulcerated, surface. The lesion soon begins discharging a thin, foul, unhealthy-looking ichor, or sanies; the ulceration spreads and deepens, becoming irregular, with purplish and ragged edges. Later on the ulcera- tion becomes very rapid and destructive. In some instances the point of departure is a warty excrescence; this soon comes away, revealing an ulcer 78 NON-VENEKEAL DISEASES OF THE PENIS. beneath. The disease may invade surrounding parts very rapidly, finally opening some large blood-vessel or a succession of small vessels, the hemor- rhage from which hastens a fatal issue. Clinical observation shows that all chronic ulcerative lesions, warty or scaly growths upon the penis in men above or about middle age are open to suspicion and should be carefully watched and microscopically studied, particularly if there be a history of syphilis or recent venereal in- fection or if the lesion fails to yield to antisyphilitic remedies in cases of suspected syphilis. Such conscientious observation is the only safeguard for the patient, whose sole reliance is an early and radical operation should cancer be proved to exist. Cancer of the penis may begin primarily in the urethra, this, however, being very rare.^ Tebatment. — The treatment of tumors of the penis of whatever kind consists in excision where possible, with due regard for the genital function of the organ and the possibility of avoiding an operation that will necessarily cripple the part. Cancerous growths, unfortunately, are rarely brought to our attention until so far developed that amputation is the only recourse, though it is questionable whether a less radical operation is ever warrant- able, even when an early diagnosis is made. Amputation of the penis is a comparatively-simple operation. It has fr'equently been performed by means of the ecraseur and galvanoeautery according to the old-time methods of Maisonneuve and Chassaignac. The knife, however, is always to be preferred to such methods, as being more cleanly and surgical and more thoroughly under the control of the operator. Dangerous hemorrhage, inflammation, and sloughing may follow the ecraseur or cautery operation. In very early amputation of the penis as much of the organ should be saved as is consistent with the entire removal of the disease. To prevent the organ from shrinking back under the arch of the pubis in amputation near its root, thus preventing the surgeon from grasping the blood-vessels, the part should be transfixed through the corpora cavernosa with a stout ligature and excised anteriorly to it. The corpora cavernosa should be di- vided first. The urethra should be left a little longer than the body of the organ, according to the method of Teale. This consists in splitting the ure- thra upon its under surface, turning the resulting rectangular flap up over the face of the stump and stitching the edges of the mucous membrane to the edges of the integument. The patency of the urethra is thus secured and otherwise inevitable stricture avoided. There is usually considerable hemorrhage, and, as a rule, four or five vessels demand ligature, the vessels of the corpora cavernosa and corpus spongiosum being ligated separately. Antiseptic dressings and a retained catheter complete the operation. ^ Van Hook has reported two cases of this kind : Chicago Medical Kecorder, No- vember, 1897. AMPUTATION OF THE PENIS. 79 Should oozing of blood be persistent, styptics, hot water, or the actual cautery may be required. The retained catheter may be dispensed with, the urine being drawn with a soft catheter at regular intervals. Whenever the disease is fairly well advanced the entire organ should be removed, with the testes if necessary, and a perineal fistula made. All infected glands should be thoroughly removed. When cancer of the penis involving the deep urethra and prostate is inoperable, suprapubic cystotomy and drainage may become necessary to relieve pain and urinary obstruction. When the growth involves the perineal urethra yet is operable, an artificial urethra opening in the perineum may be easily made where it is possible to preserve a small portion of the proximal end of the normal urethra. Otherwise a permanent supra- pubic fistula is required. CHAPTEE YII. Diseases of the Skix axd QuASi:Mircous Membeaxe of THE Penis. A NUMBER of pathologic conditions of the penis are entirely super- ficial and integumentary in character, involving only the skin or quasi- mucous membrane. The most important of these are: 1. Deformities of the prepuce, congenital or acquired, comprising redundancy, phimosis, and paraphimosis. 2. Inflammation of the prepuce and quasimucous covering of the gians, balanitis, and posthitis or balanoposthitis. 3. Simple acne of the penile integument. 4. Eczema, acute or chronic. 5. Herpes progeni- talis. 6. Simple ulcer. 7. Lymphangitis (erysipelatous or venereal). 8. Phlegmonous erysipelas. 9. Venereal vegetations or simple papillomata. 10. Chancre and chancroid. 11. Various forms of syphilide. 12. Lupus erythematosus. 13. Psoriasis. Phimosis implies a constriction of the preputial orifice that prevents retraction of the prepuce and exposure of the glans. It may result from thickening produced by balanoposthitis, chancre, or chancroid. Chancroid is especially likely to cause chronic thickening of the prepuce, the tissues of which become of a cartilaginous consistency. A large proportion of children are affected with congenital phimosis: a certain number finally succeed in uncovering the glans, but many find it impossible to do so with- out surgical interference. Phimosis in young children may produce results worthy of serious consideration. It has been proved beyond dispute that phimosis is capable of producing serious reflex nervous disturbance. Thus, convulsive affections, such as epilepsy, chorea, and various forms of paralysis (most frequently paraplegia) have been produced by the reflex irritation of a phimosed prepuce. The author has seen glycosuria cured by circumcision of a phimosed prepuce.^ It being impossible to uncover the glans in phi- mosis, the smegma preputii accumulates under the prepuce behind the corona giandis and forms a hard ring about the organ that produces intense irritation. This irritation, being reflected to the spinal cord, produces seri- ous disturbance. Balanitis is also excited, and in some instances pus forms. An evil that frequently results is masturbation. The irritation be- neath the prepuce induces the child to pull at the penis in the attempt to obtain relief. Pleasurable sensations having once been experienced, the child is likely to become a confirmed masturbator. Paraphimosis consists. of the imprisonment of the prepuce behind the corona giandis. This is very apt to occur in young children, who, after retracting the prepuce, are unable to again draw it forward. It also ^ Tide chapter on "Urinalysis in its Surgical Relations.' (80) PHIMOSIS AND PAEAPHIMOSIS. 81 occurs in the adult from retraction of the prepuce when inflamed. In both chiklren and adults paraphimosis may lead to serious results. Strangu- lation of the glans and gangrene have been met with. As a rule, however, the constricting band produces ulceration upon the corona glandis and, becoming itself ulcerated, finally gives way, relieving the constriction and preventing gangrene of the glans. Treatment. — The treatment of phimosis should be circumcision. Though seemingly a simple operation, circumcision has been performed in a great variety of ways. Some little nicety of manipulation is necessary to obtain a really excellent result. The operation is best performed as follows: If adhesions exist they should be separated by means of a stout probe or director. A line is drawn in ink just in front of the corona glandis; the integument being drawn moderately well forw^ard, the prepuce should be engaged between the blades of a pair of long dressing forceps or Eicord's or Henry's preputial clamp. The tissues should be excised with knife or scissors along the line selected. The clamp is next removed and the skin allowed to retract, after which it will be found that a mucous layer of the prepuce still remains over the glans penis. This layer should be slit up wdth scissors in the median line of the dorsum of the penis nearly as far back as the corona, after which the corners, and as much as is necessary of the free border, should be trimmed off. The mucous layer is now turned back like a coat-cuff and the edges of the skin and quasimucous membrane accurately apposed. A small slit should be cut in the integumentary border of the cut surface to limit strangulation of the parts when swelling occurs, as it inevitably will. This procedure gives an abundance of room, and usually prevents tearing out of the stitches under the pressure of inflam- matory swelling. The hemorrhage having been checked, a series of interrupted sutures should be introduced sufficiently close together to insure close apposition of the cut edges. The first stitch should be exactly in the median line on the dorsum of the penis and the second at the frenum preputii, the others being inserted at regular intervals. A dressing of dry iodoform and gauze should be applied, and the patient kept quiet until complete union has taken place. If erections prove annoying, the cold-water coil may be used. The bromids, chloral, and hyoscyamus may be required to allay erections. The patient should be warned against getting up too soon, a week or ten days being usually necessary for complete union. The stitches may be removed on the third day and the wound redressed. Should the patient get about too soon, the edges of the wound will quite likely gape, the result- ing cicatrix proving a source of great annoyance. Where healing by granu- lation occurs, the line of cicatrix may remain tender for months, and so obstruct the circulation in the distal portion of the prepuce that the organ is swollen and sensitive for an indefinite time. Although sometimes advisable, sutures are unnecessary in infants. The 82 DISEASES OF THE PEXILE INTEGUMEXTS. mucous membrane should be rolled back over the glans so that the cut surfaces come into apposition. They may be retained in position by a square of gauze or linen smeared with vaselin, in the center of which a small hole has been cut for the glans. In children several years of age it is well to insert four fine stitches. When the phimosed prepuce is not very redundant, circumcision is not absolutely necessary. It is practicable to stretch the orifice of the pre- puce from time to time, finally accomplishing sufficient dilation to permit exposure of the glans. In some cases of inflammatory j)himosis a dorsal incision only is war- rantable for the time being. Circumcision should follow later on. General anesthesia is unnecessary in circumcision. Cocain may be Fig. 10. — Operation for phimosis. safely and effectively used hypodermically. The Schleich method is effi- cient. Whatever method be used, the drug should not be used in solutions stronger than 1, or at most, 2 per cent, in 1-per-cent. solution of carbolic acid. In infants painting the glans and delicate reflexion of the prepuce with a 4-per-cent. solution of cocain in 1-per-cent. carbolic solution is usually sufficient. When cocain is used hypodermically the root of the organ should be encircled by a rubber constrictor, the solution being injected just in front of it. This limits the action of the drug. Paraphimosis may often be reduced manually: The glans should first be well lubricated with vaselin or oil. The organ is now encircled with the fingers just behind the constricted point, and the prepuce is drawn forward by steady traction, the glans penis being simultaneously compressed BALANITIS AND POSTHITIS. 83 by the thumbs. If necessary, an anesthetic may be given. This procedure will rarely fail, unless paraphimosis has existed for some time and con- siderable inflammation and swelling exist. Should it be found impossible to draw the prepuce forward, the knife will be necessary. The preputial constriction should be nicked at as many points as necessary to relieve the strangulation, after which an attempt should be made to draw the prepuce forward. If the prepuce is so infiltrated that it cannot be drawn forward even after incision, the patient should be put to bed and hot applications ased. Within a few days, or perhaps hours, the swelling will have subsided, so that the prepuce may be drawn into its natural position. If gangrene has already occurred, poultices of charcoal and yeast or hot bichlorid solution and gauze, should be applied until the sloughs come away, after which the process should be treated as simple ulcer. Ulcerations from paraphimosis require the same general surgical principles as under other circumstances, especial care being taken to promote cleanliness by prevent- ing accumulation of decomposable secretions. Balanitis and posthitis — inflammation of the mucous layer of the prepuce and the delicate mucous membrane covering the glans penis — are very frequent. These conditions may occur spontaneously as a consequence of highly-acid urine or the decomposition of various secretions which accumulate beneath the prepuce in uncleanly persons. They occur, how- ever, in those who, however particular they may be regarding the toilet of their sexual organs, find cleanliness impossible because of phimosis. Bala- noposthitis may also occur as a complication in chancre, chancroid, and most frequently of all in virulent urethritis. It is under all circumstances a non-venereal disease per se, being invariably produced by irritation, which may depend upon the presence of either venereal or non-venereal secretions and may or may not be derived through sexual intercourse. When the in- flammation has existed for some little time, there occurs, in many instances, — especially where the source of the irritation is the secretion of gonorrhea or chancroid, — excoriation of the mucous membrane. The delicate epi- thelium covering the glans first becomes macerated, then abraded, and at various points small ulcers may develop that may be mistaken for true venereal ulcers. Another condition that may arise is venereal vegetations. The secretions of balanitis and posthitis are not inoculable in the strict sense of the word, unless gonorrhea, chancroid, or true syphilitic chancre be present, in which case we have an admixture of specific with non- specific secretions. Balanitis may give rise to bubo of a simple inflammatory character, which may suppurate. Balanitis may be mistaken for gonorrhea or chancroid. Autoinocula- tion will differentiate it from the latter, and inspection, before or after pre- putial retraction, will exclude urethritis. There is no period of incubation in balanitis, and the disease is variable in its course. 84 DISEASES OF THE PEXILE IXTEGUMEXTS. Treatment. — The treatment of balanitis and posthitis consists of meas- ures to promote cleanliness and the application of mild astringent washes or dry absorbent powders, the powdered oleate of zinc, stearate of zinc, calomel, lycopodinm, and oxid of zinc, all being useful. In some cases it is necessary for the patient to wear a small ring of absorbent cotton about the glans penis under the prepuce. If changed frequently this will keep the parts dry. "Wlien attacks of balanitis recur repeatedly, circumcision is demanded. If in the course of the case the prepuce becomes greatly swelled and phimosed, a dorsal incision may be necessary to expose the glans and relieve tension. Pexile acxe may appear as pustules or papules upon the skin, very rarely upon the quasimucous membrane. It may result either from general debility in combination with local irritation or from infection with pus- microbes alone. Small acneic pustules sometimes form about ordinary comedo of the integument of the penis. In appearance the disease is similar to acne in other situations. The diagnosis is usually not difficult, the lesions being totally unlike chancre and chancroid. The absence of autoinoculability and the history of the case, in addition to the physical characters of the lesions, usually serve to differ- entiate the condition from both forms of venereal sore. Acne may, how- ever, occur upon the mucous membrane as a pustule closely resembling follicular chancroid. Again, acne may precede a venereal sore. Treatment. — The treatment of penile acne consists of attention to the general health, the promotion of cleanliness, the application of soothing lotions, and incision of the pustules. Eczema of the pexis is occasionally seen, and is usually coincidental with eczema scroti. It sometimes proves very obstinate. A case which recently came under the author's observation is a striking illustration of this. The patient had been affected with eczema of the penis and scrotum for a number of years, the condition being limited to these parts. The integument and mucous membrane were extensively infiltrated, fissured, and excoriated. So severe was the disease that intercourse had become a practical imjoossibility, and the itching and irritation made the life of the patient most miserable. The case had passed through the hands of a number of competent physicians, none of whom had been able to give permanent relief. Under applications of a mild solution of salicylic acid and the inter- nal administration of arsenic slight improvement occurred, but the patient finally became discouraged and stopped treatment. Some of these cases are gout}^ and may be cured by hydrotherapy and dietetics. Treatment. — The treatment of genital eczema is essentially the same as that of other forms of the disease. HePlPES Peogexitalis. — This is a most important, though relatively harmless disease. It is important chiefly from its frequent occurrence, the moderate amount of local irritation it sometimes produces, its demoralizing HEKPES PKOGEXITALIS. 85 effect upon the mind of the patient, and its liability to be mistaken for other diseases. It consists of a development of small vesicles filled with watery, sometimes sero-purnlent, fluid upon the skin or mucous membrane of the genitals. It is rarely seen in the female, although in Hebra's atlas there is an excellent representation of the disease in a woman. According to Unna, the disease is not so very infrequent in women, and Duhring claims he has never seen it in Avomen. It is possible, as Unna says, that women are just as susceptible to herpes as men, and that females are not immune, but, if so, its apparent rarity must be due to the protected situa- tion of the lesions which prevents discovery. According to Legendre, Fournier, and Bruno, the coincidence of an herpetic eruption with menstruation is not infrequent. In some women it develops shortly before every menstrual epoch. The author's personal experience is limited to a single case: a lady who suffers from a crop of herpetic vesicles and ulcerations about the inferior commissure of the vulva at every period of menstruation. These are very annoying from pain and smarting, the act of urination being very distressing. With some attacks there occurs marked edema of the genitals. An interesting case of herpes apparently dependent upon menstruation recently came under observa- tion in which the eruption, instead of being located upon the genitals, appears between the fingers. It comes on a few days prior to menstruation, and lasts for a day or two after its cessation. During this time consider- able neuralgic pain in the arm and hand is complained of. The author has seen one case in which herpes progenitalis repeatedly occurred with preg- nancy and at no other time. Diagnosis. — The diagnosis of herpes progenitalis in uncomplicated cases of the affection is comparatively easy. There is usually a history of recurrent crops of vesicles and minute ulcerations, perhaps independently of sexual intercourse. In the larger proportion of cases there is no definite relation to any particular act of intercourse; even when due to irritating materials deposited upon the mucous membrane during uncleanly inter- course, the affection comes on at a variable interval thereafter, in some in- stances the eruption appearing within a day or two, in others not for several weeks. Etiology. — The cause of herpes progenitalis is usually said to consist of local irritation, but it would seem probable that a great majority of cases depends upon a neurosis. In this the disease strongly resembles herpes zoster. Some patients of a highly irritable, nervous temperament, readily subject to nervous depression, and perhaps suffering from more or less general debility, are affected at frequent intervals by successive attacks of herpes of the genitals. Malarial infection may produce herpes progenitalis, as well as other forms. Unna is inclined to regard herpes progenitalis as rudimentary herpes zoster and calls attention to the limitation of herpes zoster and herpes progenitalis to peripheral points of nerve-distribution. In some 86 DISEASES or THE PENILE INTEGUMENTS. cases herpes progenitalis is apparently due to disturbance of the parts in- cidental to pregnancy and menstruation in the female. Uncleanliness, decomposing secretions^ hot weather, obesity, forcible attempts at inter- course, impeded erection due to redundant prepuce, excessive venery, and masturbation are all capable of causing excessive congestion of the genital organs, which the author believes to be the essential condition upon which herpes progenitalis depends. Imperfect or perverted sexual hygiene is peculiarly liable to give rise to more or less congestion of the genitalia, with attendant disturbance of the delicate nerves supplied to these parts. That this condition of affairs may give rise to trophic changes in the mucous mem- brane and skin, as evidenced by the occurrence primarily of vesicles and sec- ondarily of ulceration, is highly probable. There has been, so far as the author is aware, no mention made by writers of the possible causal relation of syphilis to herpes progenitalis. Many cases, however, seem to be directly dependent upon the syphilitic cachexia. Syphilitic patients return, from time to time, with apparently typic crops of herpes upon the genitalia. These cases are usually obsti- nate to all local measures, excepting the application of mercurials. Tonic and mild antisyphilitic remedies are also required internally. The author attributes the herpes in such cases to several causes: — 1. (In some cases) Local irritability incidental to the chancre or mixed sore that originally initiated the patient in his venereal experience. 2. Disturbed innervation and consequent trophic changes — incidental to the effects of the syphilitic infection, excessive medication (with mer- cury especially), and mental worry upon the sympathetic sj^stem. Herpes progenitalis rarely affects the integument of the penis, scrotum, and thighs, being limited usually to the glans. Unna states that the erup- tion almost invariably corresponds with the course of the ramus dorsalis penis: a branch of the pudic nerve. The author, however, has not noted any regularity of distribution of the herpetic vesicles. Cases limited to the skin of the organ are sometimes observed. The pain of herpes progenitalis is usually insignificant. If, however, urine be brought in contact with the little ulcerations left after the rupture of the vesicles, the part becomes exceedingly tender and much burning and smarting are complained of. The disease may develop just at the borders of the meatus urinarius and occasionally Just within it. In one of the author's cases a row of some half-dozen small herpetic vesicles develops upon the right side of the meatus from time to time, while in another there is an occasional development of herpetic spots just inside the orifice. In these cases there is considerable pain and smarting during urination, and the disease seems to develop coincidently with nervous depression. Differentiation. — The diseases for which herpes is most likely to be mis- taken are chancre and chancroid. There is, of course, no difficulty in the differential diagnosis of herpes from typic chancre and chancroid when HERPES PROGENITALIS. 87 these are fully developed, but in their incipiency mistakes may be made. Fortunately, however, a few days' study of the case will generally clear up the diagnosis. Chancroid often begins as a small herpetiform vesicle or perhaps group of vesicles or ulcers. This is probably because the chancroidal or other irritating germ inoculated during intercourse produces primarily herpes, by simple irritation, chancroid afterward developing at the site of the herpetic lesions. The same explanation holds good in some cases of hard chancre. The so-called 'Tierpetiform chancre" is probably explicable in this way. Unna has noticed a form of initial sore that is probably her- petiform chancre. According to him, chancres in the male may occur on the inner surface of the prepuce which are benign in appearance and slowly involve the surrounding tissues, resembling, at first sight, herpetic erosions. These are chancres involving Tyson's glands, which develop as slight epi- thelial proliferations in small contiguous groups of sebaceous glands. The round follicular openings are eroded, abnormally patulous, and acutely hyperemic, resembling an herpetic erosion. The typic herpetic course being followed, slight induration becomes manifest, succeeded by disintegra- tion and confluent, rapidly-spreading ulceration, resembling soft chancre. These exceptional cases may lead to an unjustly-favorable prognosis. In cases in which true syphilis follows an apparently herpetiform lesion of the genitalia there will probably always be found upon close inspection, if the case be carefully watched from day to day, a certain degree of chanerous induration. An important source of error in the diagnosis and prognosis of certain atypic genital lesions is that physicians do not watch their cases with sufficient care, and are prone to give a dogmatic opinion without considering the many sources of confusion. If these cases were more carefully studied, it is highly probable that many of those cases of syphilis which have apparently followed simple, non-indurated lesions of an herpetic, simple ulcerative, or chancroidic character would be foimd to have been preceded by induration that developed after the simple sore had apparently healed, when the patient's attention was no longer directed to the local difficulty. Again, as will be seen in connection with the diagnosis of syphilis, induration may be transitory and thus escape attention unless the lesion be studied with extreme care from day to day. When herpetic ulcerations become inflamed they may closely resemble true chancroid. Indeed, under certain circumstances herpetic and balanitic ulcers, or, for that matter, ulcerations of any sort whatsoever, may become transformed into the physical characters of a mild type of chancroid. This statement is made with due appreciation of the wide clinical differences between typic herpes and typic chancroid. Eeferring to the possibility of superadded infection in herpes, a word of caution is necessary. A posi- tive opinion should never be passed upon the character of herpes progeni- talis, or, indeed, of any apparently non-specific lesion of the genitalia in 05 DISEASES OF THE PENILE INTEGUMENTS. cases in which there has been a more or less recent suspicious exposure. The patient should be made to understand the possibility of a syphilitic or chancroidal infection which has not yet developed and which there are no means of detecting prior to the appearance of the specific sore. Ti'eatment. — The treatment of herpes progenitalis is^ in the majority of instances, simple and successful, but the disease is sometimes very obstinate. Mild dusting-powders or astringent washes are usually sufficient. A most efl&cient powder is the stearate of zinc. Calomel, oxid or oleate of zinc, sub- nitrate or subcarbonate of bismuth, and lycopodium, singly or in various combinations, are all useful. A mildly-astringent wash of iodid of zinc, 5 or 10 grains to the ounce, or alum, in a strength of 20 or 30 grains to the ounce, may be used as a lotion. It may become necessary to touch the her- petic spots with nitrate of silver. Wlien the lesions are very painful mor- phin or cocain may be added to the dusting-powder. The essential point in the treatment is to keep the parts clean and dry. In some instances cir- cumcision is advisable. In many cases constitutional measures are necessary. Tonics — such as quinin, iron, and strychnin, and, where there is much nervous irritability, bromid of potassium — are indicated. In some chronic cases arsenic will be found useful. In the solitary case of menstrual herpes that the author has seen, the bromids, with very small doses of ergot for a' week or ten days prior to menstruation, has proved of some benefit, although the patient is by no means cured. In some cases of genital herpes in the male the occasional passage of a sound will prove beneficial by relieving nervous irritability, congestion, and sexual excitability. In a general way the sound may be said to improve the tone of the genital organs. Some obstinate cases are apparently cured by matrimony. A. few cases will appear absolutely resist- ant to treatment, yet may, at any time, recover spontaneously. Simple Ulcer. — Simple ulcer of the genitals is so intimately associated with balanitis and herpes that it hardly deserves separate consideration. Sometimes, however, in the course of gonorrhea, chancroid, or chancre, small ulcers appear upon the quasimucous membrane that are apparently due to irritation produced by the products of inflammation. In uncleanly persons simple ulcers of a benignant appearance may occur that are apparently due to uncleanliness. Eetention of irritating secretions in phimosis may give rise to simple ulceration with or without the intervention of balanitis. Herpes may be followed by simple ulcers of greater or less extent and persistency. This Avill quite likely occur if the herpes is neglected or the patient uncleanly. Simple ulcer is important chiefly on account of its close simula- tion of true chancroid if it be subjected to sources of irritation. The line of demarkation between simple ulcer and chancroid is the autoinocula- bility of the latter; but, as will be seen later on, this may be a difference in' degree rather than kind. The products of simple ulceration may, under favorable circumstances, produce a sore in another situation that may not LYMPHANGITIS. 89 always be clue to mere pus-infection. The fact that the secretion of a chancroid produces, when inoculated, a sore precisely similar to that from which the secretion was derived is probably dependent upon the circum- stance that the poison (germ) of chancroid is more highly elaborated (differ- entiated) than the irritating germs and germ-products of simple ulceration. This does not necessarily imply that the origin of the two diseases may not, under certain circumstances, be precisely similar. Again, chancroid after a yariable time loses its property of infection, and, while physically it is none the less a chancroid, it is practically no more noxious than any simple ulcer and takes the same course. The author thus expresses him- self with due cognizance of the Duerey-Unna bacillus — the alleged specific germ of chancroid. Treatment. — The treatment of simple ulcer consists of measures of cleanliness, mild astringents, and the proper management of the particular disease to which it may be secondary. Care should be taken not to inflame or irritate the part by overvigorous measures. Lymphangitis of the Integuments of the Penis. — This is almost invariably secondary. Any disease giving rise to irritating products capable of absorption by the capillary lymphatics (as is true of all inflammations, sim]Dle or specific) may be complicated by lymphangitis. Perhaps the most frequent disease that produces it is virulent urethritis. It is apt to occur, however, in the course of true syphilitic chancre as a consequence of local irritation and mixed infection. The chronic infiltration of the lymphatic vessels that occurs in the natural course of syphilis should not be regarded as true lymphitis, but rather as hyperplasia produced by rapid proliferation of both normal and syphilitic cells in the lymphatic structures. Chancroid is likely to be followed or accompanied by inflammation of the lymphatics of the prepuce. This may be localized in one or more lymphatic vessels leading from the chancroid to the root of the penis, or it may be diffuse and superficial, causing a uniform thickening of the penile integument. In the course of chancre or chancroid, inflammation from mixed infection sometimes occurs about the lymphatic vessels (perilym- phitis). This may cause suppuration without involving the vessel proper. Lymphitis or lymphangitis of an erysipelatous character may result from streptococcic infection; this may go on to true phlegmonous erysipelas or diffuse cellulitis. Operations about the penis followed by infection may give rise to in- flammation of the lymphatics, indicated by redness, swelling, edema, or per- haps tension of the prepuce. In diffuse lymphitis there is often consider- able constitutional disturbance, especially if erysipelatous infection exists. When the inflammation is limited to the trunks of the lymphatics, more or less hardened, reddened, and tender longitudinal lines or cords may be felt beneath the skin of the penis. The process may remain superficial and circumscribed. It may in- 90 DISEASES OF THE PEXILE IXTEGUMEXTS. crease, causing general swelling of the integuments of tlie organ. As a con- sequence of lymphitis, phimosis or paraphimosis may develop. The inflam- mation may become chronic, the prepuce remaining hardened, thickened, infiltrated, and semicartilaginous for an indefinite time. Suppuration does not usually occur in lymphitis, but may do so if the patient be debilitated, in extensive .pus-infection, or if the primary process be chancroid. Pus may form at circumscribed points in the course of the inflamed lymphatic vessels, or may diffusely infiltrate the cellular tissue beneath the integument of the penis, and perhaps cause gangrene, these latter cases closely resembling true phlegmonous erysipelas. Treatment. — The treatment of lymphangitis consists chiefly of rest and the application of soothing lotions, such as lotio plumbi et opii. This had best be applied hot, as care should be taken not to depress the vitality of the tissues. Ichthyol is valuable. A brisk mercurial purge followed by salines should be given. Aconite or veratrum may be required. If suppuration seems imminent, or the prepuce becomes dusky and brawny, free incisions should be made, these being the best prophylaxis of suppuration. Anti- septic poultices are needed where phagedena or gangrene develops. The chronic infiltration and thickening of the prepuce that sometimes follow acute lymphitis usually demand circumcision. In some cases, however, judicious strapping and the use of the faradic current will slowly bring about resolution. Frequent bathing with hot water is a valuable adjuvant. Phlegmoxous Erysipelas of the Pexis. — This usually involves the scrotum and occurs occasionally as a primary disease — one of the most formi- dable that the surgeon is likely to meet with. The disease rarely comes under the observation of the general practitioner, or, indeed, of any save those connected with public institutions; but it is nevertheless important on account of its invariably serious character. It occurs, as a rule, in broken-down, debilitated individuals with bad hygienic surroundings. Its origin is usually obscure, it being often impossible to trace it to infection with the erysipelas streptococcus. The author's cases have nearly all been seen in hospital practice, and were contracted outside the institution. In none of them was there a history of traumatism or of exposure to con- tagion.^ Symptoms. — The disease begins with a greater or less degree of swelling and redness of the part, the prepuce speedily becoming edematous. The organ soon becomes excessively swelled and infiltrated, and very tender to the touch. There may or may not be a rigor. The temperature is likely to be relatively high. Bogginess, followed by gangrene and extensive slough- ing, is likely to come on quite rapidly. ^ Since the above was ■written the author has seen in consultation a speedily fatal case of this type of infection following a simple meatotomy. The source of infection was not determined. GENITAL PAPILLOMATA. 91 The constitutional symptoms are characterized by great depression. Septemia or pyemia may supervene. After the sloughs have separated, the tissues soon undergo cicatrization. The rapidity of repair in these cases is astonishing. The author has seen the skin and cellular tissue of the penis and scrotum slough completely away, yet healing was so rapid as to be considered phenomenal. The prognosis of this disease, as given by the majority of authorities, is very unfavorable. A successful result is not to be expected from any but the most radical treatment, which often saves life. Treatment. — The treatment of phlegmonous erysipelas of the penis and scrotum must be prompt and radical. Free incisions should be made in number sufficient to completely relieve tension. Hot antiseptic poultices or wet dressings should then be applied until the sloughs separate and healthy granulation is established, when the process should be treated by dry antiseptic dressings, followed later on by nitrate of silver and strapping. The internal treatment should comprise a nutritious diet and free stimulation. Iron, quinin, strychnin, and digitalis are always indicated. The tendency to asthenia is peciiliarly marked, and supportive measures should be relied upon early and late. G-ENiTAL Papillomata. — Vegetations or papillomata upon the mucous or quasimucous surfaces of the genitals in both sexes are popularly known as venereal warts. This term is a misnomer, as the growths are in no sense venereal, but due to causes entirely independent of sexual intercourse. They may be met with in persons who have never been exposed to venereal infection. They are frequently found in pregnant women, in whom the con- ditions favorable for their development very often exist, particularly among the lower classes, to whom cleanliness is apparently obnoxious. The condi- tions that foster these papillary overgrowths resemble in many respects those essential to the development of vegetable fungi: heat, moisture, and filth, with protection from air and sunlight. Idiosyncrasy and local nerve-per- turbation are also worthy of consideration as possible etiologic factors. In the case of fleshy vegetations upon the organs of generation there exists, in addition to the above-mentioned conditions, local irritation pro- duced by the products of simple or specific inflammation or decomposing normal secretions. Secretions occurring about the ano-genital region in un- cleanly persons are prone to decomposition, and when decomposed develop irritating products that may give rise to inflammation of the mucous mem- brane in balanitis or to a proliferation of the epithelial elements of the part. Gonorrhea, chancroid, chancre, balanitis, balanoposthitis, and, indeed, any affection of the genitals giving rise to irritating secretions, may result, even under the best of care, in the development of vegetations. The papillom- atous growths consist of delicate, rapidly-proliferating epithelium that be- comes permeated when fully developed by delicate loops of capillaries; they are therefore very friable and extremely vascular, bleeding freely upon 93 DISEASES OF THE PENILE INTEGUMENTS. the slightest injury. Genital papillomata may grow to an enormous size; thus, the author has met with several cases in which vegetations involving the prepuce and glans grew to the size of an orange. In a case occurring in a comparatively-cleanly pregnant Avoman who, so far as known, had never suffered from any venereal disease, the vegetations surrounded the ostium vagince and involved the tissues about the anus, forming a tumor not unlike a large cauliflower. In passing, the author desires to call attention to the fact that syphilis seems to hear a very important etiologic relation to genital vegetations. Fig. 11. — Venereal vegetations. (After Taylor.) Syphilitics are esjDccially prone to their development and the papillomatous growths are seemingly very resistant to treatment in such patients. The frequency with wdiich genital syphilides become transformed into exuberant vegetations, with a distinct and positive tendency to form connective-tissue organization, is noteworthy. Treatment. — The growths should be treated by excision with the knife or scissors or destruction by caustics. The danger of hemorrhage in very large growths is such that caustics are sometimes preferable to excision, although, if the surface involved is not very extensive, even these large growths may be excised and their bases seared with the actual cautery. Ex- GENITAL PAPILLOMATA. 93 cellent results may soiiietimes be secured by injection of glacial acetic acid with the hypodermic needle. Small growths are best treated by excision with scissors, the underlying mucous membrane or skin being removed with the growth. If necessary, fine stitches may be inserted. Chromic acid is one of the best caustics for the destruction of venereal vegetations. It should, however, be cautiously used, as it will sometimes cause much more extensive destruction than desired. Good results may often be obtained by imbedding minute grains of the pure acid in the growth. Genital papillomata will rarely occur if proper measures of cleanliness are adopted. Secretions, whether normal or morbid, should not be allowed to accumulate beneath the prepuce, and when the mucous membrane be- comes irritated or the secretion excessive astringent lotions or drying pow- ders should be freely used. Circumcision is usually demanded. After de- struction of the oTowths the mucous membrane should be treated for some Fig. 12. — Simple penile papillomata. (After White and Martin.) little time by means of astringent or absorbent powders and lotions to pre- vent their recurrence. In the majority of cases vegetations will recur to a greater or less extent for some time in spite of treatment. They should be removed so soon as detected. Once the mucous membrane has regained its normal condition papillomata will no longer develop. Constitutional treat- ment is often essential in genital papillomata. Tonics, and especially arsenic, are often valuable. In cases with a specific foundation mercury and the iodids are necessary. The conditions remaining in the preliminary classification of penile diseases do not demand discussion in a work of this kind. Lupus erythem- atosus and psoriasis of the penis present the same features as when in- volving other portions of the body, and properly belong to the department of dermatology. Syphilides of the penis, aside from their tendency to papil- lomatous complication, are the same as syphilides in general. Chancre and chancroid will receive attention later on. PART III. DISEASES OF THE UEETHEA AXD GO^^OERHEA. CHAPTER YIII. Diseases of the Male Urethra: Anatomy and Physiology; Teatj- iiATisMs; Foreign Bodies and Tumors of the Urethra. The urethra is a musculo-membranous tube extending from the meatus Tirinarius to the bladder. It is divided^ in the male, into three portions: the penile, spongy, or pendulous urethra; the membranous; and the prostatic. The "two latter constitute the fixed, or deep, urethra. The spongy urethra is about six inches in length, extending from the meatus to the triangular ligament, where it Joins the membranous portion. The latter is about three-fourths of an inch long, extending from the anterior to the posterior Fig. 13. — The fossa navicularis. (After Cruveilhier.) layer of the triangular ligament. The remainder of the urethra is included in the prostatic portion, which is about one and one-fourth inches long. The meatus is the narrowest portion of the canal, and serves the purpose of directing the outflowing semen and urine. The meatus varies con- siderably in size. A small meatus is not necessarily an indication for a surgical operation, but if a small-calibered orifice is associated with urethral disease or reflex disturbance of the genito-urinary tract, a narrow meatus is surgically important. The meatus is sometimes narrow because of the com- paratively great thickness of that portion of the glans forming the floor of the fossa navicularis, the dilated portion of the urethra situated within the boundaries of the glans and terminating at the junction of the latter with the corpora cavernosa. In other cases narrowness of the meatus is due to a thin membranous fold at the inferior commissure of the orifice. This is dilatable, and offers little or no resistance to instrumentation, the contrary being true of the variety of narrowing previously mentioned. Narrowness (94) ANATOMY OF THE MALE UEETHEA. 95 of the meatus is generally congenital, destructive ulceration being the usual cause of acquired contraction. In some instances the canal is relatively narrow because of the presence of a congenital band just within the meatus, the orifice proper being fairly dilatable. On the roof of the fossa navicularis is a valve-like fold of mucous membrane forming a small pouch — the lacuna magna — that often becomes the seat of chronic infection which per- petuates urethritis. The spongy urethra is so called because it is surrounded by the corpus spongiosum. The mucous membrane of this portion of the canal is abun- dantly supplied with mucous glands and ducts. These, if infected, are likely to become dilated and their orifices obstructed, with a resultant accumula- tion of infectious products in the glands. Latent infection and successive gonorrheal autoinfections are often explained thereby. These ducts and Fig. 14. — Showing lacuna magna. A, Spongy urethra. B, Fossa navicularis. G, Probe separating valve-like fold from roof of lacuna magna. D, Lacuna magna. (After Bumstead and Taylor.) follicles may be so dilated as to catch the points of instruments in the ex- ploration of the urethra. They may also be the point of departure of uri- nary abscess and fistula. Their abundance and the difficulty of rendering them aseptic explains the obstinacy of some cases of urethritis. The membranous urethra is invested by longitudinal and circular fibers — the compressor-urethrce and accelerator-urince muscles. On this account it is also known as the muscular portion. Its function is very important, as it is the true sphincter of the bladder. This is under volitional control, but in rather a peculiar fashion. To the sympathetic nerve-supply of the muscle its normal tonicity is due. The voluntary nerve-fibres make it possible to inhibit the normal contraction at will, consequently the normal tonus of the detrusor urince is enabled to overcome the slight remaining 96 DISEASES OF THE MALE UEETHEA. resistance of the true sphincter, witli resulting micturition. Direct or reflex excitation of the membranous urethra may cause retention of urine. Con- versely, paralysis of it produces incontinence. Tlie prostatic urethra will receive attention in connection with the anatomy of the prostate. The anatomic relations of the jDerineal portion of the urethra are of most vital surgical importance; esjDecially is this true of the relation of the bulbous and membranous portions to the triangular ligament. These anatomic relations are of the greatest importance in their bearing upon the surgery of the prostate and bladder. The dissections of the perineum as presented in Gray's "Anatomy"' — reproduced herewith — give the clearest possible idea of the anatomy of the perineum. It is well for the surgeon who is not a practical anatomist to review these plates before the per- formance of important operations in this region, whether the operation be Fig. 15. — Diagrammatic section of perineum, showing arrangement of the tri- angular ligament (deep perineal fascia), a, Corpus cavernosum. b, In- ferior layer of triangular ligament, c, Transversus perinei muscle, d, Urethra, e, Cowper's glands, f, Superior layer of triangular ligament. g, Internal pudie artery. It, Internal pudic nerve, i, Descending ramus of ischium. ;, Superficia] fascia. A". Erector-penis muscle. J, Bulb. m, Accelerator-urinae muscle, n, Superficial fascia, o, Superficial perineal artery, p, Superficial perineal nerve, q, Skin. (After Tillaux.) perineal section, cystotomy, lithotomv, or radical methods of dealing with the prostate. While the urethra is, under normal circumstances, a urinary organ, it is not necessary to micturition. It is, however, necessary to the procreative act. The urethra is, therefore, a sexual rather than a urinary organ. The length of the urethra as given by most anatomists is from eight to nine inches, but there is great discrepancy upon this point. The esti- mates of various clinical observers show a marked variance of opinion. A difference of from 20 to 30 per cent, in the estimated measurements of equally competent observers is neither unusual nor surprising. It is prob- ANATOMY OF THE UEETHEA. 97 able that no two observers can obtain precisely similar conditions for meas- urement. The penis varies in size not only in different subjects^ but there CvngvrV GUod Fig. 16. — Dissection of perineum, showing relation of bulb of urethra to the triangular ligament. (After Gray.) is great variation in the same subject under different psychologic condi- tions. Cruvtr't Giant/- Aif*rj °f Corpiu Cattrnaim Uarta/ Arbr/f ff ft Artiry f/ Buli. Zntimal PaJic Artery Fig. yi. — Dissection of perineum, showing deeper jjarts in their relation to the urethra. (After Gray.) The individual urethra is a law unto itself as regards its length. The length of any particular urethra may be fairly said to be the distance from 98 DISEASES OF THE MALE UEETHRA. the meatus traversed by the catheter before the urine begins to flow, the penis being flaccid and Just tense enough for adequate support during Fig. 18. — Xormal cuive of luetlua. (/, Prostatic portion, h. ^Membranous portion, c. Spongy portion. instrumentation. Allowance should be made for sexual excitation or emo- tional inhibition of blood-supply. The physiologic functions of the urethra bear an important relation to the study and treatment of its diseases. While the urethra is of sexual Fig. 19. — Bell's curve, showing relation of (E) Englisli, (A) American, and {B) Benique sounds to it, and comparative length of beaks. rather than urinary importance, both functions must be borne in mind in considering its pathology and therapeutics. "Were it possible to inhibit urination and bring the sexual function of the urethra under complete con- CONGENITAL DEFORMITIES OF THE UEETHKA. 99 trol, tlie diseases of this part would be of trifling importance and their treat- ment very simple. The diseases of no other structure of the body are treated upon such irrational principles as those of the urethra, because of the necessity of mechanic disturbance of the canal at variable intervals in the act of micturition and the difficulty of obviating sexual stimuli, aside from the mechanic dangers of actual intercourse. The anterior curve of the urethra is not important with relation to instrumentation, for it can be adapted to almost any form of instrument. This is not true of the deep curve, which is relatively fixed; it cannot be said to be constantly fixed, for straight instruments can be introduced into the bladder. The fixed urethral curve is not uniform, varying widely with the period of life and condition of the prostate. It is comparatively short and sharp in the child, longer and less abrupt in the adult, the difference increasing with age. In prostatic enlargements the deep curve becomes elongated, necessitating modification of instruments and technic. This is of great importance to the surgeon. The direction and conformation of the pendulous urethra is modified by changes in the position of the penis. It is also adaptable to any form of instrument for the urethra or bladder. The average normal deep curve, as established by Bell, corresponds to a circle three and one-fourth inches in diameter, the proper length of curve being an arc of such a circle subtended by a chord two and three-fourths inches in length. The length of curve suggested for instruments by Thomp- son is generally too long. The shorter the beak of the sounds — providing it be adapted to the normal curve — the more thoroughly under control will the instrument be during insertion. The author believes that the majority of surgeons entertain an exagger- ated estimate of the required length of instruments. As a result, vesical and urethral instruments are usually much too long, and consequently often do damage. Congenital Deformities of the Urethra. — Hypospadias and Epi- spadias. — These comprise the two conditions which embrace practically all of the congenital deformities of the urethra, save the rare cases in which diverticula or double channel exists. These conditions have quite generally been accepted as due to a failure of development in intra-uterine life. The embryo being practically laid down primarily in two longitudinal sections, which subsequently become" fused together in a perfect anatomic entity, it is obvious that failure of fusion at any particular point may produce con- genital deformity. The deformity necessarily varies in kind according to the location of developmental failure, and its degree is, of course, modified by the extent of such defect in fusion. It seems logical to infer that the deformities under consideration are the results of the failure of fusion of the genital furrow. It is the normal fusion of this furroAv which eventually differentiates the sexes. A failure of development results in an approxima- tion to the male or female type according to the degree to which embrvonic 100 DISEASES OF THE MALE URETHRA. deyelopment lias arrived at the time development is interfered with. The Yarious forms of failure of differentiation have led in manj^ instances to eon- fusion in the determination of sex; the subjects of hypospadias and epi- spadias, — especially the former, — -therefore, are very closely associated with hermaphroditism in its various phases. Failure of fusion of the scrotum, associated with cryptorchidism, rudimentary development of the penis, and hypospadias, represents the most frequent type of pseudohermaphroditism — the type that most often masquerades as true hermaphroditism. As will Fig. 20. — Case of hypospadias (pseudohermaphroditism). (After C. A. Wheaton.) be seen later on, the subject of sexual perversion is very intimately blended with urethral deformities. Failure of embryonic development as the cause of urethral deformities has recently been disputed. Thiersch, for example, and others have claimed that these deformities are due, not to imperfect embryonic development, but to atresia of the urethra, with subsequent rupture behind the point of obstruction. Xumerous arguments have been advanced by these investi- gators, dilation of the ureter and pelvis of the kidney, such as is often found in hydronephrosis, and the presence of cicatricial tissue being the chief points by which the new view is supported. The author cannot accept the HYrOSPADIAS. 101 new theory; there are too many analogous conditions that must almost necessarily develop along the same lines as urethral deformities and which cannot be explained upon a simple mechanic basis. The principal argument against the new theory is the general defective development associated with urethral deformities, there being not only a failure of physical, but also of psychosexual differentiation in a large proportion of cases. It is not neces- sary to resort to a mechanic explanation of the intimate association of con- Fig. 21. — Case of hypospadias with marked feminine physUjiie. Psycho- sexuality normal. (After C. A. Wheaton.) genital diseases of the kidney and ureter f,ound coincidently with all urethral deformities. The same, aberration and failure of embryonic de- velopment are sufficiently explanatory in both. Hypospadias. — In this condition the deficiency of development is situ- ated along the floor of the urethra, and is associated with a defective penile development proportionate to the degree of hypospadias. The urethra may open at any point from the frenum preputii to the perineum; the farther back the opening, the greater the failure of differentiation of sex. In the 102 DISEASES OF THE MALE TEETHEA. majority of instances tlie deformity is slight, the urethra opening just be- hJTid or at the side of the frenuni. Cases in which the opening is located posterior to the peno-scrotal angle are relatively rare. In the milder yariety there is, as a rule, no great inconvenience resulting from the condition, soiling of the clothing with urine and sterility being the princij)al features of annoyance, these disagreeable results increasing in degree jyari passu with the extent of the deformity. Teeatmext. — In a large proportion of instances in which the condition practically consists in the opening of the urethra a short distance posterior to its normal situation in the glans, hypospadias gives so little inconvenience Fig. 22. — Operation for hyi^ospadias. (After Duplay.) that there is very little warrant for surgical interference. An important practical point, however, is the fact that in the event of gonorrheal infec- tion the resultant urethritis is liable to be very j^rotracted and rebellious to treatment, the hypospadiac meatus, or pseudomeatus, being small and perhaps attended by a pouching of the urethra anterior to it, sometimes by diverticula running either anteriorly or posteriorly. In many of the simpler cases, if, for cosmetic or other reasons, operation is demanded, a new urethral channel may be made through the glans in such a manner as to connect acctu'ately T^itli the urethra at the site of the hj'pospadiac open- ing. The new channel is, with difficulty, however, kept open, and should be made as large as practicable, to allow for subsequent shrinkage. The TREATME^TT OF HYPOSPADIAS. 103 abnormal opening, if small, may close spontaneously, but, as a rule, requires a plastic operation. In hypospadias of moderate degree — i.e., those extend- ing only so far back as the peno-scrotal angle, or perhaps slightly beyond it — Duplay's operation has achieved the best results. It consists of three stages: — 1. Straightening the penis by transverse incision through the ridge Fig. 23. — Case of simple epispadias. (After C. A. Wlieaton.) uniting the glans penis to the hypospadiac orifice. The depth of this in- cision is regulated entirely by the extent of the deformity. The second step of the operation should be deferred from one to four months after the pre- liminary straightening of the organ, the delay being governed entirely by the extent of the curvature for the relief of which the first incision was made. 104 DISEASES OF THE MALE UEETHEA. 2. A new meatus and urethral canal is made^ extending from the canal to the hypospadiac opening. In cases in which the meatus and urethra anterior to the h3qDospadiac opening is represented by a cleft, the two edges may be freshened and brought together. Where no cleft exists the glans must be tunneled through. The spongy urethra is restored as follows: An incision is made longitudinally from the base of the glans to near the hypo- spadiac opening (Fig. 22, A: a to h and a to h). The inner lips of these longitudinal incisions are dissected up for a short distance, folded over, and the edges united over a soft catheter. The outer lips of the incisions are dissected extensively so as to make two large lateral flaps; these are united in the median line over the raw surfaces of the inner flap, which have al- ready been united over the catheter. This procedure gives a urethra lined Fig. 24.- — Dolbeau's operation. 1. Glans penis. 2. Dorsal furrow (rudimentary urethra). 3. Orifice of urethra. 4-4, 5-5. Abdominal and penile flaps. 6. Scrotum. 7. Superior scrotal incision. S. Inferior scrotal incision. (After Thiersch.) with cuticle and with a double-layered cutaneous wall. Quilled sutures should be used, the best suture material being silver wire or silk-worm gut. 3. The edges of the hypospadiac opening are freshened and brought together, or otherwise operated as is usual in penile fistula. Plastic operations for hypospadias are often tedious and require fre- quent operations to secure a successful result. The statistics of the Uni- versity of Pennsylvania Hospital show that Duplay's operation demands, on the average, three or four operations, extending over from six to eight months, the principal trouble being experienced in the second stage. Epispadias. — Epispadias is rarer than hypospadias, most often found in the female, and generally associated with exstrophy of the bladder. It is sometimes associated with congenital absence of the symphysis pubis. EPISPADIAS. 105 and is so often combined with ectopia vesicae tliat its consideration properly falls under .the head of congenital deformities of the bladder, in which con- nection it will receiye further discussion. There are some rare cases in which there is a simple epispadias without exstrophy. One of the best ex- tant illustrations of this condition is a case operated successfully by Wheaton. (Fig. 23.) In these simpler cases the same operative principles may be ap- plied as in hypospadias. One of the best and simplest operations for simple epispadias is Dol- beau's modification of Nekton's method. A quadrilateral flap is first formed from the skin of the abdomen. (Fig. 2J:.) This flap should be about 3 Fig. 25. — Dolbeau's operation, flaps in position. 1. Glans penis. 2. Frenuni. 3. Prepuce. 4. Scrotum. 5. Scrotal flap. 6. Urethra. 7. Denuded surface left after removal of the abdominal flap. (After Thiersch.) inches long and 'V^ inch wide, its base corresponding with the urethral opening. Two smaller flaps are next formed from the penis, one on either side of the dorsal furrow. The abdominal flap is brought down, apron fashion, with the cutaneous side below, forming the roof of the new canal, and the edges of the turned-doAvn flap stitched to the edges of the penile flaps, making a tube lined by cuticle, with an external raw surface. A semi-elliptic flap is next cut from the scrotum. This is dissected up through an incision at its base and the penis drawn through in such wise that the glans projects below the lower edge of the scrotal flap, thus bridging over the new urethra with a la5^er of scrotal tissue, the inner raw surface of which comes in apposition Avith the outer raw surface of the turned-down ab- 106 DISEASES OF THE MALE rEETHKA. dominal flap. The bridge is sutured in position and the ra^v surfaces left in forming the flaps covered in as well as may be b}' sliding the skin from their edges. The objection to the method is that no glans canal is formed, and there is no great improvement in urinary control aside from increased Fig. 26. — Formation of glans uietlira. A, 1-1, 2-2. Denuded surfaces at sides of urethral furrow. B, Cross-section showing depth and direction of in- cisions 1-1 and 2-2. C, Glans urethra completed. (After Thiersch.) facility in wearing a urinal. Cosmetically speaking, however, the method is often very serviceable. Thiersch has devised a method of operation for epispadias that is held by most operators to be superior to Dolbeau"s. The operation is divided into five steps, viz.: 1. The formation of a perineal fistula to divert the Fig. 27. — Formation of penile urethi-a. 1, Right flap, dissected outward. 2, Left flap, dissected inward. (After Thiersch.) urine. 2. The formation of a glans urethra. 3. The formation of a penile urethra. 4. Uniting the penile and glans urethras. 5. Closing the poste- rior defect. The formation of the perineal fistula is very simple. A staff is intro- TEEATMEXT OF EPISPADIAS. 107 duced into the bladder and its jDoint pressed well down into the perineum. The rectum is guarded by passing the left index finger into the gut while 'H--^... Fig. 28. — Flaps sutured in position. 1, Large flap drawn over to the left side of penis. 2, Stitches anchoring inner flap. 3, Meatus. 4, Defect between the new penile and glans urethras. (After Thiersch.) the perineum is being opened upon the point of the sound. Drainage should be secured by a soft catheter or tube. The second step of the operation consists in converting the furrow in Fig. 29. — Formation of preputial graft. 2. 3, Incision through prepuce. (After Thiersch.) the dorsal surface of the glans into a urethra. An incision ^/^ inch in depth is made upon the dorsal surface of the glans on each side of the furrow. The incisions should traverse the whole extent of the glans antero-poste- 108 DISEASES OF THE MALE UEETHEA. riorlv, and sliould be directed toward the median line below in such wise that they would meet if continued clear through the glans. The included portion of glans-tissue is wedge-shaped (Fig. 36, A, B). The edges of the Fig. 30. — Preputial graft (1) in position and (2) sutured. (After Thiersch.) lateral flaps are denuded and brought together with harelip-pin sutures (Fig. 26, AC). - The third step consists in forming a penile urethra by closing in the dorsal furrow. An incision is made on the right side of the furrow for its Fig. 31. — Closure of posterior urethral defect. Formation of flaps (1, 2) and suture of left flap. (After Thiersch.) entire length. At each end of this longitudinal incision a transverse cut is made, extending outward so as to form a quadrilateral flap (Fig. 27, 1). A second flap is made upon the left side of the organ by a longitudinal in- TEEATMENT OF EPISPADIAS. 109 cision at a little distance from the edge of the furrow and two transverse incisions extending from either end of the longitudinal cut to the edge of the furrow (Fig. 37, 2). It will be seen that one of these flaps is dissected outward and the other inward. In forming the flaps as much subcutaneous tissue should be dissected up as possible. The edge of the left flap is pro- vided with three or four sutures, with a needle upon each end, and drawn beneath the right flap, the needles and sutures being passed through the base of the latter. The sutures are tied, and. a second line of sutures in- serted on the left side in such a manner as to appose as nearly as possible the edges of the right flap and the edge of the denuded area from which the left flap was taken (Fig. 28). The raw surfaces of the flaps are now in close apposition, the cutaneous surface of the left flap forming the roof of the new penile urethra. Care should be taken not to have too much tension Fig. 32. — Closure of posterior urethral defect. Suture of left flap. on the flaps, else sloughing may occur. This may be avoided by making them as thick as possible, especially at their bases, and dissecting them up freely enough to avoid the necessity of drawing them tightly in order to secure apposition. The fourth step in the operation consists in uniting the penile and glans urethras. The edges of the opening between the two portions of tlie urethra are first thoroughly denuded. An incision is next made in the pre- puce (Fig. 29) and the glans penis buttoned through it. The edge of the inferior layer of the prepuce is now stitched to the freshened corona glandis, and the edge of the superior layer to the penile edge of the defect (Fig. 30). The fifth and final step of the operation is the closure of the posterior defect. Two triangular flaps are formed from the abdominal wall (Fig. 31). 110 DISEASES OF THE MALE UKETHEA. The flap on the patient's left is somewhat smaller than the right. The left flap is turned downward so that its skin-snrface forms a roof for the open- ing. The edge of this flap is sutured to the freshened lower edge of the defect. The right and larger flap is now drawn down over the first flap, the raw surfaces of the two flaps heing brought in close apposition and sutured in position (Fig. 32). After thorough healing of the wounds involved in the plastic operations the perineal tube is removed and the fistula allowed to heal. According to Thiersch, considerable time is necessary between the Various stages of the operation, — about two weeks between the first and sec- ond stages, two weeks between the second and third, three weeks between the third and fourth, two weeks between the fourth and fifth, and about forty-two days for the fifth and final stage. Injuries of the Ueethra. — The subject of urethral traumatisms, while strictly surgical, is very im]3ortant to the general practitioner. He is usually first upon the scene after injuries, and may be led to believe that certain cases are of trifling importance when they urgently demand the im- mediate attention of an expert surgeon. It is by no means serious swelling, pain, and retention of urine alone that require careful surgery. A knowl- edge of the ]DOSsible immediate dangers, ultimate results, and proper treat- ment of traumatisms of the urinary canal is of the greatest importance not only because of the immediate gravity of many cases, but of the possible remote, yet serious, results. The uretlira may he contused, lacerated, or cut, either from internal or external violence. Internal injuries are generally the result of surgical operations or exploration. Occasionally, however, the patient wounds his urethra by inserting foreign bodies. The penile urethra is rarely injured by external violence, on account of its mobility. The deep urethra is often injured by violence to the perineum, the bulbo-membranous region being caught between the impinging body and the edge of the subpubic ligament. Slight blows may produce serious injury. The urethra is sometimes injured by external blows with sharp instru- ments. Hemorrhage. Eetention of urine. Extravasation of urine. Sloughing. Possible results of False passages. urethral trau- <| Urethritis. matism. | Pus-infection and abscess. I Urinary fistula. Permanent curvature of the penis of varying form. Intractable stricture. Fatal sepsis. rOREIGN SUBSTANCES JX THE UEETHEA. Ill Treatment. — In urethral injuries, however slight, the clanger of sub- sequent stricture must be remembered. It may. be averted by systematic sounding. Hemorrhage may be controlled by pressure, ice-bags, or the re- tained catheter. If the injury be extensive and a catheter can be easily introduced, it should be retained for a few days, until danger of extravasa- tion has passed. Systematic dilation should then be practiced. If the penile urethra be extensively lacerated, a perineal puncture should be made for vesical drainage and the lacerated tissues should be stitched in layers over a soft catheter or a piece of rubber tubing. The perineal tube may be removed at the end of a week. Primary union usually results. Care should be taken in passing instruments after urethral injuries lest the lacerated tissues be penetrated and a false passage made. In deep urethral injuries a catheter should always be retained for a week or more, after which dilation should be begun. If it be difficult to pass the catheter or the injury be severe, perineal section is indicated. If it be possible to suture the divided urethra, even in part, it should be done. The author is of opinion that perineal section is safest in the majority of cases of injury to the perineal portion of the urethra. Should extrava- sation of urine be suspected perineal section is imperatively necessary. In all urethral injuries strict attention should be paid to asepsis and antisepsis. The most important point in urethral traumatisms is the fact that stricture of the canal often follows injuries so trivial as to attract little or no attention. Careful after-treatment may prevent this. The author desires to especially emphasize the desirability of systematic dilation after all injuries of the urethra, however slight they may appear. Foreign Substances in the IJrethra. — Considerable space would be required to enumerate the substances that have been introduced into the urethra 1)y patients actuated by curiosity or perverted sexuality. Young lads often introduce foreign bodies, which, slipping beyond the reach of their fingers, produce a degree of subsequent trouble determined entirely by the character, size, and location of the foreign substance. Surgeons sometimes break off catheters or other surgical instruments in the urethra. French gum catheters are quite dangerous, in this respect, after they be- come old and brittle. Eetention of urine. Extravasation of urine. Hemorrhage. Urethritis. „ . T ,. , Ulceration. foreign bodies < -n , . ,^ ,^ 4„ j.T,„ ,,^^4.x,^„ I lii^ipture ol the urethra. Sloughing. Abscess and fistula. Deposition of urinary salts and resulting calculous formation. Possible results of foreign bodies in the urethra. 112 DISEASES OF THE MALE rRETHRA. Eoreign bodies are very infrequently met with in the female urethra, the canal being so short that foreign substances rarely lodge, being pushed onward into the bladder. Treatment. — Simple manipulation, combined with meatotomy, if necessary, is often successful in removing foreign bodies. Specially-con- structed urethral forceps are sometimes required. When these means fail the foreign body should be pushed on into the perineal urethra and a perineal section made. The perineal section should be made before the foreign body is pushed down, unless it be of good size; small bodies may otherwise enter the bladder. In the author's opinion, prompt perineal section is usually much safer than prolonged attempts at extraction of a foreign body by urethral forceps. In the case of soft bodies it has been recommended to insert a fine needle into the urethra from without and pry the foreign body outward toward the meatus. The author has succeeded in one case of foreign body in the urethra — a large bean that had become swollen — by ballooning the urethra anterior to it with warm water. The act of forcible urination expelled urine, foreign body, and injected water, altogether. An excellent plan in some Fig. 33. — Alligator urethral forceps. cases is to pass a large endoscopic tube down into the foreign body, fix it Math the finger posteriorly, and extract through or with the tube by means of a screw-tipped probe or with forceps. The yarious results of foreign bodies should be treated upon their merits in each particular instance. They do not demand especial considera- tion here. TuMOES OF THE Ueethea. — The urethra is occasionally the seat of neoplasms of various lands. Since the advent of endoscopy urethral tumors have been found to be more frequent than previously supposed. They vary in gravity from inflammatory neoplasms to malignant growths. Inflammatory neoplasms are usually associated with chronic urethritis, occasionall}' with organic stricture. They consist of submucous overgrowth of connective tissue projecting into the canal, and are richly supplied with blood-vessels and covered with epithelium similar to that of the normal urethra. Fungus or papillomatous excrescences sometimes form, being ap- parently due to granular urethritis. The vascular supply is sometimes so rich that the growth resembles angioma. Inflammatory urethral growths resemble the vegetations met with upon the external penile surfaces. The author has noted several cases associated TUMOKS OF THE rEETHKA. * 113 with external vegetations^, the urethral growth being limited to the fossa naviciilaris. Papillomata sometimes occur in the anterior urethra inde- pendently of external growths. Distinct mucous polypi have been observed. Prior to the invention of the endoscope antemortem diagnosis of the softer varieties of urethral neoplasm was mere guess-work. Urethral tumors, usually in the form of the well-known caruncle, are more readily recognized in the female than in the male, because of the shortness and dilatability of the canal. The following unique case of urethral tumor recently came under the author's observation: — Case. — W. H., aged 23, undeilaker. No history of injuiy or venereal disease. Has been an occasional drinker. Has drunk to excess at intervals, but does not in- dulge as a regular habit. Heredity good. Was healthy until three years ago, when he began to suffer from frequent micturition and pain over the pubes and in the perineum, especially marked after urination. The attacks lasted for. a week or more and then disappeared. Recurrences were at irregular intervals and of varying severity. Some six months since the symptoms grew worse, and have progressed in severity. There was, at the time of examination, in addition to the symptoms above Fig. 34. — Adenomata of the urethra. Natural: size. (Author's case.) mentioned, pain and burning in the urethra and glans penis, with constant desire to urinate. The symptoms improA^ed when the patient was quiet. Constipation was complained of. Appetite good and nutrition not appreciably disturbed. Color was indicative of excellent general health. Sleep disturbed by frequent micturition. Rec- tum and anus healthy. The urine was normal. There had never been any hematuria or other urinary disturbance nor any pain in the region of the kidneys. Examination by searcher, sound, and cystoscope showed the bladder to be healthy. The membranous and prostatic portions of the urethra were extremely sensitive, but there was no obstruction save that incidental to spasm of the musculo-membranous region. The urethral caliber was 30 F. Unfortunately, the endoscope was not used. The onlj^ objective condition discoverable, aside from the spasm mentioned, was moderate enlargement and tenderness of the prostate. Other methods of treatment having proA'ed ineflfectual, perineal section and dilation of the vesical neck were pro- posed, and consented to. Operation.- — The usual perineal houtonniere having been made, the vesical neck was readily stretched to the size of the index finger, and the bladder thoroughly explored without discovering anything abnormal. In exploring the bulbo-membranous region more critically, a slight elevation Mas found upon the urethral floor just in front of the opening in the triangular ligament Under manipulation, this was found to peel up under the finger. By careful dissection, still \\\Vs\ the finger, the slight 114 DISEASES OF THE MALE UEETHEA. elevation was found to be part of a good-sized mass of tissue occupying chiefly the right side of the bulb, which had been dilated outward and backward, forming a considerable pocket. The tumor was lobulated to the feel and quite friable, a good portion of its bulk breaking down under the finger and coming away piecemeal. At the posterior portion of the growth on the right side was a distinct aperture in the triangular ligament too small to admit the index finger. The final attachment of the tumor seemed to be in this opening, suggesting the origin of the growth in this situation. Recovery with complete relief of symptoms was rapid. The perineal wound was healed within a week. The only fragments of the tumor of any size that it was practicable to remove entire are shown in Fig. 34. These comprised less than half the mass as outlined by the finger. The microscopic characters of the growth, shown in Fig. 35, verify the diagnosis of adenoma suggested by the gross physical features of the tissue as felt by the finger and noted in the specimens removed. The tumor in the foregomg case probably originated in the right Cow- per gland. The absence of urinary obstruction is remarkable. Why the ti-i^mu Fig. 35. — Adenoma of the urethra, a, Normal gland-tissue. 6, Columnar epi- thelium projecting into gland, forming papillae, c. Cystic gland, d, Heaped-up epithelium, e. Columnar epithelium in single layer. (Author's case.) tumor should have become flattened in form and extend outward and back- ward rather than toward the urethral canal is difficult of conjecture. The fact that constant perineal pain Avas not experienced militates somewhat against the assumed origin of the tumor. Obviously the point of departure may have been the urethral glands. Cancee of the Ueethea. — This is usually secondary to cancer of the penis, and requires nr special consideration here. Cases of primary cancer of the urethra have been reported, but they have usually been erroneously diag- nosed until late. Most of these cases have been located in the perineum, CANCEE. 115 and rarely even in these cases the nrethra may have been secondarily diseased. Grlinfeld has reported a case in which he diagnosed primary cancer of the prostatic urethra by the endoscope. Several cases have been reported in which primary cancer began in the anterior nrethra. Van Hook's cases have already been mentioned. Symptoms.— The symptoms of urethral tumor are those of chronic urethritis with obstruction — if the growth be sufficiently large — and per- haps hemorrhage during micturition. Benign tumors of the urethra are usually found casually when the surgeon is seeking for a cause for a pro- tracted urethral discharge. They may sometimes be felt on palpation. Teeatment.- — The treatment of urethral tumors is, briefly, removal by forceps or scissors via the endoscope or urethral speculum, with subsequent careful cauterization of the base of the growth. In deep tumors perineal section is indicated. Cancer of the urethra demands amputation of the penis. CHAPTEE IX. Ueethkitis a^^d Goxoeehea. Ueethritis is the most frequent disease of the male genito-urinary tract, being relatively infrequent in the female. It is usually contracted during sexual intercourse; so exceptionally is it otherwise acquired that it has been termed the most venereal of diseases. The most common term for urethritis is gonorrhea. This is a misnomer: first, because it implies a morbid discharge of semen; second, because indicating disease of unvarying and specific type. The generic term urethritis is accurate in the male, in- asmuch as it not only implies inflammation of the urethra, but embraces all its varying forms irrespective of their origin. ISTeisser's discovery of the gonococcus has apparently fixed the generic term gonorrhea in its applica- tion to a specific type of inflammation of the mucous membranes in both the male and female. If we accept the gonococcus as specific in character, a broad line of clinical differentiation is at once established in urethritis. We are still compelled to recognize, however, certain cases in which the presence or absence of the gonococcus does not prove or disprove the venereal origin of the disease. This is especially true where the patient has cohabited frequently with different females, and has had previous infection. Here the recent attack may have been due to gonococcic autoinfection from a focus left by a previous attack of gonorrhea. In other instances the patient has a non-gonococcic discharge, and we are asked to decide as to its speci- ficity. Here we must acknowledge that the gonococci may possibly have been present originally, but have disappeared. Practically, therefore, we are often in essentially the same position as before the discovery of the gono- coccus. Especially is this true from a forensic stand-point. The sources of error in diagnosis are so numerous that it is hardly ever safe to pronounce a case of urethritis specific in origin, whether gonococci be present or not, save where the patient can be proved to have been perfectly healthy before the urethritis developed, or to have had intercourse with a woman suffering from gonorrhea — proved by microscopic examination of her vaginal secre- tions — or to have a clear history of a more or less recent attack of gonorrhea. This caution is particularly necessary in passing an opinion in the case of a married person. In any case, culture and inoculation tests are necessary for a decision. The discovery of the gonococcus has not changed the views of the author regarding the origin of gonorrhea and its congeners. This class of affections, in common with chancroid, may still be classed as filth-diseases originating de novo in the female. The author believes that germ-infection, of one kind or another, is the fons et origo in the majority of cases of (116) EVOLUTION OF THE GONOCOCCUS. 117 urethritis. It is not probable, however, that the germs producing such in- fection are always and invariably the same. Gonorrhea is as old as the human race, but that the gonocoecus originally resulted from a special act of creation seems incomprehensible. The development of the gonocoecus — and, indeed, of all germs capable of producing infection — has probably been along evolutionary lines. We cannot accept the spontaneous genera- tion of germs of either indeterminate or specific type, neither can we dis- prove its possibility. The possible transformation of innocuous germs by adaptation to environment into germs of a specifically-pathogenic character is, hoAvever, scientifically plausible enough. The female generative ap- paratus constitutes a most favorable environment for the development of ^erms and the acquirement of pathogenic properties by them. Protection from air and light and the presence of heat, moisture, and decomposable secretions of various kinds constitute conditions highly favorable to bac- terial evolution. Pathologic discharges and exposure to local irritation con- stitute an additional and important factor. In uncleanly women vaginal discharges, as well as both pathologic and physiologic discharges from the male, are allowed to accumulate and undergo decomposition. The semen is a highly complex organic substance, the decomposition of which in all probability results in the development of highly-irritating toxins. When the author uses the term de novo as applied to gonorrhea, and later to chancroid, it is with the belief that both are germ diseases, and that consequently their spontaneous generation, in the sense of the develop- ment of their germs de novo, is improbable. The perfected germs of these diseases represent the acme of spontaneous cultivation of germs that were primarily quite different, pathologically at least, from the final product. Evolutionary changes, and especially differentiation of biologic and patho- genetic properties in germs, must be admitted, for necessarily the same laws apply to the parasite as to the host. It is very interesting to the author to note that the views he expressed some years ago upon this subject in an article entitled "The Evolution of the Local Venereal Diseases" are being daily substantiated by practical results obtained in the laboratory. A recent case coming under the author's observation appears to be an illus- tration of the fact that the germ of gonorrhea is capable of transformation. Case. — The case was that of a young man troubled with posterior urethritis and stricture for nearly two years. From time to time his semen had been examined by competent microscopists and said to contain gonoeocci. Several months after the author had performed a urethrotomy the patient's semen was examined, and found to contain -germs strongly resembling the gonocoecus. Closer study, however, showed that they were slightly rod-shaped, although typically paired, like the diplococcus of gonorrhcea. Cultures and experimental inoculations proved the microbe to be patho- logically inert, and the patient was assured that he might marry with safety: a point ■of great importance to him, as he had been contemplating matrimony. Did we not have here an illustration of spontaneous alteration in the 118 UKETHKITIS AND GONOEEHEA. physical and pathogenic properties of the gonococcus? The case is certainly suggestive along the lines mentioned. It is of such practical importance that the author believes that test-cultures and inoculations should be made in prolonged cases in which the presence or absence of the gonococcus is to be accepted as the criterion of cure or of the safety of matrimony. Whether or not the gonococcus be accepted as the unvarying cause of a specific type of urethritis, the fact remains that the environmental con- ditions that have been mentioned are the point of departure of germ- evolution, the products of which are infectious and capable of producing mucous inflammation of varying grades of severity, ranging from simple urethritis to virulent gonococcic inflammation. Precisely what germ is the progenitor of the gonococcus in the process of evolution would be difficult to determine, but the difference between the specific microbe and certain germs that are normally present in the male urethra and also in the vagina is not very great. The dissimilarity between the gonococcus and pus-mi- crobe is not marked; the transformation of the one into the other under favorable circumstances of environment is perhaps possible. That we are unable to compel germs to undergo this process of evolution is not a valid argument against the theory — of which more anon. Varieties or Ueetheitis. — ^Inflammation of the urethra may be divided for description as follows: — r Bacteric. r J Toxic. (a) bimpie { ^,, I ^ ^ } Chemic. Acute and chronic <> [Traumatic. C Gonococcic. (5) Specific of great importance Avith reference to the transmission of the disease to the male. For example, in the event that a woman has been affected at one time or another with a ffonorrhea that has become localized in the 168 GOXOREHEA IN THE FEMALE. Fallopian tubes, it is probable that under sexual excitement or during men- struation a small quantit}^ of the retained germ-laden secretion may be ex- truded into the uterus, mingling with the secretions of that organ and the vagina, eventually coming in contact with the urethra of the male, and exciting therein specific or simple urethritis, the type depending on whether the typic gonococcus is still present or not. The woman's own mucous membranes are relatively imminie to infection because their susceptibility has been exhausted by the primary infection. Upon examination such women present no traces of virulent disease, although they are usually found to have more or less uterine difficulty. Parallel cases may occur in which the primary source of the disease is not infection from without. Supposing, for example, as a consequence of germ-evolution favored by sexual excess, filth, simple uterine inflammation, intemperance, cachexia, and so on, a woman develops gonorrheal infection de novo; her own mucous membranes becoming graduall)^ involved, the process finally disaj)pears elsewhere, but localizes itself in the Fallopian tubes and endometrium; as a consequence of some of the exciting causes heretofore mentioned, the pent-up poison is discharged into the vagina, and causes urethritis in the first unlucky male who has intercourse with her. Upon examination — even upon microscopic examination of her se- cretions — she, too, presents no evidences of disease other than ordinary endometritis, and perhaps even this in mild degree. To go a little further with the morbid possibilities of latent gonorrheal processes in the Fallopian tubes, let it be supposed that, as .a consequence of sexual excitement, traumatism, parturition, or violent exertion, a small quantity of the infectious secretion is discharged into the peritoneal cavity; obviously, localized peritonitis with possible pelvic abscess is likely to re- sult. It is a suggestive fact that latent gonorrheal processes do not usu- ally produce general peritonitis, probably because of some transformation of the mater ies morhi. This disease may occur as a consequence of gonor- rhea, but almost invariably as a direct result of rupture of a pelvic abscess — which is, in itself, due to gonorrheal infection — or extension of virulent vaginitis, endometritis, and salpingitis. The jDeritoneum, like the bladder, is relatively immune to the gonococcus, but susceptible to the mixed in- fection of secondary gonorrheal processes, especially if the products of such mixed infection be discharged suddenly and in large quantity into the peritoneal cavity. Localization by plastic hanph-barriers usuall}^ protects the general peritoneum Avhere the infection is gradual and the amount of infectious material limited. Chronic gonorrheal inflammation may become localized in the glandulce Nahothii and Bartholini; under such circumstances women may continue to transmit contagion for an indefinite period after all clinical and micro- scopic evidences of specific vaginitis or endometritis have disappeared. This explains many of those puzzling cases in which urethritis is contracted UKETHRITIS IN WOMEN. 169 from apparently healtlw women. Sucll women continue to be infections in some instances, until the glandular foci of infection have been extirpated by the knife. The urethra of the female is very rarely involved in virulent inflam- mation, on account of its protected situation. The vulva, at least the more external portions of it, not being particularly susceptible to virulent in- fection, the process does not readily extend to the meatus; possibly it never does so, excepting in cases of typic virulent vaginitis due to specific in- fection. Whenever urethritis develops in the course of vaginitis, with or without vesical inflammation, it is prima facie evidence that the disease was primarily caused by infection. This fact is not due to any peculiar selective Fig. 50. — Gonorrheal inflammation of the left vulvo-vaginal gland. (After Bumstead.) property of the gonococcus, but to the fact that the urethra is very rarely affected excepting in the more violent cases of vaginal inflammation, which are invariably due in the female to venereal contagion. It should be noted, however, that, while urethral inflammation is fair presumptive evideiice of specific infection, its absence proves nothing. Most cases of gonorrheal in- fection in women are not only uncomplicated by urethritis, but exception- ally by vaginitis. It has been claimed by Martineau that the reaction of the secretion of vaginitis determines the diagnosis of its specific or non-specific character. He claims that the pus of specific vaginitis is always acid, while in the simple variety it is alkaline. It is to be hoped that this fallacious test may 170 . GOXOKEHEA IX THE FEMALE. not be depended upon in differential diagnosis. No one has thus far con- firmed the opinion of Martineau. The only test, as in the case of the male, is microscopic and culture study of the secretions, and even this is open to serious fallacies — more serious than in the male. Symptoms and Couese of Gonorrhea in the Female. — The multi- form results of gonorrheal infection in women present a wide range of varying conditions which, save from the stand-point of infectiousness, are clinically the same as in affections of similar tissues and organs dependent on other causes. They are consequently fully discussed in all modern works on gynecology. Treatment. — The therapeutics of gonorrhea in the female dtmands attention in this work only with respect to the specific infection per se. The treatment involves most of the principles set forth in the chapter on genito-urinary and sexual hygiene. Especially is rest, both sexual and physical, to be enjoined. The disease is normally self-limited, and if com- plications can be prevented, not only is recovery likely to be secured within a reasonable period, but prolonged infectiousness may be averted. The higher the process extends, the more prolonged and insidious will be the infection. The chief aim of the surgeon should therefore be the prevention of extension of the infectious inflammation. Eest is the best means of ac- complishing this, sexual rest especially being quite as important in this respect as in the male when similarly infected. V'aginal douches of potas- sium permanganate 1 in 3000 to 1 in 1000 are a sine qua non. They are indicated whether vaginitis is present or not, if only to remove the products of infectious inflammation as fast as formed, and prevent urethral infec- tion if, as is generally the case, it has not already occurred. Although, as has already been remarked, the infection is usually above the vagina, the permanganate solution seems to be of especial service. Whether more or less absorption by the vaginal and cervical mucosa occurs and secures a certain degree of germicidal effect is open to question. The perman- ganate irrigations should be given quite hot, slowly, and in large quantity, Avith the patient in the recumbent posture. Unless vaginitis exists and be- comes chronic, it is hardly worth while to consider any drug but the per- manganate for vaginal douches in gonorrhea. Mercury bichlorid and silver nitrate are valuable, but by no means to be compared with the perman- ganate, which is the nearest approach to a specific at our command. Urethritis and vesical complications demand balsams and alkalies in- ternally, with the permanganate irrigations. Later on, silver-nitrate irriga- tions may be substituted with advantage. Instillations of permanganate or silver solution with a syringe may be useful, especially Avhen the process shows a tendency to become chronic. Anodynes and sedatives may be indicated in some cases, especially if complications occur or sexual irritation be marked. In chronic gonorrheal endocervicitis and endometritis topic applica- TEEATMENT OF VAGINITIS. 171 tions of silver, permanganate, bichlorid, iodoform, and iodin may be re- quired to effectuall}^ remove infection. Curettement may even be necessary. Chronic vaginitis, whether gonorrheal or not, may often be subdued by topic applications of very strong silver solution or pure tincture of iodin thoroughly applied with a brush via the speculum. The free administration of saline laxatives is a most valuable measure in gonorrhea in women. Drainage of the peritoneum is thereby secured and is not only curative iii case utero-pelvic inflammation supervenes, but prophylactic as well. Another familiar method of securing local deple- tion — the use of glycerin — must not be forgotten. Glycerin suppositories or injections in both vagina and rectum are very serviceable. The more remote and serious effects of gonorrhea in women are likely to demand the knife. Laparotomy or vaginal section with abscess-evacua- tion and drainage, or even removal of the uterus and its appendages, one or all, may eventually be required to remove the source of successive dan- gerous reinfections and perpetual invalidism. Specific Bartholinitis is likely to demand incision for the cure of the abscess, followed by carbolic-acid ap- plications to destroy the infected surface; even total extirpation by the knife may be required. The duration of acute gonorrheal infection in the female is quite as variable as in the male. The more conscientious the application of the principle of rest, the more favorable will be the progress of the case. A month in bed is a by no means too rigorous measure. With this prolonged period of rest, providing no serious complications occur, the acute symp- toms will usually subside in from four to six weeks. Treatment should be persisted in for some time, however, to obviate possible autoreinfection. CHAPTER XI. Stricture of the Urethra. Stricture of the male urethra is the most important of the surgical diseases of the genito-urinary apparatus, not only on account of its extremej frequency, — its special cause affecting sooner or later a large proportion of] male humanity, — but also because of its important relations to secondary] pathologic conditions of organs more vital than the urethra. Stricture of the urethra is an abnormal diminution of its caliber, tem- porary or permanent, due to any cause whatsoever. It may be caused byj any of the following conditions: — 1. External pressure, due to: (a) neoplasms; (&) extravasations oi blood or urine; (c) purulent collections and infiltrations; (d) fracture ofj the pelvic bones. 3. Spasm of the urethral and cut-off muscles, due to: (a) direct irrita- tion of the canal by lesions or foreign bodies; (b) reflex irritation by foreign] bodies or remote pathologic conditions; (c) introduction of instruments; {d)\ emotional excitement; (e) malaria [?]; (/) highly-acid and concentrated] urine, and occasionally oxaluria and gravel. 3. Congestive or inflammatory engorgement of the urethra, due to:] (a) acute urethritis; (h) traumatism; (c) acute inflammation in and about] organic obstructions. 4. Thickening of the urethral walls, due to: (a) congestive and granu- lar patches, — i.e., superficial infiltration from chronic inflammation; (6)| plastic infiltration and connective-tissue formation in the corpus spongiosu] from inflammation; (c) traumatic cicatricial deposit in the corpus spon- giosum and urethral walls; (d) cicatricial deposit from caustics and power- ful irritants; (e) cicatricial deposit from ulceration or sloughing producedj by foreign bodies, chancre, chancroid, or mucous syphilides. 5. Deficient elasticity of the urethral walls and corpus spongiosum: (a) from congenital sparsity of elastic and muscular fiber and a preponder- ance of fibroconnective tissue; (h) from chronic inflammation. 6. Congenital narrowing of the urethra: atresia from defective fetal development. 7. Urethral polypus. Strictures may be divided clinically as regards their origin into: (ij congenital; (2) acquired, the latter comprising (a) traumatic, (b) chemicJ (c) acute inflammatory or congestive, (d) chronic inflammator}^, and (e)| neurotic. As regards the essential condition producing obstruction, they may hi divided into: (1) spasmodic; (2) congestive or inflammatory [circumscribed (172) SPASMODIC STKICTUEE. 173 or general]; (3) organic or fibrous [permanent], — i.e., inflammatory neo- plastic. Strictures, the nomenclature of which depends upon variation in the obstructive conditions, cannot always be differentiated clinically; the sev- eral conditions may co-exist in varying proportions. Thus, inflammatory or congestive narrowing of the urethra, although often sufficient to produce obstruction, is generally associated with spasm. Simple spasmodic stricture is relatively rare, occurring only as a result of remote reflex irritation, psychic impressions, or instrumentation of a sensitive urethra. On the other hand, spasmodic stricture dependent upon acute or chronic organic changes in the urethra is frequent. Again, there are few cases of organic stricture uncomplicated at one time or another by inflammation, congestion, or muscular spasm; in fact, all of these elements — styled by the author '•plus conditions" — and especially spasm, may require attention during the treatment of oro-anic stricture. SPASMODIC STKICTUEE. Spasmodic stricture — or, more jDroperly, pseudostricture — is a diminu- tion of urethral caliber due to spasmodic contraction of the muscular fibers in and about the wall of the canal. Clinical experience should have taught the surgeon at a very early period the possibility of such a condition as spasmodic stricture, but such was not the case. The varying caliber of the urethra during treatment for organic stricture, or during the course of that disease unmodified by treatment, is strikingly suggestive of the element of spasm. It will often be found that a stricture that will at one sitting admit a sound of fair size Avill at another time only permit the passage of a small instnmient or perhaps none at all. Complete retention may occur at any time from acid urine, intemperance, or sexual indulgence. To be sure, spasmodic contraction is often associated with congestion and inflamma- tion, but, even here, spasm is the preponderating condition. Again, the passage of an instrument may be obstructed until after gentle pressure, when it Avill pass the point of contraction quite readily. The grasping of the instrument by the urethral walls in withdrawal conclusively proves the existence of spasmodic contraction. Xotwithstanding the facility of demonstration of spasmodic stricture, its existence was not accepted until Hancock and Kolliker demonstrated muscular fibers in the urethral walls. Their researches, although valuable, unfortunately led to the belief that contraction of these fibers was the essential element of spasmodic stricture. A comparison of the mechanic effects of spasmodic stricture with the power of the muscular fibers that were first supposed to be chiefiy involved in spasm will readily demonstrate the fallacy of this belief. The planes of muscular tissue are chiefly longitudinal, and so sparse that, no matter how firmly contracted, they are incapable of 174 STEICTUEE OF THE UEETHKA. producing serious obstruction. AVe must, therefore, look further for the seat of the spasm, and seek for structures the function of wliich is to nor- mally obstruct the canal and prevent the escape of urine. A group of such structures is found in the cut-off muscle of Cruveilhier, and it is at a point corresponding to this that the principal spasm occurs. The last few drops of urine or semen are normally expelled by the accelerator-urince and com- pressor-tirefhrce muscles: the cut-off muscle simultaneously closes the deep urethra: i.e., the vesical neck. Spasmodic stricture is a mere exaggeration of this physiologic function, in which, from irritation, the muscle is spas- modically contracted and the volitional power of urination temporarily in- hibited. The accelerator-urince and compressor-urefhrce muscles play only a minor part in such spasm, the chief factor being the contraction of the voluntarv cut-off muscle. A certain amount of spasm produced by B Fig. 51. — Showing the manner in which urethral coarctation and spasm opix)se the entrance and withdrawal of a bulbous bougie. A, Shoulder of bulb caught at stricture. B. Opposing urethral walls in front of stricture. contraction of the circular fibers — compressor-urefJircB muscle — may occur anywhere in the canal. This explains in part obstruction to instrumenta- tion in penile strictures of large caliber. This spasm also facilitates explora- tion with bulbous instruments. It is by spasmodic contraction that the sensitive urethra resents at diseased points the passage of the bulb, thus giving evidence of obstruction. LocATiox or Spasmodic Stricture. — There are nearly always two points of spasm: (a) the seat of irritation and (&) the musculo-membranous region. 1. ^Tien a foreign body is introduced the urethra resents its presence by contraction at the point of irritation, and simultaneously by reflex spasm of the cut-off muscle. The same holds true in penile organic stricture, especially those at the meatus. Instruments produce stretching and irrita- SPASMODIC STEICTUKE. 175 tion of the lesion in the anterior portion, refiexly exciting spasm of the deep urethra; so that in a large proportion of cases of stricture there are at least two points of obstruction: one at the diseased point impinged upon by the instrument, and another in the deep urethra. The same phenomenon results Avhen the anterior obstruction is a congenital stricture or point of normal contraction. This is important, for, simultaneously with the re- moval of the anterior point of obstruction and irritation, the supposed deep organic stricture usually disappears. 2. The entire canal may be spasmodically contracted and resent the introduction and withdrawal of instruments. 3. The musculo-membranous region ma}^ alone be involved. This hap- pens where an organic lesion exists in the deep urethra and also in reflex spasm. Etiology.- — Predisposing Causes. — (a) General hyperesthesia; (b) local hyperesthesia. These conditions are modified by a nervous temperament, debility and cachexia, the rheumatic and gouty diatheses, intemperance, high living, faulty sexual hygiene, etc. (c) Acute or chronic genito-urinary disease. This is the most frequent predisposing cause; indeed, spasmodic stricture is rarely met with where a more or less damaged urethra does not exist. So uniformly is it present that it is always to be suspected until organic disease has been excluded by exploration. Congested and f ungating patches, mucous erosions, acute and chronic urethritis, and organic stricture predispose to spasmodic contraction, both at the point of irritation and at the cut-oif muscle. Congenital narrowing of the meatus or other parts of the canal may give rise to reflex spasm of the deep urethral muscles when- ever an instrument is passed of sufficient size to produce stretching of the sensitive tissues at the point of contraction. As already noted, when in- struments are introduced under these conditions there is spasm at the site of the lesion and also deep in the canal. 3. Exciting Causes. — (1) Passage of instruments; (2) sexual excite- ment or excess; (3) urethral injury, chemic or traumatic; (4) a debauch; (5) cold-taking; (6) foreign bodies; (7) drugs, such as cantharides and tur- pentine; (8) reflex irritation; (9) malaria [?]; (10) mental emotions. In surveying. the various exciting causes of spasmodic stricture it will be observed that in nearly all instances spasm is associated with congestion or inflammation: conditions that such special causes are most apt to de- velop. Spasm due to drugs is usually associated with considerable inflam- mation, with frequent and painful micturition, and possibly urethral hem- orrhage. The most frequent exciting causes are intemperance, exposure to cold and wet, and sexual excess. Highly-acid urine in gouty patients is said to act as an exciting cause per se, but it is doubtful if such a condition of the urine can cause obstructive spasm in a healthy urethra. Again, the existence of a perfectly sound urethra in gouty patients is open to ques- tion. Acid urine is an important element in spasm due to excesses of vari- 176 STEICTrKE OF THE UEETHEA. ous kinds and cold-taking superadded to organic disease. Instrumentation of a sensitive canal, especially if organic disease exists, is likely to develop spasmodic stricture, which may last for some days or weeks. Cases of intermittent spasm due to malaria and curable by quinin are recorded, but it is questionable whether malaria alone can act directly as an exciting cause; that it may predispose to spasm is admitted. In passing instruments into the virgin urethra, and in delicate and nervous patients, — whether organic disease exists or not, — the instrument is apt to be obstructed by spasm in the deep urethra. The obstruction generally gives way under gentle, continous pressure with the beak of the instrument. In withdrawing the instrument a sense of biting or grasping, upon it is felt by the operator; the patient may herself experience a sen- sation of urethral traction. It is a common observation that some individuals cannot urinate in the presence of others. This is usually regarded as spasmodic stricture from mental emotion, but is jarobably due to psychic inhibition of volitional power over the cut-off muscle and the normal involuntary contraction of the detrusor tirince, rather than to spasm. Eeflex spasm of the cut-off muscle most often arises from irritation of structures bearing a direct relation to the genito-urinary tract through com- munit}' of nervous supply; diseases of the bladder, kidneys, rectum, and anus are very apt to produce it. Retention is not uncommon after forcible stretching of the sphincter ani in operations for hemorrhoids, fistula in ano, and rectal stricture. Inflammation in and about the perineum may pro- duce retention through spasm, independenth' of pressure. The possible occurrence of deep spasmodic stricture should be consid- ered in every vesico-urethral disease. The point from which irritation is reflected may be above or below the site of spasm — -i.e., the perineo-urethral muscles. The urinary flow may be greatly lessened during a gonorrhea, and yet be sufficient for physiologic needs, when suddenly retention occurs and this without extension of infiammation to the deep urethra or bladder. Such retention usually means a deep extension of inflammation, but the reten- tion is not so sudden, and is preceded by symptoms of prostatic or vesical irritation. In chronic prostatitis and cystitis with or without calculus sud- den retention may occur. Congestion is the primal cause of obstruction in such cases, but it is the reaction of the muscular structures to irritation that brings about the sudden and final occlusion of the urinary way. Spasm plays the principal role and congestion the preparatory. In prostatic hypertrophy the least disturbance of the usual regimen or the slightest venereal or dietetic excess or exposure causes congestion of the deeper parts of the urethra. This may excite reflex contraction of the surrounding muscles, with consequent retention. Some interesting examples have been cited where irritation of neigh- SPASMODIC STRICTURE. 177 boring parts has produced spasmodic retention. Thus, le Dentu cites a case of testicular neuralgia the exacerbations of which were accompanied by spasmodic retention. He also calls attention to the providential spasmodic retention that often prevents urinary extravasation in wounds of the ure- thra and perineum. Uterine affections have been known to cause spasmodic retention, and it is probable that post-partum retention often has a strong spasmodic element. It has been held that injuries of parts very remote from the urinary apparatus .may produce spasmodic retention; thus, a fall upon the knees, fractures of the ribs, surgical operations (such as laparotomy), and many other accidents of a traumatic character are sometimes associated with re- tention. It is doubtful if this retention is due to spasm. Inhibition of the detrusor urinse or of volitional power over the cut-off muscle, due to shock, commotio cerebri, or commotio spinalis seems a more logical explanation. There may, however, be apparent retention — i.e., suppression — due to reflex inhibition of renal secretion, especially after abdominal operations. Ob- tunding of vesical sensation from shock or concussion may have much to do with the temporary retention. In slighter cases exaltation of emotional sensibility may be a causal factor. A patient who has been operated upon or seriously injured and is compelled to use a duck or bed-pan, often with an attendant close at hand, sometimes experiences a temporary inhibition of voluntary control over the cut-off muscle. Urethrismus, or chronic spasmodic stricture, is occasionally seen. This condition may result from various more or less remote sources of irritation. It may be caused by chronic abscesses in and about the genito-urinary organs. Fessenden Otis has reported a very interesting case of this kind due to fistula and chronic abscess of the scrotum and testicles. Dr. Otis's remarks anent urethrismus are worth repetition: — The term spasmodic stricture has usually been applied to all temporary con- tractions of the urethra which interfere in any degree with either the passage of instruments into the bladder or the voluntary discharge of urine from it. As thus understood, it has been described as varying in degree from the slight localized mus- cular spasm, which but momentarily arrests the progress of an ingoing instrument, to the firm, close contraction which more or less persistently resists its introduction in skilled hands, or from that which occasionally diminishes the strength of the outgoing stream of urine in urination to that producing complete and enforced retention of urine. In whatever degree present in any case, it is claimed by all authorities to be characterized by its transient duration and its ready yielding to remedial measures. In accordance with this teaching, all permanent or habitual interference with urina- tion or the passage of instruments (except in some rare instances complicated by vesical paralysis) must have an organic cause, and depend either upon the presence of an intravesical growth, an enlarged prostate, or close organic stricture. It is also within the experience of many surgeons to see supposed cases of close organic stricture placed upon the operating-table for the performance of external perineal urethrotomy. 178 STRICTUEE OF THE UEETHKA. which, when fully anesthetized, astonish the operator by permitting the full-sized exploratory staff to slip easily into the bladder. In other cases the entire absence of that peculiar resistance to the knife which the experienced surgeon recognizes when dividing cicatricial tissue, and the failure to locate with exactness the contracted point, will suggest to the memory of some that occasional patients, similarly affected, have not escaped so easily. Not infrequently persistent difficulty in urination and perhaps retention of urine requiring the habitual use of the catheter has been observed by surgeons where no proofs of intravesical growths were present, and where the easy passage of an ordinary catheter jjrecluded the idea of enlargement of the prostate or of close organic stricture. If it can be proved that purely spasmodic urethral contraction may, and not infrequently does, present all of the important diagnostic features of the true close organic stricture, and, further, if it can be shown that polypoid and prostatic obstruc- tion are often simulated by chronic spasm of the accelerator-urinse muscles, pro- ducing obstruction and persistent closure of the membranous urethra, then it will be conceded that failure to appreciate so important a complication will conduce to grave errors in diagnosis, terminating possibly in an operation for conditions which exist only in the mind of the surgeon. It must at once be apijarent to every surgeon of experience that Dr. Otis has given us in the foregoing remarks a most valuable and practically reliable principle in genito-urinary surgery. So evident, too, is the point involved that it is remarkable that it remained for him to discover. In a large proportion of penile strictures a sound large enough to put the contraction on the stretch either will not enter the bladder or does so with great difficulty. A bulbous, flexible bougie of any size will not enter at all, and, even if a small one does pass the deep urethra, it is firmly grasped on withdrawal, the sensation imparted to the hand being not always decep- tive to the expert, but to the surgeon of little or moderate experience consti- tuting irrefutable evidence of deep organic stricture. The association of spasmodic contraction of the deep urethral muscles with renal disease has not received special attention. It is an element, how- ever, of the painful and frequent micturition incidental to nephric stone and pyelitis. The author has a case now under observation in which there was marked urinary obstruction coincident with an acute exacerbation of pyelitis, although the urethra had previously been entirely free from ob- struction. In such cases there may be associated with the spasm more or less reflex neuralgic pain in the back, groins, hypogastrium, and thighs. It should, of course, be remembered that there exists in these cases a special irritating factor: i.e., morbid urine. Diagnosis. — The diagnosis of spasmodic stricture is usually easy, espe- cially where retention occurs suddenly. It is obvious that the sudden oc- currence of retention in organic stricture or other obstructive lesion of the genito-urinary tract, in which the stream of urine has previously been fairly free, must depend upon some complication — either inflammation and con- gestion at the site of the organic lesion or spasmodic contraction of the cut- SPASMODIC STEICTUEE. 1?9 off muscle, or the two combined. Inflammation or congestion is to be in- ferred in every case of spasmodic retention, and demands due consideration ; the predominating element of spasm is, however, the principal feature. As a rule, in cases of sudden retention of this kind there is a histor}^ of some one or more of the exciting causes that have been enumerated. In the diagnosis of spasmodic retention it should be remembered that in by far the majority of cases there is some organic foundation for the con- dition. When, in the course of treatment for organic stricture of small caliber, retention suddenly occurs, the predominating condition is usually congestion or inflammation. The occurrence of acute urethritis during the course of organic stricture is likely to superinduce sudden retention. The condition in these cases, although a spasmodic element exists, is mainly con- gestion and inflammation at the site of the stricture producing sufficient swelling to completely occlude the urethra for the time being. Traumatic urethritis causes retention in the same way. In strictures of large caliber in which the passage of urine is comparatively free, spasmodic retention may suddenly develop. It is doubtful whether congestion or inflammation alone could produce complete closure of the canal in such cases. It is sometimes difficult to determine during instrumentation what proportion of the obstruction is due to organic contraction and what to spasm. For example, after an instrument has passed a stricture of large caliber in the penile portion of the urethra, or an inflamed and irritable meatus, it will often be obstructed on entering the membranous region. A steel sound is less likely to be obstructed than a soft bulbous bougie, and the spasm is more likely to yield to steady and gentle pressure with the point of the sound than to a soft bulb. If there is a slight organic con- traction at the bulbo-membranous Junction, a steel instrument small enough to pass the stricture in the anterior portion of the canal will, in all prob- ability, slip by the deeper constriction and fail to detect it. A large bulbous instrument usually fails to pass altogether, but if a small bulbous bougie be introduced, it will be found that the spasm of the surrounding muscles, although not sufficient to prevent the instrument from entering the bladder, will contract the stricture so that the shoulder of the bulb catches upon it as it is withdrawn. The peculiar feel imparted to the bougie and the sud- den snap produced by the passage of its shoulder through the organic con- traction will show the character of the case. It will thus be seen that a comparatively small bulb may detect an organic contraction with predominating spasm in the deep urethra where a steel sound of considerable size would fail. The peculiar sense of elasticity imparted to the instrument as it presses against the portion of the urethra spasmodically contracted gives the expert a tolerably accurate idea of the real condition of affairs. Because of the spasm usually encountered there are few individuals in whom deep stricture cannot be demonstrated by a bulb. If, however, a very small bulbous instrument be passed and slowly 180 STRICTUEE OF THE URETHEA. withdrawn^, organic contraction can usually be excluded. The ordinary sound cannot be relied upon for a diagnosis. Exceptional cases of chronic spasmodic stricture are met with in which the real condition can only be demonstrated after the subtraction of alli sources of irritation, direct or reflex, when the supposed organic stricture disappears. Eeferring to spasm in the penile urethra, it is important to know that in many cases denominated penile "stricture of large caliber" the urethra isj not organically strictured, but as instruments pass over a thickened, granu- lar, and hyperesthetic patch there occurs at the site of the lesion, spasm of] the accelerator-urinm and compressor-urethrce muscles, giving rise to thej same objective symptoms as organic stricture. It is probable that urethrot- omy is often performed where true organic obstruction does not exist, the! condition just described explaining the obstruction to instruments and the grasping of the bulb as it is withdrawn. This, however, is not necessarily] an argument against the necessity for urethrotomy. Teeatment. — The first indication in the treatment of spasmodic j stricture is the removal of all predisposing causes so far as possible. Such I conditions as the gouty and rheumatic diathesis require correction. Gen- €ral nervous irritability and hyperesthesia demand nervine tonics, sedatives,] or antispasmodics, according to special indications. The principles ofj genito-urinary and sexual hygiene should be thoroughly impressed upon the patient's mind. Once he is convinced of the fallacy of the notion that his penis and testes are the axis of his earthly existence, the surgery of the] case is much simplified. All sources of local and reflex irritation must bej removed. This necessarily involves, as a rule, the cure of organic urethral lesions. The urine should be kept bland and non-irritating by dietetic measures and the administration of alkaline remedies. Careful study should be given to the degree of tolerance of the urethra for instruments. The amount of irritability of the urethra and the degree of spasm excited by. instrumentation constitute a fair criterion of the frequency with which] they should be introduced in the treatment of organic stricture. In spasmodic retention an attempt should be made to relieve the con- dition by derivation — to remove possible congestion — and antispasmodics. The passage of instruments should be avoided, if possible, as tending to in- crease irritation and spasm. The full hot bath and morphia by the mouth] or hypodermically should be depended upon so far as practicable. The patient often succeeds in passing urine while in the hot bath, which is both derivative and sedative. When these simpler measures fail, a small soft] catheter should be passed, — -while the patient is in the bath, if possible. Chloroform or ether may be given to the extent of full anesthesia, if neces-j sary, to relax the spasm and facilitate instrumentation. When retention! comes on in organic stricture, it must be remembered that it is not due to I organic contraction per se, but to certain plus conditions: i.e., spasm, con- CONGESTIVE STEICTUEE. OEGAXIC STKICTUEE. 181 gestion, and edema of tissue in varying proportions. Eelief of retention depends upon the subtraction of these plus conditions from the primary predisposing factor of organic contraction. The treatment of urethrismus is chiefly operative. After all sources of reflex irritation have been removed the urethrismus disappears. CONGESTIVE^ OE INFLAMMATOEY, STEICTUEE. This is usually a complication rather than a distinct pathologic entity^ being even less frequently met with as a primary condition than spasm. Its existence as an essential condition is denied by many surgeons, but it nevertheless appears to be the main feature of a minor proportion of cases of urinary obstruction with or without retention. Congestive, or inflam- matory, obstruction may occur: (1) as the result of occlusion of the ure- thra by extensive infiltration of the mucous membrane, periurethral con- nective tissue, and corpus spongiosum in severe or virulent urethritis; (2) at the site of injury to the mucous membrane produced by instrumental or accidental trauma; (3) as a consequence of acute urethritis afEecting strict- ures of large caliber or congested and granular patches of mucous mem- brane. Congestive, or inflammatory, stricture necessarily occurs most fre- quently in connection with organic stricture. It is often difficult to de- termine in a particular case exactly what relative proportions of spasm and congestion exist. Some cases of congestive stricture are of a chronic type, and exhibit a marked tendency to hemorrhage, from instrumental interference, sexual indulgence, or in rare instances without apparent cause. The author has noticed this symptom with especial frequency in syphilitics and patients having a tendency to varices. Teeatment. — The therapeutic indications are the same as in spas- modic stricture, — which is usually a complicating factor, — excepting that in cases in which congestion is believed to be a prominent element the ap- plication of leeches in the course of the urethra, particularly in the perineal region, is advisable. OEGANIC STEICTUEE. Organic, permanent, or fibrous stricture is a contraction of the urethra produced by localized adventitious tissue-formation, either congenital or acquired. It is usually acquired and most frequently met with between the ages of twenty-four and forty-five. Stricture very rarely gives trouble for the first time after the age of forty. It may occur at any time after the period of puberty, perhaps before puberty, if traumatic. The frequency of stricture between the ages men- tioned is easily explained by the fact that it is at this period of life that urethritis — the most frequent cause of stricture — is most likely to occur. 182 STEICTUEE OF THE UKETHBA. Teaumatic Steictuee. — Traumatic organic stricture may occur at any age. The youngest ease that has come under the authors observation was a boy of 13, who was operated upon by external perineal section. In this case the stricture recontracted, — probably from neglect on the patient's part, —and is now with difficulty kept open. Another operation will be eventu- ally required., Erichsen records a case in a boy 11 yeaTs of age. Traumatic stricture is usually located at the triangular ligament. It; is here that the urethra is most likely to be injured by blows or falls. A| fall astride a hard object or a kick in the perineum is the usual cause. The bulbo-membranous urethra is caught between the impinging body and' the sharp, knife-like lower border of the subpubic ligament, and a very slight degree of force may therefore produce permanent injury. It does not require great violence to sever completely the deep urethra. The pendulous urethra, on the other hand, is rarely involved on account of the difficulty with which it can be caught between two impinging bodies. Whatever the location of traumatic stricture, it is composed of cica- tricial tissue, the extent of which depends upon the degree of destruction of the urethral walls that has given rise to the stricture. Obviously, such a stricture is the worst with which we have to deal. It is rarely amenable to dilation and usually requires perineal section. Congenital Steictuee. — Narrowing of the meatus aside, the con-' genital form of stricture is rare. The occurrence of congenital stricture below one-fourth of an inch from the meatus is denied by most authorities. If, however, we take into consideration the occasional occurrence of con- genital atresia of a part or the whole of the urethra, the possible occur- rence of localized congenital narrowing of the canal is readily understood. The author has seen a number of cases of linear stricture of the pendulous portion of the canal that he believes to have been of congenital origin. It' may be asserted that such cases are traumatic, or due to the mechanic irritation produced by masturbation. The possibility of this is admitted. In speaking of congenital stricture points of slight relative contraction that may be demonstrated in most subjects are not included. Congenital stricture of the meatus is a relative matter, inasmuch as it' is not, pe7- se, productive of discomfort in the majority of cases. A meatus: narrower than the average is not likely to be annoying, providing gonor- rhea is not contracted. As already noted, the size of the meatus varies greatly in different] individuals, and there is very frequently not only a narrow meatus, but a distinct linear contraction of the canal about one-fourth of an inch within] it. When such a urethra becomes affected by inflammation, or when it is found necessary to explore the urethra or bladder, the meatus at once assumes a position of pathologic importance, inasmuch as it is impossible to satisfactorily explore — and more difficult, if possible, to thoroughly treat] — a urethra of moderately large caliber through a narrow meatus. OKGANIC STKICTUEE. 183 In order to acc-urateW determine the condition of the urethra or treat oroanic disease of the mucous membrane the meatus must admit instru- ments of a size corresponding to the largest mean diameter of the canah Obviously, when the normal caliber of the urethra is 38 French, it is im- possible to satisfactorily explore or treat it when the extreme capacity of the meatus is only 30 French. Otis's urethrometer in the hands of the expert has obviated the difficulty of exploration in such cases, to a certain extent, but it is by no means so satisfactory or safe for routine use as the bulbous bougie. AVhenever, therefore, there exists a suspicion of urethral, prostatic, or bladder disease and the meatus is contracted, it should be enlarged by incision sufficiently to admit an instrument that will thoroughly distend the canal. In quite, a number of instances a contracted meatus has been known to induce reflex neurotic disturbances. Vesical irritability, with frequent micturition, and perhaps more suspicious symptoms of stone, have been known to arise from this cause. The author has met with a number of cases of this character, and one more interesting still in which atony of the bladder resulted, as was demonstrated by the cure that followed mea- totomy. Congenital narrowing of the meatus may be due, as already mentioned in connection with the anatomy of the urethra, to partial occlusion by a thin membranous septum at its inferior commissure, the fossa navicularis terminating in a pouch behind it. In others, however, the narrowing is due to exceptional thickness of the tissues of the glans below the meatus. In the former the meatus may stretch easily when instruments are passed; in the latter, however, the introduction of an instrument of sufficient size to distend the meatus produces spasm, in some cases of the entire canal, always of the cut-off muscle. It will be seen, therefore, that it is not alone the size of the meatus which is important, but also its dilatability and degree of tolerance of instrumentation. Whenever, during the passage of an instrument, the meatus is drawn tightly above it in a thin white line, it is safe to conclude that that particular instrument cannot be introduced into the deep urethra without unwarrantable force. Ueetheal Steictuee in the Female. — The female sex enjoys rela- tively great immunity from urethral stricture. This is explicable by the shortness and simple structure of the canal and the extreme rarity of urethritis in the female. The author has never seen but three cases of the kind; one of these occurred in a masturbator, probably from laceration by the introduction of foreign bodies. Erichsen records a case in a woman, but does not state the probable cause. Eecent contributions to surgical literature, however, have shown that stricture in the female is more frequent than is generally supposed. Van de AVarker has reported a number of in- teresting cases. Otis has also observed that stricture of the urethra is more often seen 184 STEICTITEE OF THE UKETHRA. in women than is generally believed. Symptoms that in men would be at once attributed to stricture of the urethra are most often attributed in women to an irritable bladder. It has been asserted that stricture may occur in lithemic female patients independently of inflammation, specific or otherwise, and require the same treatment as in men. Vaeieties of Organic Steicture. — Organic acquired stricture occurs in three principal varieties as regards conformation: 1. The first and simplest is the linear stricture, the resulting obstruction corresponding to that which would be produced by tying a narrow cord about the canal. 2. The second variety, annular stricture, is wider, the condition being me- chanically similar to that which would result from tying a piece of tape about the canal. 3. The third form, tortuous stricture, has been needlessly Fig. 52. — Linear stricture. (After Voillemier. divided into numerous subvarieties. It involves a considerable extent of the urethra in an irregular contraction. For practical purposes these three varieties are sufficiently distinctive. Strictures may be classified clinically as: (a) simple and readily di- latable; (h) irritable, involving local hyperesthesia and hyperemia; (c) re- silient or elastic; (d) recurrent. This classification of stricture necessarily depends largely upon its behavior under treatment. Linear strictures appear in several different forms. There may be one or more membranous septa encroaching on the caliber of the canal. These have been termed bridle or pack-thread strictures. A number of these bridles may exist, the orifices of which may or may not correspond. In some cases they are transverse and in others oblique in direction. Their orifices may correspond to the center of the canal, or be located at its side. ORGANIC STRICTURE. 185 Occasionally the septum — or band — has a crescentic form, involving only a part of the canal. The precise method of formation of these bridles and bands is not known. It has been generally accepted that in- flammatory lymph is never thrown out upon the surface of the mucous membrane. This is difiicult to determine positively, however, in the ab- sence of abundant post-mortem evidence. It is certainly possible where the mucous membrane has been injured by instruments or chemic irri- tants. It has been claimed that in some cases the bridles are due to the fusing together of the natural longitudinal folds of the urethra. In some instances the condition results from a tearing up of valvular flaps of mu- cous membrane by unskillful instrumentation. In others it is possible that there is a certain amount of atrophy of submucous connective tissue and mucous follicles, giving rise to a loose flap of mucous membrane. Fig. 53.— Bridle stricture. (After Dittel. That the natural folds of the mucous membrane may fuse together, so to speak, and form part of a stricture-mass the author firmly believes from conditions found in certain cases of perineal section. Annular stricture may be due to thickening of, and interstitial deposit in, the mucous membrane or to submucous inflammatory infiltration. The author holds that, in some instances of apparent annular stricture of large caliber observed clinically, the condition is really superficial thickening of the mucous membrane in the form of congested and granular plaques at a point of normal relative inelasticity of the urethra. This lesion need not necessarily involve the entire circumference of the canal, although it apparently does so because of coincident spasm. Immediately the bulbous bougie impinges upon such a sensitive spot the urethra contracts down in front of the shoulder of the instrument, giving the same sensation as 186 STKICTUEE OF THE UEETHEA. the latter is withdrawn as that imparted by decided narrowing of the canal. Obvionsly, it is impossible^ even with the endoscope, to determine whether such a lesion involves the entire circumference of the canal or only a cir- cumscribed patch. Tortuous strictures are made to include all those above one-fourth to one-half inch wide. They are irregularly contracted, — i.e., narrower at some points than at others, — as a rule. The whole pendulous urethra may be involved, always in varying degree. The fact that extensive tortuous stricture is narrower at some points than others is explicable upon the same grounds as the localization of congested and granular patches and Fig. 54. — Annular stricture. (After Dittel.) stricture of large caliber in the pendulous urethra, viz.: the existence of normal points of relative inelasticity where the inflammatory process is necessarily severer than in other portions of the canal. As already remarked, the formation of some tortuous strictures may perhaps be explained by the fusing together of the natural folds of the canal. If the spiral or rifled form of the urethra in a flaccid condition be admitted, it is conceiv- able that pronounced infiltration of the corpus spongiosum may perma- nently fix it in its tortuous conformation. The number of strictures varies. It has been most generally accepted that stricture is usually single, but careful exploration will show, in the majority of cases, more than one stricture. The surgeon who believes that i OEGAXIC STEICTUEE. 187 a urethra which will admit a medium-sized sound is necessarily free from stricture is apt to recognize only marked cases occurring in the bulbo-mem- branous region, whereas if familiar with strictures of large caliber he might discover by careful exploration in a given case several strictures in the penile portion of the canal. Dr. Otis's investigations, while perhaps ex- aggerating the frequency and multiplicity of strictures, have certainly shown not only that stricture of large caliber may exist where the urethra "d Fig. 55. — Tortuous multiple stricture, a, Annular cicatricial band, ft, &, Dilated portions of urethra, c, Callous periurethral tissue at point of deep stricture, d, Sinuses in paraprostatica. (After Dittel.) will admit a large sound, but that penile stricture is much more frequent than has been commonly supposed. Some cases of so-called multiple strict- ure consist of irregular contractions of a long, tortuous stricture. The amount of contraction in strictures varies greatly between those of large caliber, in which there is but superficial thickening and loss of elasticity of the mucous membrane, and those severe long-standing strict- 188 STRICTUKE OF THE UEETHKA. nres in which the lumen of the urethra is so contracted as to resist the introduction of a fine bristle, even when the stricture is exposed post- mortem. The contraction is very rarely sufficient to completely prevent the passage of urine. It has been asserted that in this sense impermeable stricture does not exist. This, however, is incorrect; the urethra may be so injured by traumatism that the resultant stricture completely occludes its lumen. The same is true of inflammatory organic stricture complicated by fistulas that divert the urine from its normal channel. The rarity of strictures impermeable to urine is easily explained. Every intelligent practitioner knows how difficult it is to heal a fistula that communicates with secreting structures or a cavity containing materials that escape and enter the lesion. Urinary fistula, fistula in ano, and Fig. 56. — Multiple stricture, penile and deep, showing varying caliber. (After Fessenden Otis.) salivary fistula are familiar illustrations. The patency of urethral stricture it not only facilitated by the passage of urine, but also by the fact that at least a part of the mucous membrane is usually intact. The inflam- matory deposit occurs, as a rule, in and beneath the mucous membrane, and produces obstruction by pressure upon it, instead of by fusing opposing surfaces of the urethral walls. Just so long as an intact strip of mucous membrane, however narrow, exists in the track of stricture just so long is it permeable. Strictures impermeable to instruments are also rare, particularly in the practice of surgeons who exhibit sufficient patience, gentleness, and skill in instrumentation. A stricture should not be pronounced impermeable because at one, or perhaps a dozen, attempts it is found impossible to pass an instrument, for sooner or later, especially if appropriate general measures OEGANIC STKICTUEE. 189 be instituted, an instrument will usually pass, and, no matter how small it may be, the successful passage of a bougie at once gives the surgeon control of the case. The most competent andrologist may fail to pass a stricture, but impermeability of the stricture at one end of the bougie often means a lack of tact or patience at the other. Location of Steicture. — The location of stricture has been the sub- ject of much controversy. Dr. Otis's investigations have modified in certain quarters the prevalent views of the relative frequency of stricture at differ- ent points in the urethra. That the opinions of Otis have not been allowed to pass unquestioned goes without saying. Until recently the dicta of Sir Henry Thompson and his disciples re- garding the location of stricture have been almost universally accepted. Thompson found, in 330 cases of stricture examined clinically, 213 at the bulbo-membranous Junction, 51 in the spongy portion of the canal — at variable points between one inch anterior to the opening in the triangular ligament and 3 V2 inches posterior to the meatus — and 54 at the meatus, or within 2 ^/o inches posterior to it. In 370 cases examined post-mortem he claimed a decided preponderance of stricture in the bulbo-membranous region, i.e., the space between a point 1 inch anterior to the triangular liga- ment and another ^/^ of an inch posterior to it. H. Smith examined 98 preparations of stricture in the London Museums, and found only 31 in the membranous urethra, the other 77 being anterior to it. The majority of the latter were in the bulbous urethra or just anterior to it. Otis claims — the author thinks justly — that stricture is most frequent in the penile urethra. It is obviously impossible for surgeons to arrive at harmonious conclusions so long as standards of stricture and methods of exploration differ so widely. Post-mortem evidence is only relatively valuable. The surgeon who reasons from clinical experience and the skillful use of the urethrometer and bulbs can hardly agree with Thompson, and must acknowledge the accuracy of Otis's methods, even though he may consider the conclusions of the latter somewhat overdrawn. In the author's experience stricture appears clinically to be most fre- quent at the meatus or just within it, being in most cases congenital. The next most frequent site is the junction of the spongy urethra with the fossa navicularis, or just posterior to it; i.e., ^/ ^ to 1 '^J ^ inches from the meatus. iSText comes the bulbo-membranous junction, and finally a point about 1 inch anterior to it. It seems to occur with varying frequency in the inter- mediary portions of the canal. As Otis remarks, strictures occur, as might naturally be expected, with greatest frequency Avhere infiammation begins the earliest and rages the hottest, the frequency gradually diminishing in the deeper portions of the canal. From a clinical stand-point stricture may be regarded as any condition of the urethra capable of producing friction by obstructing the flow of 190 STRICTURE OF THE URETHRA. urine, to however slight an extent, providing said obstruction and friction are productive of pathologic disturbances, or, if the latter have already begun, tend to perpetuate them. A point of normal contraction or relative inelasticity becomes a stricture only when the urethra assumes a patho- logic state; the previously normal lack of distensibility is then of great pathologic and surgical importance, and its removal may be imperatively necessary. Holding that any point of contraction or inelasticity in the urethra in the presence of a pathologic condition of the mucous membrane consti- tutes a stricture, the author reiterates the conviction that stricture is most frequent in the pendulous portion. If care be taken to exclude the element of deep urethrismus, — which is not always so easy as some would have us believe, — ^the proportion appears to be at least ten to one. That there is great variance of opinion upon this point is well known, and as Bumstead and Taylor remarked many years ago, there can be no harmony of results between those who study the subject upon the living and those whose estimates are formed entirely upon observations of the cadaver. In 1857 Folet called attention to the frequency of fibrous stricture in the pendulous urethra, and its comparative rarity in the bulbo-mem- branous region. This author claimed that deep obstruction existed in all cases of stricture of the spongy portion, but that deep stricture was nearly always spasmodic and secondary to trouble in the anterior portion. In 1866 Verneuil cooly appropriated Folet's thunder, and expressed essentially the same views, almost verbatim. Otis, writing at a later period, while not so radical as his French predecessors, promulgated similar views, but in a much more comprehensive and thorough manner. His demonstration of the relation of urethrismus to more or less remote reflex irritation was one of the most important modern contributions to genito-urinary litera- ture, and is decidedly complimentary to the genius of American surgery. In estimating the frequency of deep spasmodic stricture as a complica- tion of obstruction in the pendulous urethra an important source of fallacy should be remembered: While deep stricture may apparently be demon- strated by instrumentation in nearly all, if not all, cases, it does not necessarily follow that deep obstruction exists at other times. The tender urethra resents a foreign body quite as vigorously as does the eye, and as soon as the sound touches a tender spot or sensitive stricture, even of large caliber, in the pendulous urethra, a pronounced reflex contraction is ob- servable throughout the entire canal: this is, of course, most pronounced in the deep portion. In some cases, as already stated in discussing spasmodic stricture, deep spasm exists more or less constantly; but in many of these there is actual organic change at the site of the spasmodic stricture; this may be true or- ganic infiltration, erosion, or a congested and granular patch. Here it is often very difficult to determine, even approximately, the relative propor- LOCALIZATION OF STKICTUEE. 191 tions of spasm and organic lesion. The true condition of affairs can often- times only be determined by subtracting the sources of reflex spasm in the anterior urethra by urethrotomy. The prostatic portion of the urethra is never involved in inflammatory stricture, so far as known. Thompson says on this point: "I may confidently assert that there is not a single case of stricture of the prostatic portion of the urethra to be found in any of the public museums of London, Edin- burgh, or Paris." The dicta of authorities on this question are correct only as regards acquired stricture. The author has dissected several specimens in which congenital narrowing and distortion of the distal portion of the prostatic urethra existed. In one case a distinct musculo-membranous bridle ex- tended across the prostatic urethra. Pathologic Localization of Stricture. — The predilection of stricture for different portions of the canal has not been clearly explained. The explanation usually given for the relatively greater frequency of stricture in various portions of the canal, more particularly in the bulbo-membranous region, is that there is in these situations a greater amount of erectile tissue, and a more marked tendency to localization of inflammatory proc- esses, than in other portions of the canal. There are several points to be considered in attempting to explain the occurrence of stricture in any particular location, and in some instances there are certain special elements that are worthy of attention. Acquired strictures at or Just within the meatus are favored by con- genital narrowing at this point. There* is constant obstruction to the uri- nary outflow, and the resulting friction inevitably enhances inflammation. There is also a tendency to pocketing of secretions in the fossa navicularis, and these secretions — primarily acrid in virulent inflammation — soon de- compose, aggravating the existing inflammation. The nozzle of the ordinary faulty syringe used for injecting the urethra necessarily produces consider- able irritation if the meatus be small. The frequency of acquired stricture Just within the meatus is thus explained. Long-nozzled syringes often pro- duce stricture some little distance within the meatus by the frequent impact of the point of the instrument against the inflamed mucous membrane. At such an area of irritation the inflammation will necessarily become local- ized and chronic. The relative dilation of the bulbous urethra and fossa navicularis favors retention of urine and pathologic discharges at these points, but this is not very important in the causation of stricture until actual obstruction by inflammatory thickening of the mucous membrane occurs Just in front of the dilated point. Under ordinary circumstances these expanded por- tions of the urethra are flushed out from time to time by the urine. When, however, the formation of stricture begins, a small quantity of decomposable fluid will inevitably be left in the canal at these points. 193 STEICTUEE OF THE UEETHEA. Traumatic strictures produced during instrumentation necessarily oc- cur at the site of injur}'. The principal obstruction to instruments, even in the normal urethra, being at the opening in the triangular ligament, — i.e., the bulbo-membranous junction, — it is at this point that such strictures are most often found. Traumatic strictures from falls or blows upon the urethra correspond to the site of injury. It is very difficult, however, to catch the pendulous urethra between two impinging bodies unless done with deliberate intent to produce injury. In the case of the deep or fixed urethra, however, injury is readily produced by falls or blows upon the perineum. Stricture thus produced occurs most frequently at the bulbo-membranous junction, for, as already noted, this point corresponds with the opening in that tense fibrous septum, the triangular ligament, and also with the sharp lower border of the subpubic ligament. This latter structure is of semicartilag- inous consistency, its edge being like a narrow border of bone. It is be- tween this hard tissue and the impinging body that the urethra is usually caught in perineal injuries, and slight force may produce sufficient injury to cause traumatic stricture. Comparatively slight force may sever the urethra completely. Injuries that are practically unnoticed in early life may produce organic stricture later on. These traumatic strictures are, on the average, the worst with which we have to deal. The location of stricture due to the introduction of strong chemicals into the urethra may be determined by the same normal anatomic con- ditions as in ordinary virulent urethritis. They may, on the other hand, occur at the point chiefly affected by the caustic or chemic substance. Foreign bodies in the urethra may produce localized inflammation and perhaps ulceration that determines the site of future stricture. Foreign bodies are most likely to lodge in one of the dilated portions of the canal. Under such circumstances the foreign material produces pressure and irrita- tion chiefly at that point in the mucous membrane where its outward passage with the flow of urine is obstructed. Injury incidental to chordee is. often responsible for the localization of stricture. This condition interferes with the normal distensibility and elasticity of the urethra, and during erection produces a strain upon the^ tissues of the corpus spongiosum and the urethra at some particular point or points. The point of greatest convexity of the curve produced by the chordee is, as a rule, where the greatest strain is experienced. The irrita- tion produced by this straining of tissue is apt to induce the localization of stricture at this point. In some instances the corpus spongiosum or mucous membrane of the urethra yields to the tension and is lacerated to a greater or less degree. This may be produced by the patient's forcibly bending the penis in the fatuous notion that rupture of the chordee cures gonor- rhea. The author believes, however, that in marked cases it may result from frequent and vigorous erections, the laceration being unrecognized, LOCALIZATION OF STEICTUEE. 193 save perhaps where the patient calls the attention of the surgeon to the fact that there has been more or less hemorrhage during the night as a result of the chordee. This is a frequent cause of stricture, the subsequent stricture occurring at the site of injury. Whenever an appreciable quantity of blood appears in gonorrheal discharge such minute traumatisms may be inferred. These slight injuries often form the groundwork for future stricture-building. Certain normal anatomic peculiarities of the structure of the canal are the most important elements in the determination of stricture at special points in the urethra. These are the chief bones of contention among the warring factions whose causus lelli is the question: To cut or not to cut? It has been shown by Weir, Sands, and others that certain points of narrow- ing exist in the spongy urethra, termed by them normal contractions, being distinct from the normal narrow points usually recognized — i.e., the meatus, bulbo-membranous junction, and the point of union of the spongy urethra with the fossa navicularis. This description appears to the author some- what misleading. The urethra is an elastic tube susceptible of considerable dilation. Its elasticity, however, is not uniform throughout, but as a con- sequence of sparsity of elastic tissue, with a preponderance of connective and fibrous tissue in the erectile structure of the corpus spongiosum and deficiency of areolar tissue beneath the mucous membrane, there are various points of relative inelasticity and limited dilatability. In certain portions of the canal relative inelasticity and limited dilatability are due to anatomic peculiarities of the surrounding structures. For example, at the opening in the triangular ligament the urethra is not only narrow, but surrounded by dense and unyielding tissues. The meatus is comparatively inelastic in most individuals, even when it cannot be said to be congenitally contracted. The corpus spongiosum is a little thicker at the junction of the fossa navic- ularis with the spongy urethra and at the junction of the latter with the bulb than elsewhere. At these various points, moreover, the areolar tissue beneath the mucous membrane is disproportionately scanty and the latter is more closely applied to the tissues which it invests. It would seem also that, as there is more strain at these points than in other portions of the canal, the urethra is normally reinforced at these points by increased density of fibro-connective tissue. In explaining the localization of stricture we will take as our point of departure the fact that the urethra is a dilatable tube, the elasticity of which varies at different points in the canal. Through this tube water at a certain pressure and in a certain volume is forced at more or less frequent intervals. Obviously, the greatest friction is produced at the various points of normal contraction and relative inelasticity. Against the strain and friction pro- duced at these points Nature has provided a certain amount of reinforce- ment of tissue, and under normal circumstances, with a healthy mucous membrane, the pressure and friction do not produce injury. When, how- 194 STRICTURE OF THE URETHRA. ever, the canal is inflamed, as in acnte nrethritis, its Innien and elasticity- are decreased. Urine is neyertlieless pumped tlirongh the tube in as great volume and as often as under normal circumstances, producing by its press- ure and friction and chemic effects considerable irritation, as evidenced by pain and smarting. Obviously, the greatest amount of irritation occurs at the points of relative inelasticity, and consequently it is here that inflam- mation tends to localize itself, and persists long after the remainder of the mucous membrane has returned to an approximately normal condition. This continual friction and irritation is interpreted by the controlling 1 centers and nervous supply of the part as a demand for reparative material;] hence there must inevitably be more or less plastic exudate at these points. This exudate is Nature's bulwark against strain and irritation and aims toi secure physiologic rest. Unfortunately, however, this conservative process is here misapplied, for if complete absorption does not occur, the exuded inflammatory material remains, organizes, contracts, and constitutes a| stricture. The existence of points of relative inelasticity probably also explains abraded, congested, and granular patches of the mucous membrane in cases that are not due to frequent contact of instruments. The relatively greater amount of friction at such points tends to produce abrasion of the mucous membrane and removal of epithelium, more frequently than at other points. Eapid removal and reformation of cells results in impaired vitality and a vicious habit of cell-formation. This is one of the most important factors in chronic urethritis. The physiologic and biologic elements in the localization of stricture must not be forgotten: the vicious habit of cell-formation already referred to is of great importance. In the course of acute urethritis there is a tend- ency to rapid formation of epithelium of a low grade. This is a reparative, a conservative, process, but, unfortunately, a certain biologic law comes into play here, viz.: in inverse proportion to the degree of differentiation of cells is their rapidity of proliferation and their tendency to degeneration. Tile consequence of this law is an erosion at the point of friction, and, secondarily, a plastic deposit to resist strain. Comment upon this is un- necessary; the subsequent metamorphosis of this deposit into fibrocon- nective tissue is well known. In the pendulous urethra especially — and probably also in the fixed portion — the plastic deposit may absorb, but the friction remains and a gleet is often kept up. The points of normal con- traction and relative inelasticity have now become of pathologic importance. It would seem to be immaterial whether these points were primarily present in the canal as normal conditions or not, as regards their surgical relations. The question is not whether they are adventitious, as claimed by Otis, or normal as claimed by Weir and Sands, but "What relation do they bear to the abnormal state of the canal?" The difference between the two conditions is one of degree, not kind. MORBID ANATOMY OF STRICTURE. 195 From what has been said, the direct relation of stricture to the severity of the primary urethritis may be clearly seen. It is a self-evident proposition that if what has been said regarding the relation of stricture to friction be true, the same holds good with relation to granular, congested, and eroded patches in the canal. Within certain limits the indications for treatment may be the same. In addition to the element of friction in producing stricture and other lesions of the urethra, a varying degree of importance of retained infectious and inflammatory products at points of narrowing is acknowledged. Eegarding the importance of urethral friction, Otis says: — It is only necessary to establish the fact that the normal resiliency of the urethra is diminished, at a given point to prove that during micturition a perturba- tion of the stream must occur at such pointy even if it is not sufficient to attract attention in any way. Hence the slightest contractions assume an importance which could not be inferred from the apparent freedom from trouble in passing the urine. They establish a localized point of friction, and of necessity an increased excitement in the vessels of the part, possibly only enough to disturb the complete elaboration of epithelial material and to cause a shreddy deposit to take the place of the clear normal secretion; and this may occur with very slight or without the least abnormal sensation being present. The presence of the mucoid shreds in the urine may be the only evidence of commencing trouble. But a permanent point of friction once established, greater than the natural conservative power of the surrounding parts is able to counterbalance, obstruction is increased by the natural aggregation of plastic material at the point of irritation. In this way the tendency to recovery is com- bated and a permanent point of inflammatory action is established. Thus the difficulty, which commenced simply as an obstruction to the resiliency of the urethral walls, progresses certainly and naturally to the point of narrowing, to a greater or less degree, the caliber of the urethral canal. When the views of Dr. Otis first appeared they gave rise to much opposi- tion. Among those who vigorously combated the teachings of Otis was the author's lamented friend, the late Henry B. Sands. Among other arguments, Dr. Sands presented some carefully prepared casts of the infer- entially normal urethra that showed great variation of caliber. What struck the author as most peculiar was the controversy as to the normal or ab- normal character of many of the penile strictures diagnosed by Otis. Taking into consideration the purely mechanic effects of stricture of the urethra, it is difficult to understand how" quibbling was possible. What difference in results and in treatment could be maintained between a gleet perpetuated by normal points of friction in the urethra and a gleet perpetuated by ac- quired stricture? Sooner or later, true adventitious deposit occurs and the point of normal relative indistensibility merges into an acquired neoplastic contraction. Points of relative inelasticity or contraction and points of ac- quired contraction may be precisely the same from a clinical stand-point in the presence of a pathologic condition of the mucous membrane. The cure of the case demands their removal independently of their origin. Morbid Ajf atomy. — When inflammation becomes localized at any 196 STEICTUEE OF THE UEETHEA. point in the urethra an extension of the process to the snbinucous tissue results, or there is an increase of pre-existing periurethral inflammatory thickening. This consists of a submucous infiltration of embryonal cells Fiff. 57. — Casts of alleged normal urethras, showing points of contraction, 1, 2, 3, 4, 5, 6. (After Sands.) that soon forms a more or less dense zone of periurethral sclerosis. It may or may not, at the beginning, form a distinct thickening of the corpus spongiosum. This process constitutes the dehut of stricture, and is the con- dition most frequently detected in chronic urethritis by the bulbs or ure- MORBID ANATOMY OF STRICTUEE. 197 thrometer. Obviously it is upon the loss of elasticity at the affected point that the detection of the lesion depends. The same loss of elasticity explains the symptoms of stricture and its tendency to growth. In some instances there is slight thickening of the mucosa^ with little or no submucous proliferation of connective tissue, the epithelium being more or less denuded and covered with muco-purulent secretion. The fol- licles of the urethra at this point are dilated, thickened, and disposed to hypersecretion. When the process is a little farther advanced the mucous membrane is thickened, congested, perhaps covered with fungous granula- tions, with more or less infiltration and thickening of the submucous con- nective tissue and corpus spongiosum. In more advanced cases the corpus spongiosum is extensively infiltrated and of semicartilaginous consistency, often so dense that erection is imperfect. This condition is really chronic interstitial inflammation of the corpus spongiosum, acting precisely like ^cute inflammation in the production of chordee. Bridles, bands or flaps of thickened mucous membrane, may be present. The degree of occlusion of the urethral lumen is variable. In some strictures of large caliber superficial infiltration and thickening of the mucous membrane are localized in a very small area, — perhaps not involv- ing the entire circumference of the canal — its lumen being contracted but little, if any. In the severe forms occlusion may be almost complete. The secondary results of stricture are chiefly incidental to urinary ob- struction, varying greatly in degree. In extreme instances all the condi- tions possible to urinary obstruction and chronic inflammation of the urinary way have been found post-mortem. The urethra anterior to organic stricture may be somewhat contracted from chronic inflammation of the mucous membrane associated with com- parative disuse. The stream of urine passing through the stricture not being large enough to fully dilate the urethra anteriorly, contraction naturally results. The urethra anterior to a stricture has been said to be, in rare cases, dilated. It is difficult to understand, however, how this could occur, unless from extensive atrophy of submucous follicles and connective tissue. Urinary obstruction necessarily first afEects the urethra behind the stricture. At this point the canal becomes more or less dilated, perhaps thinned. As a consequence of interference with the wave of contraction of the accelerator-urince and compressor-urethrcB muscles produced by the stricture, in combination with urethral dilation behind it, this part of the canal is never free from urine, a drop or so invariably remaining after micturition. This residual urine decomposes and enhances the chronic in- flammation. The inflammation is also aggravated by the friction of the urine, and in extreme cases by straining efforts in voiding it. As a product of the inflammation a pasty, muco-purulent secretion will be found at this point. This constitutes the discharge in most cases of gleet due to stricture. 198 STEICTUKE OF THE UEETHRA. As the urine flows over the diseased part the secretion^ in combination with desquamated epithelium, is rolled up in little thready filaments {tripper- fdden) that may he seen floating about in the voided fluid. There may be considerable congestion of the mucous membrane; so that the secretion is sometimes mixed with a certain quantity of blood. In the author's ex- perience this is especially likely to occur in syphilitics. Consequent upon urinary decomposition a deposition of more or less earthy material, possibly a small calculus, may be found behind a tight stricture of long standing. Eenal or vesical calculi may become lodged at this point. In a recent perineal section the author found a calculus as large as a marrowfat-pea behind a tortuous stricture. In another case which he operated upon Dr. Buell S. Sogers, of Chicago, found eight small calculi. Fig. 58. — Dilation and trabeeulation of prostatic urethra, secondary to close bulbo-membranous stricture. As the case advances the mucous membrane behind the obstruction becomes thin and fragile, and perhaps ulcerated; sometimes, as a conse- quence of a straining efi'ort during micturition, a slight rupture occurs, a drop or two of germ-laden urine escaping into the periurethral cellular tis- sue. Abscess with inevitable fistula — or possibly burrowing and a number of fistulas — and infiltration of urine, with resultant sloughing and death, may occur. Wherever such septic fluid comes in contact with cellular tis- sue it inevitably destroys its vitality. Its destructive efi'ects upon cellular tissue resemble those of erysipelatous infection; it produces, in short, septic cellulitis. The various glands that open into the urethra posterior to organic stricture are affected to a greater or less extent in marked cases by the MOEBID ANATOMY OF STKICTUEE. 199 lu'inary obstruction and mucous inflammation. The urethral follicles,, pro- static glands^ and Cowper's ducts become dilated, thickened', and inflamed as a consequence of frequent infection, combined with straining in micturition. Even anterior to the stricture the sinuses and follicles will be found to ]je dilated — often sufficiently to obstruct the passage of fine instruments. This dilation is due to successive distension with and evacuation of in- flammatory products. The prostate becomes more or less congested from the frequent bruising incidental to spasmodic and difficult urination. It is possible that this condition is one of the causes of enlarged prostate in advanced life. The bladder is always more or less involved, even in stricture of mod- erate degree. As a result of continual obstruction to urination, the detrusor- urince muscle becomes hypertrophied. As obstruction increases, the viscus may rarely become dilated, portions of its walls, where the bundles of mus- cular fibers are deficient, becoming dilated and thinned, thereby producing sacculi. In these sacculi urine collects and decomposes, possibly forming calculi. Barely, the bladder, instead of being dilated, is enormously thick- ened from interstitial cystitis, ^nd contracted so that it holds but a very small quantity of urine. iSTeither dilation nor contraction are so marked nor so frequent as in prostatic hypertrophy. The mucous membrane is the seat of chronic inflammation and pre- sents a characteristic dusky or slaty hue. It is covered by muco-purulent secretion, perhaps mingled with sabulous material, and is usually greatly thickened, perhaps rugose. Calculi may form in the bottom of the blad- ■ der in the same manner as under other circumstances involving urinary obstruction. Inflammation and dilation of the ureters and pelves of the kidneys occur sooner or later in extreme cases. Pyelitis, with or without the forma- tion of calculi, develops under such circumstances. Kephric or perinephric abscesses may occur. The secreting structure of the kidneys undergoes those characteristic changes that have been described under the omnibus term of "surgical kidney." One of the conditions observed in the so-called surgical kidney is interstitial proliferation of connective tissue and deficiency of normal stromal elements. Nature is very prodigal in her supply of reparative material to relieve strain, prevent irritation, or repair breaches of tissue. Obstruction to the urinary outflow results in the accumulation of a physio- logic army of proliferating cells sent to the renal tissue or developed in loco for the purpose of resisting strain — which strain is interpreted by the trophic centers as a threatened breach of tissue. Unfortunately, this tissue reinforcement develops no qualities of elasticity as it organizes, but as the strain goes on yields before the pressure and enhances the passive dila- tion. Moreover, it not only absorbs almost as rapidly as it is formed, — after a certain point has been reached, — but it displaces, strangulates, and 200 STEICTUEE OF THE URETHRA. produces absorption of the normal secreting elements of the renal structure. In some of the more marked forms of surgical kidney associated with pyelitis, pyelonephritis, or pyonephrosis we find disseminated suppurative foci in the secretory structure,- — i.e., the cortex of the kidney. These foci may form in two ways: by direct infection — i.e., contiguity of tissue — or indirect infection by pyemic infarcts. Whether this be due to toxins or to germs, per se, is not pertinent here. Fig. 59.- — Showing extreme dilation of proximal side of genito-urinary tract in stricture of long standing. (After Morris.) In fatal cases of uremia following operations for stricture the secreting structure is usually intensely congested and swollen from reflex hyperemia, produced by the shock of the operation or the anesthetic. It is to be remembered that these various consequences of stricture are not due to any specific quality of the lesion, but are the typic results of extreme and prolonged obstructive disease of the genito-urinary tract. ETIOLOGY OF OEGAKIC STEICTUKE. 201 The description given of surgical kidney, for example, fits all cases of renal disease secondary to obstruction of the urinary way, however produced. So far as stricture is concerned, the possible pathologic results are numer- ous and severe enough to convince the most skeptic that through the medium of stricture gonorrhea is, indeed, a serious disease. The results of stricture and the operations it necessitates are often directly fatal to life. This makes gonorrhea much more dangerous than syphilis. The density of stricture necessarily varies considerably according to its origin and duration, the habits of the patient, and the degree of irritation present. In old and severe cases it may be almost cartilaginous in con- sistency. Strictures of traumatic and chemic origin are very hard, because a greater or less amount of normal tissue has been destroyed and superseded by true cicatricial tissue. Etiology. — The most frequent cause of stricture is urethritis. It has been said that it is the duration rather than the severity of the inflamma- tion AA'hich determines the occurrence of stricture, — i.e., that a long-con- tinued inflammation of low grade is the most usual cause. This, however, is open to question, for, while stricture is usually associated with chronic urethritis, it must be remembered that in the majority of cases the symptoms of chronic inflammation are dependent upon the stricture, and the stricture itself upon antecedent virulent inflammation; in brief, the stricture causes a perpetuation of the inflammation, and not the reverse. It may be safely assumed that the danger of subsequent stricture and of chronicity of urethritis is directly proportionate to the severity of the acute inflammatory process. Eepeated attacks of inflammation almost in- evitably lead sooner or later to organic stricture. It is rather exceptional — if, indeed, it ever occurs — that the urethra assumes its normal condition throughout its entire extent, for a prolonged period after virulent ure- thritis. There exists in most instances a greater or less number of more or less damaged spots in the mucous membrane, which, sooner or later, are likely to form a foundation for stricture. They will inevitably do so if the patient has a succession of attacks of gonorrhea. Stricture may result from traumatism produced by instruments within the canal or injury from without. Severe injuries to the perineum usually involve the urethra, and are inevitably followed, as already indicated, by the worst form of organic stricture. When the urethra is entirely cut across or severely bruised the loss of tissue is replaced, as in other situa- tions, by cicatricial deposit. This is disproportionately dense, because of the lack of rest incidental to urination and sexual excitement. The con- traction of this tissue constitutes the stricture. Injuries that were ap- parently trivial at the time, and have perhaps been long since forgotten, are often the source of stricture. It takes but little force to injure the deep urethra, and an accident that has apparently produced little or no injury is liable to produce stricture later on. 303 STEICTUEE OF THE UEETHKA. Injury to the perineal urethra may result from kicks, blows, and falls astride such objects as a wall or a fence. The author has seen a case oc- curring in an athlete as a consequence of falling astride a horizontal bar. Fracture of the pelvic bones and gunshot and stab wounds have been known to produce traumatic stricture. Eupture of chordee often superadds traumatism to the usual inflam- matory causes of stricture. Careless instrumentation is sometimes responsi- ble for stricture. It is very easy to force a catheter or sound through the urethral walls or produce sufficient injury by bruising and laceration to result in cicatricial deposit and stricture. Cicatrices from chancre and chancroid occurring at the meatus or within the urethra inevitably produce stricture. Urethral injections are popularly supposed to be responsible for a large proportion of cases of stricture, and this, it must be confessed, has some foundation in fact; for some surgeons, in their enthusiasm and desire for a speedy cure of their cases, are apt to forget that the urethra is lined by a very delicate mucous membrane, which is normally extremely sensitive to irritants, and is cer- tainly more than ordinarily sensitive when inflamed. Mild injections given in a proper manner and at the proper period will not produce stricture, but, on the contrar}', tend to prevent it by their beneficial effect upon the in- flamed membrane. The prejudice existing in the minds of the laity re- garding injections is to be deplored, as they are often very useful. Although the surgeon may sometimes be responsible for the occurrence of stricture, it is safe to say that in the majority of instances the disease is due to ag- gravation of the inflammation by lack of rest, sexual indulgence or excite- ment, intemperance, and self-treatment. The counter-prescribing in vogue among a certain class of druggists is often responsible for stricture. This is a matter that physicians would do well to take under advisement. There is no disease with which the counter-prescriber takes so many liberties as with gonorrhea. The results are oftentimes very disastrous. Independently of the strength of injections, it is to be remembered that even simple water may cause mechanic injury when urethritis is very acute. It is probable that individual peculiarities are sometimes predisposing causes of stricture. Thompson believes that heredity is a factor in its formation in some instances. The theory that the members of certain families show a special tend- ency to connective-tissue formation and flbrous thickenings in various situa- tions from chronic inflammation is plausible enough, yet it would be diffi- cult, in the majority of cases, to trace the relation of heredity to stricture. Cachexias of various kinds sometimes constitute predisposing causes of stricture by perpetuating and enhancing the severity of inflammation in any situation. It has occurred to the author that persons with syphilis are espe- cially predisposed to stricture, seemingly because localized proliferation of SYMPTOMS OF OEGAXIC STRICTURE. 203 sypliilized cells is likely to occur at any point of local irritation developing during active syphilis. This is a practical point, as it is obvious that spe- cific internal medication may sometimes be a useful adjunct to surgical meas- ures. The same considerations apply especially to the gouty and rheumatic diatheses as regards a tendency to fibrous thickenings. Any condition favoring hyperacidity of the urine predisposes to stricture. Habitual drink- ers are more liable to stricture than abstainers. The ingestion of alcohol makes the tissues in general irritable and susceptible to inflammation. Symptoms. — One of the earliest symptoms of stricture is disturbed micturition. The decomposition of the small quantity of residual urine remaining behind the urethral obstruction gives rise to toxins that are very irritating to the mucous membrane, as shown by the chronic inflam- mation — sometimes ulceration — found at this point. This causes reflex or direct irritation of the vesical neck, — i.e., the deep urethra, — with conse- quent frequent desire to urinate. Some patients first consult the surgeon regarding frequent micturition, possibly occurring only at night. Under normal circumstances the bladder tolerates its contents during the hours of sleep, but in the presence of irritating affections of the genito-urinary tract it becomes intolerant of the urine and must be frequently evacuated. It is not unusual to meet with strictured patients who have been annoyed by re- peated calls to urinate during the night for some years, yet have experienced no other anno3^ance. Oftentimes such patients are strictured at the meatus only. Meatal stricture may cause frequent urination through reflex irrita- tion of the vesical neck, although the remainder of the urethra is healthy. A frequent early symptom of stricture is dribbling of urine after mic- turition. This is due to interference Avith contraction of the accelerator- urince and compressor-urethrcB muscles, the function of which is to expel the final drops of urine or semen from the canal. As soon as the penis is allowed to hang downward the residual urine escapes. It is not unusual, even in stricture of large caliber, for imperfect ejaculation of semen to occur, with dribbling after the penis becomes flaccid. The stream of urine may be forked or twisted corkscrew-fashion, ac- cording to the form of the stricture. In some instances a straight stream is projected from the meatus, a second stream falling perpendicularly down- ward. The size and form of the meatus modifies the stream. In stricture of large caliber a narrow meatus may counteract the effect of the obstruc- tion and maintain the natural form of the stream. When the meatus is large and its lips turgid the stream may be fan-shaped, or several streams may run in different directions. This sometimes occurs in persons free from stricture. Later on more or less straining effort is required in micturition, the abdominal muscles being unconsciously brought into play to supplement the detrusor urines. More or less atony of the detrusor soon develops, and still greater effort is required to empty the bladder. The strain is so severe 204 STEICTUEE OF THE UEETHEA. in pronounced cases that hemorrhoids, rectal prolapse, and congestion of the prostate may develop. The stream of urine eyentually becomes very small, perhaps escaping by drops, necessitating the expenditure of considerable time in urination. Ejaculation of semen may be interfered with, so that the fluid, instead of escaping normally, is forced backward, overcoming the resistance of the verii montanum and passing into the bladder. If this condition lasts for a long time the function of the veru montanum may be inhibited completely and permanently, so that the individual ever afterward ejaculates the greater portion of the semen into his own bladder. Very often little or no semen will be discharged during the orgasm, because of the increased turgescence of the corpus spongiosum, in conjunction with obstruction produced by the stricture, occluding the urethra during erection. The semen under such circumstances may remain in the urethra to dribble away as soon as erection subsides. Sterility is an inevitable consequence. Partial or complete im- potency may result from stricture as a consequence of its local and reflex enervating effect. Stricture often reflexly produces obstinate priapism and excessive desire. Neuroses from Stricture. — A^Tiile strictiire is usually unattended by pain, there may be both direct and reflex painful symptoms. Neuralgic pains in the groins or darting along the spermatic cord, the front of the thighs, and through the lumbar region are not unusual. Neuralgic pains in remote situations are occasionally experienced. The author has met with numerous cases of this kind. One case in particular was very interesting in that ob- stinately recurring angina pectoris was apparently cured by urethrotomy. The remote or direct nervous disturbances produced by stricture are too often lost sight of in the strictly-mechanic aspect of the condition. The complex relations of the genito-urinary apparatus and the sympathetic deserve attention. The reflex neuroses from genital irritation in children are a key to the solution of many problems in adult urethral pathology. There is a general impression that stricture is not important unless it produces urinary obstruction. Wlien, however, one sees vesical atony, in- continence of urine, impotency, neuralgia of the cord and testes, lumbo- hypogastric and lumbo-sacral neuralgia, profound mental depression and other neuroses relieved by urethrotomy of large-calibered strictures, the im- portance of this question is suggested in a very forcible manner. The rela- tion of such conditions to congenital or acquired stricture at or near the meatus is especially marked. General malnutrition, hypochondria, and malaise are often noted in stricture. Nervous irritability is frequently a prominent feature. Local pain, referred to the vesical neck, rectum, perineum, and hypogastrium is sometimes experienced. The author has noted glycosuria as a result of stricture. As the stricture increases in density and narrowness it becomes more NEUROSES AND TOXEMIA FE03I STEICTUEE. 205 irritable, and there is danger of complete retention of nrine as a conse- quence of deep urethral spasm, with or without congestion or inflammation of the stricture. Acute cystitis may arise as a complication. The plus con- ditions that cause retention of urine are usually superinduced by sexual excesses, intemperance, or exposure to wet and cold, often in combination with dietetic excesses. Gouty and rheumatic patients are especially liable to retention. As a consequence of retention, rupture of the urethra behind the stricture, or even of the bladder, may occur, the urethra being the more likely to give way. Following retention, acute cystitis may develop. The danger of this complication, however, depends, to a great extent, upon the degree of care exercised in emptying the distended bladder. Infection and traumatism are very easily produced. Toxemia from Stricture. — The relations of stricture to uremia, so called, is not a new theme. Special attention has already been given to the rela- tion of the shock from surgical operations upon the urethra to toxemia and consequent urinary fever; hence the subject does not require exhaustive discussion at this point. The relation of absorption of toxins from the site of the lesion in stricture, or from behind it, to the general results of stricture is unques- tionably of great importance. The rapidity with which many constitu- tional symptoms disappear after cure of deep stricture is thus easily ex- plained. Urethral chill following instrumentation is often readily expli- cable. The possibility of mixed infection in stricture must be taken into consideration. Cystitis, epididymitis, periurethral phlegmon, pyelonephri- tis, and other special phenomena secondary to stricture are not due to direct extension of inflammation, but probably in many cases to secondary infection. A recent case of the author's is strongly suggestive in this rela- tion. A patient under treatment by dilation for several irritable strict- ures of comparatively large caliber developed multiple nephric and peri- nephric abscesses, without intermediate cystitis. An interesting point was the fact that the formation of the abscesses was heralded by great increase of irritability and spasm in the deep urethra. The all-important point is the apparent fact that all patients with serious strictures — particularly of the deep urethra — suffer from a greater or less degree of toxemia, and that many cases develop secondary single or multiple infections of one kind or another. That the passage of instruments may precipitate toxemia is granted. The danger is enhanced by uncleanliness, but aseptic instruments may cause it. It is questionable, however, whether any instrument passed through a diseased anterior urethra can be aseptic by the time it reaches the deep canal. It is probable that strictly aseptic urethral surgery would involve a flushing out of the canal prior to the introduction of even an ordi- 206 STKICTUEE OF THE TEETHRA. nary sound. ThiS;, of course, is not generally done, nor is it always prac- ticable. Most surgeons, therefore, as a matter of routine, are committing cardinal sins from the stand-point of aseptic surgery. The various complications and sequels of stricture produce special and characteristic modifications of its symptomatology and course. Thus, a special set of symptoms may occur dependent upon prostatic inflammation and abscess, vesical and perivesical inflammation, urethral rupture with infiltration of urine, and various renal complications. Diagnosis. — The diagnosis of organic stricture can only be made by instrvimental exploration. The facility of examination depends largely upon the condition of the meatus. It is obvious that with ordinary instru- ments a thorough exploration cannot be made through a narrow meatus. For example, if the canal be very large, its extreme capacity being 35 French, and stricture exists at different points, the canal being contracted at one or more of them to a diameter of 25 French, the condition cannot be readily detected through a meatus of a caliber of 20. Otis devised an instrument that has become very familiar to American surgeons for the purpose of overcoming the obstacle afforded by a narrow meatus. This Fig. 60. — Otis's urethrometer. instrument- — the urethrometer (Fig. 60)— consists of a series of blades operated by a thumb-screw and connected with a scale-plate or dial, with an indicator showing the exact degree of expansion of the blades as repre- sented by the French scale. This instrument is especially useful when an accurate record of cases is to be kept. With the soft bulbous bougie it is possible to accomplish almost as much from a practical stand-point as with the urethrometer. After a proper meatotomy the urethra may be explored with a series of such bougies as accurately as is necessary, and perhaps, on the average, more intelligently and safely than with the urethrometer. Meatotomy is free from danger if properly performed, and almost invariably beneficial in cases of genito- urinar)' irritation, whether stricture exists or not. The author has seen, however, one case in which considerable sloughing had followed meatotomy. This was unquestionably due to instrumental sepsis. The danger of injury by the urethrometer may be obviated to a great extent by covering the end of the instrument with a thin sheath of rubber; this does not usually interfere with the separation of the blades, and pre- vents the mucous membrane's falling between them. With some patterns DIAGNOSIS OF STEICTUEE. 207 of urethrometer and when the rubber sheath is thick the blades of the instniment are apt to twist, corkscrew-fashion, as they are opened. A vahd objection to the nrethrometer is that by its use strictures of large caliber can be foimd in practically every urethra. Some nicety of judg- ment is therefore necessary in estimating at their true value the points of narrowing demonstrated by the urethrometer. The author believes that in quite a large proportion of healthy urethras strictures may be detected with the urethrometer if Otis's method of examination is arbitrarily followed. This objection, of course, falls to the ground in cases in which there is a more or less definite relation between the points of narrowing and existing pathologic conditions. In such cases it is of little or no importance whether the points of narrowing were once physiologic or not; they have assumed surgical importance, even though not of pathologic origin. Meatotomy is often a necessary preliminary to the diagnosis and treat- ment of urethral disease where the meatus is not of a caliber of at least 30 French. Some latitude, however, must be allowed, the size of the penis espe- cially being taken into consideration. Otis adopts as his criterion of the nor- mal urethral caliber the circumferential measurement of the flaccid penis, believing that there is a constant relation between the size of this organ and Fig. 61. — Meatotome. the caliber of the canal. This is probably true within certain limits, but the size of the organ is so variable at different times that it seems hardly safe to adopt this as an arbitrary rule. The mental effects of simple sound- ing often cause the penis to shrink to very small dimensions. Some patients claim that dread of exposing the organ produces this temporary shriveling. In incising the meatus due deference should be paid to its form. When the orifice is situated low down upon the extremity of the glans it cannot be incised so widely as when higher up, and, as a rule, it will be found that, the lower its situation, the more distensible it is apt to be and the less fre- quently it requires incision. When practicable, the orifice should be cut larger than the size which it is desirable for it to retain permanently, as some cicatricial contraction is inevitable. Several instruments have been devised for meatotomy, the most familiar being the histouri cache of Civiale. This instrument is composed of two blades, one cutting and the other blunt, separable by means of a screw. Having been introduced for a sufficient distance within the meatus, the blades are separated to the required extent and the instrument with- drawn, thus incising the inferior commissure of the meatus. With this in- 208 STEICTUEE OF THE IJKETHEA. strument more cutting is apt to be done than is intended, and it is, to say the least, a bimglesome device for the performance of a very simple opera- tion. A straight-backed, probe-pointed, narrow bistoury is the best instru- ment for this purpose, and in expert hands an ordinary scalpel will do in lieu of a special instrument; the scalpel may be used in combination with a director or its point covered with a bit of wax, thus preventing accidental injury to the canal. The incision should be made directly downward, care being taken not to cut through the floor of the urethra. Under oocain the operation is practically painless. Two per cent, of cocain in 1-per-cent. carbolic solution or an 8-per-cent. oleate of cocain should be injected into the canal and retained for about five minutes, at the end of which time the part Avill usually be well anesthetized. The hemorrhage following meatotomy is sometimes considerable. The author has experienced more trouble in this respect since using cocain than formerly. The drug not only produces local anesthesia, but also appears to produce vasomotor paresis and venous congestion; the escaping blood will be found to be dark and of a more venous hue than under ordinary cir- cumstances. Severe bleeding is not usual, however, at the time of opera- tion, as the drug seems to act primarily as an astringent. The next act of urination, however, after the efi'ect of the drug has passed off is apt to be attended by considerable bleeding. If oozing is obstinate at the time of operation much inconvenience may be avoided by plugging the meatus. For this purpose the author uses a wedge-shaped piece of dentist's "spunk." This is prepared by saturating it in solution of bichlorid of mercury, 1 to 1000, and drying. The spunk swells somewhat when it is wet, and plugs the meatus sufficiently to check bleeding. Should it escape at the next act of urination, as it is likely to do, the patient should be instructed to pinch the under surface of the glans at the site of the incision with the thumb and finger imtil the bleeding is arrested. Dangerous loss of blood cannot occur if this be done, and a few minutes' pressure will usually check the hemorrhage. If the patient be nervous and excitable, he may become frightened, and, losing his presence of mind, may not apply pressure prop- erly, as a consequence of which considerable loss of blood results. An in- stance of this kind occurred in the author's own practice, in which suffi- cient blood was lost to induce syncope. Aside from the trifling danger of hemorrhage, the author has never seen any untoward results from meatotomy, excepting a case seen in consultation in which fatal septic cellulitis developed, and another in which sloughing of a portion of the glans about the incision occurred. Such accidents may be avoided by strict asepsis. The meatus should be dilated every day or two for about two weeks. Stitching the edges of the quasimucous covering of the glans and the mucous lining of the urethra together, to insure patency of the meatus, is often wise. The author has frequently practiced it with advantage. If meatotomy is a preliminary to systematic dilation, it is well to DIAGNOSIS OF STRICTUEE. 209 wait until the incision has healed before treating the urethra. Explora- tion or internal nrethrotomy may, however, be completed at the same opera- tion. "\ATien the patient cannot visit the surgeon frequenth^, a loop of silver wire or a hair-pin may be bent to the required size, aseptized, and passed into the meatus several times daily. Careful suturing is also of service under these circumstances. Aside from the existence of obstruction in the course of the canal, there are several other points that may be determined by expert exploration with the urethrometer or bulbs: — ■ 1. The degree of contraction of the stricture. 2. The distance of the stricture from the meatus. 3. If the bulbous bougie or urethrometer be passed beyond the stricture and then withdrawn until its shoulder is caught, the distance of the poste- rior surface of the obstruction from the meatus may be determined. The space included between the two measurements corresponds very nearly to the width of the stricture. 4. The number of strictures. This is determined with only moderate Fig. 62. — Otis exploring bulbs. facility with the bulbs, for the reason that the obstruction in the anterior portion of the canal may be so small as to prevent the introduction of in- struments large enough to catch upon the deeper strictures. This applies to the urethrometer only in very tight penile strictures. 5. Tbe condition of the urethra posterior to the stricture. This may be approximately determined by examining the secretion withdrawn from the canal by the shoulder of the instrument. When this is thick, with a preponderance of purulent qualities and containing sabulous material, the existence of a relatively-pronounced degree of chronic inflammation may be inferred. When there is little or no secretion, or when it is mucoid in char- acter, the stricture may be considered to be moderately passive and the ure- thra behind it comparatively healthy. 6. The degree of congestion present at the site of the stricture may sometimes be estimated. When blood appears upon the shoulder of the bulb or escapes from the meatus after its withdrawal — the exploration hav- ing been conducted with gentleness — considerable congestion at the site of the strictiu'e mav be inferred. 210 STEICTUEE OF THE TEETHRA. 7. Eesiliency or irritability of the stricture may be determined. Ee- siliency is sliown by the ready passage of a comparatively large sound, ■whereas the bulb of a much smaller bougie is obstructed. Irritability is demonstrated by the pain and spasm excited by the exploration; possibly by the subsequent occurrence of urethral chill. After exploration of the urethra for the first time the canal should be irrigated with a 1 to 5000 permanganate or 1 to 10,000 bichlorid solution to obviate possible chill and fever. This should be followed by 10 minims of eucalyptus three times daily. Diuretin has been recommended as prevent- ing chill. Should the patient be very sensitive or the stricture severe, it may be well to administer a dram of fluid extract of jaborandi or a h)'p- odermic of Ve ^^ ^/ z grain of pilocarpin. By virtue of their derivative and eliminant effects these drugs are very useful, especially where uremia is feared because of the existence of more or less marked renal disease. The patient should be advised of the probability of pain and smarting at the next act of micturition, and the possibility of increased urethral dis- charge. Alkaline diluents, balsams, urotropin, salol, or boric acid may be administered. Xo further meddling is usually admissible for several days after the exploration. Prognosis. — The prognosis of stricture involves two considerations: (1) its curability and (2) its danger to life. The possibility of radical cure of stricture is disputed by most author- ities; indeed, the general opinion up to a recent date has been that without continual attention a stricture, once formed, will sooner or later give the patient trouble, no matter how skillfully his case may be treated. For ex- ample, it has been supposed that, as a rule, a person who has been ap- parently cured of stricture during early adult life will again be troubled by the disease as he approaches middle age, unless he has, in the meantime, persisted in treatment by dilation, the necessity for which increases with advancing age. But for the investigations of Otis and his disciples this old- time belief would probably never have been disputed. It has been shown by them that quite a proportion of radical cures of strictures located in the pendulous urethra may be attained by dilating urethrotomy. No system of treatment 3'et devised has been conclusivel)^ shown to permanently cure stricture of the fixed urethra, with the possible exception of perineal sec- tion in some cases. It has even been questioned whether penile strictures have ever been radically cured; but, as. a number of cases operated upon by dilating urethrotom}^ have been examined man^^ years after operation and the urethra proved healthy by careful urethrometry, it is fair to assume that such cases are radically cured. The author bases his opinion not alone upon the claims of Otis, but upon many years' experience with the opera- tion, embracing over fifteen hundred cases of urethrotomy. This point will be expatiated u|)on in the discussion of urethrotomy. It is not probable that in the instances of apparent cure by various PEOGXOSIS OF STEICTUEE. 211 methods^, in cases in which the disease recurs sooner or later, the canal, if examined from time to time during the interim, avouIcI be fonnd to be con- tinnonsly free from obstruction. If recontraction occurs after complete dilation, rujDture, or division of a stricture, such recurrence is probably discoverable by thorough exploration within a very short time after the cessation of treatment. Indeed, it will be found on careful exploration that, if recontraction occurs, it usually begins within the first year following ap- parent cure. An individual who at the age of forty presents evidences of recontraction of a stricture that was apparently cured some years before, if carefully examined during the interim would probably have been found to have a certain degree of narrowing of the canal. There are few eases in which recontraction does not commence within six months after cessation of treatment; but this recontraction may progress very slowly or finally come to a stand-still until some years have elapsed. At any time during this period, however, rapid recontraction may occur as a consequence of acute or subacute inflammation excited by intemperance or sexual excesses. Eecurrence of stricture occurs much more readily in cachectic, stru- mous, gouty, rheumatic, and syphilitic patients than in those of healthy constitution. The patient's habits necessarily have an important bearing upon the liability to recurrence. It may be formulated as a practical rule: 1. That traumatic or chemic strictures invariably recur. 2. That deep chronic inflammatory strictures re- cm- sooner or later. If the urethra is carefully explored they will be found to have recontracted to a greater or less extent within a comparatively short time after cessation of treatment. 3. That penile strictures rarely disap- pear completely under dilation, and always recur unless operated upon by urethrotomy; they rarely, however, recur, in the absence of fresh gonor- rheal infection, when properly, operated upon by dilating urethrotomy. It is usually possible to prevent recontraction of simple stricture when the co-operation of the patient can be secured. Strict adherence to the principles of genito-urinary and sexual hygiene, and occasional dilation Avitli a steel sound of proper size will generally prevent recontraction, at least to a degree appreciable by the patient. When the patient is able to secure the services of a surgeon, it is un- necessary for him to practice self-instrumentation; under other circum- stances, however, he should learn to use the sound and introduce it at first once a week, later on once in two weeks, and finally once a month. Once an individual has suffered from organic stricture the introduction of the sound becomes an important item in his toilet. The prognosis of stricture as regards danger to life varies greatly ac- cording to duration, the severity of its complications and sequels, and the character of operations undertaken for its cure. The most important factor in prognosis is the condition of the kidneys. The renal structure and func- tion- are almost invariably impaired; indeed, in organic stricture of lono- 212 STEICTUEE OF THE URETHEA. standing such impairment is to be inferred. Pathologic aberrations of the kidney are not only immediately dangerons to life — either through acute exacerbations of inflammation induced by intemperance or exposure, or by reflex inhibition of the function of the kidney produced by surgical shock in attempts at the cure of the stricture — but they bear an important rela- tion to the welfare of the jDatient after the primary condition has been relieved. It is probable that a patient who has once suffered from sec- ondary disturbance of the kidney incidental to organic stricture is rarely, if ever, a sound man again. His kidneys — and, for that matter, the struct- ures composing his entire genito-urinary tract — are in a weakened, possibly degenerated, relaxed and irritable condition that constantly predisposes to congestion and inflammation. The slightest excess or exposure may develop acute nephritis. Chronic nephritis may supervene at any time. Pyelit's may develop after the patient is apparently cured of stricture. In brief, a patient who has once suffered from severe organic stricture possesses ever afterward a renal locus minoris resistentue that is apt at any time to lead to serious renal disease. Stricture may destroy life by the supervention of uremia consequent upon complete inhibition of the already impaired function of the kidne3'^s. detention of urine, due to inflammation of stricture, may be fatal through rupture of the urethra or bladder, with consequent extravasation of urine or acute cystitis — perhaps with gangrene of the vesical mucosa. In these -conditions, secondary to retention, the patient may sink into a typhoid state and die, the condition ])eing modified b}^ a greater or less degree of uremic intoxication. Septemia in its various forms may result. Debility and nervous exhaustion from pain and loss of sleep, in coml)ination with the depressing effects of urinary intoxication or fever, are important ele- ments in all fatal cases. Xotwithstanding the serious nature of marked types, it is surprising how rapidly some apparently desperate cases of stricture improve, once the obstruction has been removed. Even when the kidneys are seriously impaired, the constitutional symptoms marked, and the secondary bladder- changes severe, the patient often improves with wonderful rapidity as soon as the patency of the urethra has been restored. The improvement in the patient's general condition is oftentimes remarkable. The very gradual in- volvement of the upj)er portion of the genito-urinary tract in pathologic conditions secondary to stricture probably explains the tolerance of the patient for severe renal and bladder-changes. A condition not usually recognized in stricture is the toxemia due to the constant absorption of toxins from behind the obstruction. This tox- emia has much to do with numerous little ailments of which the patient complains, but rarely attributes to his stricture; its cure suggests the cause by the fact of the sudden and complete disappearance of the anomalous symp- toms. This toxemia, too. constitutes a constant predisposition to urethral TKEATMEXT OF STKICTUKE. ' 213 chill. The nervous system is loaded with toxins, so to speak, and ready for the explosion that instrumentation is oftentimes sufficient to produce. Tkeatmext. — General Management. — The successful treatment of stricture depends not only upon proper selection of surgical methods and skill in their performance, but upon wise general management. Careful attention, on the one hand, or neglect, on the other, may determine the result of surgical treatment. Thus, dilation may fail, because of irrita- bility or resiliency that might have been avoided by attention to certain details of general management. Urethrotomy, divulsion, or perineal section may result fatally, because the surgeon fails to study carefully the conditions of other portions of the genito-urinary tract, and is ignorant of the general and local conditions prevailing at the time of operation. In no genito-urinary disease is attention to hygiene more essential than in the management of stricture. Eegulation of diet, tempeiate habits, sex- ual moderation, and avoidance of exposure to cold and wet are all-impor- tant. The use of tobacco should be interdicted as tending to induce gen- eral irritability and hyperesthesia. The author believes, moreover, that it is especially irritating to the genito-urinary tract. Chilling of the feet and legs is apt to be especially injurious, its effect upon stricture in the pro- duction of acute hyperemia and inflammation being precisely the same as in enlarged prostate — in which the disastrous effects of exposure are well known. The administration of alkalies to neutralize the urine is essential in most cases. When severe cystitis exists, certain remedies are beneficial by preventing decomposition of the urine, thus lessening its irritating prop- erties. Oil of eucalyptus, boric acid in 10- or 15-grain doses several times daily, naphthalin, creasote in small doses, cystogen, benzoate and salicylate of soda, and small doses of turpentine are useful for this purpose. In the author's experience the oil of eucalyptus in 10-minim doses has been of especial value. The activity of the skin should be promoted by Turkish baths and rubbings. The effects of sudden atmospheric changes should be avoided by wearing warm flannel garments of uniform weight. Exercise should be taken in moderation; fatigue and overexertion should be avoided; perfect rest may possibly be indicated. Certain local measures are very essential. A tendency to spasm and congestion at the site of stricture may usually be corrected by daily hot sitz-baths or the occasional application of leeches to the perineum. As a matter of routine, the author often advises a hot sitz-bath nightly. By proceeding in this manner it will be found that the majority of cases of stricture will be made much more tractable. In some cases of tough^ resilient stricture the canal may be much more readily dilated if the patient be directed to take, night and morning, copious injections of water as hot as can be comfortably borne. These injections should be kept up for half an hour at a time, and may advantageously be made antiseptic by the ad- dition of bichlorid of mercury, 1 to 20,000, or boric acid in saturation. 214 STKICTUEE OF THE UKETHEA. Where manipulations of tlie canal tend to excite urethritis, hot bichlorid irrigations, as recommended for chronic urethritis, may be cautiously em- ployed. The various balsamic preparations are of service in such cases. Pain and spasm may be caused by every attempt at dilation, in spite of judicious general measures. Under such circumstances a small dose of morphia may be given, hypodermically, by suppository, or by the mouth, shortly before the operation. "\Yhen each operation tends to produce chill or fever, opiates undoubtedly have a conservative and prophylactic effect. The author has found that in irritable stricture with a predisposition to chill or fever thorough irrigation with a hot permanganate or bichlorid so- lution before and after the introduction of a sound or before cutting oper- ations generally obviates the diihculty. It will certainly tend to prevent the septic element in the production of fever. Quinia, jaborandi, eucalyptus, and diuretin are probably all serviceable as prophylactics against chill, but eucalyptus is the most valuable of all. Selection of Method. — The various forms of treatment that have been recommended for stricture are: — 1. Caustics. 2. Continuous dilation. 3. Gradual dilation. 4. Dilating urethrotomy, or a combination of section and rupture. 5. Divulsion, — i.e., rupture. 6. Internal urethrotomy. 7. External perineal section, or urethrotomy: (a) with a guide; (h) without a guide. 8. Electrolysis. 9. Subcutaneous section. 10. Excision, with or without a plastic operation. Caustics. — The treatment of stricture by caustics is a relic of surgical barbarism, and is unworthy of discussion. The inevitable consequence of such atrocious surgery was necessarily the substitution of a chemic stricture for the ordinary type, and, as is well known, stricture due to actual destruc- tion of tissue is the most severe and intractable variety. All the other methods of treatment enumerated have their advocates at the present day — either as a matter of routine or a range of treatment from which to make a selection — and may under proper circumstances be practiced with advantage. The selection of the method is, to a certain extent, a matter of choice on the part of the individual surgeon. The vari- ous methods will receive special consideration after their applicability to the various forms of stricture has been outlined. For practical purposes the surgical treatment of stricture may be divided into that of: — TEEATIIEXT OF STRICTUKE. 215 As regards location. 1. Stricture of the meatus. 2. Stricture of the penile urethra. 3. Stricture of the deep urethra. As regards character. (a) Simple uncomplicated strict- ure. (b) Irritable stricture. (c) Eesilient and elastic stricture. (d) Eecurrent stricture. (e) Dense and hard, tortuous stricture. Multiple stricture. (/) Complicated stricture. (g) Traumatic stricture. The treatment of each particular case is modified by the caliber of the contraction; for example, in tight strictures which it seems advisable to treat b}^ dilation metallic instruments should not be used until a moderate amount of dilation has been attained. The treatment is further modified by the occurrence of complications, such as false passages, retention of urine, severe cystitis and pericystitis, infiltration of urine and abscess, fistula, enlarged prostate, etc. Stridure of the Meatus. — Irrespective of their etiolog}^, meatal strict- ures require incision. Dilation is not only useless, but produces irrita- tion. The structure of the meatus is such that it cannot be permanently stretched, and attempts to do so not only produce local disturbance, but also reflex irritation and spasm of the deep urethra. The proper method of performance of meatotomy has been outlined as an essential preliminary to the proper exploration of the urethra. Any meatus that prevents the introduction of instruments large enough to distend the remainder of the canal to its normal capacity should be regarded as strictured. As already remarked, stricture of the meatus may be a relative afi^air, especially the congenital form, Avhich assumes surgical importance only when organic or functional disease of the urethra exists behind it. In all cases of obscure nervous affection, with concomitant urinary or sexual symptoms, it is wise to' perform meatotomy, for, whether or not there exists apparent irritation at the meatus, the effect produced upon the nervous system is frequently strikingly beneficial; that this effect may sometimes be a moral one is ad- mitted; that it is not always psychic is indisputable. In many cases of narrow meatus the urethra behind it may be demon- strated to be pouched by exploration with a bent probe. In this pouch inflammation goes on indefinitel}', its perpetuation being facilitated by the accumulation and decomposition of a few drops of residual urine. Me- atotomy therefore often cures a most obstinate gleet. Stricture of the Penile Urethra. — Strictures in the pendulous urethra cause more annoyance to the patient and more perplexity to the surgeon, on the average, than those of the perineal portion, although they are less dangerous, and their direct and remote results less serious, than those oc- ■•216 STKICTUEE OF THE UEETHRA. curring dee23er doAvn. They rarel}^ contract sufficiently to produce serious obstruction to micturition^ and wliere slowly formed several tight strictures may exist;, producing little or no trouble, and being discovered accidentally or during exploration for the purpose of determining the cause of an inter- current simple urethritis. In a recent case of the author's there were three strictures of the pendulous urethra, the narrowest barely admitting the closed blades of the dilating urethrotome. These strictures had produced no inconvenience whatever, and probably would have remained undiscov- ered for some time if the patient had not, at the suggestion of a friend, submitted himself to examination for the purpose of ascertaining whether a gonorrhea that he had contracted some years before had left any permanent results. Such a passive condition of penile stricture is, of course, excep- tional, as they usually cause frequent attacks of so-called "bastard clap" — i.e., simple intercurrent urethritis — or an indefinite perpetuation of gleet. Although stricture in any portion of the canal is apt to cause vesical irritation, its liability seems to be in direct ratio to the distance of the con- traction from the meatus. Comparatively slight deep strictures often pro- duce by direct irritation, through contiguity of structure and nervous siTp- ply, and by infection of the deep urethra, annoying frequency of micturition. In occasional cases, however, this symptom is the i^rincipal feature of strict- ure at or near the meatus. The degree of contraction in penile strictures is variable. It is ex- ceptional that such strictures are so tightly contracted as those in the deep urethra. This statement may seem at variance with the experience of many surgeons, but the discrepancy is explicable by the fact that they do not recognize that vast number of cases in which stricture of large caliber exists. When the author speaks of the relative rarity of penile stricture of small caliber, he means as compared Avith the total number observable by careful exploration with the bulbous bougie. Stricture of the pendulous urethra is quite likely to be multiple. In- deed, there are few cases in which a full-sized bulb or the urethrometer fails to detect two or more points of contraction in different parts of the canal. These strictures are frequently irritable and almost always resilient. They are a potent cause of chronic urethritis, and explain the obstinacy of many apparently incurable cases of urethral discharge. Even when not, strictly speaking, the cause of the chronic inflammation, they invariably tend to perpetuate it. If the profession had nothing else for which to thank Otis, it would be under lasting obligations to him for his demonstration of the true pathologic condition in the majority of those obstinate cases of gleet which have so long been the hefe noire of the surgeon. When such . strictures are irritable, as they are ver}^ apt to be, very slight exciting causes may develop urethritis, the severity of which depends upon the degree of irritation. In short, penile strictures of large caliber constitute a constant predisposition to both virulent and simple urethritis. TEEATMEXT OF STEICTUEE. 317 The more important of the conditions which, in addition to stricture, must he talven into account in estimating the causes of gleet are as fol- low: — • 1. Constitutional debility. 2. Intemperance, alcoholic and sexual. 3. The gouty and rheumatic diatheses. 4. Tuberculosis of the genito-urinary tract. 5. Chronic superficial urethritis, with or without distinct erosions. 6. Periurethritis or loss of elasticity, — nascent stricture. 7. Folliculitis and chronic inflammation of sinuses and lacunas. 8. Cowperitis. 9. Posterior urethritis — i.e., prostatitis^ folliculosa. 10. Chronic abscesses from periurethral phlegmon. 11. I'rinary fistulas. 12. Xeoplasmata. Admitting stricture to be the most frequent cause of gleet, the fore- going etiologic factors are still worthy of the most discriminating attention. One point that should be constantly borne in mind is that, although the urethra will permit the introduction of a large-sized steel sound, this is no evidence against the existence of stricture, for it will often be found, upon exploration with the bulbous bougie, that one or more strictures of large caliber exist. The tendency to irritability and resiliency of penile stricture consti- tutes the principal obstacle to treatment by dilation. Dilation of stricture in this portion of the canal is usually disappointing: the patient either does not get entirely well of his gleet or apparently does so only to ex- perience a recurrence of urethritis from the slightest exciting cause. The author is of opinion that the majority of such strictures are never thor- oughly cured save by cutting. Increasing experience has seemed to show the necessity of radical interference and the uselessness of temporizing by dilation. When stricture is young and soft,- — i.e., of recent date and not yet fully organized, — dilation offers a good prospect of a cure, and it is but just that the patient be given the benefit of the doubt and an attempt made to cure without a radical operation. In old cases, no matter if they be apparently slight, dilation is not apt to be successful, and, if it be tried, the patient should be given to understand that operation may become necessary. Some cases, however, yield to the Oberlaender method of com- bined dilation and irrigation. The prospect of cure of penile strictures by dilation is apparently proportionate to their distance from the meatus. Strictures located any- where between the meatus and a depth of two and a half inches bear al- most the same relation to dilation, so far as the prospect of cure is concerned, as strictures directly at the meatus. When stricture of the penile urethra is of small or moderate caliber, — 218 STEICTUEE OF THE URETHEA. i.e., below 15 or 16 French, — it is often advisable to begin treatment by dilation with soft instruments, in stricture of the fixed urethra. If de- sired, the dilation may be continued until resiliency of the stricture begins to manifest itself; urethrotomy then becomes necessary. Some cases M'ill apparently dilate readily at each sitting; yet little progress is made, as recontractipn seems to occur during the intervals between seances. The canal may be dilated apparently to its fullest capacity, so that it will ad- mit a large-sized sound, and the patient discharged, only to return in a short time with a recurrent urethritis. In such cases exploration with bulbs from time to time will show whether the stricture is really absorbing or not. When improvement is not steady and permanent, resiliency of the stricture may be suspected, no matter how large a sound the urethra may admit. The only recourse in such eases is a cutting operation. Eesiliency and elasticity are rarely met with in deep strictures. They are, however, common conditions in the penile portion of the canal. The fact that dila- tion is so unsuccessful in penile strictures as compared with those of the deep urethra is probably explicable by anatomic differences in the loca- tion of the contraction. In some cases of penile stricture the thickening and induration occur principally in or just beneath the mucous membrane, rather than in the erectile tissue, and, moreover, the process occurs at a point of normal inelasticity of the canal — i.e., at a point which nothing will eifectually dilate. The infiltration occurring in deep strictures is more ex- tensive, and located principally in the corpus spongiosum, beneath the mu- cous membrane, at a point where the urethral walls are thick. It is located, moreover, upon each side of the bulbo-membranous junction, and chiefly anterior to it rather than at a point exactly corresponding to it. The press- ure of the sound produces absorption on account of the thickness and succulency of the tissues and the abundance of absorbents. Stricture of the deep urethra is not so apt to be produced by strong injections as are penile strictures. Virulent inflammation is not so severe in the deep ure- thra, as a rule, as in the anterior portion. When the urethral mucous membrane is severely abraded the conse- quent stricture is invariably tougher and more inelastic than under ordi- nary circumstances. Stricture of the penile urethra resembles traumatic stricture in this respect; it will be found to be quite like the latter, as regards its amenability to dilation. Another point not generally recognized is the relative unrest of penile stricture incidental to varying conditions of blood-supply. The treatment of penile stricture may be briefly summed up as fol- lows : — • 1. Those located within two and a half inches of the meatus cannot, as a rule, be cured by dilation, but must be cut. 2. Pronounced cases in any portion of the penile urethra usually de- mand cutting, either immediately or after preliminary dilation. TEEATMEXT OF STEICTURE. 219 ^*^ I to I f r7^© 3. The treatment of stricture of small calilDer may be begun b}^ con- tinuous or gradual dilation with soft instruments up to the size of 15 or 16 French; in some cases it may be advisable to continue the dilation with steel instruments beyond this point — until the stricture develops irritability. /^ >- 4. Strictures of large caliber of re- cent formation, and those consisting of points of normal inelasticity that are perpetuating gleet, may be treated by dilation, the patient being forewarned that the treatment is apt to prove un- successful and that urethrotomy may be necessary, sooner or later, on account of recurrence of urethritis. ,In other words, !^ E ^~— ^ ^ — ^ the patient should be informed that dilation, although it may temporarily relieve the gleet and other symptoms of stricture, may at the same time fail to produce a satisfactory result, and that he will constantly be predisposed to at- tacks of inflammation from the slightest indiscretion. Should the patient be satisfied with treatment of this kind, it is hardly wise for the surgeon to insist upon operation. Stricture of the Deep Urethra. — Stricture of the deep urethra implies contractions involving the bulbo-mem- branous region. Strictures in this loca- tion are much more important with refer- ence to serious secondary and compli- cating conditions that are intrinsically danoferous to life than those occurring anteriorly. As an invariable rule, the gravity of stricture is directly propor- tionate to its distance from the meatus. The structures surrounding the deep ure- thra are thick and vascular, and opera- |U? tions here are a much more serious matter than elsewhere in the canal. Complica- tions of stricture are not only most likely to arise in these cases, but they involve such important structures that they may result most disastrously. The method of treatment is, therefore, of vital importance, and in general it O .0® iV^ O <3i w O (^ ©:: 220 STKICTUEE OF THE ITEETHKA. may be said that, the more cautious and conseryative the surgeon and the more delicate his manipulations, the better the prospect of success. A care- ful study of each case is necessary to determine the probable existence of serious vesical, and more particularly of renal, complications prior to sur- gical interference. The duration, condition, and caliber of the stricture and the habits and general condition of the patient demand careful attention, as they are criterions for the selection of the method of treatment. In old strictures of small caliber, particularly in intemperate and ca- chectic patients, probable disturbance of the structure and function of the kidneys is to be inferred, independently of the results of urinalysis. Even in cases of deep stricture of comparatively large caliber care should be exercised if the patient be at all broken down in health, intemperate, or the stricture is of long standing. Although in the majority of cases the danger of secondar}^ and complicating conditions is proportionate to the degree of contraction, it must be remembered that the fibrous deposit of stricture forms and contracts more readily in some patients than in others; so that in some cases a stricture of short duration may be of very small caliber, while in others that have lasted much longer there may be little contraction. Other things being equal, however, the tighter the stricture, the greater the danger of renal complications, although in cases of sIoav- forming stricture of large caliber the bladder and kidneys may be in a much more serious condition than in rapidly-formed cases of small caliber. In selecting the method of treatment the surgeon should remember that no method of management of deep strictures has yet been generally accepted as yielding a permanent cure. Inasmuch as radical operations do not promise enough to counterbalance their dangers, he should lean toward conservatism. If an approximately successful result can be obtained by simple, conservative measures, it is certainly unfair to subject the patient to the dangers of a radical operation. Simple uncomplicated deep stricture should be treated by dilation. If the stricture be of small caliber it may be necessary to begin by con- tinuous dilation with soft bougies, successive instruments being intro- duced in increasing sizes until the stricture is dilated as far as possible without force. If a soft instrument is allowed to remain in the urethra for a few minutes, it will be found that the next larger size can, as a rule, be Cjuite easily introduced. In cases in which a small instrument is introduced Ayith difficulty, it may be left in the canal for from six to twenty-four hours, at the end of which time sufficient absorption of the stricture will usually have occurred to permit of the introduction of a larger instrument and to permit of the passage of the urine beside the instrument while in siiv. This is a desirable method in some cases of tight stricture in which there is considerable congestion and a tendency to spasm, in which it is hazardous to introduce and immediately remove an instrument, because - of the danger of spasmodic or congestive retention coming on within a TEEATMEXT OF STEICTUKE. 221. few hours as a consequence of reaction. After the stricture has been dilated, to a certain extent tliis is not so likely to occur. Gradual dilation per- formed conserYatively, with due regard to general and local measures for the correction of general nervous hyperesthesia and irritability or con- gestion of the lesion^ will bring about what is practically a cure in by far the larger proportion of deep strictures. Anesthetics are sometimes necessary in dilation. In many persons, as a consequence of nervous excitement and fear, the passage of instruments produces so much reflex spasm that a comparatively small bougie causes con- siderable bruising and inflammation at the site of the stricture. Here anesthetics may be required; the preliminary administration of morphin is, however, often successful. It is exceptional that radical operations become necessary in deep stricture, for, given a patient who is able and willing to visit the surgeon or be visited by him as frequently as may be required, and an operator who has an abundance of patience as well as expertness in urethral manipu- lations, gradual dilation is generally successful. The surgeon who regards the urethra as an insensate tube susceptible of the various operations of divulsion, cutting, and forcible dilation without resentment is the one who is able to report the largest number of cases of radical operations for deep stricture. In direct proportion to the degree of gentleness and patience exhibited in the management of strictures of the deep urethra will be the. success achieved in their treatment. With all the patience, perseverance, and gentleness that can possibly be exhibited, however, cases occasionally occur that are insusceptible to treat- ment by dilation. In some cases the stricture is highly contractile and elastic, and resents dilation beyond a moderate degree, all attempts at further stretching and absorption being followed by chill, exacerbation of urethritis, or painful vesical symptoms. It may apparently yield quite readily, and yet immediately recontract as soon as the dilation is sus- pended for a time. So much pain and irritation are sometimes produced by instrumentation that it is impossible to successfully carry out the treat- ment by dilation. This state of affairs rarely exists in simple stricture, but is frequently observed in complicated forms. The conditions requiring radical measures are: — ■ 1. Irritdble {Ey per esthetic) Stridnre. — In this form the patient is usu- ally nervous and irritalDle and the urethra hyperesthetic. Every dilation is attended by pain and spasm — sometimes with general convulsive mani- festations — ^followed by chill and perhaps fever. Such strictures are also resilient, and liable to congestion and inflammation; so that attempts at dilation are not only unsuccessful, but it is impossible to pass instruments that were previously admitted with only moderate difficulty. Such strict- ures are usually of small caliber. 2. Besilient and Elastic Stricture. — Although often irritable, this form 222 STEICTUEE OF THE UEETHEA. may be dilated quite readily until the urethra is apparently restored to its fullest capacity. The symptoms^ however, are not completely relieved, and on exploration Avith the bulbous bougie it is found that, although a large- sized sound will pass, the stricture is still present. This condition is ex- ceptional in the deep urethra, being more frequent in the penile portion; still, it is occasionally met with deeper. 3. Recurrent Stricture. — This is really a variety of resilient stricture in which the quality of resilienc}^ or elasticity does not immediately mani- fest itself. Such strictures recontract shortly after cessation of treatment, either spontaneously or from some slight cause. As a rule, resilient, elastic, and recurrent strictures do not exhibit their evil propensities until they have been fairly well dilated, when they become exceedingly stubborn. Very often they are of comparatively large caliber. Other things being equal, such behavior is more likely to occur in stricture of large caliber. Like the preceding form, recurrent stricture is most frequent in the penile portion, although occasionally met with in the deep urethra. Recurrence of stricture is most rapid and certain in gouty or rheu- matic subjects. The habits of the patient have a very important bearing upon this form of stricture. 4. Very Hard Stricture of C ariilaginous Consistency and Long Dura- tion. — Strictures of this kind, although often traumatic, may arise from the ordinary cause, — i.e., virulent urethritis. They are usually tortuous, and instruments are passed with difhculty. Dilation cannot be carried beyond a moderate degree, owing to the density of the quasicicatricial stricture- tissue. Strictures of this kind will neither dilate permanently nor can absorption be induced in them by pressure. Deep strictures, involving one- half or three-fourths of an inch or more of the canal, are likely to present these characteristics. 5. Hard, Tortuous, Complicated Stricture. — Strictures of this kind are apt to be complicated by serious retention, urethral rupture, and urinary infiltration or formation of fistulas. There may be considerable plastic exudate, not only in the urethra, but in the cellular tissue of the perineum. There is invariably a formation of dense fibro-connective tissue about these parts if fistulas have developed. 6. Cases Demanding Economy of Time, or Where the Condition of the Patient Urgently Demands Immediate Relief. — ISTon-resident patients who cannot afford the time involved in gradual dilation must be included un- der this head. Irritable, resilient, and recurrent strictures of large caliber in the deep urethra are best treated by external section, although the combined method of urethrotomy and divulsion — a relatively-small nick being made in the strictured tissue, just sufficient to facilitate rupture- — sometimes gives good results. American surgeons, however, are properly abandonins: all internal cutting operations in the deep urethra. When such strictures are of only TEEATMENT OF STRICTUEE. 223 moderately large caliber, the tissues being relatively dense and cartilaginous, jDerineal section is to be preferred, although simple divulsion is often successful. In cases of irritable stricture radical operations are, on the average, productive of less constitutional disturbance than repeated attempts at dila- tion. The contracted, resilient stricture-tissue is so hyperesthetic that the slightest attempt to stretch it may result seriously, whereas division by in- cision or rApture relieves the hyperesthesia at once and produces compara- tively little irritation, the danger from o]^>€ration being rather of a direct character and incidental to the possible occurrence of sepsis than due to any remote impression produced through the medium of reflex nervous dis- turbance. The difference in results obtained by stretching a contracted and highly- .sensitive fibrous and muscular structure and completely dividing it is well illustrated in certain cases of talipes, torticollis, and other conditions in which fibrous, tendinous, and muscular structures are shortened, and per- haps thickened, by interstitial connective-tissue or fibrous deposit. When dilation produces severe pain and reflex spasm, with perhaps alarming constitutional manifestations, further attempts are contra-indicated, and more radical measures, involving rupture or incision, are demanded. Com- plete rest for some days or weeks occasionally allays irritability and facili- tates dilation. Very hard, cartilaginous deep strictures of long standing, whether com- plicated or not, require perineal section, especially in cases attended by seri- ous bladder complications. The simpler varieties of complicated stricture do not necessarily demand such radical measures. In these severe forms of stricture divulsion or internal urethrotomy are very dangerous as well as unreliable. There is great danger of hemorrhage, which is difficult to con- trol on account of the depth of the operative lesion and the induration of the bleeding tissue. There are also the special dangers of septic infec- tion, infiltration of urine, abscess, and fistula, due to laceration of the stricture and surrounding parts, these complications being favored by the heat of the tissues and the unavoidably sept-ic condition of the wound. Internal incision of dense stricture of the deep urethra is unsuccessful because it is impossible to introduce a cutting-blade of sufficient size to accomplish thorough division. To accomplish complete division the incision must in some cases necessarily extend entirely through the urethral wall. The relation of urethrotomy to deep strictures is not the same as it bears to those occurring in the penile portion. In the latter the blade of the urethrotome, when properly used, nearly or quite divides the strictured tissue, which involves in many instances — invariably in strictures of large caliber — only the mucous membrane and a more or less superficial layer of the tissues beneath it. It is, of course, admitted that many cases of penile stricture are extensively indurated, but these are exceptions to the 224 STRICTURE OF THE URETHRA. rule. In the dense varieties of deep stricture tlie urethrotome merely makes a comiDaratively superficial incision in the strictured tissue^ and does not completely divide it. It is obvious that complete rupture of such strict- ures is impossible without considerable injury to the corpus spongiosum. Taking these things into consideration, external perineal section is to be recommended because (1) it completely divides the stricture; (2) complete relief of retention is secured; (3) perfect drainage and comparative asepsis are provided for; (4) hemorrhage is easy of access and control; (5) the result of the operation is better and much more easily maintained perma- nently by occasional dilation than after deep internal operations. The author believes that perineal section is less dangerous, on the average, even in the slighter forms of deep stricture, than either internal urethrotomy or divulsion. Cases demanding immediate interference because of retention had best be treated by external perineal section. If, however, the patient can be under the control of the surgeon and there is a prospect of a favorable ]'esult from conservative measures, the case should be temporized with until such time as it is practicable to begin dilation. The aspirator is sometimes warrantable in such eases. In certain exceptional selected cases divulsion may be judicious. If the stricture be of small caliber, external perineal section should be performed. In some cases of deep stricture, especially when complicated by retention, electrolysis — i.e., galvanism — is a service- able preliminary to other treatment. Treatment of Stricture by Sijstematlc Dilation. — Instruments. — The instruments used for dilation of stricture are of three varieties: (a) soft and flexible bougies; (b) fine, stiff, hair-like bougies known as filiforms; (c) metallic sounds. Soft bougies are of various patterns, the French and English varieties being chiefly used. They are made in two forms, viz.: {a) with a plain conic point and (b) with an olivary tip. Their flexibility varies according to composition. The best bougies (the French) are com- posed of a web of woven material covered with rubber. The plain conic form is the most serviceable. The olive-pointed variety is designed chiefly to avoid passing the instrument into the crypts or enlarged follicles so fre- quently found in chronic urethral disease. In selecting French bougies the least flexible should be chosen; they are apt to be more durable and serviceable than the very flexible forms, which are so limp that they bend upon themselves when they come in con- tact with the slightest obstruction. The French bougies are preferable to the English, but, unfortunately, they are not so durable. Filiform bougies — so called because of their thread-like fineness— are composed of -rubber, catgut, or whalebone. The whalebone variety is the best. The rubber variety is of the same composition and construction as the ordinary French or English bougies. Some forms of soft bougie are made with a small, screw-threaded cap, which may be fastened to a urethrotome or divulsor, TEEATMENT OF STEICTUEE. 325 the bougie acting as guide or conductor for the larger instrument. Soft bougies of considerable length may be procured when necessary as guides for cutting or divulsing instruments. The whalebone variety is stifEer and more durable than those composed of rubber, and if dipped in hot water the point may be molded into any form that may be deemed useful in ayoiding urethral diverticula which might prevent engagement of the bougie in the Fig. 64. — Olive-tipped soft bougie. orifice of the stricture. AVhen a filiform is used as a guide, a tunneled in- strument may be passed it. The late Professor W. H. Van Buren was the inventor of the first tunneled instruments ever used, and should have due credit for them. Some care is necessary in the selection and preservation of filiform guides. They should be at least 18 inches in length, smooth, and perfectly straight, save when necessary to bend them for adaptation to tortuous strictures. A partial fracture of a filiform bougie is a warning to Fig. 65. — Soft straight catheters. condemn the instrument. Any irreo'ularities, inequalities, or rough surfaces of the filiform guide are likely to catch the loop of tunneled instruments, thus obstructing their passage; oftentimes a filiform guide is cut through. Soft bougies and catheters are not so easily managed as stiff metallic instruments; their flexibility permits them to bend upon themselves when they come in contact with a tight stricture. It is difficult, however, to pro- duce injury with them, and, as instruments should be coaxed, not forced. iG^ aett=3— - Fig. 66. — Screw-tipped guides. through a stricture, their function in the treatment of close strictures is very important. In warm weather gum instruments are apt to become soft and sticky; this may be prevented by dusting with talcum. Care should be taken to have them perfectly free from oil before laying them awa}^ else they ■will become soft and worthless. They tend to grow brittle with age, and 226 STEICTUEE OF THE UEETHEA. are easily broken. Care should therefore he taken to guard against the iTse of superannnated instruments. In cleansing soft instniments alcohol shonld be used. Strong solutions of carbolic acid should be avoided; if allowed to remain in such solutions for a few minutes they become rough, thus impairing their facility of introduction. Soft instruments may be introduced with the patient in either the re- cumbent or standing posture, the latter being sometimes preferable. In practicing dilation soft instruments should be used wheneyer a size smaller than 16 French is required. In tight stricture with pain and spasm during Fig. 67. — Bank's whalebone bougies. instrumentation soft instruments are absolutely essential until the urethra has been dilated moderately, after which steel instruments may usually be substituted. Sounds are usually composed of inflexible metal. There is an old- fashioned variety composed of soft metal capable of being bent in any form, the use of which is very limited. The most important features of the metallic sound are the shape and length of its point. The English (or Thompson) instrument has a point the diameter of which is but slightly less than its shaft, being consequently Fig. 68. — Correct cairve for instruments. comparatively blunt. The curve is rather long, and the point is at right angles with the shaft. Tan Buren devised a modification of the English instrument that is ver}^ popular among American surgeons. The point of this instrument is smaller, more conic, and the curve shorter than that of the English instrument. It is advantageous on account of its short curve, which makes the instrument easily controlled by the hand. There is a compensatory disadvantage in the fact that the point is so small and conic that injury in the hands of a careless operator is produced more readily than by the English instrument. As the sound acts somewhat on the prin- TKEATJIEXT OF STEICTUEE. 227 ciple of a wedge, it is obvious that stretching the stricture is more likely to he forced hy the x\merican than by the English instrument. Care should be taken that the sounds are perfectly clean — i.e., aseptic — before their introduction into the canal. Should they become rough they should be thrown aside or polished anew. It is desirable for the sur- geon to have a second set of sounds Avith a very short curve and conic point for use in the jDcndulous urethra. In the majority of cases of stricture it is not necessary to pass instru- ments into the bladder in order to secure the maximum of beneficial effect from dilation. Prostatic and vesical irritation is very often caused by me- chanic injury incidental to the passage of sounds in the treatment of strict- ure located several inches anterior to the vesical neck. After some years of careful study of urethral sounds the author has devised an instrument that seems eminently satisfactory. This instrument is much shorter and its point blunter than those in common use. The point of the sound should not be too tapering, or it will be necessary to introduce it some distance Fig-. 69. — Author's urethial sounds beyond the obstruction before its greatest diameter is brought to bear upon the stricture. A blunt point similar to that of the author's sound is of some advantage in diagnosis. While by no means so accurate as the bulbous bougie, it is far more serviceable than the ordinary conic sound. The proper form for metallic instruments, as already stated, is that IviKnvn as the Thompson curve. This corresponds to the curve of a circle 3 V4 inches in diameter. According to Thompson, the proper length of arc of such a circle for the beak of sounds is that subtended by a chord 2 '/^ inches long. A shorter curve, however, is better, for reasons already given. Continuous dilation is serviceable in tight stricture where instru- mentation is difficult. In such cases considerable nicety of judgment is required as to the advisability of withdrawing an instrument once it has ])assed the obstruction. Continuous dilation is tempting under such cir- cumstances, and the surgeon is certainly excusable for hesitancy in decidin'^- to remove an instrument that perhaps required the utmost patience and perseverance for its introduction. It is usually safe to leave a small soft or 228 STEICTUEE OF THE UKETHRA. filiform bougie in tlie uretlira after it has j^assed tlie stricture, and, as a rule;, tlie effect is beneficial, for in a short time it will be found that more or less absorption has occurred, and the bougie which was previously tightly grasped has become loosened. It may now be removed and a larger instru- ment introduced. The first instrument passed should be tied in the bladder, and allowed to remain in situ for from twelve to twenty-four hours, during which time the urine usually escapes beside it. When the first instrument is removed the next larger size should be immediately introduced, as a certain degree of recontraction maj' occur in a few minutes and prevent the introduction of another instrument. A certain amount of urethritis is caused by the bougie, Init this is rarely severe, and subsides very soon after gradual dila- tion has been substituted for the continuous method. Continuous dila- tion should be practiced until Xo. 10 or 12 French can be introduced, after which gradual dilation with the soft instruments should be substituted. AVhen practicable, a very small catheter may be passed instead of a bougie to facilitate evacuation of the bladder in case retention should occur. At the second passage of instruments, as a rule, a small catheter or bougie may be introduced, even though at the first operation it may have been dilhcult to pass even a filiform. Tlie principal objection to continuous dilation is the tendency to cystitis. If a catheter has been inserted this may be obviated by daily ves- ical irrigations of the viscus with a mild, warm, antiseptic solution. Slough- ing of the urethral mucous membrane with perineal abscess and fistula has been known to occur as a result of continuous dilation. Such an accident can only occur from extreme distension by the forcible introduction of an instrument larger than necessary. Gradual dilation is generally the most practicable method of treating stricture. It should be begun on about the third day after preliminary ex- ploration has determined the location and various qualities of the stricture. It may be necessary to vary the length of interval following preliminary exploration according to the amount of reaction. Much depends upon the tolerance of the urethra and the nervous susceptibility of the patient. If a preliminary meatotomy has been performed, it is often well to wait imtil the meatus has completely healed before going on Avith the treatment of the deeper portions of the canal, unless the necessity is urgent, as in very tight strictures, in which retention may occur at any time. The irritation of the raw cut surface produced by the passage of the sound invariably gives rise to more or less reflex spasm of the deep urethra. x\s a conse- quence irritation and inflammation of the stricture may be produced even by instruments of small size. If treatment by gradual dilation be decided on, it should begin with the insertion of a small sound at the next sitting following the preliminary exploration, or as' soon as the meatus has healed, as the case may be. The TEEATMENT OF STEICTUKE. 239 first instmment passed should be small enougli to pass easil3^ In this way the sensibility of the stricture may be blunted to a certain extent and the canal opened up, facilitating the passage of an instrument large enough to distend the stricture. After the withdrawal of the small instrument a second should be inserted that is large enough to distend the stricture with- out the exhibition of force in its introduction. If pain and spasm result, the sound should be immediately withdrawn. If, however, the urethra be tolerant, it should be allowed to remain for a minute or two to secure the full effects of the distension. It should now be removed and the next larger size introduced in the same manner. It is rarely advisable to use more than two, or at most three, sounds at a single operation, a single in- strument being best if the stricture be very irritable. If the surgeon un- dertakes to hurry matters severe urethritis, prostatitis, cystitis, epididy- mitis, or urinary fever may result, or a tractable stricture become irritable and resilient. Any of the accidents mentioned ma}^ prove a serious com- plication, and will inevitably delay treatment. It is the author's opinion that the surgeon is often responsible for congestion, inflammation, irri- tability, and resiliency of stricture occurring in the course of treatment by dilation. One of the cardinal principles that should guide the operator is the avoidance of force, conjoined with efforts to "coax" the stricture to a cure. Nothing is gained by torturing the sensitive tissues by the intro- duction of too large and too many instruments. The preliminary administration of anod3'nes, the continuous use of nervous sedatives and antispasmodics, and even anesthetics, are frequently useful adjuncts to dilation. The sudden acquirement of a spasmodic element in a stricture under treatment may indicate renal complications. In a case of the author's the formation of perinephric abscess was heralded by severe spasm of a strict- ure that was under treatment by dilation. At the next sitting dilation should be begun with an instrument a size smaller than the largest previously introduced. Should the urethra be very irritable, it ma}^ be necessary to again pass as a preliminary measure a very small instrument for the purpose of blunting sensibility. Two sizes should be introduced as before. The frequency of dilation should vary according to the exigencies of each particular case. Many surgeons in their enthusiasm for a speedy cure of the stricture are tempted to introduce instruments too frequently. It is not unusual to meet with cases that have been tortured into irritability and resiliency, by the daily introduction of sounds. While it is permissible in very tight strictures to introduce soft instruments every day, it is rarely beneficial, and usually injurious, to pass metallic instruments oftener than once in three days. In many cases once in four or five days or more is sufficient. Some patients complain greatly of pain and severe spasm, with per- 230 STRICT L'EE OF THE UEETHKA. liajjs chill and fever, if the sound be introduced oftener than once a week. Quite prolonged intervals of rest are essential in some cases. It is necessary in all tight strictures to begin treatment with soft in- struments, jDcrhaps by continuous dilation. After the stricture has been dilated to the caliber of about IG French, steel instruments ma}" be sub- stituted. "With small steel instruments there is great danger of traumatism. Such instruments do not pass by their own weight, but require some force. The degree of pressure exerted requires some nicety of judgment; it takes very little force to drive the jDoint of a metallic instrument through the urethral wall, causing a false passage. In some instances it is wise to use soft instruments up to a considerable size before substituting sounds. Dilation acts in two ways: (1) by mechanically stretching the strict- ure, thus temporarily increasing its caliber: (2) by producing absorption of the advcutitious tissue, with resultant permanent dilation. In order that this may occur a certain degree of reaction should follow the introduction of the sound. It is upon increase of nutrition of the part, incidental to slight hyperemia resulting from mechanic stretching, that the cure de- pends. This reaction must be kept within bounds, however, for when it merges into inflammation the stricture can only be aggravated by sound- ing. Slight increase in discharge following the use of the sound is usual; a marked increase is an indication that imdue inflammation has been ex- cited, and should serve as a caution against further dilation until the re- action has subsided. For a short time after the introduction of the sound the flow of urine is facilitated by the mere mechanic stretching produced by the instru- ment. This increased caliber persists for twenty-four to thirty-six hours, at the end of which time reaction occurs, with coincident hyperemia and increased activity of the processes of nutrition in the diseased tissues. A moderate amount of swelling results that serves to diminish the caliber of the stricture. Within a day or two, however, absorption begins and con- tinues for several days, at the end of which time recontraction commences. If a sound be introduced during the time reaction is at its height, more or less acute inflammation is excited and the case aggravated. As reaction diminishes the benefits of absorption are apparent in the increased size of the stream. If the operation be successful, the stream of urine will be larger than before. The rapidity with which reaction comes on, its degree, and the amount and duration of absorption vary greatly. A careful study of each case teaches the surgeon when another operation is permissible. If the canal be dilated in a routine manner and increasing degree every few days, many disappointments will be experienced. Each case is a law unto itself and should be treated upon its own merits. In some cases the urethra will not tolerate any increase of the size of the in- strument for several successive operations, it being necessar}' to introduce the same instrument several times. TEEATMENT OF STEICTL'EE. 231 The proper method of introduction of the sound is an important matter for consideration. It is to be remembered in this connection that the final steps of the operation of urethral dilation are not always necessary. Un- less there is some special indication for deep dilation, the membrano-pro- static urethra should not be entered by the soimd. The necessity for deep dilation is regailated by the location of the stricture and the condition of the posterior urethra. The patient had best be in a partially-recumbent posture, with the knees flexed, the feet at rest, the thighs flexed slightly on the abdomen, and the shoulders somewhat raised. The first step in the introduction of the sound is to grasp the penis in the left hand and with the right hand insert the sound into the urethra to a depth corresponding Fig. 70. — First position in introducing a sound. to a point just past the junction of the straight with the curved portion of the instrument. The shaft should be held close to, and parallel with, one or the other groin — according as the surgeon is right- or left- handed. (Fig. 70.) The operator should stand upon the corresponding side of the patient. The sound is now dipped well down into the perineal urethra until its point has almost reached the opening in the triangular ligament, the handle being raised, but still held parallel with Poupart's ligament. (Fig. 71.) The instrument is now swept toward the median line, its point being simultaneously dipped still farther downward until the bulbo-mem- branous opening is reached. (Fig. 72.) It is finally swept downward toward the feet. If for any reason exploration of the bladder is desired, the final stage of the introduction is required (Fig. 73), the shaft of the sound being 232 STEICTURE OF THE URETHRA. brought down until almost in line with the central axis of the patient's body. In most cases this is not necessary. When at an angle of about 45° the point of the sound is usually at the orifice of the bladder or just within it. This suffices, as a rule, in treating stricture and chronic urethritis. Gath- ering the testes up in the free hand, and holding them up until the sound finally enters the bladder, is a useful maneuver. Pressure upon the pubic region to relax the subpubic ligament is often useful, but rarely necessary. The introduction of the sound usually occasions more or less smart- ing and a variable degree of pain, most marked as the instrument ap- proaches the vesical neck. As it passes over this highly sensitive part more or less nausea and faintness, possibly s3?ncope, may be produced. Fig. 71. — Second position in introducing a sound. Care should be taken that the instrument is well warmed and lubricated before introduction, else pain and spasm will be greatly enhanced. The best lubricant is albolene with mercury bichlorid, 1 in 1000, in combina- tion with 5 to 10 grains of cocain to the ounce. Should medicated applica- tions to the canal be required after removal of the sound for the purpose of curing refractory gleet, glycerin should be used as a lubricant. Oils coat the surface of the mucous membrane and prevent effective action of astrin- gents. Lubrichondrin is a new and satisfactory lubricant. Accidents and Morhid Effects Sometimes Incidental to Dilation. — Urinary, or urethral, fever in its various phases is one of the most frequent TREATMENT OF STEICTUKE. 233 and serious results that may follow dilation of stricture. It has already been fully . considered in a preceding chapter. Hemorrhage. — Hemorrhage is a frequent result of the introduction of urethral instruments. As a rule, its occurrence is an indication that undue force has been used. In most cases where dilation causes hemorrhage, the instrument used is too large or too much force has been exhibited. An instrument that will enter the bladder by its own weight will rarely produce bleeding, as the stretching of the stricture-tissue is accomplished in a gentle manner. In very tight strictures and those in which there is considerable congestion and spasm the introduction of any instrument, however small, is liable to produce hemorrhage. When, therefore, the in- Fig. 72. — Third position. troduction of an instrument that will enter the bladder without the em- ployment of force is followed by bleeding, that there exists considerable congestion at the site of the stricture may be inferred. The hemorrhage, 'per se, is not injurious; on the contrary, it is beneficial by producing local depletion. If, however, it results from forcible instrumentation, the ex- ces.sive reaction folloAving the traumatism more than counterbalances any benefit that could be derived from local abstraction of blood. Some cases in which congestion predominates will bleed occasionally after urination, particularly if the patient has recently indulged in inter- course or become sexually excited. Such strictures are particularly apt to occur in intemperate individuals and syphilitics. Under such circum- stances the utmost gentleness in the introduction of instruments will not 234 STRICTUEE OF THE UEETHEA. prevent more or less bleeding. It is rarely if ever necessary to treat the hemorrhage; on the contrary, it should be allowed to continue within reasonable limits. Should it become excessive, however, the application of the cold-water coil, penile bandage, or ice-bag will usually check it. False Passages. — These result from instrumentation more frequently than is generally believed. They are due to the passage of the instrument through the urethral walls into the surrounding tissues. The mucous mem- brane only may be torn up, in which case the passage rarely extends for a great distance, or the corjjus spongiosum may be entirely traversed and the tissues of the perineum entered. The danger of their occurrence is greatest with small metallic instruments, it being difficult to produce them by means Fig. 73. — Fourth and final position. of flexible bougies or catheters. The common English catheter with the stylet is, however, nearly as dangerous as metallic instruments. In pack-thread or bridle strictures numerous urethral pockets may exist, or there may be a sort of membranous diaphragm thrown obliquely across the urethra in such fashion that the instrument impinges upon it just at its junction with the urethral walls, instead of entering the orifice of the stricture. Under such circumstances the conditions necessary to the production of a false passage are very favorable, and it takes but little force to jDerforate the urethra. Symptoms. — The occurrence of this accident is usually quite evident. The surgeon is usually conscious of having used considerable force or of carelessness in respect to conforming the instrument to the natural direc- TKEATMENT OF STKICTUEE. 235 tion of the urethra. The obstruction suddenly yields to the pressure, and the direction of the handle of the instrument shows that the point is out of the proper line. If the handle of the instrument be rotated between the thumb and fingers, it will be found that the point is fixed, thus showing conclusively that it cannot have entered the bladder. When the bladder is entered the point of the instrument is usually freely movable within the viscus, and there is no sense of resistance imparted to the handle when rotated. Exceptionally the instrument may not only traverse the urethral walls, but pass onward until the bladder is perforated. Coincidently with altera- tion in the direction of the instrument the patient complains of severe pain and perhaps impending syncope, and may be conscious that something has Fig. 74. — False passage in stricture. A catheter in tlie abnormal channel. (After Dittel.) been torn. Free bleeding usually results. On rectal examination the beak of the instrument is found in the connective tissue of the vesico-rectal septum. False passages are most often formed in the deep urethra, as it is here that the lever action of the sound is most powerful and strictures so tight as to demand small instruments are usually found. It is not easy to pro- duce false passages in the pendulous urethra, as the point of the instrument is continually under control of the fingers and its proper direction is easily maintained. The seriousness of false passages is proportionate to their distance from the meatus. Their direction is usually to one side of the canal. They ma}', however, perforate it above or below. When above they are not likely to penetrate for a great distance on account of the firmness of the tissues. 236 STEICTUKE OF THE UKETHKA. The corpus spongiosum, or even the prostate^ may be completely perforated when the false passage occurs below. The character of the perforation has also mnch to do with the degree of danger. If the false passage enters the corpus spongiosum and rnns along the urethra, perhaps to open again into the canal, or the bladder be entered after a lateral lobe of the prostate has been perforated, the dan- ger to life is comparatively slight. When, however, the instrument passes clear outside the corpus spongiosum into the vesico-rectal areolar tissue, serious extravasation of urine may result, with consequent inflammation, suppuration, or perhaps gangrene. Old false passages are occasionally very annoying and frequently not only interfere with treatment, but prevent complete relief of symptoms, even though the caliber of the canal be restored. As a rule, the history justifies a suspicion of the formation of a false passage or passages at some previous instrumentation. The abnormal direction of the sound, failure to enter the bladder, and the peculiar gristly sensation imparted to the in- strument are often sufficient to indicate its existence. Oftentimes the pa- tient is aware of the presence of false passages. Occasionally he will feel that the abnormal channel has been penetrated by the instrument AAdien its course is not evident to the surgeon. In some instances only the most careful study of the symptoms and course of the case will enable us to determine the true condition. In some cases a diagnosis cannot be made. Acute inflammation of the urethra, prostate, Madder, and epididymis is a by no means infrequent complication of stricture jDroduced by instru- mentation. Following dilation of stricture, there is always moderate re- action ajoproximating inflammation. This, however, should properly be limited to the stricture itself. There may occur, on the other hand, a sharp urethritis. Much depends on the condition of the urethra at the time of dilation; of more importance, however, is the cleanliness of the sound and the degree of gentleness displayed in its introduction. Inflammation of the prostate, incidental to rough instrumentation, is an occasional result of dilation. It should be remembered that the pros- tate is invariably congested and irritable, as a consequence of bruising dur- ing frequent and spasmodic efforts at urination. In the presence of this condition comparatively slight traumatism may cause prostatitis. This may be acute from a single act of violence or ma}^ appear in a subacute or chronic form consequent upon repeated bruising and irritation. Ab- scess may occur, especially if trauma and infection be produced by a septic sound. Cystitis in the course of stricture arises in several Avays:- — - 1.. It may be due to injury done the vesical neck by large instruments. 2. It may result from prolonged contact of instruments with the ves- ical neck in continuous dilation. Ulceration of the vesical walls may result from pressure produced by the point of faulty sounds. OPERATIVE TREATMENT OF STRICTURE. 237 3. Pre-existing chronic inflammation of the vesical neck, due to direct infection or extension of inflammation from stricture, may be so enhanced by the introduction of instruments that acute generalized cystitis and per- liaps pericystitis results. 4. A small quantity of poisonous material, formed by bacterial evolu- tion posterior to the stricture, is carried by the point of the instrument to the vesical neck and sets up acute infectious inflammation. The relation of bacterial organisms — not necessarily specific — to the morbid processes at the site of stricture and to cystitis is a very important one. 5. Poisonous materials — i.e., bacterial organisms or their products- may be conveyed to the cavity of the bladder by unclean instruments. Epididymitis is one of the most frequent complications of stricture. It may be produced in two ways: (a) by the production of acute inflamma- tion at the site of the stricture, which extends down to the mouths of the ejaculatory ducts and thence to the epididymis; (h) by the conveyance of organic poisons to the mouths of the ejaculatory ducts via the sound or catheter. It is possible that the testis may become involved via lymphatic in- fection. The various complications of stricture may usually be avoided if the patient keeps quiet, is temperate, and follows directions implicitly, and, more important still, if the surgeon is gentle in his manipulations and ab- solutely cleanly as regards his instruments. It is desirable for patients under treatment for stricture to wear a sus- pensory bandage if the testes be sensitive. OPERATIVE TREATMENT OF STRICTURE. DivuLSiox. — Divulsion of stricture consists of rapid and forcible dila- tion with the object of rupturing the morbid tissues. Various instruments have been devised for divulsion. Some of these consist of sliding tubes of varying caliber that are forcibly introduced over a central guide. Another variety splits the stricture after the fashion of a wedge. Still another, and the most popular variety, consist of several parallel blades separable by means of a powerful screw. Divulsing tubes were first used by Desault something like a hundred years ago. They are used in the following manner: A small bougie is in- troduced into the bladder as a guide, over this an open-ended catheter is passed, and over this another catheter or tube a trifle larger, as much force as is necessary being used. A succession of tubes of increasing size are passed imtil the urethra is dilated to its fullest capacity. Divulsion upon the wedge principle was first recommended by Rey- band; it has been modified to a certain extent by Holt, whose instrument consists of two grooved blades of strong metal joined at their points. Be- 238 STEICTUKE OF THE UEETHEA. tween the two points and fastened to them at their point of juncture is a wire that acts as a guide; over this wire a tube of considerable size is forcibly passed. This separates the blades and splits the stricture. It is claimed by Holt that the rupture produced by the instrument does not extend be- yond the morbid tissue, the healthy urethra not being injured. The ac- curacy of this statement is questionable. It is hardly possible for stricture of any extent to be ruptured without injury to the urethra. Divulsors with separable blades are the most popular instruments for rupturing stricture. Various patterns of screw-divulsor have been devised; they have been made with two, three, and four blades. The best device is probably that of Sir Henry Thompson, which has two strong, separable parallel blades. This instrument may be used for the purpose of rapid dilation by sloAvly separating the blades with successive turns of the screw, or it may be used to rupture a stricture by se^jarating the blades as rapidly as possible. When the operation is slowly done little bleeding occurs, and there is probably little or no laceration of the urethral walls. Divulsion has not been very popular in America. It still, however, has many advocates in England and on the Continent, and is being revived in the East in this countr}'. Tlue operation seems unsurgical, and unless considerable damage is done at the site of the lesion is apt to fail of its object. Eapid stretching, unless attended by complete rupture of the strict- ure, will usually only inflame and irritate the stricture-tissue and make it resilient and elastic. It is, perhaps, safer than internal urethrotomy in the deep urethra, but external perineal section is far safer than either in severe stricture.^ Eesilient, elastic, and recurrent stricture of large caliber in the deep urethra may sometimes be divulsed with advantage. In these strictures gradual dilation is usually carried on until the morbid tissue is very slight in amount and involves but a superficial extent of the urethra and its sub- lying connective tissue. Under such circumstances urethrotomy may be objected to on account of the danger of hemorrhage, and external perineal section for such slight lesions is likely to be considered severe. Under these circumstances divulsion is a useful operation. Divulsion should be followed by gradual dilation. A steel sound of moderate size is to be introduced four or five days after the operation, the time varying with the amount of inflammation resulting from rupture of the stricture. An instrument should be passed at first every third da}^, the intervals being subsec|uently lengthened. ^ It is only fair to state that several of our ablest American surgeons are now advocating divulsion and commending the operation very highly. The author, how- ever, still believes that the tearing and bruising of what must be a septic field is not in accord with modern suroical art. INTERNAL UEETHROTOMY. 239 Internal Ueetheotomy. — Internal urethrotomy consists in division of the stricture by incision. Urethrotomes are practically of three kinds, viz.: (1) those which cut the stricture from before backward; (2) those which cut from behind forward; (3) those which, in addition to a cutting- blade passed through a hollow central guide, have two separable blades, the object of which is to complete the operation by divulsing or tearing any of the fibers of the stricture that are not divided by the incision. The only reliable instruments for internal urethrotomy are those of Maisonneuve and Otis and their modifications. The most reliable and satisfactory in- strument is the Otis dilating urethrotome. Maisonneuve's instrument cuts from before backward, and is service- able for division of deep strictures. It consists of a hollow tube with a central slit corresponding to the roof of the urethra. Triangular knives of different sizes fastened to a wire shaft are passed along the central tube after its introduction into the bladder until the stricture is divided. This urethrotome is supplied with a screw-tip to which a filiform bougie may be attached. The principal objection to the use of this instrument is that it Fig. 75. — Maisonneuve's urethrotome. never divides the stricture completely unless a very large blade is used, in which event there is more cutting than necessary, and serious hemorrhage may result. The latest modification of Maisonneuve's urethrotome consists of a straight timneled shaft with a secondary blade, the two being separable by a powerful screw. The cutting-blade runs in a groove upon the central shaft. Attached to the handle near the screw is a dial-plate. By this in- strument the urethra may be cut — or dilated and cut — to a caliber of 45 French. General anesthesia is only occasionally necessary for internal ure- throtomy. In very nervous patients it may be essential. It must be remem- bered, however, that a general anesthetic should be avoided where possible, especially in chronic genito-urinary disease, because of possible evil effects upon the kidnej'^s. Cocain has probably been responsible for certain acci- dents, especially in urethral surgery, but if used in relatively-weak solu- tions it is safer than general anesthesia. Internal urethrotomy may ordi- narily be performed with a 1-per-cent. solution of cocain in a 1-per-cent. 2-iO STEICTUEE OF THE URETHEA. solution of carbolic acid. Four per cent, slioulcl not be exceeded in the urethra. The carbolic acid is antiseptic, more or less anesthetic, and suf- ficiently astringent to limit the action of the cocain. The canal should first be flushed with solution of mercury bichlorid in a strength of 1 to 20,000 to 1 in 10,000 or potassium permanganate 1 to 5000. Operation. — The number of strictures and their distance from the meatus having been estimated, the dilating urethrotome (Fig. 76) is passed down until the point upon the shaft at which the blade will first appear when vrithdrawn is about half an inch behind the stricture. The blades are now separated by turning the screw until tension of the stricture is evident; the cutting-blade is then steadil}^ and with moderate rapidity withdrawn. The dilating blades are now separated to the required extent. They are finally screwed together again and the instrument withdrawn, care being taken not to catch the mucous membrane between the blades during withdrawal. Exploration with a full-sized bulb should now be made to determine whether the strictures have been completely divided. If the urethra is not perfectly free, the urethrotome should again be used. The The Otis dilating urethrotome. operation is completed by the passage of a full-sized sound. After the op- eration the urethra should be irrigated with hot saturated solution of boric acid or mercury bichlorid 1 to 20,000. The patient should be put to bed, and if there be much hemorrhage an ice-bag or the cold-water coil applied. The determination of the size to which the urethra should be enlarged involves some nicety of judgment. The only fixed standard that has been suggested is that of F. N. Otis, already alluded to. According to Otis, the average size of the urethra, as determined by numerous measurements with the urethrometer, is as follows: When the circumferential measurement of the penis is three inches the urethra should admit a sound No. 30 French. With each one-eighth of an inch increase in circumference the urethra should increase one-third of a millimeter in diameter; i.e., one size larger upon the French scale. Thus, the penile circumference being 3 Vs inches, the urethra should admit 31 French; with a circumference of 3 ^/^ inches, 32, and so on. A circumference of 4 ^/^ inches is rarely exceeded. In such cases the urethra should admit at least 40 French. One of the principal objections to the Otis system is that it is liable to apparently demonstrate the existence of stricture of large caliber at INTEENAL UEETHEOTOMT, 241 points of normal relative inelasticity of the canal. There is, however, as a rule, no danger and no disagreeable results to be apprehended from dilat- ing the urethra after preliminary incision to as large caliber as possible with the Otis instrument. Occasional cases may arise, however, in which damage might be done by a too-arbitrary application of the Otis measure- ments. It is generally practicable — and, as a rule, advantageous — to enlarge the urethra as recommended by Otis where urethrotomy is necessary, but it by no means follows that the size attained at the time of operation should be maintained. In fact, it will often be found impracticable to maintain a caliber of more than 32 to 35 French even where the urethra has been incised and stretched to the fullest capacity attainable by the dilating urethrotome (45 French). The urethral enlargement secured by operation, even when thoroughly done, is, to a certain degree, temporary in character, being partly dependent upon overstretching of the muscular fibers of the urethral walls. This makes the urethra flaccid, and for a few days a large- sized sound will be admitted; after a time, however, the tonicity of the urethra is restored, and as a consequence an instrument which it was prac- ticable to introduce immediately after operation can no longer be passed without undue force. In fact, the caliber of the urethra which it is prac- ticable to permanently secure by operation is usually some sizes smaller than that primarily secured. There has recently developed considerable opposition to urethrotomy on the part of certain authors who treat upon genito-urinary surgery. Much of this opposition is based upon underestimation of the normal ure- thral caliber. Of the recent treatises in which the subject is discussed, two are especially noteworthy. In one work the maximum urethral caliber is given as 31 French, while in the other 30 is claimed to be the maximum, and the assertion is made that an individual whose urethra will admit 26 French has no stricture worthy of the name. It should go without the say- ing that inasmuch as a normal caliber of 35 to 40 French is by no means extraordinary, many cases in which 26 or even 31 French can be passed may still require surgical attention. There is necessarily a wide discrepancy of opinion between operating and non-operating surgeons. The author is of opinion that, the meatus being sufiiciently dilatable, there are few cases in which the normal male urethra will not admit from 30 French upward. In performing internal urethrotomy the rule should be: (a) to cut downward at the meatus and a short distance within it; (b) to cut upon the roof of the canal in the penile urethra. Untoward Effects of Internal Urethrotomy. — Considerable inflammation sometimes follows dilating urethrotomy. This may give rise to chordee lasting for some little time, perhaps leaving a curvature that persists for some weeks or even months after the operation-wound has healed. There is no question but that cases occasionally arise in which a greater 242 STEICTURE OF THE UEETHEA. or less degree of deformity results after internal urethrotomy. This is usually temporary and slight, but has been the jorincipal reason for the terrific howl that has been sent up by the anti-operation faction of the pro- fession against internal urethrotomy. Failure to cure chronic gleet is fre- quently offered as an objection to the operation. The author is not aware of any other operation in which infallibility and absolute freedom from dis- agreeable results is demanded in every case operated upon. Such a demand in the case of internal urethrotomy is hardly logical or fair. A discussion of the various arguments pro and con in relation to internal urethrotomy would merely consume space. The author simply states that in an experi- ence of nearly twenty years with internal urethrotomy he has not only had no occasion to alter his views upon the subject, but, on the contrary, has become more firmly convinced of the solidity of the foundation upon which the doctrines enunciated by Otis were constructed. The author has observed imperfect erection in several cases which lasted a year or more after urethrotomy. The complaint usuall}^ made is that, while the rest of the organ becomes normally erect, the glans remains soft and flabby. This is only explicable on the ground of cicatricial inter- ference with the circulation of the organ. The occurrence is very rare, but none the less demands consideration. Eecovery is the rule. After-treatment in Dilating Urethrotomy. — The prevailing tendency is to regard the operation of urethrotomy as trivial, requiring little attention to details. The surgeon often operates at his office and allows the patient to go about at will. This is injudicious. Where possible, the patient should, as a rule, be put to bed for from four or five days to a week. Cases occasionally occur in which there is little bleeding at the time of operation, but very free hemorrhage comes on during the night as a con- sequence of erection. This makes the application of cold a necessity. In a case of the author's severe hemorrhage followed an erection two weeks after operation. In addition to the application of cold, anaphrodisiacs may be given to prevent hemorrhage. Ergot, potassium bromid, and gelsemium meet the indications admirably. A suppository of hyoscyamus, morphia, and monobromicl of camphor is often of great service. The bromids should be given in large doses. It is the author's custom to give oil of eucalyptus in 10-minim doses three or four times daily after a urethrotomy. This drug keeps the urine bland and aseptic. Boric acid, cystogen, sodium benzoate, gaultheria, and salol are also of service. Dilation is usually carried on too vigorously after urethrotomy. The danger of hemorrhage, urethritis, and curvature of the penis is directly proportionate to the frequency of dilation after operation. The best re- sults follow infrequent dilation beginning on the third day — or even later if bleeding be profuse — dilation being repeated every third day for a week, and every fourth or fifth day thereafter. There is no danger, as a rule, in INTERNAL URETHROTOMY. 243 allowing a stricture that lias once been thoroughly cut to go for an entire week without dilation. The cut ends of the urethral circular muscular fibers probably retract, and this serves to keep the incision sufficiently open for all practical purposes. Intermittent dilation by the urinary outflow also plays an important role in maintaining urethral patency. Permanency of Result. — The claims of dilating urethrotomy have been chiefly based upon permanency of result. The only reliable test in any particular case is re-examination with bulbs some time after operation. In most cases of stricture appreciable recontraction will probably occur within a very short time — a few months, perhaps — after treat- ment, if at all. Surgeons with whom the passage of an ordinary sound is a crucial test for stricture will, of course, not ac- cept this, but it will hardly be disputed by andrologists who rely upon bulbs for exploration. Eecurrence is not likely to occur if sounding be persisted in; hence old-time cases of urethrotomy in which the sound has. been used at intervals are no criterions of the permanency of the re- sult in dilating urethrotomy. Otis, Mas- tin, and many others have made careful re-examinations of operated cases at variable periods after operation, and have found a majority still free from stricture. As Mastin tersely remarks, "It is not the number of cases, but the per- manency of results, that counts for the operation." A large number of operated cases examined within a few months are not nearly so valuable as a few cases ex- amined several years after operation. The author has examined a num- ber of cases at periods varying from one to twelve years after internal ure- throtomy, and has become convinced Fig. 77.- — Condition of urethra fifteen years after operation of dilating urethrotomy. A, Remains of fossa navieularis and a closed false passage found at the time of operation. B, Small soft bridle. C, Small soft cicatrix. D, Fine linear cicatrix. E, Depression at site of an old sinus. F, Soft bridles. (After Eldridge.) 244 STEICTUEE OF THE UEETHEA. that in the larger proportion of cases the operation is followed by permanent cure. Cases in which fresh gonorrheal infection has occurred after ure- throtomy are apt to be found strictured, but such cases should not be used as an argument against urethrotomy. ExTBENAL Ueetheotomy.- — External urethrotomy, or perineal section, comprises essentially two varieties of operation, which, though involving the same structures, differ in prognosis and facility of performance. They are termed perineal section with, and perineal section without, a guide. Perineal sediori ivith a guide is the simpler and safer operation, but adapted only to strictures permeable to instruments. The best procedure is Syme's operation. The special instruments necessary are a staff with a central groove (Fig. 80), a silver catheter of a caliber of 7 or 8 English, a sharp-pointed scalpel of moderate size, and a strong, broad, grooved director. The size of guide or staff required necessarily varies according to the caliber of the stricture. Syme's staff has a shoulder that impinges upon the surface of the stricture anteriorly, the groove on its convexity beginning just at this point. If false passages exist a grooved hollow staff -...■>.— -■-CTtn;^ ^^ Fig. 78. — Gouley's catheter staff and guide. may be used; the successful passage of this instrument into the bladder is indicated by escaping urine. (Fig. 78.) Operation. — The patient is anesthetized and put in the lithotomy posi- tion, with the feet and hands fastened together with lithotomy-anklets or ordinary roller bandages or held by assistants, and the staff or guide passed into the bladder. The perineum should be thoroughly scrubbed and. bathed with bichlorid solution 1 to 1000. The operator, seated in front of the patient, now enters his scalpel, cutting edge upward, into the perineal raphe ^/a to ^/^ inch in front of the anus; an upward dissection of about an inch and a half is now made and the urethra exposed, when the knife is made to enter the groove of the staff behind the stricture, after which the latter is thoroughly divided from behind forward. The staff is now withdrawn, and a good-sized sound is passed into the bladder to demon- strate that the canal is perfectly free. A soft catheter should now be passed into the bladder and tied in for twenty-four hours. There are several varie- ties of drainage-tubes that are excellent substitutes for the catheter. The author has devised a hard-rubber perineal tube that has proved very service- able. (Fig. 82.) At the end of from four or five days to a week gradual EXTERNAL UEETHEOTOMY. . 245 dilation should be commenced, sounds being introduced at first every third day, and later at less frequent intervals. The urine escapes by the perineal wound for some little time, but healing gradually occurs and the urine finally flows through its normal channel. Fistula rarely results; sooner or later the track of the wound closes spontaneously, incurable fistula being very seldom seen. The rules for guidance in the operation as outlined by Syme are essentially as follows: — - 1. Be positive that the staff or guide has really penetrated the stricture and entered the bladder, this caution being especially necessary if false passages exist. r J Fig. 79. — Filiform bougies. 2. Take care not to deviate the incision from the median line. In this location a sort of septum exists even in the deep perineal tissues. So long as the incision does not deviate from this line there is little or no danger of injuring any vessel of considerable size. The principal vessel that is in danger is the artery of the bulb; but this need not be cut, as a rule, if the incision is carefully made in the raphe. 3. Keep the edge of the knife mainly upward to avoid opening the posterior layer of the deep fascia of the perineum, with consequent danger of infiltration of urine into the pelvis, with serious inflammation and per- haps gangrene of cellular tissue. .«=imv»«l333Jl Fig. 80.— Tunneled sound. 4. Insert the point of the knife posterior to the stricture, and incise it by cutting from behind forward in the groove of the guide. (This is not always practicable.) 5. There is sometimes considerable trouble in passing an instrument into the bladder after the stricture has been cut. This may be obviated by inserting a director with a broad groove into the posterior portion of the urethra after the stricture has been divided and before the withdrawal of the staff. The grooved director is turned upward in such a manner that as the sound or catheter is passed through the canal its point is directed past the incision into the bladder. In cases in which it is difficult to insert the ordinary grooved staff a 246 STEICTUEE OF THE UEETHRA. filiform bougie (Fig. 79) may be passed into the bladder and Thompson's dilator threaded upon it. With this the stricture is expanded until it will readily admit the staff. A tunneled staff may, however, be used, being forced into the bladder over the bougie as a guide. Perineal section u-itliout a guide is a most troublesome and formidable operation. Skilled surgeons have attempted the operation and failed. Others have succeeded only after a bunglesome, tedious, and prolonged search for the urethra. It is a very fortunate circumstance that such opera- tions are rarely necessary, for if the surgeon is patient and administers an anesthetic he will usually succeed in passing an instrument through the stricture sooner or later, ^o matter how small the instrument may be, it Fig. 81. — Deep urethrotomy. (After Wheelhouse.) is an accurate guide to the course of the urethra. Once an instrument is passed into the bladder, the case is practically under control. A tunneled staff can be threaded over a filiform bougie and pushed through the stricture, the operation being then completed as in simple perineal section. The practicability of instrumentation, therefore, determines the safety of perineal urethrotomy. In considering perineal section without a guide we must admit that, although rare, cases of practically impassable stricture are encountered. These may be termed surgically impermeable. Complete obliteration of the urethra can only be produced by injury or sloughing from some cause. Even where fistulas co-exist with old indurated stricture the urethra is rarely impervious to either instruments or urine. It is conceivable, however, that EXTERNAL UEETHEOTOMY. 247 it may become so as a result of diversion of the urine from its normal channel by a fistula^ providing there is an exudate-producing lesion of the mucous membrane. It is nothing unusual for the surgeon to discover while preparing for perineal section that anesthesia has relaxed the parts, so that an instrument of moderate size may be readily introduced. Whenever, therefore, a radical operation is determined upon, an attempt should be made to pass instru- ments under anesthesia, in the hope of either providing a guide for opera- tion or paving the way to treatment by dilation. As a rule, a stricture permeable to fluid is permeable to bougies. It must be acknowledged, how- ever, that there are occasional exceptions in which the urethra has become so tortuous and contracted, and the tissues of the perineum so indurated by inflammatory deposit — perhaps occurring as a consequence of extrava- sation of urine — that no instrument can be passed, although urination is comparatively free. In such cases perineal section without a guide is neces- sary. Fig. 82. — Author's perineal drainage-tube. Operations begun without a grooved guide or bougie to indicate the course of the urethra may often be completed with a guide after the ante- rior surface of tbe stricture has been exposed, a filiform bougie being then passed. Operation. — There are two ways of performing perineal section with- out a guide: 1. The urethra is opened in front and the stricture divided from before backward. 2. The urethra is opened posteriorly and the strict- ure divided from behind forward. The first method is preferable. A good- sized sound should be passed down to the stricture. It is then turned so that its point projects in the perineum. An incision aboiit an inch and a half long is now made upon it and the urethra exposed. A small opening is then made in the canal just in front of the stricture, and the sound hooked up into the angle of the wound. A ligature is passed on each side of the incision, and given to an assistant. These, in conjunction with the hook- like action of the staff, hold the edges of the wound apart and facilitate in- spection and exploration of the stricture. After hemorrhage has been 248 STKICTUEE OF THE UKETHRA. checked the opening through the stricture may often be readily seen. A tine probe or small director is slipped into this if possible, and a fine-bladed tenotome passed along the guide, dividing the stricture. Great pains should be taken to find the orifice of the stricture, for, if a filiform bougie can be passed through it, the operation is greatly simplified, the chief danger of the operation being that the surgeon will lose the urethra, and in his aimless efforts to find it produce severe or even fatal hemorrhage. The author re- calls such a case, operated by a very capable surgeon, in which there was so much hemorrhage that the patient died within a few hours. Should it be impossible to pass a guide after the face of the stricture has been exposed, the urethra may be opened up posteriorily and an at- tempt made to pass a probe or bougie from behind forward. Failing in this, a dissection from before backward in the normal direction of the urethra is necessary. In difficult cases of this kind the author inclines to suprapubic section and retrograde catheterism. This procedure has proved Fig. 83. — Shirted cannula. very useful on several occasions. Suprapubic section is safer than a pro- longed search for the urethra. After the stricture has been divided a full-sized sound should be passed into the bladder to demonstrate that the passage is clear. The sound is then removed, and a catheter or tube passed via the perineal wound. This is tied in and allowed to drain into the urinal. It may be removed in two or three days. Such a drainage-tube facilitates washing the bladder and the perineal wound with antiseptic solutions and prevents infection. The sound should be passed at proper intervals, as after the ordinary perineal operation. Hemorrhage after perineal section may usually be controlled by press- ure. If venous oozing be free, the wound may be plugged with styptic cot- COMPLICATIONS AND RESULTS OF STRICTURE. 249 ton, or cotton saturated with spirit of turpentine. Irrigation with, very hot water is often efficacious. When bleeding is obstinate a petticoated or "shirted" cannula (Fig. 83) may be introduced, as in lithotomy. In one case the author found the following device to act very well: A stifE gum catheter was passed through an ordinary condom and into the bladder. The condom was then blown up by a small catheter introduced into the outer end, and tied firmly about the catheter left in the bladder, so as to prevent the air's escaping. By this device sufficient pressure was secured to stop the hemorrhage. A perineal crutch may become necessary. One word of caution to the operator may not be untimely. He should begin his operation, if possible, early in the day, and be sure and secure plenty of light. A dark day and a hurry have been fatal to not a few pa- tients in the practice of difEerent surgeons. COMPLICATIONS AND RESULTS OF STRICTURE. False Passages. — False passages are rare in the practice of surgeons who exhibit the necessary patience and gentleness in instrumentation. They are rarely caused by the use of large instruments in ordinary dilation, and are very exceptionally produced by other than metallic instruments. Forcible instrumentation was formerly occasionally practiced for the relief of retention. A catheter was passed down to the stricture and forcibly crowded toward the bladder. Very rarely indeed did the instrument pass through the stricture. More often it was forced entirely through the ure- thral walls into the cellular tissue. Once in awhile the operator succeeded in reaching and evacuating the bladder. The almost inevitable result of such surgery was the frequent occurrence of false passages. When an in- strument is thus passed it may enter an enlarged urethral follicle and pro- duce rupture at that point. More frequently the instrument enters a pocket in the face of the stricture, the false passage beginning at this point. The signs indicating this accident have already been enumerated. Treatment. — When the surgeon realizes that a false passage has been made, he should let the urethra severely alone for several weeks unless retention exists. Further instrumentation will in all probability result in a chronic induration of the false passage. There is at first slight hemor- rhage, and within a few days more or less purulent discharge. As a rule, the false passage closes within two or three weeks. It may, however, in spite of conservatism, become chronic. Such accidents as urinary fever, infiltration of urine, abscess, and fistula are occasional results. In exploring a canal in which a false passage is known to exist great care should be taken to avoid penetrating it. The oftener such a passage is dilated the longer will it persist; it may become incurable. The devia- tion of the instrument, the sensation imparted to the hand, and the pa- tient's subjective sensations usually indicate the position of the sound. Careful study is necessary to determine the location of orifices of old false 250 STRICTURE OF THE URETHRA. jjassages. As a rule, the instrument engages in the orifice of a false passage more easily than in the stricture, and the comparative facility with which the instrument is passed into an abnormal channel may mislead the sur- geon into the notion that he is dilating the stricture. A false passage may sometimes be avoided when its location has been determined. It may be necessary, when an instrument has once been passed, to allow it to remain in situ, other and finer instruments being passed in the hope of engaging one in the orifice of the stricture proper. The expedient of filling the ure- thra with filiform bougies is sometimes successful, one or more instruments finally j^assing the stricture. An excellent plan is to pass an endoscopic tube down to the face of the stricture, a filiform being passed through it and an attempt made to enter the proper channel; if necessary the tube may be filled with filiforms. When once an instrument is passed through the stricture it should be alloAved to remain in situ, and the stricture either dilated to a moderate extent by a Thompson dilator slipped along a filiform guide or treatment by continuous dilation begun. If it is found impos- sible to pass instruments and retention exists, an aspirator or trocar may be used, while attempts at instrumentation are still persisted in. The best operation for stricture complicated by false passages is peri- neal section. Should it be impossible to introduce a guide, it is necessary to operate without it. Eetextiox of Urixe. — Eetention of urine is the most frequent complication of stricture. In all strictures of small caliber the patient is constantly in danger of ^Dractically complete closure of the urethra from spasm, or congestive and inflammator}- infiltration — i.e., plus conditions — at the site of the lesion. The liability to this accident is greatly modified by the patient's constitutional condition, his habits, and, what is quite as important, the delicacy of the manipulations instituted for the cure of the disease. Chilling of the feet and legs, indulgence in alcoholics even to a moderate extent, overeating, and sexual excitement with or without grat- ification are the most frequent exciting causes. When retention of urine becomes complete the bladder soon becomes distended to its utmost capacity, and perhaps yields to the pressure of the contained fluid until it fills a large portion of the abdomen; as a result of this distension there is considerable "pain and constitutional disturbance. It now becomes urgently necessary to speedily evacuate the bladder. If this be not done, overfiow may occur after a time or the urethra will yield posterior to the stricture, with extravasation of urine either in front or behind the triangular ligament. Gangrene of the cellular tissue, with profound pros- tration, a typhoid condition, and usually death, will ensue if the extravasa- tion be extensive; in more fortunate cases an abscess may form that sub- sequently discharges and leaves a fistula. In long-standing cases where the bladder is dilated and sacculated the bladder itself may possibly rupt- ure, with an inevitably fatal result. After an attack of retention the COMPLICATIONS AXD EESULTS OF STKICTUEE. 251 bladder is always left in a much worse condition than before, and perhaps may be left in a more or less acutely-inflamed state. Treatment. — It is well to avoid instrumentation at this time if possible, as the contact of a catheter with the inflamed structures is apt to increase the irritation. Antispasmodics and a full hot bath should be given. Mor- phia may be given by the mouth or hypodermically until its full narcotic effect results. Should these measures fail, an attempt should be made to pass a small catheter. Contrary to what might be expected, an instrument sometimes passes through a stricture more easily where retention exists than under other circumstances. This is probably because slight absorption of the stricture-tissue occurs as a consequence of inflammation. In addition, it is probable that the pressure behind the obstruction serves to stretch the stricture slightly, thus facilitating the entrance of an instrument. If neces- sary an anesthetic should be given. The surgeon should never despair of being able to introduce a catheter until he has failed with the patient under an anesthetic. If a catheter cannot be introduced primarily, a filiform bougie may possibly be passed. This should be left in the bladder for some little time, and if when it is withdrawn the urine does not flow, as it is very apt to do, a small catheter may usually be introduced. When once an instru- ment has been passed the case is under control. The instrument should be tied in the bladder. Leeches may now be applied to the perineum. Free saline catharsis usually benefits in a derivative manner. Deriva- tion may also be produced by the hypodermic injection of pilocarpin. Should it be impossible to relieve the retention via the urethra, it is usually wise to temporize by the employment of an aspirator in preference to radical operations. In most cases the urine flows by the natural chan- nel shortly after vesical distension has been relieved by the aspirator. Should this not occur, however, the aspirator may be again used a number of times, if necessary, the surgeon meanwhile proceeding with antiphlo- gistic and derivative measures and cautious and gentle attempts to pass an instrument. Should the surgeon be unable to see the patient frequently, it is well, after the introduction of a filiform bougie or small catheter, to pass a tun- neled Thompson dilator over it as a guide, and stretch the stricture mod- erately. Divulsion and internal urethrotomy are not to be recommended at this time, as a rule. The passage of a catheter for the relief of retention should usually be considered as the commencement of treatment by con- tinuous dilation. When other means fail perineal section without a guide should be performed. Infilteatiox of Urine. — Infiltration of urine is the most serious complication of stricture. It may be produced by: — 1. Eupture of urethra or bladder from prolonged retention. 2. Eupture of the dilated and ulcerated urethra behind the obstruc- tion, from straining efforts at micturition. 253 STEICTUEE OF THE UKETHRA. 3. Laceration of the urethra due to overdistension by large sounds. In this instance infiltration occurs at the next act of urination. 4. Division or rupture of the urethra in internal urethrotomy or divul- sion. 5. Burrowing of urine betAveen the layers of tissue about the wound in perineal section. Infiltration occurs in three forms: (a) Extravasation of urine into the pelvic cellular tissue from rupture of a dilated, thinned, and sacculated bladder, (b) Eupture of the urethra within the confines of the deep layer of the superficial fascia of the perineum or Buck^s fascia, (c) Infiltration produced by rupture behind the triangular ligament or deep perineal fascia. The most common method of extravasation is due to rupture of the urethra immediately behind the stricture. This structure, already thinned and dilated, becomes overdistended, and eventually ulceration occurs, usu- ally upon the floor of the canal. As a consequence of retention or straining in micturition a few drops of urine escape into the surrounding cellular tissue, and extension of the ulcerative process immediately begins, with perhaps more or less sloughing. As a consequence, the trifling aperture in the urethral floor becomes enlarged, and in a short time the urine escapes in considerable quantity into the cellular tissue of the scrotum, perineum, groin, and, if Buck's fascia gives way, the thighs. In some instances a dilated urethral follicle becomes acutely inflamed, as a consequence of which its duct becomes occluded. Within the follicle a drop of urine is retained in conjunction with the products of decomposition and inflammation, dis- tending the little pseudocyst. Under these circumstances it is apt to give way, either into the urethra or externally. Should it give way externally, extravasation of urine may not occur, the process remaining as a folliculitis or, if more extensive, a urethral phlegmon. The resultant abscess may be quite extensive. If the contents of the follicle escape into the urethra, an opening is afforded for the entrance of urine. Later on the follicle ruptures from overdistension, and abscess occurs. Fistula may result. In some in- stances the abscess flrst ruptures externally and subsequently into the ure- thra. Under such circumstances serious extravasation is not apt to occur, the entire extent of the fistula having become lined with pseudomembrane that protects the tissues from burrowing urine. In other instances rupture of the urethra occurs, with the formation of abscess or sloughing, the process finally appearing externally and a fistulous opening into the urethra being thus established. The slower the infiltration, the more apt it is to be con- fined by inflammatory exudate, which acts conservatively by preventing serious inflltration. The slighter forms of infiltration may occur anywhere in the urethra and produce folliculitis, periurethral phlegmon, abscess, and fistula. Wlien extensive extravasation of urine occurs, the portion of the canal that usually gives way is the membranous urethra, between the layers of the triangular COMPLICATIONS AND RESULTS OF STEICTURE. 253 ligament. Here the wall of the canal is rather weak, because of lack of support by the surrounding tissues. It is here also that dilation and thinning are most apt to exist, severe stricture being most frequently situ- ated at the bulbo-membranous junction. Strictures anterior to this point are more often of comparatively large caliber, and are not apt to develop the conditions that predispose to or excite serious extravasation. The infiltrated urine finds its way after a time through the anterior layer of the triangular ligament at the point where it is penetrated by the urethra. It is now beneath the deep layer of the superficial fascia of the perineum — i.e., within the confines of Buck's fascia — which, if it remains intact, subsequently guides the course of the urine. This structure, it will be remembered, is attached to the anterior layer of the triangular ligament in the perineum, and laterally to the rami of the ischia and pubes as far upward as the pubic spine, where it becomes continuous with the deep layer of the superficial fascia of the abdomen. This latter fascia in its turn is attached anteriorly along Poupart's ligament as far as the crest of the ilium. The infiltrated fluid, therefore, invariably takes a direction, first, forward into the perineum and scrotum, and, second, upward upon the genitalia and the anterior abdominal wall and outward along the groin upon either side. Were it not for this limitation of extravasation the fluid would be governed by gravity, and would pass backward and downward, extrava- sating about the rectum and down the thighs. When Buck^s fascia gives way, the infiltrated urine takes this course. The effects of infiltration are general and local. The general symptoms are, from the first, in some instances, asthenic and irritative. Even in the strongest patients extensive infiltration is likely to be soon succeeded by asthenia with typhoid symptoms; low, muttering delirium; dry, brown tongue; sordes, and finally coma and death. If treatment is unsuccessful in relieving cases of limited infiltration, abscess results, with the symptoms observed under ordinary circumstances, with perhaps more marked pros- tration. The local effects of infiltration are very marked. The results are not those of contact of urine per se, but of urine vitiated by decomposition and the products of inflammation. Healthy urine is harmless when injected into the cellular tissue. When urine is infiltrated into the perineum and about the genitals the effect of the irritant poison is immediately manifest wherever the areolar tissue is touched by the fiuid. A diffuse cellulitis is set up, the tissues being converted into dark, pultaceous, stringy sloughs, mingled with dark fetid pus and decomposing ammoniacal urine. If the urethra gives way sud- denly, the irritant fluid is forced into the tissues for some distance. Under these circumstances tissue-destruction is very extensive. The scrotum may slough, baring the testes. The patient is likely to die before this occurs, however; so that the condition is rare. Extravasation sometimes occurs 254 STEICTUEE OF THE UEETHRA. more slowly, as alread}' indicated. A few drojis of the irritant fluid escape from the canal through a slight solution of continuity in its coats; this gives rise to phlegmonous inflammation about the urethra that limits for a certain time, perhaps indefinitely, progression of the extravasated fluid. This inflammation usually develops abscess that may break internally or externally followed by general extravasation or fistula. AVhen extravasation is rapid and extensive the perineum becomes brawny, and finally boggy, the scrotum distended and edematous, and the parts dusky or purplish red, the tissues speedily becoming gangrenous. If the patient resists the depressing effects of the resulting destruction of tissue, repair may be very rapid. The reparative power of the tissues involved is something remarkable, and is noted not only in these cases, but in phlegmonous erysipelas and cellulitis affecting this region. The extrava- sation rarely extends farther than the groins and lower part of the abdom- inal wall, but has been known to reach the level of the ribs. When in retention the urethra ruptures between the layers of the tri- angular ligament, a sense of relief is experienced by the patient, with a feel- ing as though the tissues had ruptured in the perineum, and perhaps more or less pain. The sj-mptoms may be obscure for some little time, and very little swelling may occur, but in a few hours, or perhaps not for a day or two, a sense of heat, throbbing, or lancinating perineal pain and burning will be experienced; later on, a boggy, diffuse, purplish-red swelling appears in the perineum and scrotum and rapidly extends forward. When infiltration takes place entirely behind the triangular ligament, there is a similar sense of relief, but the subsequent symptoms are even more obscure. After a time, if the patient survives, deep, throbbing pain develops, with perhaps swelling of the perineum. Examination per rectum may detect the boggy fluctuation characteristic of infiltration. In cases of rupture posterior to the ligament the fluid is likely to burrow into the pelvis and about the rectum and prostate and destroy life without any positive external manifestations. Inflltration from vesical rupture is one of the rarest forms of this com- plication of stricture. Its method of production and effects, although more obscure, are almost identic with inflltration from urethral rupture. If the bladder be fairly healthy, retention of urine is not likely to produce rupture unless traumatism be superadded. A fall or blow upon the ab- domen may produce it under such circumstances. Eelief is usually afforded by rupture of the portion of the genito-urinary tract that offers least re- sistance — i.e., the dilated diseased urethra behind the stricture — or by over- flow. A certain amount of urine may escape by distension of the diseased portion of the urethra, although the bladder cannot empty itself. In some cases overflow occurs from subsidence of the inflammatory and spasmodic elements of the obstruction. By this time, however, the bladder has become so atonied by overdistension that it cannot empty itself. When the blad- COMPLICATIOXS AXD EESULTS OF STEICTUEE. 255 der is ulcerated, as it may be when calculus complicates stricture or if an instrument has been allowed to remain long in contact with the vesical walls, the bladder may yield at the weakened point. In cases of extreme vesical dilation and sacculation the walls of the viscus are apt to yield to the pressure of the urine at the point of least resistance; i.e., the thinnest, and usually the largest, sacculus. When vesical rupture occurs the urine escapes into the peritoneal cavity. Treatment. — The treatment of infiltration must be prompt and ener- getic. When symptoms indicating rupture of the urethra develop, perineal urethrotomy should be performed immediately. Vesical drainage should be provided for by the insertion of a large rubber tube through the wound. Thorough antisepsis by irrigations with weak solutions of mercury bichlorid should be at once established. If difEuse swelling of the perineum, scrotum, penis, thighs, or groins exists, each prominent point should be freely incised. Whenever lancinating and throbbing pain with more or less circum- scribed swelling occurs in the perineum, whether the scrotum be involved or not, perineal section should be performed. Eectal examination some- times reveals extravasated fluid where the symptoms are otherwise obscure. Under such circumstances the perineum should be opened medially, and a deep incision made in the direction of the perirectal infiltration, the left index finger being passed well up into the rectum to protect the gut from injury. The only hope of saving life in cases of extensive extravasation is free incision of all points where the infiltrated fluid can be reached. Even if extravasation and subsequent cellulitis and sloughing be severe, a favorable result may often be secured by this radical measure. It is not sufficient to liberate fluid that has already escaped; it is necessary to prevent further extravasation by section of the stricture and perineal drainage. Having obtained an outlet for the morbid urine, sloughs, and in- flammatory products of extravasation, some antiseptic dressing should be applied that will not only keep the parts aseptic, but also conserve the vitality of the cellular tissue. Both indications may be met by hot poultices of equal parts of charcoal and linseedmeal, sprinkled liberally with brewers' yeast or hot sublimate solution. All sloughs should be removed as soon as loosened, and the parts irrigated frequently to remove discharge as fast as formed. As the sloughs separate free purulent discharge begins, causing a severe drain upon the already depleted system. Liberal support, dietetic and medicinal, is required. Milk-punch, eggnog, large quantities of milk, and concentrated broths should constitute the diet. A liberal quantity of stimu- lants, either brandy, whisky, or the heavier wines should be administered. Should the patient's stomach be irritable, champagne is useful. Digitalis, carbonate of ammonia, quinin, and tincture of the chlorid of iron are the only reliable remedies against asthenia in these cases, and should be given freely. 256 STEICTUKE OF THE UEETHEA. EuPTUEE OF THE Bladdee. — This condition incidental to stricture de- mands the same treatment as under other circumstances, but is almost inevitably fatal. Peeiueetheal abscess is intimately associated with extravasation. The latter may be of comparatively trifling importance per se, the collection of pus being relatively more serious. Abscess about the urethra may arise from several causes: 1. The escape of a drop or two of toxic urine into the cellular tissue from solution of continuity of the urethral walls. 2. The escape of a few drops of urine into a dilated follicle with subsequent free suppuration and rupture of the latter. 3. Inflammation of follicles due to the passage of instruments. 4. Puncture or rupture of the urethral walls by instruments. 5. Phlegmonous inflammation from absorption of organic poison by the lymphatics from behind the stricture; this poisonous mate- rial, coming in contact with the cellular tissue, sets up suppurative inflam- mation. Periurethral abscess bears a distinct relation to periurethral phlegmon and folliculitis. When decomposing urine escapes into the periurethral areolar tissue, it sets up inflammation attended by plastic exudate; in some instances the exudative material closes the orifice through which the urine escapes and prevents further extravasation, thus circumscribing the abscess. Abscess of this kind may occur about any portion of the urethra, generally in the perineal part of the canal because of its frequent association with bulbo-membranous stricture. It may subsequently lead to extravasation, because of its opening into the urethra, thus permitting the escape of the urine into its cavity, the walls of which subsequently yield, or it may bur- row to the surface externally and heal without difficulty. Again, it may open internally and burrow externally without extensive extravasation, the track of the pus being limited by plastic deposit. Under these circum- stances fistula results. These abscesses are rarely dangerous per se, their importance being chiefly due to the danger of general extravasation and the formation of urinary fistulas. The amount of mischief done by urinary abscess depends greatly on its situation. When, as usually happens, it forms beneath the floor of the canal, it readily comes forward without extensive burrowing; but when situated on the roof (which is very rare) or at the upper part of the side of the canal, it may burrow extensively before it points, occasioning great induration, infiltration, and destruction of tissue in neighboring parts. Symptoms. — Periurethral abscess appears as a small, circumscribed, tender, painful, and hard tumor somewhere in the course of the urethra. There is usually little or no constitutional reaction. Sometimes, however, in extensive abscesses more or less fever is noticeable. When located in the perineum this part may become tense, hard, and brawny, considerable weight and lancinating pain being complained of. Such abscesses are very slow in coming to the surface because of the comparative density of Buck's COMPLICATIONS AND EESULTS OF STEICTUEE. 257 fascia, which binds them down. If the pus escapes from its environment of plastic exudate, it is most apt to follow the course taken by infiltrated urine, there being less resistance to burrowing within the limits of Buck^s fascia than to its escape externally. Treatment. — The treatment of periurethral and perineal abscess con- sists of free incision with antiseptic precautions. It is bad practice to wait for fluctuation. When the penile urethra is affected nothing is warrantable save a small puncture to relieve distension and prevent rupture into the urethra. Even in these cases, however, if puncture demonstrates the pres- ence of pus, the abscess-cavity should be laid freely open. In perineal ab- scess a free incision should be made into the induration in the median line; delay may lead to extravasation of urine. The after-treatment should con- sist of the ordinary surgical measures for the treatment of abscess. Ueetheal Fistulas. — Urethral fistulas result from extravasation of urine and abscess. They are usually located in the perineum and scrotum, but have been noted in the groin, inner aspect of the thigh, and upon the anterior abdominal wall as a consequence of extensive burrowing of pus. Their point of departure is generally in the bulbo-membranous region; ex- ceptionally they are met with in the scrotum and about the pendulous ure- thra. When perineal, numerous openings may be found about the peri- neum, nates, scrotum, and perhaps the inner aspect of the thighs. In a case of Civiale's over fifty external openings were found to communicate with the perineal urethra. There is something remarkable in the manner in which pus will creep about and form secondary fistulas in these cases. The number, location, size, and length of fistulas are cardinal points in deciding their importance. Small perineal fistulas with a single or perhaps two openings are not of great importance; they will usually close spon- taneously after all urethral obstructions have been removed. The size of fistulas depends entirely upon the amount of loss of sub- stance. They may be large enough to admit several fingers. They are gen- erally tortuous, narrow, and extend for a considerable distance. The ex- ternal orifice may be very narrow, and may heal from time to time only to reopen. Under such circumstances the urine remains in the fistula, decom- poses, and again produces suppuration, with external discharge. In some instances burrowing occurs, with resulting tributary fistulas running in various directions. In cases of multiple fistulas, the tissues of the scrotum, penis, and perineum become extremely hard and thickened, feeling almost like cartilage. Where the stricture is tight and the fistula large, the urine may not pass through the normal channel, escaping entirely via the fistula. Earely, indeed, does the stricture become completely agglutinated, although such an accident may possibly occur in cases of traumatic stricture. Treatment. — The treatment of fistulas depends upon their location, number, and the amount of substance lost. The first indication is the re- moval of all obstructions to the outflow of urine. A contracted meatus 358 STRICTUEE OF THE UEETHRA. and penile strictures require division. Care should be taken to completely restore the caliber of the urethra; the more perfectly this is done the less resistance there is to the outflow of urine. By this procedure advantage is taken of the law that fluid tends to flow in the direction of least resistance. Should there be sufficient obstruction at any point to produce distension of the urethra behind it^ the backward and outward pressure will neces- sarily force a portion of the urine into the internal orifice of the fistula and thus prevent healing. The majority of simple perineal fistulas close spon- taneously after urethrotomy or successful dilation. The tissues in this situation are thick^ and reparative action is consequently much more active than in the penile urethra. Then, too, the parts are not disturbed by erec- tions, which, by preventing rest, necessarily retard granulation and healing. Should simple fistula show a tendency to chronicity, the patient should ■ ■"'''■by^i Fig. 84. — Multiple urinary fistulas from deep stricture. (After Bryant.) be instructed to draw his urine at regular intervals, thus obviating its passage via the fistula. If this plan, however, produces irritation of the urethra and bladder, it should be discontinued. Eepair may often be stimulated by cauterizing the fistula. A good plan is to enlarge its external orifice, pare its edges, and then cauterize the track with a fine platinum galvanocautery-wire passed into the fistula cool, then heated to a white heat and rapidly withdrawn. A fine probe, coated with a bead of sulphate of copper or nitrate of silver, may be used for cauterization. After the operation a soft, moderate-sized catheter should be left in the bladder to prevent escape of the urine through the fistula and retained for several days. The viscus should be irrigated with a warm, mild, antiseptic solution at least once daily. Applications of tincture of iodin upon a cotton-wrapped probe sometimes promote healing. COMPLICATIONS AND EESULTS OF STKICTUEE. 359 If the stricture be hard, resilient, or irritable perineal section is ad- visable. All branching fistulas that can be reached should be laid open and left to granulate. After perineal section in stricture complicated by fistulas perineal drainage should be adopted. This not only drains the bladder, but prevents the urine — which is invariably irritating — from com- ing in contact with the fistulas. Fistulas involving the scrotum often re- quire free incision after the removal of urethral obstructions. Such fistulas Symanowski's urethroplasty for penile urinary fistula. are often connected with unhealthy, sloughy abscess-cavities. These should be laid freely open. Siphon-drainage has been recommended for simple perineal fistulas. A soft catheter of moderate size is tied in the bladder and attached to a rubber tube that passes into a receptacle containing carbolized water. A number of cases have been cured in this manner. Urinary fistulas occasionally open into the rectum, in which event we have, superadded to the obstacle to healing afforded by the contact of urine. g60 STEICTUEE OF THE URETHRA. the escape of fecal matter and gas. These materials are likely to pass, not only into the fistula, but through it into the urethra. Fistulas of this sort are not apt to heal even after the urethra has been restored to its normal cal- iber. The ordinary operation for rectal fistula should be performed in such cases, the rectum and, so far as possible, the track of the urinary fistula being laid into one cavity to granulate from the bottom. The rectal ex- tremity of the fistula having healed, there may still be an opening in the perineum, the urine alone being sufficient to keep the urethral end from closing. The perineal fistula may now be treated as under ordinary cir- cumstances. Thompson records an instance of successful treatment of recto-urethral fistula by position, the patient being instructed to pass urine only in the prone position. Large fistulas due to destruction of tissue require, as a rule, special Fig. 89. — Szymanowski's operation for large penile fistula. operative measures. The same is true of fistulas that fail to heal under the measures already outlined. Penile fistulas, with or without loss of sub- stance, are apt to be intractable. This is due to extreme tenuity of the tissues, which is unfavorable to plastic exudate and repair, and to the vari- able position of the organ incidental to erection, which prevents the neces- sary rest. Even with considerable loss of substance, perineal fistulas often close spontaneously, granulation and repair being very active and the parts infrequently disturbed. Loss of substance may occur in fistulas due to gangrene and sloughing, extensive abscess, phagedena, or the prolonged contact of urethral instruments or foreign bodies. They are necessarily most often noted in severe strictures. Urethroplasty is usually necessary in large fistulas of the penile ure- thra. Astley Cooper, however, reported a ease in which applications of nitric acid succeeded in closing a fistula as large as a good-sized pea after two successive plastic operations had failed. Dieffenbaeh has suggested the UEETHEOPLASTY. 261 application of a strong tincture of cantharides, which destroys the epithe- lium and stimulates granulation. Perineal fistulas may often be closed by a comparatively simple opera- tion. The edges should be liberally pared and brought together with a quilted or shotted suture. The author has succeeded in curing several by repeated suturing after preliminary cauterization. Another simple proced- ure that has served well in two cases following perineal section is as follows: The edges and track of the fistula are first cauterized with nitric acid. Three days later the track of the fistula is dissected up almost to the urethra and the portion of tissue containing the fistula twisted upon itself several times, after which it is anchored with a suture and the wound stitched closely around it. Scrotal fistulas require free paring of their edges. The tissues about Fig. 90. — Nelaton's operation for penile fistula. the fistula should be extensively dissected up to secure thick, good-sized flaps of skin and areolar tissue. These should be stitched together with silver-wire, silk-worm-gut, or the quilted or shotted suture. Several opera- tions may be necessary, each operation making the fistula smaller. The urine must be drawn by the catheter. If the urethra be tolerant of the instrument, a soft catheter of medium size may be retained for several days. Irrigation of the bladder is necessary to keep it aseptic so far as possible; so that, if urine does get in the wound it is not so likely to prevent healing. As a substitute for plastic methods Dieffenbach proposed a very simple operation. A concentrated tincture of cantharides is applied to the edges and track of the fistula. As soon as the epithelium has become detached and the surfaces are sufficiently raw, a good-sized soft bougie is introduced into the canal; a needle armed with a strong, well-waxed silk thread is now 262 STEICTUEE OF THE URETHRA. introduced about a quarter of an inch, from the fistulous opening. This is passed into the corpus spongiosum for a short distance, then made to emerge. It is reintroduced at the point of emergence, passed along, and brought out again in the same manner and at the same distance from the edge of the fistula. This is repeated until the ligature completely encircles Fig. 91. — Nelaton's operation for penile fistula. the fistula and terminates at the original point of introduction. The thread bears the same relation to the fistula that a draw-string does to the mouth of a bag. The two ends of the ligature being drawn together, the freshened surfaces of the fistula are closely approximated. A knot is now tied and allowed to sink into the point of puncture. The urine is to be drawn at Fig. 92. — Clark's operation for penile fistula: first step. regular intervals by the catheter. The ligature is allowed to remain for three or four days, then cut and withdrawn. Several operations may be necessary before the fistula is obliterated. The operation is only applicable to small fistulas. In the penile urethra it is quite difficult to perform a successful ure- UEETHEOPLASTT. 263 throplasty on account of the thinness and looseness of the integument and sparsity of cellular tissue. So scanty are the tissues that the surgeon natu- rally hesitates to pare the surfaces of the fistula sufficiently to insure the desired result. Obviously, flaps with such thick edges as can be secured in the perineum heal more readily than the thin ones that it is practicable to secure in the penile urethra. The disquiet and tension produced by erec- tions constitute another obstacle to success. Several special operations of urethroplasty have been devised. One of the best is that of Szymanowski (Figs. 85 to 89). This operation is per- formed in the following manner: When the fistula lies in the long axis of the penis, a straight incision is first made, beginning immediately in front of the fistula and terminating just behind it. The integument upon one side is then dissected up until freely movable. A half-oval flap of skin on the op- posite side is then outlined and dissected up, excepting at the edge of the fistula, its epidermis being first removed. The dissected flap is inverted and Fig. 93. — Clark's operation for penile fistula: second step. pushed under the skin that has been freed upon the opposite side, as into a pocket, where it is retained in position by sutures passed into and through the bottom of the pocket. The movable skin is then slid over it and also stitched. A soft catheter is passed into the bladder and retained. ISTelaton's operation has been somewhat popular. It is performed in the following manner: The edges of the fistula are first freely pared; the surrounding skin for an area of about an inch in breadth and extending a little beyond the fistula anteriorly and posteriorly should then be dissected subcutaneously by a narrow-bladed knife introduced posterior to the fistula. The raw edges of the latter are then brought together by fine sutures. Another method was proposed by the same surgeon. The edges of the fistula are first pared and the skin separated for about half an inch upon each side of the opening. Lateral incisions are then to be made at a dis- tance of about half an inch from the pared edges to relieve tension, A slip of thin India-rubber tissue is then passed beneath the skin-flaps to prevent 264 STKICTUEE OF THE UEETHRA. contact of iirine with the raw edges and consequent disturbance of adhesion. Should the fistulous opening close, the lateral incisions promptly heal. In both of Nelaton^s operations the extensive separation of skin causes abun- dant granulations to spring up, often closing the fistula. In extensive penile fistulas perineal drainage should be established after a plastic operation has been performed. Eicord recommended, for cases in which perineal or scrotal fistulas co- exist with fistulas in the pendulous urethra, that a catheter be passed through the lower fistula to drain the bladder during treatment of the penile lesion. He also suggested puncturing the bladder. Erichsen recommends that this be done through the rectum; but perineal drainage is far better. The perineal opening made by this latter operation will almost invariably close spontaneously when it has subserved its function. The following operation for extensive penile fistula was recommended by Le Gros Clark (Figs. 92 and 93): The edges of the fistula having been thoroughly pared, a transverse cut about an inch in length is made through the penile integuments a little distance in front of the fistula (a). Two transverse incisions are then made at the peno-scrotal angle, each being about an inch and a half in length. These transverse incisions are con- nected at each end by a short longitudinal incision (&). The flaps of skin thus outlined are dissected up and brought together by means of clamps or the quilled suture. By this procedure two broad raw surfaces (at c) are brought together instead of a narrow raw edge of skin, thus increasing the chances of perfect union. In extensive fistulas it may be well to divert the urine from the urethra altogether, by combining suprapubic drainage with urethroplasty. PART IV. CHANCEOID AND BUBO AND THEIR COMPLICATIONS. CHAPTER XII. Chanceoid. Definition. — The best definition of chancroid is probably that of Fonrnier, who says: "Chancroid is a specific malady consisting in a peculiar ulcer, secreting a virulent, autoinoculable pus. It is exclusively local, and never gives rise to constitutional symptoms.^^^ HiSTOEY. — Chancroid, or the local contagious venereal ulcer, was for- merly supposed to be identic with syphilis, and the term chancre was ap- plied indiscriminately to all venereal lesions, ulcerative or indurated, ap- pearing upon the male or female genitals. During what has been appro- priately termed the "period of venereal confusion" the greatest ignorance prevailed as to the origin, natural history, and management of venereal dis- eases. Only within comparatively recent years has there been anything ap- proaching unanimity of opinion among leading surgical scientists concern- ing them. Authorities of a century ago evidently had no conception of the physiologic and pathologic facts that should have guided them in their studies, and as a result eminent men reached widely different conclusions, from practically identic observations. According to John Hunter, there was but one venereal disease, which decidedly complex affection included the affections that we now term gonorrhea, chancroid, and syphilis. Fifty years after the appearance of Hunter's famous treatise in which he claimed the unity of the venereal diseases, Eicord demonstrated the existence of two distinct diseases, gonorrhea and syphilis, but failed to appreciate any differ- ence between the venereal sore that we now know to be local and non-con- stitutional and that which is always a manifestation of a general infectious disease. Some years later Bassereau demonstrated the duality of syphilis and chancroid. The then novel theory of Bassereau was not immediately accepted, but eventually the majority of syphilographers came to consider it as positively demonstrated. There are still, however, a few men of surgical prominence who are unwilling to east off the ancient belief that all venereal sores are ^ This, of course, covers only uncomplicated chancroid. Phagedena and inflam- mation may cause marked constitutional disturbance. (265) 266 CHAXCKOID. syphilitic. Some English authors still speak of chancroid as "local syph- ilis": a term first applied by Lancereaux.^ The Geem oe Chaxceoid. — That chancroid is a germ disease is hardly open to question, yet experimental researches so far undertaken to demon- s.rate the Sj^;eciP.c microbe haye been exceedingly unsatisfactory and incon- clusive. Ducrey and, following him, Unna have been more positiye in their conclusions than others, and their researches have been repeated, and their claims substantiated by Krefting and Wielander. Investigators of equal ability, among whom are Strauss and Jullien, have, on the other hand, denied the accuracy of the observations of Ducrey and Unna. Inasmuch as cultures outside of the body have not thus far been made, the case of the specific chancroidic microbe has by no means been proved. The Ducrey-Unna bacillus is described as a short, thick bacillus, with rounded ends and a central constriction, somewhat resembling a dumb-bell. Fig. 93o. — Section of chancroid showing Ducrey-Unna streptobacillus in the tissues. The bacillus is comi^osed of small rods arranged in chains. (After Taylor.) The germ is located both in the cell-protoplasm and between the cells. In the discharge from the original chancroid, the specific microbe is relatively scarce, but in successive pustules from autoinoculation the other microbes progressively disappear, while the chancroidic germ grows more abundant. It is claimed that in the third autoinoculation pustule a pure culture of the specific microbe "is found. Prior to the claim that chancroid is a germ disease the contagious prin- ^ In his Lettsomian lectures, some years since, Mr. Jonathan Hutchinson ex- pressed the opinion that chancroid usually occurs in persons whose systems have been impressed by syphilis at a period more or less remote. In other words, he believes that chancroid is a mild manifestation of syphilis in a person who has already been syphilized. This theory is as untenable as it is striking. OEIGIN OF CHAXCEOID. 367 ciple was believed to reside in the pus-corpuscle. It is asserted by EoUet that filtration removes all noxious properties from the fluid secretion. This, if verified, Avould practically eliminate toxins from the destructive action of chancroid. Those who have advocated the germ-origin of chancroid claim that its germ, like that of gonorrhea, acts by incorporating itself with the pus-corpuscles. Demonstration of this would support EoUet^s assertion. Oeigin of Chancroid. — Clinical observation has apparently demon- strated that, germ or no germ, the materies viorli of chancroid originates de novo in certain conditions of the genitals. Its principal source is the female genitalia; rarely, yet none the less certainly, it develops spontane- ously in the male. The conditions favoring its development are those that favor germ-growth in general. These conditions probably not only originate chancroid, but gonorrhea and its congeners as well. As remarked in the discussion of gonorrhea, it is no more conceivable that the germs of infectious diseases were specifically created than that the animals upon which they feed were originally created of a fixed and unvary- ing type. Man is subservient to the same evolutionary laws of progression and diff'erentiation as all other forms of life. G-ranting this in the case of man, — the host, — it must also be granted in the case of the disease-germ — the parasite that feeds upon him. Living germs of innocuous type are found upon practically all the mucous membranes of the human body. These germs retain their innocu- ous character just so long as their environment and the pabulum on which they feed remain unchanged. With a sudden radical change of these con- ditions comes extinction of the germ. With a gradual change extinction would also come, were it not that the germ adapts itself to its changing environment and food-supply. With this adaptation comes a change in the properties of the germ, viz.: (1) in its physical properties in a minor degree, if at all; (3) in its vital properties in a degree depending on the duration, accentuation, and character of the environmental and food-changes to whicli it is subjected. The truth of the foregoing proposition cannot be denied without de- stroying the foundation and overthrowing the entire superstructure of evo- lution. In maintaining the origin of gonorrhea and chancroid de novo it is in nowise claimed that spontaneous generation of disease-germs occurs in the genitalia — ^though this is by no means impossible, Pasteur's experiments to the contrary notwithstanding. The author's view is, briefly, that — through evolutionary changes — (1) primarily innocuous germs — whether entering from the outside or having their natural habitat in the genitalia, especially in the female — may become pathogenic; (3) that germs of mild pathogenic properties — e.g., pus-microbes — may acquire a new, or, at least, a severer, type of pathogenic power; (3) that the character and severity of the re- sulting pathogenesis (i.e., the degree and quality of virulency) varies with (a) the duration of the process, (b) the character of the local conditions, (c) 268 CHANCEOID. the condition of the secretions, and (d) the susceptibility of the individual — of which more anon. The origin of chancroid and gonorrhea must necessarily be the same if the evolutionary theory of their origin be correct. The vagina of the female is an excellent nidus or hot-bed for the cultivation of germs. Con- sidering the large number of women affected by utero-vaginal disease, it is surprising that the venereal affections are so few in number and so uniform in manifestations. There exist in the vagina, even in healthy women, the circumstances of heat, moisture, protection from air and light, and, very often, local irri- tation incident to excessive cohabitation. Superadd to these normal or quasinormal conditions a suitable pabulum for the development of germs in the form of decomposing uterine or seminal discharges, and conditions detrimental, not only to the woman herself, but also to the generative organs of anyone with whom she may chance to have sexual congress, are likely to develop. Few women are free from disease; indeed, the woman who is perfectly sound is a ra7-a avis, and in the uterine discharges bacteria may develop and wax fat. Many women — through ignorance in some eases, through natural physical indifference in others — are exceedingly unclean, and allow both natural and unnatural secretions to accumulate until the condition of their sexual organs is, indeed, filthy. This is especially the case in the low-class prostitute, and unfortunately is often the case among women who are respectable or quasirespectable. The high-toned prostitute is not so open to impeachment upon this score. As the circumstances of uncleanliness, imhealthy secretions, local irri- tation, heat, moisture, and absence of free air and light favor the develop- ment of germs, and particularly those of decomposition, it may be readily understood that sooner or later such bacterial development frequently takes place in the vagina. The innocuous germs of the atmosphere enter, and begin their work of procreation or multiplication in an environment scanty in its supply of oxygen^; decomposition occurs, and, pari passu with it, (1) new germs appear upon the scene that differ from the parent-stock; (2) germs normally found in the vagina undergo transformation, and so the process goes on until pathogenic microbes and irritating toxins are devel- oped. If, during this time, the microbe-bearing discharge from a diseased urethra be deposited in the vaginal culture-bed, so much the better for the development of "specific" pathogenic germs. Selmi and Gautier showed long ago that poisonous alkaloids develop from germ-evolution. To these ^ The experiments of Pasteur on the germ of chicken-cholera are of interest in this connection. In the hope of diminishing the infective power of £his organism, he grew it in oxygen for a long time, and found that it produced a modified disease that in most cases protected the animal from the effect of the organisms in their most virulent state. British Medical Journal, December 31, 1881, p. 1062. OEIGIN OF CHANCROID. 369 poisonous substances or toxins much, of the pathology of gonorrhea and chancroid may be due. The decomposition of semen — a highly- and com- plexly- organized compound— is especially likely to produce such a toxin. If this be correct, it is probable that it is to the products of the bacteria, rather than to the bacteria themselves, that we should attribute some of th.e results of gonorrheal and especially chancroidic secretions. It is therefore assumed that, while bacteria are undoubtedly the foundation of gonorrhea and chancroid, they are probably not the cause of all their phenomena. It is possible for the toxins in themselves to produce mucous inflammation or tissue-destruction. This would explain why scientific observers have found bacteria or cocci in some cases, while they have been unable to do so in others of apparently similar type. The varying degree of acridity and quantity of toxins produced by different germs, and the varying susceptibility of mu- cous membranes would explain the variations in type and severity of cases of urethritis and chancroid. The conditions modifying the results of the evolution of germs and germ-toxins in the human vagina are as follow: — 1. It is obvious that much depends upon (a) the age of the decom- position; (&) the nature and degree of inflammation present; (c) the fre- quency of coitus; (d) the constitution and habits of the woman; (e) the character of any germ-bearing semen or urethral discharges that may be deposited in the vagina; (/) the character of germs entering through acci- dental means other than by sexual congress; (g) the character of the normal germ-inhabitants of the sexual tract, especially in the female. 2. The amount and degree of viru.lency of the cultivated germs or germ-toxins deposited upon an absorbent surface in another individual. 3. The cleanliness, local and constitutional condition, habits, and sex- ual hygiene of the recipient of the cultivated virus. 4. Individual predisposition. With reference to the latter point, Jordan Lloyd says: — There can be no doubt that some individuals contract — and even develop — venereal disease much more readily than do others. There can be no doubt that all physicians, from the nature of their calling, must, during the course of each year, be exposed to infection of one kind or another many hundreds of times. Physicians, however, do not take any particular precautions in the way of protecting themselves from these influences. Immunity does not, in every case, depend upon their having already suffered from attacks of the various infectious diseases. How is it, then, that they so rarely become affected? It is because they have not the predisposition, whatever that word may mean; because their bodies do not present a suitable nidus for the growth and development of the germs of disease. Again, in a class of cases more closely allied, clinically and pathologically, to those under discussion, how often do we see among hospital officers men who are frequently developing crops of hospital furuncles on their hands and arms, others with constantly recurring sore throat; others with inflamed wounds and lymphatics from post-mortem abrasions; while at the same time and under precisely the same conditions, there will be men who, year after year, remain free from all such troubles. Susceptibility of one 270 CHAXCEOID. class of individuals to certain poisonous influences or insusceptibility of the other must be the explanation. There is nothing more strange in it than in that of many of the well-known "idiosyncrasies"; for example, the poisonous effects of eggs and tobacco on certain persons. There is a certain class of persons who are familiar to eveiy observant physician as "suppuraters." This is the class of people in whom, as we well know, wounds are more likely to heal by granulation than by first intention. These people, apparently of robust health and iron constitutions, frequently have boils. When their lymphatic glands inflame, as they often do, the process more often terminates in suppuration than resolution; trivial wounds in such people do not heal at once; they heal by granulation. I believe these suppuraters contract venereal diseases where ordinary mortals escape them.^ The final result of microbial cultivation in the female sexual tract de- pends mainly upon the character and properties of the germs pre-existing or primarily inoculated in the vaginal culture-bed. There are numerous organisms that may find their way into the vagina or which exist in it nor- mally. The most important of these are: — 1. Simple cocci resembling the urethrococcus and gonococcus. 2. Urethrococci, strongly resembling the gonococcus. 3. Pyogenic microbes — both staphylococci and streptococci. 4. The hacterium coli commune. 5. Gonococci. 6. Micrococcus citreus conglomeratus. 7. Diplococcus albicans tardissimus. 8. Diplococcus aTbicans amplus. 9. Micrococcus suhfaviis. 10. Microbes of decomposition, such as (a) bacillus suhtilis; (b) bac- terium urece; (c) micrococcus urece; (d) spirillum concentricum. Considering the possibilities of microbial cultivation and variation demonstrated by every-day laboratory experiment, the excellence of the vagina as a culture-field — a field far superior to any laboratory imitation, the variety of possible culture-media offered by the sexual tract, and, finally, the large number and variety of microbes having access to the female sexual tract, the spontaneous variation in type and pathogenic properties of the germs found in utero-vaginal secretions and discharges are in nowise re- markable. Nor is it at all illogical to infer that so-called specific microbes have their origin in a variation of germs that are primarily non-pathogenic. The author ventures to assert that the future history of venereal pathology will show the truth of the evolutionary theory of the origin of the microbes of the local venereal diseases for which he has so long contended. Since the publication of the author's first papers on the subject^ labora- I ^ Birmingham Medical Eeview, October, 1886. - "The Evolution of the Local Venereal Diseases." New York Medical Record, vol. xxxvii, No. 2; Medical Age, February 10, 1890; and St. Louis Medical Review, February 22, 1890. VAEIATION OF laSTFECTION. 271 tory research lias shown actual transformations of pathogenic microbes along evolutionary lines. Variations in virnlency were shown long ago by Pastenr. If the bacteriologic laboratory can show such results, Xature's laboratory should be expected to produce far more wonderful transforma- tions. Under the head of local conditions, vaginitis, inflammation of Bartho- lin's glands, endocervicitis, vesical and prostatic disease, phimosis, ure- thritis, paraphimosis, balanitis, posthitis, and herpes not only modify the course of chancroid, but indubitably act as predisposing causes. Vaeiation of Infection". — As a consequence of the wide-spread variation that exists in the foregoing conditions, there may result from dif- ferent inoculations of products of germ-evolution different degrees of in- fection. Thus, the disease acquired by exposure to such pathogenic material may be: — 1. Simple balanitis, balanoposthitis, or venereal vegetations. 2. Simple urethritis. 3. Virulent urethritis (gonococcic urethritis). 4. Herpes of the genitalia. 5. Simple venereal ulcer, indistinguishable from advanced herpes or chancroid in process of healing. 6. Typic chancroid. It would be difficult to show precisely what variation in germs de- termines one or the other type of infection. It would be fair to assume that the primal germ is different in gonorrhea and chancroid. Thus, the point of departure in the former may be simple cocci of the urethra and vagina, while, in the case of the latter, some one or other of the pyogenic microbes, or perhaps bacteria of decomposition, may constitute the parent- stock in the pathogenic germ-evolution. The evolution of both germs of decomposition and pyogenic microbes probably gives rise to an intermediate series of germs, of varying pathogenic power, that may excite such different degrees of mucous inflammation as simple urethritis, balanitis, simple ulcer, etc., the severity of the inflammation depending upon the degree of germ- cultivation and the primary character of the germ. Theoretic considerations aside, there are numerous clinical facts that not only indicate the origin of both gonorrhea and chancroid de novo, but seem to establish the correlation of the two diseases, both with each other and with simple affections of various kinds and degrees of severity. Some of these clinical facts are as follow: — 1. The discharge from urethritis when confined by a tight prepuce is liable to cause severe inflammation and phimosis (i.e., balanoposthitis). If not soon relieved, excoriations and even chancroid-like ulcerations are liable to result. 2. The discharge from these lesions as well as that from gonococcic or 272 CHANCKOID. other severe types of urethritis will oftentimes produce a pustule by lietero- inoculation or autoinoculation. It generally produces inflammation at least, and in cachectic patients ulceration, identic with the milder types of chancroid. 3. Long-continued contact of both gonorrheal and chancroidic secre- tions with mucous membranes often causes a crop of venereal vegetations. These often result from simple irritating secretions; e.g., in pregnant women. 4. Urethral chancroid is always attended by urethritis of greater or less severity. 5. Gonorrhea and chancroid are often associated, appearing either simultaneously, or at such interval as would suggest that one may be due to the secretion of the other. Both being mixed infections as they appear clinically, this correlation is not surprising. 6. Both diseases are most often contracted from the same low class of females; more rarely from the higher class. 7. Examination of women from whom both diseases have been con- tracted by different men often shows them to be unclean, but free from ordinary clinical evidences of either disease. 8. Any urethral or genital lesion may be followed by suppurating bubo. The author has successfully autoinoculated pus from a bubo sequent to balanitis. Mixed infection again comes in play in explanation of the simi- larity of the two diseases as regards glandular infection. 9. It is usually difficult to say where simple genital ulcer terminates and chancroid begins. The test of autoinoculation is hardly fair, as it pos- sibly determines, after all, merely the degree of virulency of the infection. 10. The natural tendency of chancroid is to lose its specificity, after a time, and assume the characteristics of simple ulcer. This is suggestive of reversion of type, to say the least. Eldund claims to have found in the secretions of both gonorrhea and chancroid the gonococcus of Neisser. He also describes mycelial woven fila- ments termed E diopliyton dictyoid&s. This parasite he also claims to have seen in both diseases. So far as it goes, this is confirmatory of the correla- tion of gonorrhea and chancroid. Looming tip clearly from the midst of all the confusing clinical facts are the typic, virulent gonococcic type of urethritis, and the typic, viru- lent, autoinoculaUe, destructive chancroidic ulcer. Each more than likely represents the focal point of cultivation of a microbe that was primarily innocuous. Each, moreover, in its life-history, responds to the remorseless law of evolution and gradually loses its specific property of pathogenesis, until its germ by reversion of type arrives at a point where it is again in- nocuous. Experiment and clinical observation alike prove this. As plainly as the clinical specificity of typic gonorrhea and chancroid, stands out the incontrovertible fact that the local venereal diseases have their origin in genital filth. No matter how it operates, filth is the corner-stone of their development. TAEIATIOX OF INFECTIOX. 273 As illustrative of the clinical evidence in support of the evolutionary theory of the origin of chancroid the following cases are quite pertinent: — Case 1. — Suppurative adenitis resembling virulent bubo, following balanitis with ulceration : A delicate, sickly young man of 22 came under the author's care suffering, as he supposed, from an attack of gonorrhea. He had a very long prepuce, which, through ignorance, was rarely retracted and cleansed. Attacks of mild inflammation had occurred several times before. On retraction of the prepuce the glans was found to be covered with filthy secretions and pus, and the mucous membrane highly in- flamed and excoriated, but there was no urethritis. The inflammation, according to the history, had begun three or four days after a suspicious intercourse. Although perfect cleanliness was insisted upon, the patient was careless, and it was several weeks before any improvement was noticeable. Meanwhile several small ulcera- tions appeared that within three or four days presented all the characteristics of chancroid. Autoinoculation was successful, but the resulting ulcer was of mild type. The author examined the woman from whom the young man had most certainly contracted the disease, if venereal in character, within three days after the appearance of the balanitis, and found her healthy save for a chronic endo- cervicitis and leucorrhea. At the end of the second week the patient developed a large inguinal bubo, that \\'as subsequently opened, the pus from which w^as auto- inoculable, but did not produce a typic lesion. No symptoms of syphilis ever developed and the balanitis and attendant ulcerations healed in a few weeks. It was nearly three months, however, before the bubo was completely cicatrized. In this case an unhealthy subject with a tight and redundant prepuce, beneath which irritation was constant,, suffered from balanitis from time to time. 'No attention was paid to the genital toilet, and filthy secretions, both natural and pathologic, accumulated beneath the prepuce. The patient finally exposed himself by intercourse with a woman who, although prob- ably not venereally diseased, was uncleanly, and affected by uterine disease with irritating discharge. Some of this discharge, mixed with semen, was deposited beneath the patient's prepuce,, and found there a state of affairs most favorable for germ-development. Under these circumstances of heat, moisture, filth, and local irritation, decomposition occurred, and pathogenic microbes ard their toxins developed. These grew more virulent from day to day, and ulceration finally occurred at several points upon the mucous mem- brane. Glandular infection by absorpt'on from the affected area next oc- curred, and a suppurating bubo appeared. Case 2. — Herpes, bubo, and apparent chancroid from infection with the dis- charge from a subacute endoeervicitis: A young married couple were referred to the author by their family physician, who supposed them to be syphilitic. They had been married two weeks and had indulged in sexual intercourse Avith most unreasonable frequency, although, as the wife claimed, the attendant pain had been severe, and had within a few days necessitated a suspension of marital relations. The first few attempts at intercourse had been attended by considerable bleedino- and left the ostium vaginae very sore and painful. Four or five days after marriage a leucorrhea, by which she had been annoyed for three or four years, became verv profuse, and of a greenish color. At the same time, more or less pelvic pain began, and had persisted, although its severity had greatly decreased. Thinking that the 274 CHAXCKOID. trouble was a physiologic consequence of her new circumstances, she paid little attention to it. At the end of the first week the husband detected some small sores upon his penis, and two or three days thereafter inguinal adenitis. Upon close questioning the author concluded that, so far as his knowledge of human nature permitted him to judge, he had to deal with two of the most un- sophisticated persons imaginable. Subsequent observation served to confirm the be- lief that they were not only innocent of any wrong-doing that might have exposed one or the other of them to venereal infection, but that they had not the slightest suspicion that such an idea couldj by any possibility, enter a physician's mind, the gentleman who referred them to the author having kept his suspicions to himself. Upon examination the husband was found to have several small herpetic ulcer- ations behind the- corona glandis. These had slightly -yellowish bases with very scanty secretion, surrounded by a narrow, non-indurated area of inflammation. A small apparently simple bubo was observed in the right groin. Upon examining the wife, the ostium vagime was found to be swollen and tender and marked by several little abrasions, evidently traumatic in character. The remains of the recently ruptured hymen were especially sensitive to the touch. There was no vaginitis, but the cervix was highly inflamed, and from the os was pouring the secretion characteristic of an inflamed endometrium. There were no evidences of syphilis in either patient, nor has a single suspicious manifestation appeared at any time during the two years that the family has been under obser- vation. The trouble in the husband disappeared after four or five days' careful atten- tion. The case of the wife did not progress so favorably, a circumstance afterward explained by the discovery that she was pregnant, conception having occurred immediately after marriage. At the end of the second week after coming under observation a small excoriation at the fourchette increased in size and became ulcer- ated, and in a few days the resulting ulcer was in appearance a typic chancroid. Autoinoculation of the secretion from this sore produced a small, apparently-typic ulcer. The inguinal glands upon both sides became slightly swollen and tender, but did not suppurate. The sore healed in about two weeks, the inguinal glands mean- w'hile returning to their normal condition. Several examinations of the woman's secretions for gonococci were made, but with a negative result. This case is certainly very instructive. The trouble appeared first in the wife, who was a perfect ignoramus so far as her sexual organs were con- cerned, and who certainly had never had intercourse before marriage. The husband had no urethritis when first examined, and probably did not have at the time of marriage, else some evidences of it would have been present at the time of examination. Sexual excess would have guaranteed this. It is not likely that he attended to other than legitimate duties during the first two weeks after marriage — men rarely do, it is only after the novelty wears ofE that they are open to suspicion, as a rule. Moreover, the trouble in his case was simple and quickly disappeared. As for the wife, admitting that she was a rirgo intacta at the time of marriage, it is scarcely conceivable that she was unfaithful so soon afterward, and at a time when intercourse was so painful to her. Then, too, her trouble was primarily not of a character to excite suspicion, as was shown by specular examination. The apparent chancroid appeared some days after the husband's trouble disappeared, and at a time when sexual congress was well-nigh impossible, even if the couple PECULIAEITIES OF CHAXCKOIDIC IXrECTIOivT. 275 had been inclined to disobey instructions. The woman's sore was situated at a point where^, if the disease had been contracted from the husband, even admitting tliat he had venereal ulcer, it would have appeared within a few hours, for at this spot an abrasion existed. Tkansmissibility to Animals. — Unlike syphilis, chancroid is trans- missible to the lower animals with comparatively little difficulty. The suc- cessful inoculation of animals was first accomplished by Auzias de Turenne in 1844. In 1868 Eicordi reported a case of virulent bubo in the rabbit, produced by inoculation of chancroidic secretion. Pus from this bubo was successfully reinoculated upon healthy animals. Syphilizatiok. — Auzias was also the first to demonstrate that suc- cessive inoculations attenuate chancroid. He was not himself aware of such an attenuation however, but confounded the propter with the post, believ- ing that the final impossibility of inoculating the same animal was due to gradual loss of susceptibility. As Auzias had no conception of the existence of two varieties of venereal ulcer, he concluded from his experiments that he had produced, by his inoculations, saturation of the systems of the ani- mals experimented upon with the virus of syphilis. To this supposed con- dition of saturation he applied the term "syphilization." With this idea in view, he drew the erroneous conclusion that by his supposed process of syphilization both animals and man could be made insusceptible to syphilis. This mistaken and fatuous idea has been perpetuated, and until quite re- cently had still a few learned advocates. The late Professor Boeck, of Christiana, was the best-known expounder of the absurd system of treat- ment of syphilis by so-called syphilization. Apparently beneficial results bave been produced by the treatment, it is true, but they are due to the same efi^ects as those induced by pustulation with tartar emetic, the benefit, such as it is, being incidental to the fatty degeneration caused by the ex- tensive suppuration. The beneficial effects are hardly sufficiently marked to compensate for the annoyance and suffering incidental to the treatment, in comparison with which syphilis itself is a mild disease. Peculiarities of Chanceoidic Infection. — The infection of chan- croid being practically specific, a perfectly characteristic sore can only be produced primarily by inoculation with the secretion of a similarly-charac- teristic lesion. The rule that "like produces like" is nowhere more applicable than in the study of chancroid. A perfectly typic sore produces a secretion that is capable of producing a sore precisely like that from which it was derived; while the secretion of a sore that is less plainly marked and destructive is only capable of producing a sore of a comparatively mild type, thus showing that the severity of its effects depend upon the degree of cultivation of the germ; i.e., upon its stage of evolutionary progression or reversion, as the case may be. The degree of autoinoculability of chancroid varies with the degree of development of the germ in every case; but a person having chan- 276 CHAXCEOID. croid is fully as susceptible to infection by the secretion of his own sore as is a person who is free from disease. Experiments with chancroidic pus have shown that the infections principle is still active after desiccation^ or even freezing, but that boiling or the admixture of strong acids or alkalies at once destroys its virulent properties. It is said that decomposition also destroys it; but this is doubt- ful. There is little, if an}^, difference in the virulency of the secretion of an exposed tyj)ic chancroid and the foul-smelling, decomposed pus from concealed cases complicated by phimosis, one form of secretion being quite as inoculable as the other. Gangrene — and, it has been claimed, phagedena, — will destroy chancroid infection. This is not true in all cases, however, as autoinoculation of the secretion of phagedenic chancroid is usually suc- cessful. When, however, the phagedena becomes chronic, the virulency of the secretion usually disappears. Bland and non-corrosive menstrua do not modify the infection of chancroid. It is quite as active when mixed with semen, milk, blood, or healthy urine as when taken alone, provided the cir- cumstances of its inoculation are favorable. Xo definite quantity of the infection-bearing secretion is required for inoculation. Its results are modified by the extent of abraded surface upon which it is inoculated, the resulting chancroid corresponding in size and shape Avith the inoculated area. The fallacious practice of syphilization has taught us some points wortlw of mention. While the number of times that a person can be suc- cessfully inoculated has not been positively shown, it has been proved to be considerable. One experimenter inoculated himself nearly three thousand times before the operation failed. The infection does become exhausted after a time — by attenuation, not by of loss of susceptibilit}^ of the subject. Xo permanent period of immunity, complete or partial, is attained by syph- ilization, and with fresh secretion from a different individual the inocula- tions are again successful. There is, therefore, no limit to the number of attacks of chancroid that one individual may acquire. Some regions of the body are more susceptible to chancroid than others. The inner aspect of the thigh, the scrotum, and anus are very susceptible; hence we often see these parts affected by numerous chancroids, accidentally caused by inoculation from a penile or vulvar sore. The face is not very susceptible to inoculation. Eelatiye Feequexcy of Chaxckoid. — The frequency of chancroid varies greatly in the different strata of society. Being essentially a filth dis- ease, it is most often seen among the lower classes and those who consort with them. The relative frequency of chancroid decreases pari passu with advance in social status. Cleanliness and good health do not necessarilv ^ This is contradicted by Taylor, who found that exposure to the air upon glass plates for twenty-four hours destroyed the virulency of chancroidic pus. METHODS OF IXFECTIOX. * 277 increase morality, but tliey certainly lessen the frequency of venereal affec- tions. In dispensary and hospital practice chancroids and mixed sores are frequent, while in the better class of private practice they are not nearly so numerous as syphilitic chancres. The syphilitic initial lesion is of trifling local importance and rarely recognized by the prostitute; but chancroid produces considerable local annoyance and is -likely to be attended by sup- purating bubo. Among the better class of prostitutes, therefore, syphilis is often communicated because the woman is herself ignorant of her dis- ease, while chancroid is not apt to be so communicated for the simple reason that the woman is too solicitous of her own welfare to ply her trade while suffering with so troublesome a complaint. The lower-class prostitute not only has no scruples in the matter, but, nolens volens, she must continue her trade or starve. Then, too, she often becomes inured to the existence of a chronic chancroid, and goes on spreading the noxious disease among her patrons who, being themselves of low character and filthy habits, not only contract severe chancroid, but act as carriers of the disease.^ Methods of Infection. — It is fortunate for the human species that the venereal diseases are not infectious in the sense of the term as applied to some other transmissible diseases. The contagium of each venereal affec- tion is a material substance, and not a miasm, and, as a consequence, actual contact of the poison-bearing secretion with some portion of the body is necessary for infection. This is eminently true in the case of chancroid. As contact of the secretion with an absorbent surface only is necessary to inoculation, it is obvious that there are several ways of transmitting the disease. The modes of contagion are broadly classified as mediate and im- mediate. The first method implies the contact of a diseased surface with a healthy one. This may occur during sexual intercourse or by handling the diseased surfaces with abraded fingers. Hang nails and insignificant scratches upon the hands of the surgeon are often the sites of contagion. The anxiety consequent upon the always justifiable doubt as to the possi- bility of double infection is one of the worst features of such accidents. In the second method of transmitting chancroid some person or object intervenes and acts as a carrier of infection. Thus, the poison may be con- veyed by the instruments or fingers of the surgeon, or the patient with chan- croid may infect himself in new situations by scratching himself with his finger-nails after having handled the diseased surface. Autoinoculation may occur accidentally through a healthy surface coming in contact with the seat of disease, and remaining so exposed until infection occurs. It is not uncom- mon to see the scrotum and thio'hs covered with sores contracted in this ^ As an evidence that chancroid is essentially a disease of filth and faulty hygiene may be advanced the fact that chancroid is growing less and less frequent with advancing civilization and increasing sanitary and hygienic knowledge. Mauriac and Taylor both claini that it is decreasing in frequency. 278 CHAXCKOID. manner. Patients with a long foreskin who have chancroids upon the glans penis often develop by autoinoculation an almost exact reproduction of the penile chancroids upon the contiguous surfaces of the prepuce. Again, the acrid secretion of chancroid ma}' flow' over healtl\y tissues and finally ex- coriate and infect them. Where there is a long foreskin a perfect collar of chancroids is often found about the preputial orifice. In Avomen, the secre- tions from the vagina and vulva are directed downward over the perineum, and anal chancroids are apt to develop. A very interesting method of transmission, a knowledge of which some- times clears up the obscurity surrounding the manner of infection, is the following: An individual with a long prepuce cohabits with a woman whose vagina contains the infection of chancroid, and the circumstances not being favorable to cleanliness, or being negligent, he fails to wash himself and the infection remains beneath his prepuce. He soon afterward has intercourse with another and healthy woman, deposits the infection in her vagina, by chance washes himself and goes his way. Not having any abrasions upon his penis and having washed himself thoroughly before infection could oc- cur, he escapes chancroid. The healthy woman may or may not escape, the danger varying with the toughness of her vagina and the length of time that the virus remains in contact with the mucous membrane of that structure. Shortly after individual Xo. 1 has finished operations with female No. 2, along comes an unlucky wight, and, having intercourse with No. 2, becomes inoculated with chancroid. Should the woman escape, as she may do, and he accuse her of having infected him, she can get a clean bill of health from any physician.^ Physicians are not infrequently called upon to examine women accused of conveying chancroid and quite often find them free from disease. The author has had this experience where the man had not exposed himself with any other woman than the one suspected. It is often easier to get at the facts in these cases than might be sup- posed, for while married persons and dispensary patients ma}^, from various motives, lie about their venereal afflictions, the young blood about town and the professional prostitute are candid enough regarding the wounds re- ceived in their venereal adventures. It is a matter of moral indifference to the one, for she regards venereal disease as her hete noire only when it neces- sitates a cessation of business for a time or an expenditure of money for the doctor's benefit: as for the other, the scars are honorable among his class, being evidence of his very rapid existence. Abrasions upon the mucous membrane or skin necessarily facilitate the inoculation of chancroid. If chancroidic secretion be brought in contact with a raw surface, nothing short of thorough cauterization will prevent in- ^ In two separate experiments Cullerier demonstrated that chancroidic pus may remain in contact with the vagina for an hour or more without infecting it. LOCATIOX OF CHANCEOID. ' 279 fection. Primary solutions of continuity are, however, not essential to in- oculation. In the case of a man with a long prepuce cohabiting with a woman who has chancroid, and failing to wash himself thoroughly, some of the infectious secretion remains beneath the prepuce. The infection is espe- cially apt to be localized in the little crypts beside the frenum preputii. The mucous membrane being thin and delicate and the infectious secretion cor- rosive, and the circumstances of heat, moisture, and continuous local irrita- tion prevailing, maceration of the epithelium occurs after a time, followed by absorption and local infection. Similarly the chancroidic poison is sometimes rubbed into the open mouth of a minute follicle upon the surface of the glans penis; maceration and removal of epithelium subsequentlj' occurring, impetiginous chancroid develops. In the same Avay syphilitic chancre is sometimes acquired. The development of infection in such cases requires some little time, varying with the virulenc}^ of the virus, and the thickness of the epithelium. The occurrence of such cases is the only possible explanation of the difEerence in the rapidity with which deliberately-inoculated chancroid, and some of those contracted during sexual intercourse, appear. The occasional cases of greatly prolonged incubation would otherwise be difficult to comprehend. Location of Chaxckoid. — Chancroids are confined to a rather more limited area than chancre. They are rarely found excepting about the genital organs. The exceptions are chiefly due to inoculation of the hands. Chancroid about the head and face is so rare that it has been supposed that these regions are insusceptible to it. Such cases have, however, been re- ported, but they are very few in number.^ The author has seen one case of chancroid of the face due to a patient's scratching a pimple after handling his genitals. In general, the different areas of the body are susceptible to chancroid in direct proportion to the tenuity of their tegumentary covering and the facility with which they are exposed to infection. In the female chancroid is almost always located about the vulva and ostium vagince. In this location the mucous membrane is very thin, and there are numerous little pockets for the accumulation of noxious secretions. Here, too, the secretions are naturally foul and prone to decomposition, and irritation from extraneous sources is most marked. There is little doubt that many cases of chancroid in the female are primarily autogenetic. The infection-bear- ing secretion is elaborated above, but the vagina is quite tough, and in addi- tion has become acclimated, so to speak, by the time the evolved infection has arrived at its acme of virulence. As it trickles down over the external genitals, however, it either accumulates in the numerous little crypts there * Although usually mild when it occurs in this situation. Taylor has shown that chancroid about the head may be quite sevei'e. Archives (Brown-Sequard's), Xo. 5, 1873. 280 CHANCEOID. present, and after maceration of the epithelinm produces chancroid, or else it immediately infects the abrasions that so often exist in this location. The line of progression often extends still further, the tissues about the anus becoming infected. Anal chancroid is most frecjuent in women because of the trickling doAvn of vaginal discharge when they are in the recumbent posture. This gravitation of infectious fluid also explains why the four- chette and posterior vulvar commissure are, of all locations upon the female genitals, most often aifected by chancroid. Intra-uterine chancroids have been reported, but their occurrence is problematic. Chancroids of the anus and rectum are occasionally contracted through Fig. 94. — Multiple chanc-roid in the female. sexual intercourse by perverts. Anal chancroid from sodomy in both sexes has been seen. The author's experience in such cases comprises but a single instance: that of a woman, who freely admitted the origin of the disease. Chancroid in the male may occur anj^where upon the penis, but is most frequently located in the fossas beside the frenum preputii. Discharges most frequently collect in this situation and are with difficulty washed away. Chancroid of the meatus is not rare, and sores involving the urethra are occasionally met with. Anal and rectal chancroid is especially rare in the male and always justifies a suspicion of sexual perversion. Scrotal chancroids occur from autoinoculation, and may be very numer- ous. The thighs may be inoculated from either penile or scrotal sores. CLINICAL HISTOEY. FORMS. 381 Chancroid may be inoculated upon growths of various kinds, and has been produced upon cancerous neoplasia and elephantiasis. It ma}^ be grafted upon chancre. There is a possibility, also, that some mixed sores are instances of transformation of chancre by the autogenesis of chancroidic infection in filthy individuals. Sores are certainly met with in which ulcera- tion, the secretion of which is autoinoculable, appears some time after the chancre, Avhere the patient coidd not have been exposed since the syphilis appeared. This certainly harmonizes with the evolutionary theory of the origin of chancroid. Clinical History. — The history, course, and symptoms of chancroid may be studied with most facility by means of autoinoculated sores. In this manner the phenomena following inoculation may be observed under the most favorable circumstances. The best point for inoculation is the inner aspect of the thigh or the abdomen. The results of autoinoculation vary but little, when the inoculated secretion has been obtained from typic chancroid; thus the definiteness of the result seems to depend upon the degree of cultivation of the infec- tion. The lesions consequent upon the inoculation of all morbid secretions about the genitals vary from a slight redness, perhaps followed by an acnei- form papule or pustule or herpetiform ulceration, to severe eroding chan- croid. Inoculation may be performed with either an aseptic lancet or needle. As a rule, chancroids resulting from accidental autoinoculation are less severe than those from which they originated. Gradually decreasing viru- lency of the secretion of the original sore will explain this. In some cases, however, secondary chancroids are both virulent and destructive. Within twenty-four hours after the inoculation of the secretion of typic chancroid, a reddish areola appears about the spot; by the second day there is distinct inflammation, and perhaps pustulation has already begun. When ruptured, this pustule is found to surmount a small circular ulcera- tion that increases proportionately in depth as it spreads. When it has at- tained about the size of a dime, it usually becomes stationar}^ but it may increase to the size of a silver quarter or involve quite an area of tissue, de- pending greatly upon the constitution of the patient. The promptitude with which chancroid follows inoculation demonstrates conclusively that the dis- ease has no normal period of incubation. The inflammatory action begins quite as promptly as when other irritating infections or materials are intro- duced beneath the skin or mucous membranes. A splinter of wood would act in much the same manner. Inflammation after injury is an effort at repair, but it requires a few hours for the tissues to react to the injury. It is, of course, possible that the immediate effects of autoinoculation are due to mixed infection and simple irritation, -and that the chancroidic infection does not assert itself until the characteristic ulceration appears. Pure culture inoculations may one day settle this question. Forms of Chancroid. — When contracted during sexual intercourse 282 CHAXCEOID. chancroid appears in several different ways and at variable periods. The methods of its appearance, according to the author's experience, are: — 1. An abrasion previousl}^ existing or produced during coitus becomes inflamed, and begins secreting a thin muco-purulent fluid. Ulceration next appears, the shape of the ulcer at first corresponding to that of the abrasion, but gradually becoming circular or oblong, the secretion also growing more profuse and purulent. If there are numerous abrasions a complete collar of small ulcers may encircle the penis. (Fig. 95.) 2. A small pre-existing fissure inflames and begins secreting. This deepens rather more rapidly than it spreads laterally, but if located in a Fig. 95. — Multiple chancroids in the male. natural fold of the skin or mucous membrane the sore extends along it for a considerable distance, often involving the greater part of the circumfer- ence of the penis. 3. A small papule with a reddened base first appears, but in a day or so suppurates, breaks down, and forms the typic ulcer. 4. A small pustule is first noticed, and this speedily breaks down, re- vealing the typic ulcer. This and the preceding form have been termed the follicular chancroid. The terms papulo-pustular and impetiginous chancroid are, however, more comprehensive. 5. A pre-existing herpes or simple ulcer becomes infected and speedily takes on the form of typic chancroid. CHARACTEKISTICS. TYPIC COUESE. 283 6. Double infection results in the so-called mixed chancre, which com- posite sore presents eventnall}^ the combined characteristics of chancre and chancroid, and occurs in several ways: (a) The first and most common is where the poisons are received simultaneously, the characteristic chancroid appearing first and subsequently indurating, (b) Chancroid is acquired first and is subsequently inoculated with syphilis. This takes the same course as the preceding form, save that the time elapsing before induration is longer, being dependent upon the period in the life-history of the soft sore at which syphilitic infection occurs, (c) Chancre is transformed by autoinfection, and presents the characters of a mixed sore. Chaeacteristics of the Ulcer. — The ulceration in typic chancroid is peculiar, tending to a circular or elliptic form, with clearly-cut or un- dermined edges, usually steep and precipitous, though sometimes everted'. The sore is comparatively deep, especially if its edges be undermined, its floor being covered with a grayish or yellowish tenacious deposit resembling chamois-skin that has been chewed. It is surrounded by a reddish inflam- matory areola in most cases, and produces a tolerably thick yellowish pus, which, however, changes to an ichorous or sanious character if the sore be irritated. The ulcer is not painful unless it is irritated or becomes phage- denic, in which case the pain is of a burning character and may become very severe. Typic Course. — If not disturbed, chancroid usually runs a quite definite course. For from two or three days to as many weeks the sore in- creases in size without change in its peculiar characteristics. At its maxi- mum of development it is rarely larger than a dime, although it may be much larger. A stationary period of a week or two now supervenes, at the end of which repair commences. There may be no stationary period: i.e., repair may begin at any time, as evidenced by improvement in the character of the secretion and a lessening of surrounding inflammation. "\^'lien repair once begins, the sore sj^eedily assumes the character of a simple ulcer, healthy granulations spring up, the pus becomes healthy-looking, and cica- trization begins at the periphery. The pus is autoinoculable in gradually- decreasing degree during repair.^ About' the time the chancroid is nearly cicatrized its infectious properties are usually lost. The self-limitation of chancroid under favorable circumstances is another evidence of its spon- taneous origin. The environment of chancroid, when kept clean, is different from that in which the infection originates, and the life-history of the sore is neces- sarily different. "When the conditions are unhygienic the chancroid is not ^ It was long supposed that when repair of chancroid sets in its secretion in- variably ceases to be poisonous. It undoubtedly does lose much of its viruleney, but, as Fournier has shown, characteristic sores may sometimes be produced by tUe in- oculation of the discharg-e from chancroids that are nearlv healed. 284 CHAXCEOID. only not self-limited, but may be continued indefinite j, as is seen in cer- tain chronic chancroids in both men and women. Chancroid may lose its virulence as a consequence of gangrene, or may be transformed into chronic nicer, simple or infections, of indefinite dura- tion. The latter is occasionally seen in the form of old chronic chancroids about the anus or on the vulva or vagina in old prostitutes, in whom more or less irritation is constant. CiCATEix. — The cicatrix of chancroid varies in size and appearance ac- cording to the size and location of the sore. In some slight cases it disap- Fiff. 96. — Chronic chancroid of rioht labia. pears entirely, but in the majority of instances it is permanent. It is usu- ally white, and presents no characteristic features. Peogxosis. — When chancroid runs a normal and self-limited course it is an affair of comparative insignificance. Unfortunately, however, it does not always act so benignantly. It sometimes undergoes transformation by gangrene, inflammation, phagedena, coalition with other sores, or serpigi- nous ulceration. In the latter event it is very apt to become chronic, ad- vanciiig upon one side while healing upon the other, such cases being espe- cially obstinate and discouraging. NUMBER OF SORES. EXTEXT. DITRATIOX. 285 Number of Sores. — The number of chancroids has no arbitrar}^ limit, and, as already noted, a large number ma}^ be inoculated upon the same in- dividual. Chancroid ma}^ remain single throughout or may become numer- ously multiple through autoinoculation; thus, the same individual may have chancroids upon the penis, foreskin, scrotum, anus, and inner aspect of the thighs. Extent. — Chancroids vary in extent, being usually of very moderate size. In exceptional cases, however, they invade a very large area of surface. Thus, they may vary in size from the dimensions of a pin's head to those Fig. 97. — Extensive destruction of the genitals, perineum, and ischio-rectal fossas from chancroid in an old syphilitic. Showing rectum exposed. (After T. A. Davis.) terrible phagedenic affairs that sometimes lay. bare quite an extent of the thigh, testes, groin, or abdominal walls. Duration. — The duration of chancroid, when simple and untreated, is four or five weeks and upward, depending greatly upon the size of the sore and its location, some situations being more exposed to irritation than others. On this account, chancroids of the meatus, urethra, anus, rectum, and posterior vulvar commissure are apt to become chronic, and their bases hardened and infiltrated. The causes of prolonged duration of chancroid may be summed up as: — 286 CHAXCKOID. 1. Exposure to heat, moisture, filth, and contact of irritating and acrid discharges. 2. Cachectic constitutional conditions, of which chronic inehriety, syphilis, struma, and phthisis are most important. 3. Friction induced by sexual intercourse or excessive movement. It is lack of rest as much as anj^thing that; prolongs anal chancroid. ■±. Debility from insufficient or improper food, bad air, and other un- hygienic conditions. 5. Intemperance in eating and drinking. 6. Improper treatment at the hands of the patient and his friends, drug-clerks, or inexperienced physicians. From any of these causes, and often without any apparent cause, chan- croid may relapse when it seems to be healing nicely. This is especially apt to occur in chancroids that have been phagedenic or gangrenous. Often- times a chancroid that is progressing favorably will be suddenly attacked by phagedena and spread quite rapidly. Complications of Chanceoid. — The principal complications to which chancroid is liable are: 1. Inflammation, — simple cr erysipelatous. 2. Lym- phitis,— simple, suppurative, or specific. 3. Phimosis and paraphimosis. 4. Venereal vegetations or vegetating papillomata. 5. Gangrene. 6. Serpig- inous ulceration. 7. Phagedena. 8. Simple adenitis. 9. Virulent ade- nitis. 10. Syphilis. 11. Urethritis, — simple or gonococcic. Inflammation. — Inflammation of chancroid is often met with; the in- fection is a mixed one, and sources of irritation are numerous and constant. Etiology. — The causes of inflammation are: 1. Constitutional predis- position or cachexia. As Lloyd expresses it, the patient may be a "suppu- rater.'*' 2. Uncleanliness. 3. Phimosis or paraphimosis. 4. Sexual inter- course. 5. The injudicious application of caustic or irritant drugs. 6. In- temperance. 7. Sepsis from pus or toxin infection often superinduced by the foregoing causes. Chancroids beneath a tight prepuce are especially apt to inflame, often producing phimosis or paraphimosis. When the prepuce is constricted and inflamed it becomes enormously swollen and infiltrated. The edema is often so extensive that the part is translucent. Clinically, the condition is really lymphangitis, and it is but a step from this to classic erysipelas. In this condition gangrene of the prepuce, or perhaps the glans, is apt to occur from circulatory obstruction. Preputial gangrene in phimosis usually be- gins just over the superior surface of the glans. In all cases of phimosis the secretions are pent up, thus predisposing to gangrene, erj^sipelas, phage- dena, and serpiginous ulceration. When true erysipelatous infection occurs, severe and dangerous sloughing may ensue. The scrotum may become in- volved, and death from exhaustion, pyemia, or septemia is possible. Pus confined beneath the prepuce may burrow in various directions, forming chronic sinuses and fistulas, possibly undermining the entire penile COMPLICATIONS OF CHAXCEOID. 287 integument. If the patient be debilitated or cachectic — and this is espe- cially true of hard drinkers — the inflammation may be indefinitely pro- longed. Inflammation of the lymphatics may take a suppurative course and cause considerable destruction of tissue. A frequent element in the causation of inflammation in chancroids is the application of silver nitrate, copper sulphate, or some other superficial caustic or irritant to the lesion. Patients often do this themselves or em- ploy irresponsible persons to do it for them. Ointments are often applied and allowed to become rancid. The results of this ill-advised therapy are not only painful, but greatly confuse the diagnosis. When inflammation begins the chancroid becomes greatly transformed. It becomes excessively painful, the pain being of a burning character; the color of the lesion changes to an angry red or livid hue, and its secretion becomes scanty, thin, and sanious or ichorous. The ulceration now extends rapidly, and, if suppurating inguinal adenitis has not already occurred, it is quite likely to supervene. The changes in the base of the chancroid are the most important re- sults of inflammation, and usually confuse the diagnosis. Normally, the base of the ulcer is soft or, at most, slightly boggy. When inflamed, how- ever, it speedily becomes indurated to a greater or less extent. Induration may also occur in any genital lesion, especially in balanitic or herpetic ulcers, but rarely to such a marked degree — sufficiently marked, however, to render the diagnosis more or less obscUre. This induration is often mistaken for the initial lesion of syphilis. As a rule, there are quite pronounced differ- ences between indurated chancroid and true chancrous induration.^ In lieu of the hard, abruptly-defined, cartilaginous induration found in chancre, that of inflamed chancroid is softer, boggy to the feel, is not circumscribed, but shades off into the surrounding tissues, and may be con- siderably reduced in size by squeezing out the infiltration with the fingers. It is quite painful to the touch: a point in which it differs markedly from the uncomplicated initial syphilitic lesion. The ulceration is always primary, and the induration secondary in typic soft sores, while in chancre the reverse usually holds true. Too much stress must not be laid upon this difference, because mixed infection or transformation of hard sores may make this clinical fact of little value. Chancroid sometimes presents exuberant granulations. Erichsen de- scribes this condition as "fungating sore."^ ISTotwithstanding what has been said, the difficulties of differential ^ It is a clinical fact which the author believes most surgeons have observed, and on reflection will substantiate, that all lesions about the genitals have a most peculiar tendency to obstinate ulceration and to induration. The influence of gravity on the circulation, the abundance of fine lymphatics, and the looseness of the areolar tissue probably account for this. " "Science and Art of Surgery." 388 CHANCROID. diagnosis are often very great. In quite a proportion of cases only the sub- sequent history permits a correct conclusion. Considering the sources of continued and severe irritation that exist in most cases of chancroid;, and the fact that clinically it is a mixed infection, such perplexing cases are in nowise remarkable. To impress this point more fully the following cases are presented: — Case 1. — A young man consulted his physician for what was claimed to be his first attack of venereal disease. He stated that about two weeks after suspicious intercourse he developed a small ulcer upon the glans penis. This was pronounced syphilitic and cauterized with silver nitrate. The case finally came into the author's hands. There was a scantily secreting, slightly painful, and apparently typically indurated sore just back of the corona glandis. The induration was cartilaginous to the feel, and quite abrupt, being about the size of a hazel-nut. The inguinal glands were moderately enlarged and quite hard, but not especially tender. These features of the case, in combination with the alleged prolonged "period of incubation led the author to suspect syphilis. Diagnosis, however, was reserved. The patient being anxious to avoid eruptions and convinced that he had syphilis, became restless and sought other counsel. A full mercurial course was begun by the new medical adviser. After about eight months' careful treatment, the patient returned, stating that he had "another dose." On examination, another sore was found at the site of the first one and of essentially the same physical characters. This sore was followed by a moderately severe and typic course of secondary syphilis. Case 2.- — This case was similar to the preceding, with the exception that copper sulphate was applied by the patient himself. A suppurating bubo formed, leading the physician in charge to consider the case one of double infection. Mercurials were given, and, as a slight sore throat with small eroded patcties in the mouth soon afterward developed, this treatment Was continued for a year. At the end of this time there developed, three weeks after exposure, a typic Hunteriau chancre that was followed by a quite severe course of secondai-y lesions. When the genuine chancre appeared the ease came under the author's care. In both of the foregoing cases a serious, but instructive, mistake was made. Such errors are, however, only too frequent, and should warn the surgeon against a speedy and arbitrary diagnosis. PJiimosis and Paraphimosis. — These conditions are most often asso- ciated in chancroid, and are frequently due to inflammation. Phimosis may be congenital or inflammatory, and acts in two waj^s, viz.: (1) by pen- ning up foul secretions, thus preventing free drainage and antisepsis, and (2) by cutting off the circulation to a certain extent. Paraphimosis causes gangrene just as a string would do if tied behind the corona glandis; fortu- nately, however, the resulting tissue-necrosis often first attacks the con- stricting ring of prepuce itself, destroying its continuity and relieving the constriction. In this way the glans penis is probably sometimes saved from destruction. Gangrene. — This complication of genital disease is not necessarily lim- ited to chancroid, but may occur with any lesion of these parts. Herpes, balanitis, simple phimosis and paraphimosis, simple ulceration, and chancre are each occasionally attended bv sfanOTene. COMPLICATIONS OF CHANCKOID. 289 Gangrene of genital lesions occurs in two forms, viz.: (1) circum- scribed or self-limiting; (2) progressive or phagedenic. In addition to mechanic causes, gangrene is predisposed to by alcoholism, old age, debility, and syphilis. The first form is generally secondary to acute inflammation, as in phimosis and paraphimosis. The tissue-tension is extreme in these cases and the vitality of the tissues becomes so impaired that gangrene comes on very suddenly. In the more fortunate cases, the prepuce sloughs and the glans protrudes through the "button-hole" thus formed upon the dorsum, •or else the entire prepuce sloughs, constituting a neat, spontaneous circum- cision that leaves the organ in better shape than before. When the prepuce sloughs only partially the remaining tissue sometimes becomes dense and infiltrated. This variety of gangrene rarely complicates chancroid unless it be subpreputial, and is the least dangerous form of the affection. After the separation of the slough a clean, healthy, granulating surface is left, the secretion of which is not inoculable save as simple pus-infection. When the inflammation and disturbance of the circulation are not severe enough to destroy the tissues en masse, the phagedenic form of gan- grene supervenes. In this variety sloughing slowly progresses, or a suc- cession of sloughs form and are cast off as the ulcer gradually increases in size. Sometimes this increase is very rapid and destructive. Wliether a special infection is the fons origo in such cases is still sub judice. In all forms of genital gangrene the pain is severe, and of a burning or stinging character, this being most marked in the phagedenic variety. The slough in the circumscribed form varies in color from a dirty brown to a deep black, while in the phagedenic form it is of a grayish or greenish hue. The secretion in gangrene is a fetid, thin sanies or ichor that emits a stench so foul that the odor of the dissecting-room is agreeable by comparison. The constitutional symptoms are usually more or less fever, great de- bility, and in fatal cases a somewhat characteristic typhoid state. The ]3robabilities are that in many of the cases the constitutional condition is one of sapremic or toxin infection secondary to the gangrenous process. These constitutional disturbances are important, for they not only deter- mine certain therapeutic indications, but they are the type of general mani- festations present in gangrene wherever situated. Phagedena. — True phagedenic chancroid is, to the author's mind, the nearest possible approach to sloughing phagedena or classic hospital gan- grene, and should be treated upon the same principles. It differs from the latter in that it does not usually present a distinct slough. Occasionally, however, it merges into ordinary gangrene. In such cases small adherent sloughs ex;ist — gangrenous phagedena. Phagedena, properly speaking, is rapid ulceration or molecular gangrene, probably due to streptococcic, in- fection, and may attack ulcers of all kinds, not being limited to chancroid. Although the ulceration in phagedenic chancroid extends very rapidly, it 290 CHANCKOID. retains its typic characters, and, excepting in a few very chronic cases, its secretion is autoinocnlable and virulent throughout its course. Phagedena may be either superficial or deep, its destructiveness varying accordingly. Its advance is not especially rapid and may be serpiginous, advancing in a devious manner and healing upon one side while progressing upon the other. Cellular tissue seems to be especially susceptible to the in- fection. It often dissects up the entire integument of the penis or traverses the course of vessels and nerves, perhaps dissecting them out quite cleanly. The superficial form of phagedena may be obstructed in its progress by fascia or fibrous structures, but the deep form is no respecter of tissues and consumes them all indifEerently.^ Either simple or virulent bubo may be attacked by phagedena, the virulent form being especially susceptible. It has been claimed that only virulent buboes are subject to it. The author has, however, seen a bubo in process of repair that had lost its virulent properties and well-nigh healed by healthy granulation and cicatrization suddenly become phagedenic, and not only lay the abdominal muscles bare over a large area, but actually invade their structure to a considerable depth. The serpiginous form of phagedena may advance very slowly, and, becoming chronic, lay bare the penis and perhaps the testicles, sometimes healing behind as it advances, and sometimes not. In discussing this form of chancroid, the author recalls a striking case that was for a time under his care in the New York Charity Hospital: — Case. — The phagedenic process involved the penis and scrotum, and before it was finally checked had invaded the groins and loAver portion of the abdomen. The parts affected were entirely denuded of integument, and, in great part, of cellular tissue. When the disease was finally checked — more by Nature's own efforts than the result of treatment^ — it Avas hoped that healing would occur, but, instead, the process remained stationary, and no form of treatment seemed to benefit it in the least. The case was in the hospital for several years, during which time every form of "regular" torture was applied that ingenious and enterprising house and visiting surgeons could devise. He finally drifted into the hands of the surgeons at the homeopathic hospital, but their treatment met with no more successful result than had ours, and he finally died, worn out with much suffering and more treatment. There is a ease of serpiginous phagedena related by Fournier that had existed for fourteen years, at the end of which time there was still an ulcer at the knee, the lesion having healed behind as it progressed. This case passed through the hands of M. Eicord; so that it is safe to assume that its formidable character was not due to lack of proper^ treatment. Chancroids ^Wallace divides phagedenic chancre into three varieties Aaz. : (1) that without slough; (2) that with white slough; (3) that with black slough. This is certainly simple enough, but too arbitrary, and scarcely borne out clinically. - "Nouveau Diet, de medecine et de chir. prat.," Paris, vol. iii, p. 771. COMPLICATIONS OF CHANCKOID. 291 of this character may appear to be in process of repair, .and suddenly with- out any apparent cause relapse and continue their work of destruction. There is one form of chronic phagedenic chancroid that merits special consideration. This occurs in the vagina and vulva of broken-down pros- titutes, often involving not only these parts, but the anus and a considerable extent of the surrounding tissues. As a result of friction, and local irrita- tion from the contact of foul secretions, these sores become chronic. Their bases become indurated and hyperplasic, quite extensive proliferation of tissue resulting, thus giving the lesions an elevated appearance. Specificity is lost and secretion is quite scanty, the eroded surface being covered with a more or less tenacious yellowish coating of pus and tissue detritus. These sores show no tendency to repair, and are about as terrible an affliction as can be imagined. A fatal result is inevitable in such cases, but, unfortu- nately, it is only after months or even years of suffering that death from exhaustion closes the scene. ^ The author recalls several similar cases from hospital practice: — Case 1. — A girl, 17 years old, had been a prostitute for several years, having commenced at a very tender age. Some months before entering the hospital she contracted chancroid. This became phagedenic and Avas followed by bilateral phage- denic bubo. The sores originally involved the vulva and vagina, but had invaded the groins and become fused with the buboes upon either side, forming one huge area of chronic ulceration. The surface had become hyperplasic, giving it an elevated contour. The unhealthy granulations were covered with a tenacious pulpy secretion. Every conceivable method of treatment was tried in this case, even the actual cautery being freely employed, but without avail. The poor creature finally died, worn out by pain and exhaustion. Case 2. — This case was one of chronic chancroid in a pregnant woman. The entire vulva was involved, and from the diseased surfaces frequent hemorrhages occurred as a consequence of the great congestion of the sexual organs incidental to pregnancy. Nothing in the way of treatment proved of benefit, and labor was looked forward to with much apprehension. When the labor finally did occur, forceps were found necessary. The consequent laceration of the friable diseased tissues was con- siderable and the prospect for recovery seemed very dubious. However, the woman not only recovered, but the chancroids healed perfectly within three weeks, showing plainly that their chronicity had depended mainly upon the congestion of the parts due to pregnancy.^ The cases of chronic chancroid that have Just been considered are termed by some authors "lupoid ulceration," or "lupus of the vulva." They are, however, not allied to lupus, but, like that disease, they probably have ^ This form of ulceration Avas carefully described by Costilhes and Bois de Loury in 1845. See also Huguier, "Esthiomene," 1849; Taylor, New York Medical Journal, January 4, 1890; and Lydston, "Transactions of the Chicago Academy of Medicine," 1892. ^Apparently simple chancroids with a marked tendency to bleeding are occa- sionally seen in both men and women. These "hemorrhagic chancroids" are due to local irritation and congestion from sexual excitement, often combined with alcoholic indulgence. 292 CHANCKOID. underlying their causation some as yet undetermined constitutional predis- position. A syphilitic constitution is often the underlying cause. Etiology of Phagedena. — It is a peculiar fact that some persons de- velop phagedena, while others, who have contracted the disease perhaps from the same woman, and who, moreover, are hygienically situated pre- cisely like the victims of phagedena, escape it. As compared with the total number of cases of chancroid, phagedena is exceptionally seen; hence when it does appear a special cause seems plausible. Whatever the exciting cause may be, there will usually be found underl3dng phagedena that mysterious something which will always prevent medicine from becoming an exact science, viz.: individual predisposition, or idiosyncrasy. Persons so pre- disposed may have numerous attacks of chancroid, and phagedena with each and every one, and this, too, when they appear ]3erfectly robust and healthy, and their habits and manner of living are hygienically irreproach- able. There is probably no such thing as a complicating specific infection as an explanation for the occurrence of phagedena, for it is an established fact that a phagedenic sore may be acquired by confrontation with a simple chancroid and vice versa. Again, if we autoinoculate the virus of a phage- denic chancroid, phagedena will result in the majority of cases, while if we heteroinoculate the same poison — i.e., if we transfer it to another individual — simple chancroid generally results, although not so uniformly as when the virus of a simple sore is employed.^ So far as researches have gone, superimposed streptococcic infection is the most likely point of departure for phagedena. Koch discovered an or- ganism, probably allied to the streptococcus erysipelatosus, to which hospital gangrene is probably due. A variation of the same germ ma}^ be the cause of genital phagedena. The author is inclined to attribute the tissue-destruc- tion in phagedena to the action of microbiall3^-generated toxins, operable only in certain individuals. Eacial characteristics modify liability to phagedena, the negro being especially predisposed to it, as, indeed, he is to a severe type of any variety of venereal disease with which he may be afflicted. Why this is so has never been satisfactorily explained. Possibly venereal diseases are comparatively new to the negro race, as is true of small-pox. Although idios3^ncrasy is all- important in the etiology of phagedena, it is by no means the only cause. In a general way, it may be said that any disease or condition that lowers tissue-vitality predisposes to it. Old age, malaria, alcoholism, the adynamic fevers, syphilis, the cancerous cachexia, bad air, food, and water, insufficient food, scrofula, and scurvy may act as predisposing causes. Hospitalism ^ Irrespective of any special poison in phagedena, it must be acknowledged that the secretion of phagedenic nicer is at least more irritating, on the average, than that from simple chancroid. This the author believes may be verified by frequent experi- ments in autoinoculation. DIAGNOSIS OF CHANCEOID. 393 probably explains many cases, and also partly explains the infreqnency with which we meet phagedena in private, as compared with hospital, practice. JSTumerous local causes favor phagedena, uncleanliness being a prime factor. Only by scrupulous attention to the genital toilet can such condi- tions be prevented in most cases of chancroid. Any irritating secretion pre- disposes to phagedena in suitable subjects. In women, especially, it is diffi- cult to keep the parts clean, and in both sexes the urine is very apt to come in contact with the ulcer and — especially if it be allowed to remain and de- compose — produce great irritation. Phimosis is a prolific cause in the male, through retention of pus and other unhealthy secretions. Very often self- treatment is at the bottom of the difficulty, although the patient rarely admits it. Eicord asserts that mercurial ointment is extremely irritating and is often a cause of phagedena. Any rancid ointment will act in the same manner both by its own irritating properties and the damming back of secretions that it produces. Grease is incompatible with cleanliness. Irritating powders often have a similar effect. Last, but not least, we have the careless application of caustics. Simple Papillomata. — Vegetations constitute the mildest complica- tion of chancroid. These papillary growths have already been dealt with in considering the simple external afi:ections of the sexual apparatus. In chan- croid, vegetations usually occur only after the sore has shown a tendency to become chronic. They merit no special consideration in connection with this disease, excepting, perhaps, that it may be well to caution against cut- ting them before the chancroid has lost its specific properties. Should it be done prior to this time, autoinoculation will probably occur, and create much additional trouble. Syphilis. — Syphilis as a complication of chancroid, either as a primary sore or a constitutional disease, should be borne in mind, as it may mark- edly modify the characters of the chancroid, and, more than all, may seri- ously retard healing. This disease acts not only specifically, but generally; few diseases so profoundly modify nutrition. The possibility of the exist- ence of the syphilitic dyscrasia should always be taken into consideration when a chancroid becomes obstinate and ceases to heal. The difference in the rapidity of healing before and after antisyphilitic treatment is often remarkable. A brilliant cure of chronic chancroid may occasionall)^ be ac- complished through a knowledge of this important fact. Adenitis. — The most frequent and important complication of chan- croid is adenitis, or bubo, which will be considered later. Diagnosis. — The diagnosis of typic chancroid requires its differentia- tion from chancre, simple ulcerated abrasions, ulcerating herpes, balanitic excoriations, simple ecthyma, furuncle, ulcerating mucous patches, tertiary or gummy ulceration, and, in very rare instances, from epithelioma. There is but little liability to error in diagnosis, however, save in true chancre, herpetic ulcers, ulcerated abrasions, and ecthyma. 394 CHANCROID. The simple affections mentioned do not bear so constant a relation to sexnal intercourse as chancroid and hard chancre, and may usually be diag- nosed readily enough if typic and seen early. They are the result of numerous influences independent of venereal and local causes. They often depend upon debility and certain nervous conditions in conjunction with various sources of local irritation, and are an occasional result of fever. A tight prepuce, uncleanliness, traumatism during masturbation, and irrita- ting discharges and applications may cause these simple lesions in persons who seldom or never have intercourse. They often bear a certain relation to chancroid, it is true, and may be the result of irritating discharges com- ing in contact with the parts during copulation, but they are in no sense venereal. In the case of herpes, ulcers from balanitis, and ulcerating excoriations, the secretions are neither heteroinoculable nor autoinoculable. In ech- thyma — impetigo — the pus is not autoinoculable, and, in addition, there is usually a crop of pustules distributed more or less extensively over the body. Furuncles may resemble chancroid at first, but they, are not followed by ulceration, as a rule. It must be remembered that these simple lesions under favorable cir- cumstances may be transformed into lesions that are clinically almost, if not quite, identic Avith chancroid. The secretion from any of them when autoinoculated may j)roduce a pustule or even ulceration from simple pus- infection. The course of these lesions as well as their physical appearances gen- erally differ markedly from typic chancroid, although some of them, and herpes in particular, may closely simulate that disease. In stating that the simple affections above alluded to bear no relation to sexual indulgence the author means that they primarily bear no other relation than is incidental to friction and exposure to filth. In cases in which the source of irritation is derived during sexual intercourse the various simple affections have no definite period of incubation, either apparent or real. They are apt to come on within a very short time, but this is variable. Occasionally an examina- tion of the j)erson from whom the lesion is supposed to have been contracted will assist in the diagnosis, but such examinations are usually merely of relative value. The period of incubation in venereal sores may or may not be of value; rarely, indeed, can it be positively determined, as the patient has usually exposed himself with a number of different females within a comparatively short period of time, and it is well-nigh impossible to determine in such cases exactly when infection occurred. Even where the patient has been having intercourse with but one woman, it is often impossible to decide when the disease was contracted. The chief difficulty is the differentiation of chancre and chancroid. DIFFEEENTTAL DIAGXOSIS. 295 The following table — modified from Bumstead — presents the chief points in differential diagnosis: — The Chancroid. Origin (confrontation). Always due to contagion from chan- croid or chaucroidic bubo or lym- phitis, either mediately or immedi- ately. Incuhation. None; the sore appears within a week after exposure. Commencement. Commences as a pustule, or as an open ulcer, as a rule, but may begin as an abrasion or perhaps a papule. Number. Most often multiple, either from the first or by successive inoculation. Deiyth. Perforates the whole thickness of the skin or mucous membrane; "punched out" and excavated, with evident loss of tissue. Edges. Abrupt, sharply cut, eroded, under- mined. Floor. Whitish, grayish, pultaceous, "worm- eaten." Secretion. Abundant and purulent unless com- plicated by inflammation, and auto- inoculable. Induration. No induration of the base of the lesion, although may be caused by caustics or other irritant applications, or even by simple inflammation. In such event the engorgement is not cir- cumscribed, but shades off into the surrounding tissues and is of short duration. May be quite painful. Destructive Tendency. This is characteristic in typic ■chancroid and very marked in the phagedenic variety. May become chronic and last for years. The Chancre. Origin (confrontation). Always due to contagion from the secretion of a chancre, syphilitic lesion, or from the blood of a person affected with syphilis, mediately or immedi- ately. Ificubation. Constant ; usually of from ten days to three weeks' duration, often longer. Commencement. Commences as a papule or tubercle, w'hich afterward, in most cases, be- comes ulcerated. May begin as a small ulcer. Number. Generally single; multiple, if at all, from the first, rarely if ever by suc- cessive inoculation. Depth. Most frequently a superficial ero- sion "scooped out," fiat, or elevated above the surface; rarely deep, and then cup-shaped, sloping toward the center. Edges. Sloping, flat, or rounded, adherent. Floor. Eed, livid, or copper-colored; often iridescent. Sometimes covered by a false membrane, scaly exfoliation, or scabs. Secretion. Scanty and serous, in the absence of complications. Autoinoculable with great difficulty, if at all. Induration. Firm, cartilaginous, or woody to the feel; movable upon sublying tissues; sometimes very thin, resembling parch- ment beneath the skin. Generally persists for some weeks or perhaps months. Typically a non-inflamma- tory neoplasm. Perfectly painless xm.- less inflamed. Destructive Tendency. Phagedena rare, with greater tend- ency to self-limitation. Should phage- dena occur, it rarely becomes chronic. 296 CHANCROID. The Chancroid (continued). Number of Attacks. Indefinite. May attack the same subject any number of times. Suscep- tibility is never lost excepting after numerous autoinoculations, such loss being only temporary. Lymphangitis. Acute inflammation not infrequent. May result in abscess, or even in genu- ine erysipelas. May denude the parts, or cause extensive burrowing with re- sulting sinuses. Adenitis. Ganglionic reaction is present in about one-third of the cases. When present it is inflammatory and sup- puration is frequent; pus often auto- inoculable. Transmission to Animals. May be transmitted to the lower animals. Prognosis. Always a local affection; the gen- eral system never infected. May be- come chronic and incurable. May be fatal. Effects of Treatment. Treatment by mercury always use- less and in most cases injurious. (Save where complicated by syphilis.) The Chancre (continued). Number of Attacks. Rarely but one, protection from a second attack being always partial and generally complete. Lympliangitis. Acute inflammation and suppura- tion rare. Chronic hyperplasia of a jjainless character is usually present, although not always perceptible ex- ternallJ^ Not destructive, and no burrowing of pus Avith consequent sinuses. Adenitis. Superficial ganglia on one or both sides enlarged and indurated, painless, freely movable; suppuration rare and pus not autoinoculable. . Transmission to Animals. Peculiar to the human race. But may possibly be transmitted to ani- mals. Prognosis. A constitutional disease; general symptoms usually occur in about six to eight weeks after the appearance of the sore, very rarely later than three months. Never fatal per se. Effects of Treatment. Improves under the influence of mercury. An "ulcerating niucons patch may be mistaken for chancroid. This lesion, when sitnated about the genitals, is so subjected to heat, moisture, and local irritation that it sometimes becomes transformed into an ulcer closely simulating chancroid. It usually co-exists with patches in the mouth or about the anus, and is apt to be associated with either general syphilides or condylomata or both. It is rarely ulcerated so deeply as chancroid, and its secretion is not only scanty and serous, as a rule, but is not autoinocu- lable. It is not subject to phagedena, and shows no tendency to extensive tissue-destruction. It is also unaccomj)anied by marked adenitis, as a rule, and never leads to the virulent form. If adenitis occurs it is the result of mixed infection. Tertiary or syphilomatous ulcer of the genitals sometimes closely re- sembles chancroid. The differential diagnosis can only be made by careful study of the history, physical characters, and inoculability of the lesion. The preliminary syphilomatous neoplasm of the syphilitic lesion is the im- portant feature in the physical history of the case. If the patient be trust- DIFFERENTIAL DIAGNOSIS. 397 worthy, a history of prolonged continence may clear up the diagnosis. There is more induration in the syphilitic lesion than in chancroid, and this enlargement is always painless unless inflammation sets in. Bubo is usually absent or slight in the sequelar syphilitic ulcer, unless some super- added source of infection exists. Whenever it is found necessary to perform autoinoculation in order to clear up certain diagnostic points, some spot should be selected for the operation in which there are no immediately contiguous lymphatic glands. AVhere convenient, the skin of the chest beneath the nipple may be selected. The inner aspect of the thigh is not so safe, perhaps, on account of the proximity of the femoral glands, but it is usually more accessible. In sub- preputial or urethral chancroid the diagnosis can only be made by auto- inoculation, although a painful spot in the urethra followed by suppurating bubo is very signiiicant. As soon as a characteristic result has been produced, if such occur, the site of inoculation should be thoroughl}^ cauterized. Autoinoculation rarely, if ever, fails in typic chancroid, unless phage- dena or gangrene has destroyed the virulent properties of its secretion. Under such circumstances an erroneous opinion may be formed on account of the negative result of autoinoculation, the sore being pronounced syph- ilitic and constitutional syphilis prognosticated. Again, mixed sores afford a prolifie source of diagnostic confusion, as they are autoinoculable and the surgeon may decide in favor of chancroid and against the possibility of con- stitutional syphilis.^ After all that has been said regarding the differential diagnosis of chan- cre, chancroid, and simple lesions of the g&nitals, it must he acknowledged that it is never safe to pronounce against the possibility of syphilis in any indurated or ulcerative lesion upon the genitals. Many a trifling and ap- parently simple sore, wnd many apparently typic chancroids of both severe and mild types, are followed by syphilis. Such atypic cases are the chief argument of the unicists, and demand extreme diagnostic and prognostic caution. As a matter of routine, the practitioner is only safe in stating the possibility of syphilis in all genital sores, however be-nign they may appear. The value of differential diagnostic tables is therefore open to question. Diagnosis of Chronic Chancroid. — The only lesions for which chronic, chancroid can j)ossibly be mistaken are the tubercular syphilide of the sequelar period and epithelioma. If the patient be known to have syph- ilis, there may be great difficulty of differentiation. The history of the case is, of course, very useful in diagnosis. In syphilis the syphilomatous deposit ^ Campana has called attention to the fact that if some hard ulcers be irritated, the secretion becomes capable of producing an apparently typic soft sore by auto- inoculation. He believes, moreover, that the soft sore is an aflfection belonging to general rather than special surgery. Giornale Italiano del Mai. e Veneree del. Pelle, March, 1883. 298 CHAXCEOID. occurs primarily, and ulceration secondarily, while in chancroid the ulcer is jDrimary and the hardening and thickening of tissue secondary. Small portions of the characteristic deposit often remain about the gummy syph- ilitic ulcer, and effectually settle the diagnosis. If not too late in the case autoinoculation is a crucial test for chancroid. Finally, the best of all is a course of mercury and iodin, for if the condition be syphilitic it will almost inevitably clear up, while, if it be chancroid, it will not only fail to 5deld to treatment, but may grow worse under it. Cancer may often be excluded by the history, but the case may be sufficiently confusing to require micro- scopic investigation. Peogxosis. — The prognosis in chancroid is generally good. When bad or doubtful, it is dependent, not upon the chancroid per se, but upon various serious complications. Even in extensive phagedena recovery is usual, the danger being loss of tissue rather than death of the individual. An excep- tion must be made in the case of the extensive chronic chancroids already described. These lesions sometimes prove fatal, but even in such cases the fatal result is usually due to some intercurrent affection superinduced by exhaustion. Man}^ cases of chancroid might possibly prove fatal were their complications allowed to progress unchecked; the fatal cases are those in which phagedena, gangrene, or erysipelas have either been neglected or have not yielded to treatment. In a few such instances the patient dies from the combined effects of exhaustion, septemia, and pain. The destruction of tissue that chancroid is capable of producing is most to be dreaded. The organs of generation, especially in the male, may be so far destroyed as to practically unsex the individual. A case of this kind occurred in the author's hospital service: — ■ Case. — An Italian, about 30 years of age, had contracted chancroid some weeks prior to his admission to the hospital, and had sadly neglected it. By the time he con- cluded to seek advice the process had become gangrenous, or possibly phagedenic, and when he finally came to the hospital for repairs his penis had been completely amputated at its root. The final appearance of this case was very peculiar. The in- tegument had closed in about the root of the organ, and a valve-like fold of skin so completely hid the urethra from sight, that it could only be seen by lifting the flap. Thus the surface of the pubes was almost perfectly smooth, without even the slightest elevation to mark the spot formerly occupied by the penis. A precisely similar case of serious destruction of tissue by chancroid is reported by Eemondino. The severity of this case — that of a native Mex- ican — was also due to neglect.^ The cicatrices resulting from severe chancroids are sometimes very ex- tensive and productive of great deformity. The degree of damage depends, in a measure, upon the situation of the scar. Chancroids of the meatus and urethra are inevitably followed by stricture of severe type. ^ Journal of Cutaneous and Venereal Diseases, vol. i. No. 2. TEEATMENT OF CHANCEOID. 299 Teeatment of Chanceoid. — Prophylaxis. — The prophylaxis of chan- croid involves that of gonorrhea, and, in a measure at least, also that of sj'philis. Consistently with the evolutionary theory of the origin of chancroid and gonorrhea, prophylaxis must begin with the hot-bed of cultivation it- self: i.e., with the vagina of the female. It is in this laboratory of organic poisons that the infections of these diseases are elaborated, and, obviously, attention should first be given to the favoring circumstances known to exist in many women. Prostitutes, professional or clandestine, should be under surveillance. It is true that the method in vogue in Paris is very faulty, and apt to work great injury in special cases, and the author is far from advocating an identic surveillance in our own social system, but much good might be done by a modification of it. The Parisian method for the regulation of the social evil, with all its faults, has proved to be productive of much benefit. Eespecting chancroid, Mauriac has shown that the dis- ease has decreased considerably under the modern system of police-regula- tion. The registration of prostitutes, and the licensing of bagnios may not be pleasant to the mind of the theoretic moralist, but in the light of pre- ventive medicine it has its manifest advantages. Laws might be enacted compelling the proprietors of licensed houses to submit their inmates to frequent and thorough medical inspection. Women who are suffering with known infection, or with severe forms of utero-vaginal infiammation, should be quarantined until recovery, or at least until the infection has disappeared, on the one hand, or great improvement is evident, on the other. The poor unfortunates of the lower grade of prostitutes should be confined in public institutions established for the purpose until they cease to be dangerous to the health of the community. Prostitution is coeval with society, and probably will always exist; hence, the sooner we cease moralizing and deal with the subject from a philosophic stand-point, the better it will be for civilization. Prostitution cannot be prevented, nor is it certain that it would be wise to suppress it, but it can, and sooner or later must be, regu- lated. This much is certain, viz.: that supervision of the health and habits of prostitutes would lessen the frequency of venereal disease in great meas- ure, cleanliness being by far the most important factor in this result. The male sex should come in for its share of responsibility for venereal contagion. It may not be possible for the profession to teach all men that even immorality may be mitigated by cleanliness, but every physician can contribute his mite of infiuence for the public weal. Why it should be necessary to impress upon the minds of some men that they ought to ab- stain from sexual congress while affected by venereal disease is difficult of conjecture, but certain it is that many men have so little decency that they will indulge their licentiousness while still suffering from a urethral dis- charge, a more or less plainly-marked hard or soft chancre, or a mucous 300 CHAXCKOID. jDatch upon the genitals. To be fair to both sides, prostitutes should be advised to demand that each of their patrons submit to a preliminary in- spection. Such measures as those outlined would, if they could be effectually carried out, not only diminish the frequency of chancroid and gonorrhea to a great extent, but would also decrease the number of syphilitics, hereditary as well as acquired. In suggesting measures of prophylaxis it is, of course, taken for granted that absolute safety lies only in the strictest virtue. But as physicians we are compelled to face the conditions as they exist, and always will exist, unless human nature changes. After exposure in suspicious intercourse much may be done by both male and female to prevent contagion. In women vaginal injections of a solution of mercuric chlorid, chloral-hydrate, carbolic acid, tincture of iodin, or potassium permanganate will effectually prevent infection, unless chan- croidic or syphilitic poison has been already absorbed through some breach of surface in the skin or mucous membrane. In the male, careful washing with soap and water, followed by any of the solutions above mentioned, will prove effectual unless, as is stated in the case of the female, absorption has already occurred, in which case they are valueless. Prompt urination followed by solution of mercuric chlorid, will prevent gonorrhea, as a rule. Silver-nitrate solution is also efficacious. Any of these applications require the advice of the physician, in order that they may be used intelligently, and in proper strength, otherwise serious trouble may result. Whenever, after suspicious intercourse, slight abrasions are noticed, the parts should be thoroughly washed with some antiseptic solution — prefer- ably p3^rozone, 3 per cent. — and, after thorough dr3dng, each denuded spot should be thoroughly cauterized with fuming nitric acid. Silver nitrate is quite generally used, but is the worst thing possible for infected wounds. It produces more irritation in the end than mineral acids or the thermo- cautery, and, being but a superficial caustic, it merely coagulates the albu- min upon the surface of the lesion, thus sealing up the infection in the tis- sues to perform its work of destruction Avithout opposition and more vi- ciously than if nothing had been done. Inflamed tissues are favorable soil for the development of infection. These remarks apj^ly also to the treat- ment of the bites of animals, dissecting wounds, and infected lesions of all kinds. The student on entering the dissecting-room should abjure the time-honored stick of caustic if he would not enhance the dangers of dis- section. In presenting these various measures of prophylaxis the author does not wish to be understood as tacitly sanctioning fornication. What has been said has been directed to the mitigation of the results of what seems at present to be an unavoidable evil. TKEATMENT OF CHANCEOID. 301 Surgical Treatment. — When a commencing or fully-developed chan- croid is presented for treatment, Nature should be imitated so far as pos- sible by converting the so-called specific sore into a simple ulcer. This indication demands thorough cauterization. The thermocautery or gal- vanocautery is the best method. An 8-per-cent. solution of cocain muriate or eucain applied five minutes prior to cauterization will make the operation absolutely painless. If the cold button or wire loop of the galvanoeautery be applied first, and heated while in contact with the anesthetized area, the patient's nervous appre- hension will be avoided. A pinch of the dry alkaloid laid upon the surface of the ulcer is, perhaps, more active than the solution of cocain. In lieu of cocain or eucain there is nothing so effectual as pure carbolic acid, a drop of which will markedly mitigate the pain of subsequent cauterization. In the absence of the galvanoeautery the best application is fuming nitric acid. The surface must first be thoroughly dried with absorbent cotton or blotting-paper, after which the acid is applied by means of a small glass rod, or a cotton-wrapped wooden point. After the caustic has done its work thoroughly, a pinch of sodium bicarbonate should be applied to neutralize any excess of acid. Every portion of the affected surface and every suspicious spot must be completely destroyed, else reinfection will occur as soon as the sloughs produced by the cauterant separate and expose the sublying raw surfaces. The form of caustic is by no means a matter of indifference. The solid stick of silver nitrate is often used, and not infrequently produces severe inflammation. Gangrenous sloughing and phagedena are among the possi- bilities. Yet nitrate of silver has its advocates, who probably attribute their unfavorable results to Providence and the natural course of the disease. The average patient whom unlucky circumstances have provided with a stick of silver nitrate is like a bull in a china-shop, and does about as much damage. Silver nitrate has its uses in chancroid, but it should never be used until all destructive properties have been corrected and the sore is in process of repair as a simple ulcer. Then, and then only, it is useful to stimulate repair, allay irritability, or repress exuberant granulations, as the case may be. Pure bromin is a most reliable caustic, but unstable and too inconven- ient for routine use. Several other caustics are useful after the surgeon has familiarized himself with their properties and uses. The familiar mixture of the chlorid of zinc and flour, known as "Canquoin's paste," and much used by both respectable surgeons and quacks in the treatment of neoplasms, is an ex- cellent caustic. Potassic hydrate with lime and the Vienna paste — a com- bination of charcoal and sulphuric acid — are also useful as destructive cau- terants. Eicord highly recommends the carbo-sulphuric paste, it being ap- parently his favorite caustic. 303 CHANCROID. Where chancroid is inflamed or very large and multiple, and when the prepuce is tight the patient should be put to bed after cauterization until the sloughs separate, which will be within three or four days. The patient should always be apprised of the necessity of keeping the parts perfectly clean. Moist antiseptic dressings are usually advisable after cauterization, if the latter is extensive. A piece of lint or soft gauze should be wrapped about the part, and kept constantly wet with a solution of the mercuric chlorid 1 to 5000. This is cleanly and antiseptic, and tends to prevent in- flammatory complications. Any mild antiseptic lotion will, however, an- swer the same purpose. Boric-acid solution is one of the best. After the sloughs have separated, a dry dressing may be used, although the water-dressing is still preferable in many cases. The best dry applica- tion is, without question, the old stand-by, iodoform. This may be applied in any form, providing its chemic composition be not altered. An excellent method is by means of an ethereal solution: — IJ lodoformi 3ij. Jiltlier. sulph §j. M. Sig. : Apply with a camel's-hair pencil several times daily. By means of this solution a thin film of the drug is deposited upon the surface of the ulcer. Another useful formula is the following: — IJ lodoformi 3ij. Tr. benzoini co Sj. M. Sig.: Apply with a swab of cotton. The chief advantage of this method of using iodoform is that a water dressing may be applied over it. Glycerin and alcohol form a good vehicle for the application of iodo- form. As recommended by Ashurst, the formula is as follows: — I^ lodoformi 3ss., Glycerini 3ij. Sp. vini reet 3ij. M. Sig.: Apply. Dry iodoform powder is to be preferred as a matter of routine. It should be finely triturated, and when applied pressed down so as to enter all of the little irregularities in the surface of the ulcer. A small bit of oiled silk or water-proof paper laid over the ulcer will prevent the external dressings from adhering to the diseased surface. Absorbent cotton laid over this will take up the secretions that freely escape from under the pro- tective dressing. In conjunction with the iodoform the ulcer should be cleansed several times daily with pyrozone. When repair begins, iodoform with balsam of Peru is an excellent stimulant. This is the only ointment that should ever be used in chancroid. TEEATMENT OF CHANCEOID. 303 Ordinary ointments are foul and dirty applications that speedily become rancid^ producing the most intense irritation.^ The ointment of which an exception has been made is composed as follows: — ij lodoformi 3ij. Bals. Peru 3iv. Lanolini 3iv. M. Sig. : Apply on lint. The greatest objection to iodoform is^ of course, its offensive odor. Many patients refuse to use it on this account. Its odor may be disguised to a great extent. Balsam of Peru is tolerably effective. Tannin has been recommended, but it is too bulky and irritating. A good formula is the following : — IJ lodoformi 3iv. Nitrobenzolis m. v. M. Trit. subtil. Sig.: Apply. The essential oils, such as rose and verbena, are useful, but not so effectual as nitrobenzol. Many attempts have been made to deodorize iodo- form, but without success. Iodoform without its characteristic odor is "Hamlet without Hamlet." lodol is a popular ''substitute" that does not substitute, but is often useful. Europhen and nosophen are also useful to a limited extent. Salicylic acid has been recommended as a substitute for iodoform in chancroid and bubo,- and, while it does not seem so effective as that drug, it sometimes acts well both alone and in combination with bismuth, oleate of zinc, or boric acid. A good combination is the following: — IJ Ac. salicyl 3j. Bismuthi subnit • • 3ij . Zinci oleat 3j. M. Trit. subtil. Sig.: Apply. Salicylic acid is sometimes too irritating and painful. This may be obviated by mixing it with a little acetate of morphia, cocain, or eucain. These latter drugs are always useful in painful chancroid. A new anes- thetic antiseptic powder called orthoform is useful in painful sores. Andrieu and Vidal highly indorse pyrogallic acid as a substitute for iodoform.^ This drug may be used either as a dry powder, alone or in com- ^ Sigmund, of Vienna, uses mercurial ointment as an application to chancroids. Ricord, Ziessl, Bumstead, and Taylor all condemn its use, and with reason, as it is the filthiest of all ointments. = Antier, These de Paris, 1881. ^Andrieu, "These de Paris," 1881; Journal de Medecine et de Chirurgie. 304 CHAK-CEOID. bination, or as an ointment. The author has nsed it in both ways, bnt can- not indorse it. Absorbent powders of various kinds have been used extensively: car- bonate and subnitrate of bismuth, oxid of zinc, lycopodium, and talcum are among the substances employed. These powders have the same objec- tionable features as tannin; they tend to cake upon the part and cause irri- tation. Powdered oleate and stearate of zinc are not so objectionable. There are few good preparations of this drug, most of them being inclined to beconae lumpy and gritty after trituration. The powdered oleate pre- pared by Parke, Davis & Co. is free from these objectionable features. Zinc should only be used during the process of repair. As chancroid progresses toward recovery, healing may at any time be retarded by either local or constitutional causes, necessitating a change of treatment. Lotions of silver nitrate, zinc sulphate and copper sulphate, or similar astringents are often sufficient to stimulate granulation. An excel- lent vegetable preparation is the fluid extract of hamamelis, or witch-hazel, applied in full strength. The iodoform ointment is often successful in pro- moting healing. Should these milder measures prove insufficient, or if exuberant granulations exist, the pure crayon of silver nitrate or copper sul^jhate is indicated. Chancroid sometimes becomes very irritable and painful during healing. Cauterization, preferably with the galvanocautery, will relieve this condition. When the edges of the ulcer are much under- mined, they usually become thickened and calloused, seriously retarding healing. Under such circumstances they should be trimmed with scissors. The tissues surrounding chancroid often become infiltrated and hard- ened, thus impeding repair; this is especially liable to occur if the prepuce be involved. This condition is remediable by Judicious strapping with ad- hesive (diachylon) plaster. Snbpreputial chancroids require careful syringing with antiseptic solu- tions, the best of which is pyrozone, 3 per cent.; mercuric chlorid, 1 to 1000, is also good. A flat-nozzled syringe has been devised for eases of this kind, but the ordinary syringe suffices. The composition of the lotion is not so important, for one antiseptic is often about as good as another. Solutions of carbolic, boric, and salicylic acids; iodin, and potassium permanganate are all useful. The chief indication is to inject the lotion frequently. The lotion should be mild, else inflammation, and perhaps a new crop of chan- croids, may be excited by excoriating the mucous membrane and thus af- fording new atria for infection. Where urination is painful, relief may be afforded by prolonged soaking of the organ in very hot water. If the urine is passed while the penis is in the hot bath, pain will be trifling. Iodoform may be used in snbpreputial chancroids by injecting a mixture of the finely powdered drug in glycerin, oij to the ounce. This should be used once daily after a thorough washing with warm water, preferably at night. As soon as the prepuce can be retracted, the case is to be managed as in ordi- TEEATMENT OP CHANCEOID. 305 nary cases of cliancroid. Incision may become necessary in order to expose tlie glans. Chancroids of the meatus should be cauterized with great circum- spection, if at all, as any loss of tissue will enhance the almost inevitable subsequent stricture. Especial care should be taken to avoid ezcess of acid. The meatus may be dressed with a small conic plug of lint dipped in vase- lin and sprinkled with iodoform. This should be frequently changed, and will lessen cicatricial contraction. The iodoform and balsam ointment acts well in these cases. After the specific properties of the sore have been de- stroyed healing is often slow on account of the necessity of movement of the part and contact of urine. Under these circumstances the mixture of iodoform and benzoin affords a protective antiseptic coating for the ulcer. During cicatrization the passage of sounds may be necessary to prevent con- traction so far as possible; after complete cicatrization meatotomy is often required. When chancroid is located within the meatus the treatment should be mainly expectant. Cauterization is difficult and rarely-wise. Fortunately such lesions are infrequent and generally mild. As in all urethral lesions of whatever kind, the urine should be neutralized, and suitable hygienic measures advised. Cleanliness is promoted by urination, the consequent benefit being increased by the free secretion of antiseptic, or at least un- irritating, urine. The internal administration of eucalyptus, salol, and guaiacol is rational therapy. Antiseptic injections are of service, and any of the formulas recommended for subpreputial chancroids may be used, iodoform and glycerin being especially valuable. The urethra may be cleansed with 3-per-cent. pyrozone prior to injection. Iodoform may be applied very readily to any part of the urethra by means of the endoscope. Urethral suppositories of cocoa-butter are excellent vehicles for iodoform. During the healing of intra-urethral ulcers dilation must be frequently practiced, else serious organic stricture will result. Stricture is to be ex- pected, but may be moderated by judicious sounding. When chancroid is situated beneath the frenum freputii, the latter should be cut through to prevent rupture and troublesome hemorrhage from the frenal artery. When severe inflammation attacks chancroid, the patient must be put to bed at once. If the prepuce is long and phimosed and inflammatory swelling marked, or the discharge foul and fetid, justifying a suspicion of phagedena, the lesion should be promptly exposed by dorsal incision of the prepuce. This incision should be free enough to thoroughly expose the glans. The author performs this operation in all concealed lesions, where destruction of tissue is feared, whether severe inflammation exists or not. This plan has been censured on account of the danger of autoinocula- tion of the cut surfaces, but this is of minor importance as compared with the destruction of tissue occurring in some cases of concealed chancroid, and is rarely serious. 306 CHAXCEOID. The cavity beneath the prepuce and about the glans should first be thoroughly washed with pyrozone to remove tenacious secretions; this should be followed by a solution of mercury bichlorid 1 to 1000. The pre- puce should be divided upon the dorsum by means of a straight director and a sickle-shaped bistoury, or scissors. In nervous j)atients cocain may be used hypodermically in the line of incision. As soon as the parts are exposed, they should be freely bathed in the bichlorid solution and dried with gauze. First the sores and then the wound should be thoroughly cau- terized with carbolic, followed by nitric, acid. After cauterization the parts should be thickly sprinkled with iodoform and dressed with gauze. Wet dressings may be applied if preferred, and, if necessary, a bladder of ice may be laid upon the part to subdue inflammation. Hot charcoal and lin- seedmeal poultices sprinkled with laudanum sometimes act better. The progress of such cases after operation is generally favorable, the ulcers and line of incision healing promptly. Should healing be retarded from any cause, the various methods of stimulation already presented may be used. Judicious strapping is often beneficial in these cases. Should the patient be debilitated, tonics are indicated. In cases in which gangrene or phagedena have begun, whether phimosis exists or not, there is great danger of serious loss of tissue; hence treatment should be both prompt and energetic. Phimosis should be relieved by in- cision, sloughs detached, the parts washed thoroughly with bichlorid solu- tion, and all of the surfaces thoroughly cauterized either with the actual cautery or pure bromin.^ The latter is, in the author's judgi^ient, by far the best caustic in these conditions. The work must be done thoroughly, else the destructive jDrocess will not be checked. After the operation the old-fashioned charcoal poultice, preferably mixed with brewers' yeast, should be used continuously until the sloughs separate, after which time the treatment is that of simple ulcer. The poul- tice may be dusted with iodoform, or, if great pain be complained of, it may be sprinkled with laudanum. Sheet lint or gauze saturated with some hot antiseptic solution may be used instead of the poultice. Eicord recom- mends a solution of the potassio-tartrate of iron in a strength of 20 grains to the oimce of water. Should a single cauterization be insufficient to check the disease, it must be repeated as often as necessary. The constitutional treatment of phagedena and gangrene is of vital importance. It may always be inferred that they are dependent, to a cer- tain degree, upon constitutional depravity, debility and exhaustion being usually marked. Stimulants, quinin, iron, and, later on, codliver-oil are usually required. An excellent plan of stimulation is to administer a milk- punch or eggncg, with 3 grains cf qu'nin, every two cr three hours, in ad- ^ Bromin was highly recommended by the late Dr. F. H. Hamilton in hospital gangrene. TREATMENT OF CHANCEOID. 307 dition to a liberal dietary. Iron and strychnia are often serviceable, and, if pain or restlessness be marked, opinm should be given. According to Ricord and Kodet, opium has a special effect in these cases. The former highly indorses the internal administration of potassio-tartrate of iron as a specific for phagedenic chancroid, it being termed by him "the born enemy of phagedena."^ After the parts have become thoroughly cicatrized it may be necessary to trim off ragged edges of prepuce left by the gangrenous process, or the dorsal incision for phimosis, thus completing circumcision. In some cases of chancroid, extensive cauterization is not to be thought of: e.g., in severe anal chancroid and sores located in close proximity to large blood-vessels. Under these circumstances the application of such remedies as the potassio-tartrate of iron, pyrozone, iodoform, charcoal, and carbolic or salicylic acid is about all that can be done. Fortunately, how- ever, such chancroids are rare. The utmost cleanliness is required, and gauze sprinkled with iodoform should be constantly kept between the op- posing surfaces. It may be necessary to stretch the sphincter. Obstinate cases of chronic phagedenic and serpiginous chancroid cf the vulva are best treated by the actual cautery. This is to be applied from time to time in the hope of stimulating repair. Unfortunately this hope is but rarely realized, as may be seen by a visit to the wards of any large hos- pital devoted to venereal diseases. Broken-down prostitutes with this form of disease are almost always to be found in such institutions. It is not un- usual for the surgeon to go through the entire range of antiseptics, astrin- gents, and caustics in his search for a remedy for these cases. Bumstead recommended dry persuljihate cf iion in such chronic chancroids, but the author has failed to see any perceptible benefit from its use. The constitutional treatment is the most important. Attention should be paid to general h3^giene and diet. Stimulants, iron, quinin, codliver- oil and other tonics are always required, and are, as a rule, more beneficial than any form of local treatment. As a rule, the use of mercury in chancroid is injurious, but in syph- ilitic subjects it is necessary — most often in tonic doses. Exceptional cases of simple chancroid that tend to chronicity heal quite rapidly under small doses of mercury. In several cases of this kind under the author's observa- tion syphilis was excluded by the contraction of chancre followed by sec- ondary symptoms several months after the chancroid had disappeared. In nearly all cases of chancroid of whatever type, frequent prolonged hot sitz-baths are of great service. This particular method of applying moist heat seems to be of especial value in chancroid and its attendant adenitis. ^ The author's preceptor, the late Dr. F. B. Norcom, of Chicago, himself a pupil of Ricord's, relied almost exclusively upon opium in phagedena. CHAPTEE XIII. Vexeeeal Adenitis, oe Bubo. The subject of bubo has been deemed wortlij^ of separate consideration, although it rarel}', if ever, exists as a primary condition. ISTotwithstanding the fact that it is most often a complication due to secondary infection from one or the other of the local manifestations of venereal disease, it never- theless frequently occurs in conditions of a simple, non-specific, and even non-venereal character. The only conditions necessary for its development are (1) some sort of infectious inflammation situated in tissues the lym- phatics of which are tributary to lymphatic glands in the immediate vicin- ity; (2) the absorption of the products of the aforesaid infectious process and its conveyance by the lymphatics to the glands; (3) a degree of viru- lency of the infectious materials too great to be overcome by the tissues of the lymphatic glands to which the infection is conveyed. The term hiiho is generally applied only to those glandular enlarge- ments occurring in the inguinal or femoral regions, irrespective of cause, and which are usually accepted as an evidence of venereal infection of one kind or another.^ This popular interpretation of the term is unfortunate, as the affection is often due to causes of a simple and innocent nature and may involve the lymphatics in any situation. The term adenitis is better, and may with equal propriety be applied to glandular swellings occurring in the groin, femoral region, axilla, or neck, irrespective of their origin, and signifies a glandular inflammation, simple or specific. In genito-urinary practice we deal chiefly with the form of adenitis that occurs in the groin or femoral region, or in other situations when due to extragenital venereal lesions. The consideration of bubo is of the greatest importance as bearing upon diseases of a general surgical character, and a careful study of the subject will enable the student to understand other forms of adenitis that are so often met with in general practice. There is often no practical dif- ference between the sup^Durative axillary adenitis resulting from a dissec- tion wound or other injury to the hand and a suppurating non-sj^philitic bubo, and a knowledge of the causes and proper treatment of the one is apt to be of service in the management of the other. Adenitis is one of the most interesting of all surgical phenomena, the more especially as it is, so to speak, a manifestation of the special ph3^siologic function of the lymphatic glands. The lymphatic system is interposed be- tween the venous and vascular systems, and is designed for the collection and return to the circulation of any superfluous nutritive material that may ^ Bilbo ( jBovPov ) , groin. (308) PATHOGENY AXD CLASSIFICATIOX OF T EXEEEAL ADENITIS. 309 accumulate in the tissues. The fine lymjDliatic vessels are seemingly hungry for nutritive substances at all times, but unfortunately they do not possess the power of discriminating between beneficial or innocuous and injurious substances. Any soluble or finely-divided organic material may therefore be taken up by the lymphatics and conveyed to the nearest glands, and thence even to the general system by way of the veins, heart, and arteries, inducing morbid changes in the blood and various solid tissues. This is well illustrated in general or systemic pus-infection, or, as it was formerly termed, pyemia. This peculiar property of the lymphatics is well marked in cachectic or debilitated patients in whom there is a decided systemic demand for an increase of nutritive material. As is well known, the aver- age results of dissection wounds in robust and debilitated students are widely different. One may have either no morbid manifestations at all or such as are mainly local, while the other is quite apt to have a severe or even fatal result. This rule will also apply to venereal adenitis, there being a marked difference in the suscejDtibility to glandular complica- tions of different patients aff'ected with lesions of a similar nature. The lymphatic glands, fortunately, are interposed between the general system and the atria of infection in surgical affections, and, in a general way, often jDrotect the human organism against serious or even fatal results from the absorption of poisons. By undergoing inflammatory reaction, the glands interpose a barrier of plastic exudate to the further progress of pathogenic germs and their products, which by suppuration and ulceration are finally eliminated. The well-known odor of the dissecting-room, as observed in the pus from axillary abscesses following dissection wounds, is ample proof of this. In some patients, and with some infections, this glandular reac- tion is either absent or slight, and, as a consequence, systemic disturbance occurs, the degree of reaction being mainly dependent upon the corrosive- ness of the poison and the plasticity of the patient's blood. It is probably, therefore, a fortunate circumstance for humanity that the infection of chancroid causes severe adenitis when carried to tha lym- phatic glands. What results, if any, would ensue from the direct introduc- tion of chancroidic secretion into the veins has never been demonstrated by experiment, but from a priori considerations one would naturally expect quite serious trouble from such inoculation. The chancroidic process is a mixed infection — whether primarily or not — and might consequently prove dangerous if thrown into the general circulation. As seen in practice, bubo occurs in a variety of forms, which may be classified as follows: — 1. Simple non-venereal adenitis dependent upon simple lesions of the neighboring tissues. 3. Simple venereal adenitis dependent upon "specific" lesions, usually, but not necessarily, of the genitals. Simple bubo may be suppurative or non-suppurative. 310 VEXEKEAL ADENITIS, OK BUBO.. 3. Virulent adenitis due nnder all circumstances to chancroidic infec- tion and indicating the action of this sjDCcial form of irritant upon the lym- phatic glands, this form being invariahh' suppurative and quite liable to phagedena and gangrene. 4. Primary sj'philitic adenopathy. 5. Eecurrent sjqjhilitic bubo, — inguinal or femoral adenoj^ath}', — a form that is not generally recognized. 6. Subacute adenitis, or chronic adenitis, primarily of venereal origin, but perpetuated by some form of cachexia or diathesis. Its ehronicity is most likely to be due to superadded syphilis or tubercular infection. In general, bubo ma}' be classified as acute, subacute, and "chronic; suppurative and non-suppurative. The- two varieties of simple buljo (simple adenitis) may result from any inflammatory lesion of tissues contiguous to, or draining into, lym- phatic glands. A "specific" lesion of the genitals may or may not give rise to specific Ijubo, such an occurrence depending entirely upon the absorption or non-absorption of the special jjoison of the primary lesion; but it is none the less likely to give rise to simple bubo from the conveyance of simple inflammatory products, or the products of mixed infection, to the contigu- ous glands. Simple bubo, therefore, may be due to chancroid, chancre, balanitis, herpes, gonorrhea, or even stricture. It has been known to occur as a result of genital eczema, eczema of the leg, erj^sipelas, an inflamed corn, yaccination, etc. In short, any inflammatory or infectious process involv- ing those tissues the lymphatics of which are tributary to the inguinal or femoral glands is apt to cause bubo, and this fact should be remembered. It is probable, moreover, that violent strains and overexertion in some sub- jects predispose to buba. The term "sympathetic bubo'' has been quite generally applied to the simple form of the affection, but, in the light of our present pathologic knowledge, such a form of adenitis is not to be ac- cepted. Wherever bubo develops it is certain that either infection, simple or specific, has been carried to the affected gland or that actual injury to the gland has been jDroduced by trauma, which trauma is followed by infection. The only possible exception to this rule is the so-called "scrofu- lous bubo." and even in this form some injury or source of irritation is usually discoverable. Oftentimes the alleged strumous bubo is really tuber- cular. Simple bubo from mixed infection is quite apt to suppurate, but need not necessarily do so, the affection differing decidedly in this respect from the virulent form of adenitis. The location of bubo, whether simple or specific, depends upon the situ- ation of the primary lesion; thus, in lesions up:n the fingers, the axillary and cubital; in lesions of the genitalia, legs, and. anus, the femoral or in- guinal; and in lesions of the face, the pre-aural or submaxillary glands are most likelv to be affected. Obviouslv, the inguinal and femoral glands are FEEQUENCY OF VENEEEAL ADENITIS. 311 most often involved, and, as chancroid is the severest and most typicall}' virulent of the local inflammations of the genitalia, this lesion is more often than any other responsible for bubo, it being estimated that over one-third of the cases of chancroid are complicated by adenitis. Simple bubo, on account of the numerous infectious conditions that are likely to give rise to it, is more frequent than the virulent form. The relative frequency of bubo of all forms in men and women affected by chancroid is about two to one greater in the male, suppuration being also twice as frequent as in women. This is ascribed by Ziessl to the fact that the male sex is more Hr.Qt Fig. 98. — Double chancroidic bubo after spontaneous evac-uation. Showing hyperplasic infected glands. active and the parts are consequently more exposed to pressure and local irritation. It may also be explained by the fact that chancroids in women are apt to be better protected from local irritation by friction in walking. Last, but by no means least, the frequency of alcoholism in men as com- pared with women is to be considered. Chancroids of the mucous mem- brane are more likely to be complicated by adenitis than those occurring upon the skin, as might be expected from the relatively greater facility of absorption of germ-and-toxin-laden secretions by mucous tissues. The glands aff'ected are the same in both simple and specific bubo, there being a decided predilection for the central inguinal lymphatics upon 312 VENEEEAL ADEXITIS, OE BUBO. the side corresponding to the local lesion, although cases of crossed bnbo are seen in which the opposite side is affected, or both s'des att&cked simul- taneously. In rare instances simple bubo may occur upon one side and virulent upon the other. The infection often stops at the gland first af- fected in both simple and virulent bubO;, the process being more general in those forms dependent upon such constitutional conditions as syphilis, struma, and tuberculosis. The time of appearance of bubo does not bear a constant relation to the development and progress of the primary lesion; cases of bubo follow- ing chancroid are jnet with in which the sore is completely healed before the adenitis develops. Such cases, however, are quite exceptional. Chancroid occurring in tissues richly supplied with lymphat'cs are most apt to be attended by bubo, this being especially noticeable in those occurring beside the frenum preputii in the male. The possibility of the occurrence of idiopathic bubo has been affirmed by some, but denied by the majority of observers. The author inclines to the belief that, while simple adenitis in the inguinal and femoral glands is not so rare as has been generally supposed, there is always some source of infection, latent or active. It is probable that the majority of surgeons have met with a certain number of cases in which no causal lesion has been dis- coverable; it is certain that comparatively slight causes may produce ad- enitis in debilitated, strumous, or syphilitic subjects, and this is quite as likely to afilect the inguinal or femoral glands as those in other situations; indeed, the necessary movements of the parts about the flexure of the thigh especially favor inflammation in this locality. Notwithstanding the occur- rence of such apparently spontaneous attacks of adenitis, it is probable that in all cases the explanation is infection, either recent or remote, of some of the tissues tributary to the affected glands. The urethra is more frequently the source of such infection than is generally believed. Latent infection of the glands themselves may exist, and be developed into active infection by some accidental injury. The older authorities of the French school laid great stress upon a form of alleged spontaneous specific bubo: the hubon d'emUee. This was sup- posed to arise b}'' the absorption of ehancroidic or syjDhilitic poison through the unbroken skin or mucous membrane occurring without a preceding sore. This view, involving, as it necessarily must, the conveyance of germ- infection directly to the lymphatic glands via the absorbents, and the ex- citation of secondary glandular reaction without primary local changes, is now held to be untenable, especially in the case of chancroid. The hnho?i d'emblee has, however, been advocated by such eminent authorities as Casenave and Diday, though disputed by Eicord and Fournier. The major- ity of modern S3'philographers deny its existence. In some cases of true syphilis no manifestations of the disease are observed prior to the appearance of bubo, — i.e., primary adenopathy, — but SYMPTOMS OF VENEEEAL ADENITIS. 313 even in such instances an initial lesion has probably existed, and has either been overlooked or has disappeared prior to examination, the initial sore being in some cases so slight as to readily disappear, or imperceptible except under close inspection of the genitals. Cases of this kind, and of mild chancroid that has healed prior to examination, but has nevertheless been followed by bubo, probably most often constitute the so-called dubon d/emblee, for it is well-nigh certain that local changes of greater or less degree of severity always follow infection by syphilitic or corrosive chancroidal poison. In some cases of apparently idiopathic suppurative bubo, the test of autoinoculation may settle the question of the pre-existence of chancroid. Should autoinoculation prove successful, it will demonstrate the existence and character of a local lesion that had appeared and healed shortly before the appearance of the bubo. Symptoms. — ■ The symptoms of simple inflammatory bubo are quite characteristic. The first manifestation of the disease consists of a feeling of soreness in the groin, such as might be produced by a violent strain. On inspection, one or more small, round, or ovoid indurated swellings are found in the groin or femoral region. These are usually quite tender to the touch, and cause considerable pain in walking, although at first freely movable upon the sublying tissues. In some instances there is slight febrile move- ment. In many cases the inflammation may be aborted at this stage by proper management, and resolution will occur quite promptly; but in the majority the swelling and pain rapidly increase, the swelling of the glands becomes blended in that of the surrounding tissues, and the skin becomes adherent at one or more points. After a variable time a spot of softening develops and the abscess finally breaks, discharging a more or less creamy and healthy-looking pus for a few weeks, and healing quite promptly under favorable circumstances. In by far the greater number of cases, however, healing is apt to be slow. There are few patients who do not attempt to attend to their ordinary duties while at the same time endeavoring to obtain a cure for the bubo. This is the explanation of the majority of cases of chronic simple bubo. The lack of rest is frequently supplemented by de- bility, syphilitic or other cachexia, and intemperance, the last-named factor being second only to a lack of rest in retarding healing. Very often the conditions just enumerated result in the formation of sinuses that can be cured only by operation. The constitutional symptoms in suppurative bubo are those of simple suppuration, and the formation of pus may therefore be heralded by a chill of greater or less severity. The course of simple bubo in strumous or cachectic patients is apt to be particularly annoying, constituting subacute or chronic indolent bubo. Instead of an acute inflammation affecting one or two glands, a number of glands are likely to be involved, with slowly-progressing, indolent en- largement and chronic suppuration. The glands become matted together 314 YEXEEEAL ADENITIS, OE BUBO. in a brawny indurated mass, sometimes edematous, sometimes producing, b}' circulatory obstruction, edema of the genitals. After an indefinite time the periglandular connective tissue breaks down into a thin, unhealthy, ichorous pus, after which the abscess, if unopened, will sooner or later break spontaneously. The skin about such abscesses is thinned and bluish, its nutrition being profoundly impaired. Burrowing of pus in various directions, with consequent formation of sinuses with hard pseudocartilagi- nous tracks, may result, yielding a discharge that sometimes persists for years. When the abscess is first opened in such cases, the glands will be found to be entire and circumscribed. Jutting out from the floor or sides of the cavity, showing that the inflammation in such cases is chiefly peri- glandular. In such cases the glands are primarily the seat of small miliary abscesses, one or more of which break into the periglandular tissues, infect- ing them and producing abscess. The conformation of the glands is not altered, and there is often no evidence of suppuration in them at the time the periadenitic pus is evacuated. Miliary glandular abscesses are, in the authors opinion, the invariable cause of periadenitis in bubo. Even in simple bubo such abscesses occur very early. The author has found them as early as the third day after the development of a gonorrheal adenitis. This fact is the principal argument in favor of early extirpation of the glands in bubo, however simple the form. Good results are not to be expected, as a rule, after periadenitis has occurred. The glands may subsequent!}^ break down into pus, but more often they liecome hyperplastic and the seat of fungoid granulations that prevent heal- ing. Sometimes they hypertrophy to such an extent as to completely fill the abscess-cavity, forming a large projecting fungoid mass, in which case healing never occurs without surgical interference. Suppuration does not always occur in indolent bubo, for the glands may remain as comparatively painless, sluggish swellings indefinitely. The pus of simple bubo, whether acute or chronic, is never autoin- oculable in the specific sense, nor is the process apt to be complicated by phagedena; erysipelas and gangrene, however, are possible complications. ViEULE^fT Bubo. — This has been fallaciously termed "the bubo of ab- sorption," from the fact that absorption of the secretion of chancroid is necessary to its production. This term is obviously misleading, for simple bubo is due to absorption of pus-microbes and their toxic products, as de- velojDed in simple inflammation. The term "chancroidic bubo" is not ac- ceptable, for the reason that chancroid may produce simple bubo by the absorption of the products of mixed infection, independently of the specific character of the fons-origo et mali. This form of bubo usualty affects a single gland ujDon one side, and is not readily distinguished from the simple acute form until the pus is dis- charged and autoinoculation can be practiced or the resultant lesion in the groin assumes chancroidic characters. In a general way, it may be said that VIBULENT BUBO. 315 viinilent bubo is a more active process and suppurates much more quickly than the simj^le variety, but these characters are by no means to be relied upon for a diagnosis. There is one j)eculiar feature of virulent bubo that it is well to bear in mind, viz.: its liabilitv to aii accompanying periadenitis of a simple suppurative character. Under such circumstances, the first pus discharged from the abscess is unirritating in character and not autoin- oculable, while that which is evacuated later on from the gland proper is highly corrosive to the tissues and typically autoinoculable. This circum- stance explains how some cases of apparently simple suppurative bubo un- dergo subsequent transformation into the virulent form of the affection.^ Soon after a virulent adenitis ruptures or is inc'sed, the lesion assumes the characters of ordinary chancroid. In favorable cases the tissues become so matted together about the abscess that it remains circumscribed, but occasionally the surrounding structiires are so loose that extensive and de- structive burrowing occurs, forming sinuses and pockets that may last for 3'ears, perhaps for life. Phagedena may attack a viruLnt buljo. Phageclen'c genital chancroid is not necessary for its production, simple chancroid being frequently fol- lowed by phagedenic bubo. When phagedena does attack a bubo, it is quite likely to assume the serpiginous form. This extends upward over the ab- domen by preference, but when the process reaches the walls of the chest, which appear to be unfavorable soil for its progression, it will usually ad- vance in the other direction and descend along the thigh. Some cases of phagedena, notably the serpiginous form, will progress with greater or less rapidity in spite of the best of treatment, and others, after the phagedena has been checked and the sore is very nearly healed, will suddenly take on phagedenic action. Simple bubo may do the same thing, in rare instances. The author recalls one case occurring in the wards of the NeAV York Charity Hospital in which the bubo was apparently nearly closed and was granulating finely, when gangrenous phagedena set in and extended over nearly half the abdomen before it could be checked. By free stimulation and a nourishing diet, with the local application of the carbo- sulphuric paste, the process was finally stopped, but not until a large area of the external oblique muscle had been destroyed and even the sublying muscles attacked. This case was primarily one of virulent bubo, but had not been phagedenic, and at the time the phagedena set in was practically a simple bubo in j^rocess of granulation. There is one form of chronic bubo that merits especial attention. This is the variety that accompanies the form of chronic chancroid erroneously termed lupoid of the vulva, or, in the male, chronic phagedena. This form ^ Virehow, in his "Cellular Pathology.'" calls attention to the fact that the poison is found in the substance of the gland, and not in the surrounding tissues. Ricord first directed attention to this peculiar feature of virulent bubo. 316 VENEEEAL ADENITIS, OR BUBO. of bubo is identic in its general characters with the lesion of the genitals that it accompanies, presenting an elevated, hyperplasic mass of tissue of greater or less extent, with an unhealthy pultaceous or worm-eaten appear- ance of its surface, and secreting an ichorous fluid. The disease extends very slowly, if at all, after having attained a certain size, the process having meanwhile become .continuous in many cases with the genital ulcer. There are apt to be several of the buboes, either separate and distinct or connected by ulceration. Such cases are very apt to be of an hemorrhagic nature in pregnant females. This severe form of chronic bubo is rarely, if ever, seen Fig. 99. — Phagedenic bubo. in private practice, being found in broken-down hospital cases. It will often defy the best measures of treatment and finally wear the patient out. As has been already stated in connection with the physiology of the lymphatic capillaries and glands, virulent adenitis does not infect the gen- eral system. This fact is jDCCuliar, for, from a priori considerations, we would expect that a process so intensely infectious locally and presenting by its extent such favorable opportunities for absorption of poisonous materials Avould be apt to produce constitutional infection of greater or less degree. Not only is the contrary the case, but virulent adenitis, per se, rarely, if ever, leads to septemia. Indeed, the author cannot recall a single case of such septic absorption. In phagedenic adenitis, especially, it would seem that VIRULENT BUBO. 317 there should be danger of secondary infection. Such, however, is not the case. On the other liand, in the gangrenous form of the affection a greater or less degree of septic infection is usual, but this is independent of the alleged specificity of the bubo. Stimulated by the researches of the eminent Chauveau, in his study of the effects of heat in weakening and modifying organic poisons, Aubert experimented some years ago with the virus of chancroid, with the view of explaining some of its peculiarities, with especial reference to its non-con- stitutional character. The experiments were conducted as follows^: — Chancroidic virus was taken from different hospital patients and placed in vaccine-tubes, some of which were then subjected to various degrees of heat, while the remainder were preserved unchanged. Inoculations were performed with the heated and the non-heated virus, respect- ively, and their results compared. In this way it was found that the virus becomes powerless when heated to be- tween 37° and 38° C. — the average temperature of the interior of the human body. As a deduction from these experiments, Aubert concludes that he has explained the following points in the clinical history of soft chancre^: — 1. The seeming impenetrability of the sj^stem by the virus of chancroid, as evi- denced by the non-occurrence of internal ulcers and pelvic buboes. The long-estab- lished fact that chancroidic infection never spreads to the interior tissues or beyond the superficial glands can only be accounted for on the ground of heat. Admitting this we can scarcely conceive the possibility of a pelvic abscess of venereal origin except in a subject whose central temperature had previously been lowered by exposure to long-continued and intense cold. But if the infectious matter were able to withstand a heat of 40° or 45° C, there would be nothing to prevent its per- meating the entire organism and furnishing the most fearful manifestations of its power. 2. The occurrence of bubo, whether chancroidic or inflammatory, solely in the superficial glands. All the glands — superficial and deep — are alike in structure and function; but the former, owing to their situation, preserve a lower temperature, and this is the only conceivable reason why they alone are affected by bubo. 3. The brief duration of chancroids on the cervix uteri, and the rapid changes they undergo, are facts that should be considered from the same point of view; as, also, 4. The limitation of chancroid of the anus to the inferior portion of the latter. 5. The relative frequency of simple inflammatory bubo, which occurs almost as often as the chancroidic form. It is a familiar fact that the same primary sore will give rise sometimes to a chancroidic bubo yielding inoculable pus and sometimes to a simple, non-infectious swelling. I regard all secondary buboes as chancroidic in their beginning, but think that an attack of fever will operate to convert any such bubo into one that is simply inflam- matory. ^P. Aubert, Lyon Medicate, August 12, 1883. ^Aubert tei'ms the chancroid "chancre." The author has changed the term to avoid confusion. 318 VEXEEEAL ADEXITIS, OR BUBO. 6. Cure of phagedena by erysipelas. Erysipelas causes an elevation both of the central and local temperature, which may suffice to destroy the virulence of chan- eroidie pus and to transfonu the spreading ulcer into a simple one. 7. Cure of chancroid by gangrene. The gangrenous process is uniformly accom- panied by intense fever — sometimes passing into typhus — and itself results from a high grade of tissue-inflammation. 8. The difference in the results of inoculation in different regions. This is well known to experimenters, especially as connected with chancroid of the face. Eeasoning from the premises above indicated, Aubert believes that heat in the form of local applications and the prolonged nse of hot sitz-baths is a specific for chancroid and virnlent bubo. Anbert's theory is, to say the least, ingenious, and it is unfortunate that there should be any ambiguity in his statements resulting from looseness of nomenclature. As is well known, the system is not impenetrable to the virus of true chancre, and the interior tissues and glands are always involved sooner or later. At the time of the occurrence of general adenopathy, how- ever, ulceration or necrosis of tissue is exceptional in the natural history of the disease. In the case of chancroid, the lymphatic glands, as already indicated, seem to act as a physiologic barrier to the internal progression of the disease. This is also true of syphilis, but in the latter disease the resistance of the glands is overcome in a short time, and the infecting cells gradually invade the deeper structures. In the case of chancroid the poison so irritates the glands that acute inflammation with its accompanying ex- udate occurs, and blocks the farther progression of the poison, in all prob- ability by exudate pressing upon the absorbents, thus temporarily check- ing their functions. By the time this pressure has been removed and the exudative material has disappeared by resolution and suppuration, the ab- scess has been evacuated, either by the knife of the surgeon or by spon- taneous discharge, and later on the specificity of the infection becomes ex- hausted, as it invariably does in the natural course of the disease. An area of inflammatory infiltration of greater or less extent surrounds a virulent bubo for some little time after the specificity of the discharge has disap- peared. It will be found that the infection of chancroid tends to exhaust itself by the inoculation of successive tissues, and it is probable that it thus finally loses its power of extension along the lymphatics.^ The infection then, in all probability, becomes modified, so far as its affinity for lymphatics is concerned, in the glands first affected. It is impossible to say how much influence the temperature of the deeper glands may have in opposing the progress of the infection, but it does not seem possible that the difference in temperature of the superficial and deep tissues of the body is sufficient to determine the non-susceptibility of the latter. It is highly improbable that the conditions to wdiich Aubert subjected his virus in the vaccine-tubes were ^ Some of the experiments conducted in Boeck's method of syphilization have demonstrated this fact. VIRULEXT BUBO. 319 at all similar to those that prevail when poisons are introduced into the animal body. The short duration of chancroids of the cervix nteri is explained by the relative density of the tissues of this region and the sparsity of con- nective tissue and lymphatics (ccnd'tions which form very unfavorable soil for the development of chancroid), rather than by the high temperature of the part. That erysipelas and gangrene destroy the infection of chancroid by virtue of the elevated temperature which they produce is hardly a fair proposition. Whether the tissues are so modified by these diseases that they will no longer give sustenance to chancroid, or the germs and toxins of these diseases are inimical to the life of the organism which it is fair to assume is the essential element of chancroid, would be difficult to deter- mine, but either view of the case is more philosophic than the deductions of Aubert. This particular point has been expatiated upon because of the belief that it is one of the most interesting features in the life-history of the infection of chancroidic ulcers and bubo. So far as the local use of heat is concerned, it is, irrespective of any theory of its action, an excellent measure of treatment, and, although it is not in any sense a specific, it is clinically well worthy of the praise that our overenthusiastic experimenter, Aubert, has given it. It is unnecessary at this time to dwell particularly upon primary syph- ilitic bubo, as it is rarely troublesome and is important only as a local mani- festation of a constitutional disease, rarely calling for special local meas- ures of treatment. Whenever it is prominent per se, it is from superadded simple pus-infection, or virulent infection from complicating chancroid, and not from its syphilitic character. The more typically syphilitic the bubo, the more innocuous it is. Syphilitic bubo rarely suppurates, and then only as a result of complicating infection, pyogenic, tubercular, or chan- croidic. Its special characters will receive attention in connection with the subject of primary syphilis. There is a form of syphilitic bubo, however, to which the author de- sires to call especial attention. This he has ventured to term recurrent syphilitic hudo. The assertion is made by most syphilographers that syphilitic bubo, having once resolved, does not return, although in exceptional cases the affected glands may remain enlarged for a considerable time. Tlie author had accepted this ipse dixit without question for some years, attributing such instances of bubo as appeared in late syphilis to other causes than the old constitutional taint. In most cases this as.sumption was doubtless cor- rect, but in some of them it probably was not. The following are cases in point: — Case 1. — A young man, 24 years of age, had a typic chancre followed, by a characteristic course of secondary syphilis. Bubo of a non-suppurative, but painful, .320 YEXEEEAL ADEXITIS, OE BUBO. character was one of the prominent manifestations of the disease. Under proper measures of treatment improvement was quite rapid. Unfortunately, however, the patient considered himself cured at the end of about six months, and ceased treatment. A year later he again consulted the author for what he supposed to be a return of the disease in the form of a bubo in the right groin. This had come on independently of venereal exposure, and examination of the genitalia failed to show any local cause for the trouble. In appearance and feel the bubo was identic with the ordi- nary primary adenopathy of syphilis, and was painless except on very firm pressure. On examining the mouth several small mucous patches and a characteristically- fissured tongue were found. There seemed to be a general lowering of systemic tone, and loss of appetite was complained of. There was no history of injury. Under small doses of mercury and potassic iodid, with a liberal diet and tonics, recovery was complete in about six weeks. Case 2. — This case was similar to the above excepting in the fact that the bubo was attributed by the patient to a strain, and had appeared six months after the disappearance of the primary bubo and three months after any possible exposure. There were no evidences of an acute inflammatory process, and the patient was in fair systemic condition. The usual course of antisyphilitic treatment, combined with counter-irritation, caused resolution in about eight weeks. Case 3. — This case was that of a young woman of 18: a cachectic, debilitated subject, who had been affected by syphilis about a year and a half, during a portion of which time she had been treated very thoroughly. The femoral glands were in- volved originally, and, as was to haA-e been expected, if the author's view of its origin is correct, the recurrent disease affected the same glands. Mucous patches were pres- ent in the mouth, but the genitalia were healthy. jSTo lesions were discoverable in any situation which would account for the bubo. Suppuration occurred in this case, the pus being scanty and thin, and the glands remained indurated for some time after the abscess-cavity had healed. As soon as the patient could bear antisyphilitic treatment, however, the induration rapidly disappeared. Case 4. — A medical man, 35 years of age, had syphilis two years before the second bubo appeared. At the time of its appearance he was a little out of health, but had experienced nothing that might account for the glandular enlargement. He had not had sexual intercourse for four weeks prior to the appearance of the bubo, and no genital lesions had been detected since the original chancre. Being a phy- sician, he was naturally puzzled by the occurrence of inguinal bubo without any exciting cause, and contrary to the assertions of surgical authorities. The bubo finally suppurated, and did not heal after evacuation until a thorough course of anti- syphilitic treatment was instituted, after which recovery was rapid. These cases, with a numher of others observed by the author, seem to show that many cases of bubo, in which the causes are obscure, are due to a recurrence of glandular syphilis. That this is unusual is explicable by the fact that it only recurs in certain individuals. In strumous persons, for example, there is an inherent tendency to glandular enlargements, and, whenever in the course of syphilis in such patients there 'is a sudden re- newal of proliferative energy in the syphilitic cells, the glands are affected because of their affording a locus minoris resistentice. The same process that might in other persons produce a S3^philoderm only will in these produce a bubo. The recurrence of glandular enlargement in the groin rather than elsewhere is explicable by the greater susceptibility of these glands due to their situation, which exposes them to local irritation and invites cell-de- DIAGNOSIS. 331 posit^ and to the fact that primary adenopathy is most marked in them, leaving them relatively more susceptible than the general glandular system. Such circumstances as alcoholism, strain in lifting, an irritable corn, ex- posure to cold, or trifling genital irritation, may act as exciting causes of recurrent bubo in such patients. Debility and cachexias of various kinds bear the same relation to recur- rent syphilitic bubo as does struma. The possibility of such recurrent adenopathies constituting some of the cases of so-called huhon d'emhlee will at once suggest itself. Diagnosis. — Simple Inflammatory Bubo. — This form generally results from inflamed chancroid, but may be due to gonorrhea, balanitis, herpes, inflamed hard chancre, or any lesion of the genitalia, specific or simple. It may also result from inflammation of any tissue the absorbents of which empty into the inguinal or femoral glands. Erysipelas of the lower extrem- ities has been known to cause the disease. An inflamed corn is by no means a rare cause of inguinal or femoral adenitis. In a case of the author's at present under treatment for severe gonorrheal arthritis of the knee, well- marked simple bubo exists in the groin of the affected side. When simple bubo suppurates, it presents all of the characters of simple abscess. The pus in these cases is never autoinoculable, and the tissues are seldom attacked by phagedena. Gangrene may occur, but very rarely. Healing is generally prompt under proper measures of treatment. Virulent Bubo. — This form is invariably the result of chancroid or mixed sore, and often becomes phagedenic or gangrenous. Suppuration is an invariable result, the discharge being highly corrosive and infectious, and autoinoculable, the result of autoinoculation being typic chancroid. Soon after its evacuation virulent adenitis assumes the physical characteris- tics of chancroid, its edges being sharply cut and undermined and its base eroded and sloughy. Healing is slow and sinuses and fistulas are common results. Even before it is opened the virulent abscess presents certain feat- ures which, although not pathognomonic, are to a certain extent indicative of the character of the lesion; thus the pain and tenderness are marked, the swelling is not well circumscribed, the integument is thinned and bluish, and brawny to the feel, and suppuration is quite rapid in spite of all meas- ures to abort the inflammation. Syphilitic Bubo. — This form follows a hard chancre or a mixed sore, and is often accompanied by general adenopathy by the time the case is pre- sented to the surgeon. If recurrent, it is preceded by a more or less typic course of general syphilis. It is perfectly circumscribed, movable upon the sublying tissues, and presents a peculiar hard, woody, or bone-like feel to the touch. It is slightly, if at all, tender, and is altogether of a passive nature. Suppuration is rare, and when it does occur is due to such com- plicating circumstances as inflammation of the primary sore, mixed infec- tion, cachexia, trauma, struma, or tuberculosis, and the pus thus produced 322 VENEEEAL ADENITIS^ OE BUBO. is never autoinoculable save in the case of mixed sore, in which the viru- lent element imparted by the chancroid is responsible for its autoinocula- bility. Too much care cannot be taken to ascertain the atrium of infection in all cases of bubo. It is impossible to overestimate the importance of this in cases of suspected sj^philis. A careful search for the source of in- fection will often not only clear up a doubtful diagnosis, but in extragenital sores will also shed much light on the manner in which the infection was contracted. Teeatment. — The systematic management • of venereal adenitis re- solves itself into several practical considerations, viz.: (1) j)rophylaxis; (3) prevention of suppuration; (3) extirpation of the affected glands; (4) treat- ment of suppurating adenitis; (5) treatment of sinuses and exposed lym- phatic glands; (6) treatment of gangrenous and phagedenic adenitis; (7) treatment of chronic or indolent bubo; (8) treatment of syphilitic glandu- lar enlargement, primary or recurrent, and of other forms when complicated by syphilis. With the exception of the prevention of suppuration and the treatment of gangrenous and phagedenic adenitis, these headings apply equally to both the simple and virulent forms of the disease. The formation of pus cannot be prevented in virulent gland infection, and the simple form is not very liable to either gangrene or phagedena, although either may occur under certain conditions. The liability to the occurrence of venereal adenitis is, of course, greatly enhanced by any virulent property that may exist in the genital lesion, and is of necessity, therefore, much greater in chancroid than in gonorrhea, balanitis, or any of the simpler forms of local irritation that frequently cause adenitis. Prophylaxis is consequently much less likely to prove efEeetive in chancroid, and especially in its virulent form. Whatever the source of irritation, the chief prophylactic measure is rest, though in most cases of gonorrhea or balanitic lesions and even in chancroid, unless large and destructive, this is not practicable. The patient may at least be impressed with the importance of avoiding strains and violent efforts so far as possible. When the patient is compelled to go about, and especially if his occupation involves muscular effort or prolonged standing at the desk or counter, an excellent plan is to apply a double spica bandage with a compress in each groin on the first indication of inguinal irritation. An important indication is to maintain free action of the bowels; straining at stool tends to produce inguinal irritation. Patients with bubo generally complain of pain in the groin during a difficult stool. The most important prophylactic measure is proper treatment of the genital or ure- thral lesion from which infection of the glands is feared. The sooner irri- tation and inflammation are allayed and infection destroyed, the sooner the danger of adenitis will disappear. In chancroid the danger of gland infec- TEEATMENT OF VENEREAL ADENITIS, OR BUBO. 333 tion is inversely to the rapidity with which the virulency of the local sore is corrected. Thorough cauterization of the chancroid is therefore the best means of prophylaxis. In the event that, in spite of prophylaxis, adenitis develops, strenuous endeavors should always be made to prevent the formation of pus, for healing after incision or rupture often requires considerable time, aside from the danger of inflammatory or hemorrhagic complications. A very unsightly, discolored cicatrix is also left — a very important consideration, especially in women. One of the best local measures of pus prophylaxis is absolute rest, combined with applications of ichthyol solution in a strength of from 25 to 50 per cent. A very useful combination is the fol- lowing: — ■ . U Ichthyol 3ij. Tr. belladon 3ij. Hydrarg. bichlor gr. v. Aq. dest q. s. ad 5j- M. Sig. : Apply t. d. with camel's-hair brush. Counter-irritation, either with or without pressure, has been extensively employed. The counter-irritant most frequently used is ordinary tincture of iodin; the compound tincture with an extra amoimt of iodin added is better. A shot-bag of about five pounds' weight is an excellent means for the application of pressure. A better plan, however, is to apply a spica bandage over compressed sponge, laid upon the bubo, the sponge being sub- sequently kept wet with cold water. As the sponge swells, a very firm and equable pressure is exerted upon the tumor, in addition to the antiphlogistic effects of cold. The benefits derived from this form of treatment are ex- plained by the local anemia thus produced and the prevention of further exudate. Instead of pressure, hot poultices may advantageously be used con- jointly with ichthyol. The application of leeches has been recommended to avert suppuration by causing local depletion, but the leech-bites form lesions that may become infected by autoinoculation in case the bubo should prove to be virulent, and the fewer such lesions the better. The injection of carbolic acid into the substance of the inflamed gland has been strongly recommended. The author's experience with this method has not been encouraging. It could hardly have any effect in virulent bubo, and its antisuppurative power, even in simple inflammation, is, to say the least, doubtful. The mode of procedure is to make a number of injections of a 1 to 15 solution of carbolic acid into the substance of the inflamed gland. The author has used the bichlorid of mercury in this manner with some success. In obstinate syphilitic bubo the bichlorid or calomel may be used with the view of hastening resolution. Lead-iodid ointment, in combination with the extract of belladonna, is sometimes successful in aborting simple bubo. Acetate of lead is rec- 324 VENEEEAL ADENITIS, OK BUBO. ommended by Ziessl. His method is to soak a number of compresses in lead solution and bind them upon the bubo, keeping them thoroughly wet. The ordinary lead-and-opium wash, with an increased proportion of both ingredients, is much better than a simple solution of lead acetate. The most effective antisuppurative measure at our command is the much-used and little-understood poultice. There occurs in all inflammations profound circulatory disturbance, and at the period of purulent formation this chiefly consists in obstruction and stasis, enhanced by the circumscribed collection of cells to a degree proportionate to the tension present. As a result of the- pressure, there is lymphatic obstruction and consequent inhibition of the function of the ab- sorbents. The vitality of the tissue-elements is impaired to an extent greatly modified by the amount of pressure and circulatory disturbance, this impairment of nutrition being greatest in the tissues immediately contigu- ous to the pus and shading off into the surrounding tissues. As a result mainly of the pressure of the purulent formation, a layer of partially-or- ganized lymph forms in the abscess, which in chronic abscess forms a pseudomembrane, erroneously termed the pyogenic membrane. In acute abscess, however, it simply shades off into the surrounding tissues, which are, in a measure, matted together by exudate. The thickness and degree of organization of the layer of lymph, and the extent to which the vitality of the surrounding tissues is impaired (which, as already stated, depends mainly upon the amount of inflammatory exudate and consequent circulatory disturbance) determines the facility with which resolution of circumscribed inflammation, on the one hand, and formation of pus, upon the other, take place. It was formerly believed that pus, once formed in a circumscribed collection, cannot be absorbed, but this is erroneous. It is well known that the first factor in the production of the phe- nomena of inflammation is irritation, and that this results in the various changes just described. Irritation is enhanced by the accumulation of in- flammatory products. "\^nien a hot poultice is applied to inflamed tissues, the irritation and pain are primarily relieved, and this has an immediate effect in preventing or lessening further exudation, and probably induces also a certain amount of vascular contraction, via the vasomotor nerves. In lessening exudate circulatory obstruction is diminished, thus relieving the impairment of nutrition resulting both from pressure and stasis. Eelief of pressure is attended by restoration of function in the absorbents, which is necessary for resolution. If inflammation is severe, with extensive exudation, the nutrition of a certain number of embryonal tissue-elements becomes so disturbed that reso- lution, which readily occurs when the vitality of the tissues is only mod- erately impaired, cannot occur. Here, moist heat will fail to prevent sup- puration, but will limit exudate, and prevent further tissue-change. There is an indurated area about an abscess, as is well known, in which the changes TREATMENT OF VENEREAL ADENITIS, OR BUBO. 325 described occur. The cells in the periphery of this area may have sufficient vitality to become resolved, while the changes in those in immediate rela- tion to the abscess-cavity have gone too far to permit of resolution. It is an easily verified clinical fact that the less the degree of induration sur- rounding an abscess, and the sooner it resolves or breaks down into pus, the sooner will the abscess heal after incision. There is much of truth in the popular idea that an abscess should be "ripe" before it is opened; healthy granulations cannot arise from tissues devitalized by the pressure of a large amount of inflammatory exudate. The distinctness of fluctuation, which is so evidently increased by poulticing, depends upon the amount of surround- ing exudate, and while the tissue over an abscess is becoming thinned by the pressure of the pus, the inflammatory exudate in its meshes is being removed by the action of the poultices. The action of moist heat, then, may be formulated as follows: 1. It will prevent pus-formation if the vitality of the tissue-elements has not be- come too greatly impaired. 2. It will hasten maturation, and limit the purulent formation, if the impairment of nutrition has gone too far to per- mit of resolution. 3. It will diminish the indurated area about an abscess after incision or spontaneous rupture, and favor healthy granulation. It may be accepted, therefore, that the application of moist heat is beneficial at any stage of acute inflammation and abscess. Such applica- tions, it is true, may be continued too long, making the tissues boggy and infiltrated, but this can be avoided. In speaking of the action of poultices, it is assumed that they are properly used. They are not, as a rule, properly made, and, if hot at the outset, are allowed to become cool before they are applied. If applied hot, they are usually allowed to become cold, thus neutralizing any beneficial effects of the heat, if, indeed, the inflammation has not been augmented by clumsy manipulation and rapid changes of tem- perature. A poultice should be renewed sufficiently often to keep it hot, or no benefit can be expected. A convenient method of obviating the neces- sity of making a fresh poultice for each application, is to prepare a number, and keep them hot by means of the ordinary bread-steamer. If, after a bubo has been opened, antiseptic poultices are necessary, equal parts of char- coal and linseedmeal, mixed with hot yeast instead of water, form the best material. A valuable antisuppurative measure is the internal administration of calx sulpJiurata, or, as it has been erroneously termed, sulphid of calcium. Pure sulphid of calcium is not found in the drug-market, nor has it ever been used therapeutically. Calx sulpliurata, or sulphurated lime, as de- scribed by the new pharmacopeia, is a mixture of sulphate and sulphid of calcium in varying proportions, containing not less than 36 per cent, of the latter. This drug has been highly lauded as an antisuppurative, and has ^ Piffard, especially, has indorsed calx nulphurata in gland infections. 326 TEXEEEAL ADEXITIS, OE BUBO. been especially recommended in the treatment of venereal adenitis.^ The author believes from considerable experience in its nse that it is a remedy of great value, and that it has several effects, varying with the character of the inflammation. Its action in the prevention of suppuration is similar to that of poultices, and like the latter, unless the inflammatory changes have gone too far to permit of resolution, it will favor supjjuration and hasten maturation. It probably acts by producing fatty degeneration of the in- flammatory exudate, thus relieving the circulation. Unlike poudtices, it will cause pus that is already fully formed in a circumscribed cavity to become ab- sorbed, probabl}^ through this same fatty degeneration. The possibility of this has been denied, but numerous instances of such absorption are met with. A case observed by the author is especially striking: — Case. — A pale, lymphatic- female entered the hospital, suffering from a slight gonorrheal vaginitis, and presenting in the left groin a suppurating bubo of a peculiarly chronic character, there being distinct fluctuation throughout and no redness or induration. The tumor was as large as a good-sized hen's egg, and the skin covering it was so thin that it was expected to burst spontaneously at any moment after her admission. The woman was so anxious to avoid a scar that she was experimentally given V2-giain doses of calx svIpJiurata every three hours, and operation deferred. The pus entirely absorbed in less than a week. The dose of the drug should vary Avith the stage of the inflamma- tion. As a preventive of suppuration, ^/^g grain should be given every hour. When inflammation has so far advanced that suppuration is in- evitable, the dose should be increased to from ^/^ to ^/o grain every three hours. In chronic and indolent bubo, and in cases in which unhealthily secreting surfaces or sinuses are left after incision or rupture of the abscess, large doses will often speedily bring about healthy action, the surrounding induration rapidly disappearing and the character of the pus changing from sanious or ichorous to a free secretion, after which granulation is quite rapid' The prevailing variance of opinion as to the effect of calx sulphurata in inflammation is only explicable by the ignorance that prevails in respect to its proper use. Like moist heat, this drug, in proper doses, may produce beneficial effects at any stage or in any variety of glandular inflammation. Notwithstanding what has been said of the antisupj)urative treatment of bubo, we are compelled to acknowledge that it is only effective in simple adenitis, and that the virulent form must inevitably suppurate; but as our antisu]3purative measures may, under certain circumstances, also promote maturation, and will always limit the surrounding inflammation, they are always indicated. Again, it is not usually possible to affirm that a bubo is virulent prior to suppuration. • If, however, the primary lesion be an auto- inoculable chancroid, and the resulting adenitis runs a very acute course, we are warranted in assuming that it is virulent. After the bubo is opened the diagnosis is, of course, quite easy. TREATMEXT OF VENEREAL ADEXITIS, OR BrBO. 327 The importance of internal measures in the management of bubo can Scarcely be overrated and may properly be alluded to in connection with the antisuppurative treatment of the disease. As soon as bubo threatens free catharsis is indicated; throughout the course of the affection mild laxatives should be given, for reasons stated in connection with prophylaxis. If the patient be debilitated, tonics should be freely given, and, if struma be evi- dent, codliver-oil and the syr. ferri iod. should be administered. . As a rule, too much dependence is placed upon local measures and too little attention given to the constitutional condition. Chronic, indurated, open bubo not infrequently heals promptly under jiroper constitutional treatment. There is one point with reference to prophylaxis of suppuration in bubo which it may be well to mention. Many patients object to measures designed to "scatter" the bubo, on the ground that such a plan "drives the poison into the blood." If the treatment suc- ceeds in aborting the bubo, all subsequent skin eruptions and perhaps other troubles will be charged to it. The objections of such ignorant persons are mainly to such measures as they understand to be antisuppurative, such as counter-irritation and pressure. There might be some foundation for this popular notion if it were possible to discuss a virulent bubo. When we meet with a patient of this kind, however, we should do our utmost to pro- mote suppuration, hoping that the resulting scar will be sufficiently large and unsightly to give satisfaction. When, despite treatment, bubo progresses, there is, in the author's opinion, but one course to pursue, viz.: extirpation of the infected glands. It is not wise to delay operation after the glands have attained even moder- ate size and the inflammation shows a tendency to increase. As already stated, small disseminated abscesses appear in the gland early, and may at any time rupture, with consequent periglandular infection. Once this has occurred the time is past in which to make a clean and successful radical operation. Extirpation of the glands shortens the course of the disease and the resulting scar is usually trifling as compared with the unsightly one that ordinarily follows suppurating bubo. Primary union is the rule. When operation is refused or inexpedient, and suppuration seems in- evitable, the formation of pus should be favored. If poultices have not al- ready been employed, they should at once be applied. If calx sulphurata in small doses has already been used, the dose should be increased to 2 grains every three hours. As soon as fluctuation is distinct the abscess should be opened. An early opening is especially indicated in virulent bubo, as bur- rowing is likely to occur. The manner of opening a suppurating bubo is important. As a rule, the operation is only half-done, a small incision being made, barely suffi- cient to give exit to the pus and entirely inadequate to permit proper cleans- ing of the abscess-cavity. If the process be virulent, troublesome and ex- tensive burrowing may occur. The only way to prevent this is to lay open > 328 VENEREAL ADENITIS, OR BUBO. all sinuses and pockets tliorouglily. The abscess-cavit}' should be washed out with some antiseptic, and, if at all virulent in appearances, pure carbolic acid should be thoroughly applied by means of a swab, and carried to the bottom of all sinuses and depressions. The edges should now be thoroughly cut awa}', if undermined, and the cavity converted into the shape of a saucer, as nearly as possible. The cut surfaces will require the application of pure carbolic acid to prevent infection. The peroxide of hydrogen, or, better, pyrozone, which has come into great favor as an antiseptic, is useful in both virulent bubo and chancroid, apparently destrojdng their specific properties and setting up healthy action. It may, therefore, oftentimes an- swer in lieu of cauterization with more powerful irritants or detergent and antiseptic substances. The abscess-cavity should finally be dusted with iodoform and packed with gauze. TVhen a suppurating bubo is simple, as may usually be determined by the character of the pus, the histor}-, and course of the inflammation, cau- terization is unnecessary. If there be much surrounding induration, or if the flow of pus after incision should be scanty, poultices should be applied. All involved glands should be extirpated. Within a few days, after the bubo has taken on healthy action, it may require gentle stimulation. Peruvian balsam applied on gauze meets this indication. The author's preference is for the following formula, rather than the clear balsam: — IJ lodoformi 3ij. Ac. borici 3j. Bals. Peruviani §j. Vaselinse q. s. ad gij. M. Sig. : Apply on gauze. When a more stimulating application is required, the following is- use- ful:— li. Argenti nitratis gr. xx. Pulv. stramonii fol , 3j. Ext. belladonnse gr- x. Cerati simplieis 5ij- M. Sig.: Apply on gauze. The solid stick of silver nitrate may be required from time to time, as in ordinary granulation. When a bubo is sluggish and secreting unhealth- ily, a powder of equal parts of oxid of zinc and red cinchona-bark often acts well. The advantages of removing the edges of the bubo after incision and converting it into a saucer-shaped cavity are several. It summarily disposes of the edges, — which so frequently tend to invert and almost invariably be- come indurated and thickened, thus preventing healing, — favoring cleanli- ness, and permitting applications to all parts of the cavity. It also prevents burrowing, facilitates the removal of projecting glands, and imparts to the bubo many of the characters of simple ulcer. Finally, it favors rapid healing from the edges as well as from the bottom, and leaves a much less TEEATMENT OF YENEEEAL ADENITIS, OE BrBO. 329 puckered and discolored scar than when the edges are left. Eegarding the various methods of evacuating a suppurating bubo without free incision, such as multiple puncture, aspiration, and Auspitz's method of breaking up the inflamed gland by means of a blunt probe introduced through a small incision, they must sooner or later be followed by free incision if the bubo be virulent, with the probable result of finding that burrowing to a greater or less extent has occurred. It is, of course, desirable to avoid a scar if pos- sible, and in simple bubo this may sometimes be done, especially by aspira- tion and the use of calx sulphurata; but, as a rule, the plan that has been suggested will be found to yield the best results. The management of sinuses and exposed glands demands some atten- tion. If a bubo be properly opened, and the undermined and degenerated tissue at its edges thoroughly removed, sinuses are not apt to form, but in neglected or improperly-treated cases sinuses often result. When prac- ticable, each sinus should be thoroughly laid open, the indurated track cut away, and the wound sutured. They may sometimes be induced to heal by stimulating applications, but they are quite liable to reopen, especially if the patient is cachectic or moves about a great deal, the tissue about them being of very feeble vitality. When too deep to be freely laid open, or when in dangerous proximity to important structures, they may often be induced to granulate from the bottom by keeping them freely open with sponge- tents, curettement, and stimulation with caustics. An excellent plan for deep sinuses is that often used for sinuses and fistulas in other situations, viz.: incision of the external opening and the insertion of a wedge-shaped piece of wax, the base of which is gradually shaved off as the bottom of the cavity granulates. Injections of very hot water, frequently repeated, com- bined with the use of pencils or tents of iodoform, sometimes give excellent results. The tents are to be dipped in vaselin and inserted into the sinuses, care being taken that the bottom is reached. They are then cut off level with the surface and powered iodoform and a compress applied over all. Injec- tions of iodoform and glycerin, 5ij to the ounce, often act well. Injections of pure iodin often succeed when all other means fail. Chronic and indolent adenitis, with or without suppuration, is usually met with in strumous, debilitated or cachectic subjects. In such cases, the bubo may run an ordinary acute or subacute course, but after evacuation of the pus it becomes a chronic, indolent ulcer. The phagedenic variety is especially apt to become chronic and last indefinitely. The chief measures of treatment for chronic bubo in scrofulous or cachectic subjects consist in the administration of such remedies as iodid of iron, codliver-oil, arsenic, iodoform, quinia, and the mineral acids. A liberal diet, of which milk and cream should form the principal ingredients, and improved hygiene are usually called for. It is in such cases that the sulphurated lime will yield the best results. Maximum doses should be given. As illustrated by a case already cited, even absorption of pus may be 330 VENEEEAL ADENITIS, OK BUBO. induced by this drug. If the bubo suppurates in these chronic cases, aspira- tion may be used in conjunction with the sulphurated lime where it is espe- cially desirable to avoid a scar. Chronic bubo may remain hard and indolent for a long time before pus forms, and various local measures have been recommended for inducing resolution without suppuration. Ko method is to be considered where the bubo is troublesome save extirpation, unless, as already indicated, it is so desirable to avoid a scar that measiires of temporizing are warrantable. Here counter-irritation and pressure may be tried. All measures of treat- ment are apt to fail in bringing about resolution in chronic adenitis. Sup- puration, if it occurs at all, is apt to be long delayed, and much time may be lost while waiting for the bubo to maturate. Complete extirpation of the enlarged glands constitutes a radical cure. The operation should be performed as in cases of tumor, with full antiseptic precautions. The cav- ity left after removal of all the diseased tissues should be deeply sutured and perfectly closed. Union by first intention is the rule. This is a highly satisfactory method of dealing with a very annoying and obstinate affection. Union is often perfect even where more or less pus is present in the glands. The form of bubo associated with the genital lesion erroneously de- scribed as "lupoid of the vulva" is apt to be very troublesome, and it is doubtful whether severe cases of this kind are ever cured. When this form of bubo refuses to yield to the ordinary local treatment associated with tonics and dietetics, the occasional application of the actual cautery may excite healthy action, active granulation, and repair. As a dressing, pow- dered charcoal is probably best. An infusion of cinchona-bark may also be of service, a piece of lint being saturated with it and laid upon the part, to be subsequently wet often enough to keep it moist. Bumstead recom- mends the pure persulphate of iron. In the author's experience the man- agement of these cases is anything but satisfactory. The management of exposed and hyperplastic glands is sufficiently simple. When free glands are found on opening a bubo, they should at once be removed, for if left they act as foreign bodies and are constant sources of infection, prolonging the healing process indefinitely. In many cases the fingers will suffice for their removal; Volkmann's spoon or Piffard's curette may be used. Where practicable, all of the diseased area should be dis- sected out and an attempt made to secure primary union, as may be done in many chronic cases and in acute cases before periadenitis has developed. A very important point in the treatment of open bubo is the question of constitutional syphilis. If a genital sore be of the mixed variety, the resulting bubo is likely to heal very slowly, if at all, until mercury is ad- ministered. Where the patient has had syphilis a certain length of time prior to the occurrence of the adenitis, he will require a full mercurial course. If the syphilis be somewhat remote, or the patient debilitated and suffering from the syphilitic cachexia, a course of mixed antisyphilitic treat- TEEATilEXT OF TEXEKEAL ADEXITIS^ OR BUBO. 331 ment, on the one hand, or of small tonic closes of mercury, upon the other, will be required. The necessity for antisyphilitic remedies in instances of glandular mixed infection and suppuration following syphilitic adenopathy is obvious. In cases of syphilitic cachexia the administration of small tonic doses of the bichlorid of mercury will often rapidly induce healing in a bubo that has run a very prolonged course, the general health of the patient meanwhile improving in a marked degree. This tonic action of mercury is not generally appreciated, even by those who employ it extensively. Eecurrent syphilitic bubo requires the ordinary treatment of syphilis in combination with tonics. The treatment of venereal adenitis complicated by gangrene or phage- dena does not differ from that of chancroid attended by the same complica- tions. Much may be done to prevent these disagreeable and serious com- plications by attention to the constitutional condition. If cachectic or de- bilitated the patient should at once be put upon tonics and a highly-nour- ishing diet. There is no better tonic, under such circumstances, than the potassio-tartrate of iron: a remedy highly extolled by Eieord in phagedena. It is to be remembered, however, that we occasionally meet with cases in which phagedena occurs without evident cause, an innate predisposition to the affection apparently existing. When phagedena or gangrene attacks a bubo, the first indication is thorough destruction of the diseased surfaces by cauterization. This should not be done in a feeble, half-way manner, or it will be ineffectual, perhaps injurious, and will require repetition. An anesthetic should always be given or cocain used if the diseased surface is extensive, or the work may not be thoroughly done. All projecting glands should be first removed by the curette. The caustic used is not of paramount importance provided it be sufficiently powerful to destroy the tissues for the required extent. The Paquelin thermocautery, pure bromin, or Eicord's paste may be used, the author's preference being bromin. After the cauterization an antiseptic poultice should be applied and morphin freely given to alleviate the severe pain that is sometimes experienced. AYhen the carbo-sulphuric paste is used the patient should be kept well under the influence of opium during its application. Opium has been said to have a specific action in checking phagedena, independently of its narcotic property. As has been stated in connection with the subject of phagedenic chancroid, Eieord had great faith in opium in such cases. When cauterization is impracticable, iodoform, carbolic acid, peroxid of hydrogen, iodin, and the potassio-tartrate of iron in a strength of from gr. XX to gr. xl to the ounce of water have each their advocates. The author prefers the peroxid of hydrogen, followed by close packing of the cavity with a mixture of finely-powdered iodoform and charcoal. PART V. SYPHILIS. CHAPTEE XIV. Syphilis. histoet and geneeal chaeacteeistics; incubation and initiatoet peeiods of syphilis. Syphilis is by far the most important as well as the most interesting of the venereal diseases. There is no disease that has been more wide-spread in its dissemination or more potent in its influence upon the human species. iSTo class of individuals^ no stratum of society, has remained free from more or less general contamination by it. Especially is this true of urban com- mimities, where opportunities for indiscriminate and impure relations of the sexes are relatively great. Country communities enjoy great immunity by comparison, though by no means so free from the disease as some would have us believe. Syphilis, otherwise known as lues, popularly termed the "pox," is a "dyscrasic or constitutional affection of the type known as Tilood diseases,'" due to the infection of the human organism with a peculiar morbific prin- ciple, probably a germ of peculiar pathogenic properties, unknown as an entity, but plainly manifest in its pathologic results. Its manifestations are, to all intents and purposes, a lesion that is primarily local, followed by a succession of morbid constitutional manifestations, appearing at variable intervals, running a somewhat definite course, and being more or less amen- able to treatment. The materies morbi of syphilis has not yet been isolated, although we are justified by analogic reasoning and comparison with other infections in accepting the hypothesis that it is a micro-organism possessed of most potent evil propensities. The researches of Lustgarten, Doutrele- pont, and others, pointing to a specific bacillus as the cause of syphilis, have made an impression upon its pathology that has been felt everywhere. Al- though, up to the present time, this matter is barely beyond the hypothetic stage, it has served to elucidate many obscure points connected with the pathology of this disease — of which more anon. In many respects syphilis resembles the exanthemata, inasmuch as it is transmissible from the diseased to healthy individuals, has a period of incubation, a stage of eruption, an- other of decline, and a period of true sequels. A very minute quantity of germ-bearing syphilitic products is sufficient to produce the disease, al- (332) HISTORY OF SYPHILIS. 333 though it is fortunately only contagious, and not infectious in the true sense of the term. The wide diffusion of syphilis throughout the human family is not fully appreciated by the physician, as a rule, until after some years' experi- ence in private practice, when, especially if his' field of labor lies in a large city, he is likely to conclude that no one is above suspicion. This state- Fig. 100.— Case of hereditary syphilis diagnosed as and treated for leprosy. (After Dumesnil.) ment may seem rather sweeping; but it is certain that syphilis, like acci- dents, is liable to occur in the best-regulated families and often serves to explain otherwise-obscure cases of aristocratic aches and invalidism. This was very forcibly impressed upon the author by one of the first cases that came under his care after leaving the hospitals to enter private practice. A lady of 40, moving in the most aristocratic circles, had been affected for 334 SYPHILIS. some months with what had been diagnosed and treated as chronic rheu- matism by a number of capable, but too credulous, physicians. She had suf- fered with osteocopic pains with nocturnal exacerbations very severely, and for two months had been unable to walk, her lower extremities being par- tially paretic. A four weeks' course of antisyphilitic treatment relieved her sj^mptoms completely, and the author had the doubtful satisfaction of being pronounced "very good for rheumatism" as a reward for his incredulity. Cases of this kind are by no means infrequent, and their accurate diagnosis and successful treatment may be of inestimable value to the young phy- sician in beginning practice. The origin of syphilis is not definitely known, but it is probably quite an ancient, and therefore respectable, disease, inasmuch as it is more than likely that some of the forms of so-called leprosy of Bible-times were in- Fig. 101. — Plantar leprosy, resembling syphilis. (After Hitt.) stances of syphilis. Indeed, syphilis and leprosy were confounded only a few centuries ago. jSTearly all the "stock" accounts of syphilis state that the disease appeared in Southern Europe in the latter part of the fifteenth century, the supposition being that it was imported from America by the sailors who accompanied Columbus or Amerigo Vespucci upon their ex- peditions. As the shop-worn tale runs, the morals of the country at that time being none too rigid, the disease spread very rapidly, being later on mistaken for leprosy. Irrespective of the accuracy of this interesting and entertaining little account of the disease, its recognition in every part of the world as a distinct affection seems to date from about that time, although it is unquestionable that syphilis was known, and quite well understood, centuries prior to the Columbian epoch. That leprosy and syphilis should have been confused in ancient times is in nowise surprising, as there is often a certain degree of physical resemblance between the two diseases. The HISTOET OF SYPHILIS. 335 accompanying illnstrations show this admirably. One of these cases was mistaken and treated for leprosy. Finally coming under the care of a dis- tinguished dermatologist, the case was correctly diagnosed and under anti- syphilitic treatment recovered. Edmond Dupuy has gathered and cited authorities that tend to prove that syphilis existed even in Europe long before the departure of Columbus on his first voyage of discovery.^ Fig. 102. — Mixed type of leprosy simulating syphilis. That syphilis was known among the aborigines of America at an early period is shown by the studies of the distinguished Prof. Joseph Jones upon the bones of skeletons found in ancient mounds and other burial places in some of our Southern States. Among these relics were found un- mistakable evidences of syphilitic osteitis, caries, nodes, and necrosis. - Le Moyen Age Medical, par le Dr. E. Dupuy. 'New Orleans Medical and Surgical Journal, June, 1878. 336 SYPHILIS. The disease was described by the Japanese historians several thousand years ago, and documents are still in existence containing ancient descrip- tions of the affection that are exceedingly accurate. This would indicate the Asiatic origin of the disease, it having been brought to America by those nomadic tribes who settled this country some centuries ago when America and Asia were united by the peninsula now represented by the Aleutian Islands. As still further evidence of the antiquity of syphilis may be mentioned recent translations of ancient Chinese medical writings, Avhich show that the disease was known in China two thousand years ago. The Emperor Hoang Ti certainly recognized it, as his writings prove. Moses was un- doubtedly familiar with the disease: a fact that makes it still more ancient and respectable. According to recent researches by Leon Duchesne, syphilis was known in Europe fully two centuries before the voyages of Columbus and Ves- pucci.^ In a compilation of surgery, written in 1250 by Theodoric, a Dominican Monk, an entire chapter is devoted to what he terms the malum mortuum: a disease that is evidently syphilis. The treatment which this author recommends is certainly modern enough, and consists of mercurial inunctions — a sad commentary upon our progress in the therapeutics of the disease. In a surgical treatise written by Lanfranc, of Milan, in 1296, is a chapter devoted to "Chancre and Ulcers of the Penis in Man." De- scriptions of a disease that is undoubtedly syphilis occur in the surgical works of Salicet and G-erard, which also appeared during the thirteenth century. During the earlier years of its existence in Europe syphilis is said to have been so malignant and widely disseminated as to be recognized as a form of plague that created great havoc and, in fact, nearly annihilated the various armies of the afQicted countries. The disease has gradually grown milder in type until at the present day very severe and exceptional cases have come to be classed as "malignant." There should be some explanation for this, and it may not be amiss to digress slightly, and discuss what appear to the author to be logical reasons for the steady diminution in the virulence of syphilis. In the first place, it is obvious that improved sanitation and personal hygiene, with a steadily increasing knowledge of the pathology, and more rational measures of treatment of any particular infectious disease must eventually result in modifying its severity. This has been especially true in the case of syphilis; but there is another and more powerful influence that is constantly manifesting itself in the case of contagious diseases in general, viz.: the fact that some diseases occurring in individuals of one generation impart a certain degree of immunity to their descendants. Journal de Medeeine de Paris. HEREDITY AXD IMilUXITY. 337 A very interesting article bearing upon the influence of heredity and natural selection in modifying the severity of different contagious diseases was written some years since by H. M. Lyman, of Chicago, that seems to the author to be logically applicable to syphilis as well as to the diseases to which the originator of the interesting theory applied it. Lyman cites as an illustration of his views the extraordinary malignancy of measles among the natives of the Sandwich Islands, some years ago. These people were never affected b}^ measles until it was imported by the whites, consequently they had not acquired tolerance of the disease. Although the population of the islands was almost decimated at the time, the disease has steadily de- creased in malignancy ever since. Another illustration cited is the peculiar malignancy of variola among the negro race. Small-pox was unknown in Africa until imported by Europeans, and after its introduction created fear- ful havoc among the natives. It has probably not yet had time to become very markedly modified in the negro, — as it undoubtedly has in the white race, — but a steady modification is to be expected. When an epidemic attacks a community it attacks those susceptible to the disease, and so modifies their organisms that they become tolerant of future attacks. This tolerance is, in a measure, transmitted to their de- scendants. A certain number of individuals are insusceptible to the epidemic influence, and consequently escape the disease. This inherent in- susceptibility is also transmitted to the next generation. These facts illus- trate the influence of heredity. As already stated, a certain number of indi- viduals are primarily immune, and consequently escape the disease, while susceptible individuals are attacked, with a fatal result in those least able to withstand it. This illustrates the influence of natural selection. Apply- ing this theory to syphilis, it may be readily seen that the disease has prob- ably destroyed those subjects least able to resist it, and that the immunity acquired by exposure to its influence in the case of those who have survived, together with the primary insusceptibility of a certain ]3roportion of indi- viduals, have been transmitted to successive generations until at the present day syphilis is a comparatively mild affection. It is, of course, admitted that the insusceptibility of one generation may depend upon the inheritance of unequivocal syphilis from the parent-stock, but in certain instances this transmitted impression is very attenuated. The importance of a careful consideration of the evolutionary law as bearing upon hereditary modifications of constitution produced by syphilis is rather underestimated by the profession. This is due to the fact that syphilis may appear in successive generations, not as syphilis per se, but as hereditary perversions of growth and nutrition due to its morbific influence somewhere along the ancestral line. Malformations — such as talipes, epi- spadias, hypospadias, spina bifida, and other results of maldevelopment — may possibly owe much to a tainted ancestr3^ Eickets and scrofulosis are probably in many cases hereditary syphilis en masque. It is probable that 338 SYPHILIS. certain cases of phthisis and spinal caries are of similar origin, and depend- ent upon hereditarily faulty structure from ancestral syphilization. Duality of Syphilis and Chanckoid. — One of the most important results of modern research has been the establishment of the duality of the poisons of syphilis and chancroid. The experiments proving this have been numerous and conclusive, yet, strange as it may seem, there are those who continue to believe in their unity. Among those who adhere to the old theory may be mentioned Kaposi. Many prominent English surgeons are also o.f this belief; hence the confusion of terms existing in most English works upon syphilis. With them, chancroid is also and erroneously termed "local syphilis." Jonathan Hutchinson in his Lettsomian lectures some years ago argued that chancroid only occurs in patients who have at some previous time had syphilis, — i.e., that it is a syphilitic sore on a syphilis- immune; so that he is practically a believer in unity. Variance of opinion has resulted in a division of authorities into "unicists" and "dualists." The obscurity that formerly clouded the minds of surgical authorities regarding the venereal disease, in the post-Hunterian period known as "the period of venereal confusion," seems very remarkable to latter-day surgeons, who have profited by the errors of their medical forefathers. As already mentioned, John Hunter, the greatest surgical philosopher of the eighteenth centur}', believed that there was but one venereal disease, and that a con- stitutional afi'ection. He believed this because he had produced constitu- tional syphilis in himself by inoculating his own arm with gonorrheal virus. He labored under this delusion until the day of his death. Xearly half a century later Eicord demonstrated the error of the great master so far as the independence of gonorrhea is concerned; but he himself did not recog- nize the difference between syphilis and chancroid. Some years later their duality was shown by Bassereau: one of Eicord's own pupils. It is imnecessary to enter into a lengthy discussion of the dii?erent authorities and methods of research proving the duality of the two poisons, for the fact is generally accepted; but a few facts bearing upon it may be profitably mentioned. It is easy to appreciate the clinical force of one of the most powerful arguments of the unicists, viz.: that general symptoms frequently follow an apparently non-indurated simple sore; but such cases are merely exceptions to a well-established rule. It must be confessed that very innocent-looking sores are followed by secondary syphilis sufficiently often to necessitate caution in the matter of prognosis in every sore, how- ever innocent-looking, but not often enough to shake clinically-impressed convictions as to the duality of syphilis and chancroid. When chancroidic poison is deposited upon a raw surface and the surface is cauterized soon afterward, no chancroid results. .If, however, the syphilitic infection, as contained in the secretion of a chancre or syphilitic ulcer, be thus inocu- lated and the wound cauterized, syphilis will result, as a rule. Hill cauter- ized a ruptured frenum twelve hours after intercourse, but syphilis developed DUALITY OF SYPHILIS AND CHAXCEOID. 339 as if nothing had been clone. Fournier canterized a chancre six hours after its appearance, yet syphilis followed. Excision of the primary sore has been practiced, and has recently been revived, but has not as yet been proved to prevent the development of syphilis. It has seemed to modify it in certain instances, and in a number of personal cases the subsequent secondary mani- festations were very mild; this, however, proves nothing. The facts given are sufficient in themselves to prove the non-identity of syphilis and chan- croid. Syphilis is essentially constitutional (even if primarily local), so far as its clinical manifestations are concerned; while chancroid under all cir- cumstances is a purely local alfection. Attempts at the inoculation of animals with syphilis and chancroid have shown a marked difference between the two diseases. Syphilis is not generally believed to be transmissible to the lower animals, while chancroid is, although with a certain amount of difficulty. Depaul, however, speaks of a syphilitic monkey, and some years ago Martineau claimed to have produced a hard chancre upon the penis of a monkey. The animal was afterward ex- hibited to the French Academy, with apparently unequivocal secondary lesions, which, in the opinion of the few, proved the eommunicability of syphilis to the monkey. The monkey inoculated by M. Martineau with syphilitic virus developed chancres twenty-eight days later. These were fol- lowed by papulo-erosive and diphtheroid penile lesions; inguinal, axillary, and submaxillary adenitis; and emaciation. Later, there were numerous patches of alopecia on the head and back and, al^out ten months after the infection, ulceration of the mucous membrane of the palatal vault. Klebs has claimed that he has successfully inoculated syphilis upon monkeys and pigs, the experiments upon the latter being most questionable in results. Instances have been reported of supposed communication of syphilis from man to the lower animals by unnatural contact; but, so far as the author is aware, there are none that are sufficiently authentic to deserve attention.^ As might be imagined, such cases are quite difficult to trace and verify by actual study and observation, and, in addition, the sources of confusion are manifold. Xeumann, in numerous experiments upon monkeys, cats, dogs, rabbits, and horses, has failed to produce syphilis. If the statement that sj'philis is transmissible to the monkey alone of all other animals be true, it would seem to be a powerful support to the Darwinian theory. The course of syphilis and chancroid is sufficiently distinctive in typic cases. In con- clusion, it might be asked Avhy, if the poiscns of syphilis and chancroid are identic, all genital sores are not followed by constitutional symptoms when allowed to run their natural course without treatment, as venereal sores so often are among the lower classes. The theory of the origination of the chancroidic virus de novo, that has been presented in connection with the subject of chancroid, would, if ab- ^ Tide chapter on chancroid. 340 SYPHILIS. solntely proved, effectually settle the question of unity. The author has seen numerous cases of mixed chancre in which it is certain that the chan- croidic element was superadded b}^ secondary infection of the syphilitic chancre. In one of these cases the woman with Avhom the patient had in- tercourse after the hard sore had developed was brought to the author for examination and. found to have chancroid. Autoinoculation settled the question of the character of the sore in both. This form of mixed sore has not been alluded to by surgical writers, so far as the author is aware, and is certainly widely different in its history and course from ordinary mixed infection. The author has seen several cases where a patient with a nearly- healed chancroid has apparently contracted syphilis by inoculation of the ulcer. Sources of error in diagnosis are, of course, admitted. If chancre and chancroid are identic, both sores should be autoin- oculable, which, as is well known, they are not, this property being limited to chancroid and mixed chancre. Yaeieties of Syphilis. — Svphilis may be either hereditary (i.e., con- genital) or acquired, and is essentially the same in its manifestations in either instance, save that, as we shall see later on, hereditary syphilis has no primary stage. Acquired syphilis is, in every instance, due to confronta- tion and inoculation with a peculiar infection — presumably a pathogenic germ — derived originally from some individual suffering from the disease, and which infection is contained either in the secretion of a syphilitic lesion or blood from a syphilitic subject. Speedy Absorption of the Infectious Principle. — The length of time necessary for the absorption of the sA'philitic virus after the inoculation of a healthy tissue is unknown, but it is unquestionably very short, although no direct experiments have been made. Abrasions have been cauterized within six hours after suspicious intercourse, yet syphilis has developed. Berkeley Hill, as before stated, relates a case in which he cauterized a ruptured frenum within twelve hours after exposure, yet syphilis followed. Numer- ous experiments have been made upon poisons bearing an analogy to the S5'philitic infection, which are very instructive, and fairly permit certain conclusions with reference to syphilis. The experiments with the virus of vaccinia have been especially interesting. Seven children were vaccinated by Martin, and the site of the operation destroyed by Vienna paste at periods varying from one to twenty-four hours thereafter. None of the children had vaccinia; but all save one were protected from variola, as was subse- quently proved by failure to inoculate them by a second vaccination. Clerc vaccinated a number of children, destroying the spot with nitrate of silver one hour afterward: vaccinia was not prevented, although its local mani- festations were. These experiments suggest that possibly vaccinia consists of two essential elements, — a local and a constitutional, — permitting the destruction of the morbid impression causing the local process, without any modification of the constitutional manifestations of the virus. "Whether a ACQUIRED IMMUNITY. 341 similar view may be taken of syphilis is open to question. There are some clinical facts that apparently support such an assumption. In France nu- merous experiments with the poison of glanders upon animals have been made by different surgeons. The site of inoculation has been excised within one minute after the introduction of the virus; yet glanders has not been prevented. It is probable that the infection of syphilis is not absorbed so cjuickly as some other poisons, but, reasoning from the experiments cited, the period required must be very short. It is a noteworthy fact that the period of incubation in direct inoculation with syphilis is relatively brief. Acquired Immunity. — Unlike chancroid, true syphilis is very rarely contracted twice. Many cases of second attack, however, have been re- ported. Diday has collected twenty-five such cases, twenty of which were in his own practice. Such cases are especially interesting, both from their rarity and the fact that they most conclusively prove the curability of syph- ilis, for, were the disease not curable, a second attack would be impossible. A few of Diday's cases were contracted during the existence of tertiary manifestations of the previous attack, and this, too, is an important fact, as tending to show that typic "tertiary" lesions are not syphilitic at all, but simply non-transmissible sequels. It is probable that a true tertiary lesion is never syphilitic if transmissibility be taken as the criterion. The longer the interval between the first and second attacks, the more severe the second is likely to be, but in the majority of cases the second attack consists in the primary symptoms alone, without further manifestations of the disease. This, of course, lends color to any doubt that may exist as to the accuracy of the diagnosis in different cases. The author has seen, in his own clinical experience, five cases that were apparently second attacks of syphilis. In two of the cases the diagnosis of the first attack had been made by men of unquestionable skill, one of whom was no less an authority than Bumstead. There is no doubt jn the author's mind as to the condition of these patients when they came under his care, and the accuracy of the first diagnosis is hardly open to question. The folloAving case from the author's note-book is one of probable second infection: — Case. — A man, aged 30, was referred to the aiithor by Dr. F. B. Noreom, of Chicago, for consultation and treatment. He was suffering from a well-pronounced tubercular eruption, some of the lesions of which were as large as small plums; alo- pecia, sore throat, adenitis, and mucous tubercles about the anus and scrotum made the case a very typic and plain one. Under careful treatment this case progressed most satisfactorily, the lesions clearing up within six weeks and never recurring thereafter. Two years after the original infection, during which time the patient was under constant surveillance, a second sore appeared on the site of the original chancre, which was precisely like the latter, and apparently as typic as could be desired. This appeared on the twenty-sixth day after exposure, and was followed by characteristic mild syphilitic bubo and lymphitis. These symptoms were unyielding until mercury was given. They then disappeared, and the patient has since remained well. 342 SYPHILIS. Sources of Fallacy in Diagnosing Second AttacJcs of Syphilis. — There are several sources of fallacy in diagnosing a second attack of syphilis that must be remembered. 1. A non-specific general eruption ma}' accompany chancroid. 2. Impetigo contagiosa — ectliA'ma — or some form of eczema may be mistaken for true syphilis, and. if it follows a genuine attack, be cited as a case of second infection, or the first attack ma}' have been impetigo or eczema and the second true syphilis. 3. A chancroid, or mucous patch, may become the seat of such marked inflammatory induration that it is mis- taken for true chancre. 4. A tertiary gummy ulcer may be taken for hard chancre. 5. There may possibly be such a thing as "recurrent chancre." 6. Not infrequently chancre almost entireh' disappears, yet a slight indura- tion remains, which, at some subsequent period, enlarges into a similitude of a new initial sore. The condition termed by several French writers recurrent chancre is probably either second infection or gummy ulcer of the penis. The author does not believe that a chancre that has once entirely disappeared ever recurs. AxiMAL Syphilis. — The non-transmissibility of syphilis to the lower animals, with the exception of the monkey, as claimed by Martineau, had alread}' been mentioned. It is, as we have alread}' seen, a demonstrable fact that syphilis diff'ers markedly from chancroid in this respect. But, as is well known, animals also have venereal diseases — i.e., affections con- tracted only through sexual intercourse. Maladie du Coit. — One of the mo.st interesting studies for the syph- ilographer is the maladies consequent upon impure sexual congress in the lower animals. The only authentic and accurately described disease of apparently venereal origin in animals is the doury, la dourine, maladie du coit, or syphilis equine. This disease has been described at various epochs under at least a dozen other names more or less fallacious. It was first described by Amnion, a celebrated veterinarian of Prussia in 1796. Since that time many interesting brochures have appeared, those of St. Cyr^ and Laquerriere- having been classics upon the subject. By far the best disser- tation upon the subject in all its phases is that of J. Eollet (de Lyon).^ According to Eollet, the dourine is an affection of long duration, the evolu- tion of which should be divided into several periods. First Period. — This comprises the ensemble of symptoms constituting the debut of the disease, and differs markedly in the two sexes. Injhe Mare. — The first symptom is a more or less pronounced edem- atous swelling of the vulva — generally unilateral. This is hot, slightly painful, but attended by most intense pruritus. The mucous membrane is red, injected, and secretes excessively. A distinct discharge soon develops, ^ Annales de deimatolcgie et de syphilographie. 1877. Xo. 4. - Gazette hebdomadaire de medecine et de chirurgie, 1883, Xo. 31. ^ "Dictionnaire encvclopediqiie des sciences medicales."" MALADIE DU COIT. 343 this being quite tenacious. Micturition is frequent, the urine being scanty and thick, containing more urea tlian normally and a small amount of albu- min. The vulvo-vaginal mucous membrane often presents a polymorphous eruption, which may be papular, vesicular, pustular, or mixed in character. White patches sometimes form from loss of pigment. Follicular hyper- trophy and diphtheritic ulcerations are not unusual. These eruptions run their course quite rapidly, cicatrization being complete in two or three weeks. In some cases the process becomes chronic and persists throughout the disease. In the Stallion. — The symptoms are not so marked as in the mare. Sometimes the animal presents no evidences of disease, its existence being recognized only by the contamination of the mares with whom he copulates. When symptoms exist they consist of slight heat and tumefaction of the penis and moderate urethritis; discharge is not so constant as in the female. There is frequent — sometimes difficult — micturition; marked penile edema and apparent penile paralysis sometimes occur. The skin of the penis and scrotum may also present a polymorphous eruption. These may appear and disappear many times during the course of the disease. Coitus is difficult and painful, often impossible. Erections are never so frequent and vigorous as in the healthy animal. Ejaculation sometimes occurs only after many attempts to cover the mare. Fecundation seems to take place, however, quite constantly, despite the probable perversion of the constitution of the semen. The testes and epididymes may be swollen and tender. In both male and female only local manifestations of disease are noticed at first. The animal may present all the appearances of perfect general health for a month or more. Sometimes a little sluggishness, a capricious appetite, or a slight and irregular elevation of temperature are noted early; the animal grows thin, but the appetite, perhaps, keeps up. The first manifestation of leanness appears in the rear quarters and lumbar region. The hind-quarters appear to give way from time to time as if the animal had stumbled. In the regular course of events these latter symptoms herald the onset of the con- stitutional manifestations of the disease. Second Period. — This period presents symptoms affecting chiefly gen- eral nutrition and the functions of the nervous system, and is essentially the same in both sexes. The animal grows sensibly leaner, the muscles of the croup, lumbar region, and anterior femoral region being chiefly affected. General sensibility is sometimes greatly exaggerated, chiefly in the lumbar region, where a slight pinch may cause great pain. The functions of loco- motion are impaired and the animal favors his hind-quarters, inclining to rely upon the forelegs for support. In action the hind-quarters ill support the body-weight, a stumbling gait being the result; more or less lameness, apparently in the hamstrings, fetlocks, or knees, is observable. This is un- attended by any appreciable lesion, and disappears spontaneously in from four to twelve days. At the same time paralysis of the lips, cheeks, and eye- 344 SYPHILIS. lids supervenes; this may be temporary or permanent. The paresis of the posterior members may pass away or develop into true paraplegia. Accord- ing to St. Cyr, the affected muscles retain their electrosensibilit}', even when atrophied. It is at this time that the stallion, without becoming truly im- potent, becomes less passionate, erections being less frequent and feebler than in the normal condition; mounting, at first difficult, may eventually become impossible as paresis becomes more marked. A very striking symptom — from the stand-point of syphilitic analogy especially — is the development of round, slightly prominent cutaneous tumors or elevated plaques, varying from the size of a silver quarter to that of the palm of the hand. These are soft, almost painless, and become firmer later on. They resolve in from eight to fifteen days, more or less, leaving no cicatrices or other evidences of their ephemeral course. The}^ may recur many times during the course of the disease. In the mare — becoming pregnant after impure coitus — abortion often occurs between the third and sixth month of utero-gestation. The second period of the disease may last for some time, one or two months in some cases, in others six or eight months, or even a year or more. There are observed in the course of the disease alternations of aggrava- tion and amelioration. Such complications may occur as orchitis, mastitis, — sometimes going on to suppuration, — ophthalmia, abscesses in different locations, nasal dis- charge, and adenopathy — local or general. Third Period. — In this stage of the disease all of the symptoms become aggravated, emaciation increases, even marasmus supervenes, parah'sis be- comes general, and the animal lies down constantly. Suppurating and sloughing areas over various bony prominences — "'bed-sores" — develop. Death may result from a gradual exacerbation of the S3'mptoms — hj asthe- nia, or from some intercurrent affection, hypostatic pneumonia being fre- quently the immediate cause of death. Prognosis. — Eecovery from maladie du colt is rare, death occurr'ng after some months or perhaps not under a year. Even two years has been known to elapse before a fatal result has occurred. Morhid Anatomy. — Congestion of the lumbar cord and its envelopes, softening, chiefiy of the gray matter, serous subarachnoidean effusion, and thickening of the lumbo-sacral plexus, which shows interstitial and periph- eral infiltration — neuritis. "When paralysis has become general there is medullary softening and gelatiniform infiltration of the cervico-dorsal and dorso-lumbar nerves. The nerve-alterations are found chiefly in the posterior limbs. The nerves are swollen from a yellowish infiltration of the neurilemma and nerve-tubules. A certain proportion of nerve-fibers become markedly de- generated. The alteration of the cord is most marked at the dorso-lumbar junction, where there are distinct areas of softening, especially in the gray MALADIE DU COIT. 345 substance. The brain has been found in a similar condition of softening, presenting, moreover, a markedly hyperemic and more or less dusky appear- ance. The muscles are pale, atrophied, and in a condition of fatty degen- eration, resembling, according to Eaynol, boiled meat. The bones are very friable, especially the femurs. (The profoundly-trophoneurotic character of the disease at once suggests itself.) The bone-marrow is soft, diffluent, and contains extravasations. The joints present evidences of synovitis, the ligaments and cartilages, moreover, being softened. Hypertrophy or at- rophy of the testes, thickening of the epididymes and cords, and hyperemia of the principal viscera may be found. The lymphatic glands and peri- glandular tissues are the seat of a yellowish gelatiniform infiltration. This exudation is the characteristic macroscopic feature of these cases. Contagiousness. — Some observers have claimed that la dourine is non- contagious and is a simple paraplegia. Others claim to have seen penile ulcerations in stallions which had covered many mares without conveying contagion. Still others claim that the disease may occur without coitus (which is not surprising). There would seem, however, to be no doubt of the contagiousness of the disease. It does not occur save in breeding ani- mals nor before coitus. Hertwig reports numerous cases directly traceable to the procreative act. Experiments by direct inoculation have justified the deductions from clinical observation. The germ of the disease is as yet un- known. There would seem, hoAvever, to be little doubt of its microbial origin. Analogy with Syphilis. — Beginning with an old Arabian belief, it has long been suspected — and, indeed, even claimed — in certain quarters that la dourine was a derivative of human syphilis through the bestial variety of sexual perversion. Like most popular and vulgar notions, this has never been proved authentically. This fact, however, does not prove the impos- sibility of such an origin of the disease. Many comparisons have been made of the various periods and lesions of doury and syphilis; but, aside from a strong analogy, we are still as far from securing proofs of their kinship as ever. As Saint Cyr has sagely observed: — Human syphilis and the maladie du co'it of the horse present strong points of similarity. They are both virulent general affections habitually contracted during sexual congress. But the two diseases are none the less distinct and independent varieties, bearing no more relation to each other than sheep-rot does to human variola. While this may be true as syphilis and la dourine are seen to-day, it must be remembered that a correlation of origin is not without the bounds of evolutionary . possibilities. Mankind, however, unquestionably has a monopoly of syphilis. Lancereaux claims to have observed venereal ulcer of a purely local character in the equine species. His observations, however, lack confirma- tion. The local ulcers that he describes are probably cases in which la 346 SYPHILIS. dourine has been imperfectly studied, and in which prominent local symp- toms have existed, with superadded pus-infection. Eacial Susceptibility. — There is said to be a great difference in the susceptibility of different races to the ravages of sjqDhilis: e.g., it is- popu- larly supposed to be more severe among the Chinese than among white peo- ple; and it has been asserted by the laity that the disease is much more severe in the Caucasian where it has been contracted from the Chinese or negro race. The author has investigated this matter so far as possible, but has been unable to verify the popular, impression. It is not probable that the disease is any more severe in the dark-skinned races than in the white, excepting in the case of the negro, save when the hygienic surroundings or personal habits are in favor of the white race. Were it not for such favor- able influences, the disease should be severer in the white race — reasoning along evolutionary lines, and again excepting the negro. Opinions differ as to this point. Dr. Henry E. Carter, who has studied the subject carefully, says that enlarged and suppurating glands, rheumatoid pains, and synoviaV inflammations are more frequent in negroes than in whites. Mucous patches, nodes, and caries are less marked than the preceding lesions, but are more pronounced than in the Caucasian. Effects of Occupation. — Different occupations have been said to modify the effects of syphilis, but the question has a general rather than a special bearing upon the disease. Obviously, such occupations as tend to produce anemia, debility, and nervous or mental strain favor a severe course of syphilis, with many and various complications. Fournier saj^s that gam- blers, stock-brokers, and people leading similar lives are liable to a pecul- iarly precocious course of luetic evolution, and succumb very rapidly to the disease. They are peculiarly liable to cerebral s3qDhilis. The peculiar emo- tional life of these jDeople engenders a vasomotor instability that is pecul- iarly favorable to leucocytic exudation of any type. The same fact is illus- trated by the negroes, in whom, before the war, syphilis was of a much milder type than now, because speculative emotional alternations were rare among them, and hence circulatory changes did not alternate with great rapidity. Incubation-peeiod of Syphilis. — After the poison of syphilis has been absorbed a certain period elajDses before its morbid effects become manifest. This period is known as the stage of incubation, and lasts, upon the average, about twentj^-one days, but varying considerably from this in different cases. Fournier relates a case in which the period was seventy-five days; Guerin, one of seventy-five da5rs; and the author has noted a case of seventy days. Instead of being prolonged, the period may be shorter than iisual; thus Hammond relates one of three days, and Dr. N"ott, of Xew York, since deceased, reported his own case as developing within twenty- four hours after wounding his finger in 023erating upon a syphilitic subject. Taylor reports a case in which the initial lesion appeared upon the second BACILLUS OF SYPHILIS. 3^7 day, induration upon the fonrth da}', and general sjanptoms during the sixtli week, and another in whicli the chancre appeared at the end of the first, and the general symptoms during the fifth week. It may be, accepted, as a practical rule, that true chancre does not appear before the tenth day. Any sore appearing prior to that time is probably chancroid or some simple affection, while any appearing later is quite likely to be true chancre. It must not be forgotten, however, that the "probable" chancroid may be proved to be a case of mixed infection by the subsequent appearance of typic induration. This "is a useful practical rule to remember, although it must be confessed that it is often of little service in diagnosis, inasmuch as the majority of individuals contracting venereal disease are in the habit of indulging promiscuously in intercourse, and are therefore absolutely un- able to determine which of their numerous adventures was the unlucky one. This source of fallacy usually develops on careful questioning. Whenever the induration of a sore is absolutely characteristic, we are, of course, in nowise dependent upon the period of incubation for a diagnosis. A. Bernard found that in sixtT-nine cases of venereal sore, inclusive of chancre and chancroid, the incubation period varied from one to fifty-six daj'S, and calls attention to the apparent preference for multiples of .seven as the incubation period in a large proportion of cases. This was true of fort3^-three out of his sixty-nine recorded cases. Fournier found this pecul- iarity in twenty out of forty-five, and Lowndes, in twenty-five out of fifty cases of inoculation.^ It is unfortunate that these authors are not more explicit in their use of the terms chancre and venereal sore. In drawing deductions as to the clinical history of genital lesions differentiation must be most accurate, else the value of such observations is greatly impaired. There has been much looseness of nomenclature among syphilographers. Thus, German writers apply the term chancre only to the soft sore. Chan- croid is variously known by diiferent authorities b}' the terms soft chancre, non-indurated chancre, simple chancre, non-infecting chancre, local svph- jlis, and contagious local ulcer of the genitals. Bacillus of Syphilis. — The author, although believing in the germ- origin of syphilis, regards the bacillus claimed to have been discovered by Lustgarten as yet to be proved. In any event, its existence does not modify the patholog}^ of the disease, for Lustgarten claims that it acts by incorpo- rating itself with the white blood-corpuscles — a fact worthy of note. Neisser favors the bacillus theory of syphilis, but he is much less dogmatic than Lustgarten. Ehrlich and Birch-Hirschfeld also advocates the bacillar doctrine. Klebs, Aufrecht, Bergmann, and, following them, Barduzzi. claim that a micrococcus of a peculiar character exists in the lymphatic vessels and glands of syphilitics. As Lustgarten's investigations have gained ^ British Medical Journal, September 23, 1883. 348 SYPHILIS. more credence than those of his predecessors, the author appends his orig- inal description of the hacillns of syphilis. I have succeeded in showing, in microscopic sections of two syphilitic chancres and one syphiloma, bacilli which are perfectly characterized by their color, reaction, form, and relative position. These bacilli, which have been found in all of the examined sections, although in slightly varying quantity, represent slim, straight, or somewhat-curved little rods of about the same size and the same appearance as the bacilli of tuberculosis. They are always found either single or in small groups, inclosed in lymphoid, somewhat-distended cells, and show under a powerful micro- scope light spots similar to those which Koch regards as "spores" in the tubercle bacilli. The method of coloring, about which I shall report in a future and more exhaustive paper, makes it possible to distinguish the bacilli of syphilis both from the bacilli of lepra and tuberculosis, and from all other pathogenic bacteria as yet known. The fact that the former are always inclosed in cells excludes the possibility of deceptions by putrid formations, and so on. I never could observe anything like cocci, and I emphasize this, because a number of investigators (deceived by more or less important errors) have regarded them as specific micro-organisms of syphilis (as Birch-Hirschfeld and others). The latest claimant for bacteriologie fame in syphilis is von ISTiessen, of Wiesbaden. The conclusions to which he has arrived from his researches are as follow: — 1. Syphilis is a chronic infectious disease of the blood, and is transmitted to other tissues of the body by the lymphatics, through the latter system the contagium being first conveyed to the blood. 2. The contagium of syphilis in every case and in every stage of the disease from the moment of its entrance into the blood is demonstrable through staining and cultivation. In many cases it is found in the urine. It is also possible to find it in the milk, semen, saliva, sweat, and excrement. 3. In diseases other than syphilis, or where it is complicated with other diseases, the contagium cannot be found in the blood. 4. The cause of syphilis is a pleomorphous bacillus which is closely related to the more highly organized fungi. 5. The detection of the syphilis-germ in the blood is an absolutely-sure criterion of the presence of syphilis, and is therefore of the greatest diagnostic value in doubtful cases requiring diflferential diagnosis. 6. Syphilis in aU stages is inheritable and communicable. This applies also to rabbits, which can be infected experimentally. 7. With the therapeutic measures known up to the present time, syphilis is absolutely incurable. Relative healing denotes only a latent state. Medical art, therefore, has yet to find a certain curative for syphilis.' Von Niessen's statements are certainly dogmatic enongh, and sulTi- ciently startling to demand abundant confirmation before we are warranted in accepting them as proved. The I^TIT1AL Lesion. — Induration of a peculiar type is the distinguish- ing feature of chancre; the manner of its formation and its histologic ' Centralblatt fiir Bakteriologie. PEIMAEY LOCAL CHANGES. 349 characters are consequent!}^ a matter of considerable imiDortance. Inasmuch as the chancre is the type of all lesions of active sjqDhilis, this brings us to the consideration of the pathologic changes produced by the disease. The study of the subject should naturally begin with the consideration of the primary, or initial, lesion, and, beginning at the seat of infection, a num- ber of quite important tissue-changes occur: — The starting-point of syphilis is the absorption of a peculiar morbific principle, or contagium, which, although unknoAvn as an entity, is only too plainly manifest in its pathologic effects. The most probable view of the nature of the infection is that it is a germ of undetermined type. Otis claims that the contagium consists of a degraded infectious cell of very minute proportions, a view that is in nowise inconsistent with the germ- theory, this cell having been primarily infected by the germ and acting as a carrier of infection thereafter.^ However, deficient though we may be in jDositive knowledge of the nature of the syphilitic micro-organism, we at least have tolerably definite views of the manner of its action. Peimary Local Chaxges FRo:\r Infection. — The first effect of the S3qDhilitic infection is the j^roduction of a gradually-increasing accumula- tion of white blood-cells or lymph-cells at the site of inoculation, which is brought about by a modification of the normal leucocytes and connective- tissue elements produced by the S3^philitic infection. This modification ^ The author still believes the views expressed by F. X. Otis, in his "Physiologic Pathology of Syphilis," to be, in the main, the most logical and practical of any thus far advanced. With certain modifications, necessitated by the acceptance of the germ- theory of syphilis, the author has not altered his views upon this point since the publi- cation of his own lectures on syphilis in 1884. The theory of syphilitic pathology advo- cated by Otis was in nowise original with that gentleman, although he deserves great credit for elaborating upon it and presenting it in a rational and intelligible form. A similar theory was advanced by ISTisbet in 1788, and revived in 1863 by Sperino. li. W. Taylor ojjposes the A^ew of syphilitic pathology expounded by Otis, upon the ground that the theory demands that we should "assume certain fancies, in the ab- sence of definite facts, and felicitate ourselves with the idea that we know how syphilis Avorks in the system, when the truth is that we do not." Such argument, if univers- ally applied to the science and art of medicine, would tend to demolish all rational theorizing. The amount of positive knowledge of the modus operandi of certain pathologic influences, and of our therapeutic resources for their cure, is rather meager, according to the standard by which Taylor estimates the value of Otis's views. Taylor states that Otis assumes that the syphilitic virus consists of "disease- germs," and that "the syphilitic virus coagulates the superficial tissue-fluids, caus- ing obstruction to the circulation and attraction to the spot of wandering white corpuscles, which, by their ameboid movement, entrap the specific disease-germ." Otis does not speak of disease-germs, but of diseased germinal cells. As for the entrapping of the germ by the leucocyte, it is a pity that Otis did not express himself in the words attributed to him by Taylor. If he had, he would have fore- stalled the valuable discoveries and widely-accepted theories of Metchnikoff. In Taylor's misinterpretation of the views of Otis he builded wiser and more prophetic than he knew. 350 SYPHILIS. probably begins immediateh^, or, at least, very soon after the infection takes place, but is more or less gradual in manifesting itself; hence we have a cer- tain period elapsing before evidences of its action are exhibited. The SypMlized Cell (BesiadecJvi, Otis, et al.). — The accumulated cells, previously normal, contain the germs of the syphilitic infection, and their constitution is now. greatly modified. They have become larger, more gran- ular, and contain numerous nuclei; are infectious, and have their powers of proliferation and ameboid movement exaggerated. In addition they present a marked tendency to retrograde metamorphosis. When removed from their original situation to the tissues of a healthy individual, these cells, by virtue of their infectiousness — i.e., by virtue of the syphilitic germs they contain — produce changes in the normal leucocytes in their new en- vironment, exciting rapid proliferation in them, as well as undergoing rapid changes themselves. Modus Operandi of the SyphiUzed Cell. — Let us consider the action of the infected cell — the "syphilitic germinal celF^ of Ot's — upon the ijj3rmal leucocyte. It is claimed that through degradation the syphilitic germinal cell may be but Vioooon of an inch in diameter, — being perhaps merely one of the nuclei of some infected and degraded leucocyte, — but re- taining all its morbid powers of proliferation and ameboid activity, the latter being especially marked. As the white blood-cell or normal leucocyte is ^/osoo of ^^ iiich in diameter, it is obvious that, by virtue of the peculiar affinity of the infection-carrying cell for it, the two may become incorpo- rated, with the resulting modification of the leucocyte that has been de- scribed. The theory of phagocytosis applies here, although in this instance the phagocytic action of the leucocyte is feeble by comparison with the pathogenic power of the materies morhi of the infection. By supposing the incorporation of a bacillus, instead of the hypothetic cell described, with the leucocyte, wq can at once harmonize the bacillar theory of the origin of syphilis with its "physiologic pathology," and thus put the latter upon a probably-secure basis. The hypothesis of a germ is much more logical than that of a minute degraded cell or cell-nucleus. AVhether the infecting principle be a degraded cell of poisonous prop- erties, a bacillus, or a cell containing a bacillus — the two latter, one or both, being most likely — is of no importance in the subsequent history of syph- ilitic events. These considerations do not militate against the plausibility and practicality of the views of syphilitic pathology as Besiadecki and Otis originally jiresented them, nor do they controvert the belief that a knowl- edge of the syphilized cell — a thorough comprehension of its life-history, properties, and mode of progression — is the key to the study of syphilis. Just as the leucocyte is the primordial cell in the normal physiologic proc- esses of groAvth, so is it the basis of all pathologic processes — and particu- larly those of syphilis — when it is modified in the manner peculiar to the particular morbid change in the tissues. I MIGEATIOX OF THE SYPHILITIC CELL. 351 Taking as oiir point of departure the initial lesion of syphilis, we observe a localized proliferation of the now infected and perverted cells, and, following the infection in its course, thickening of the lymphatic ves- sels and enlargement of the lymphatic glands produced by this same cell- accumnlation are found. After a time, infection-bearing cells — or perhaps independent micro- organisms — free themselves from the initial accumulation, travel on through the lymphatics, enter the receptaculum chyli, and are finally emptied into the circulation by the thoracic duct, to be then driven to the superficies of the body, central nervous system, and viscera with the general blood-current. Various secondary phenomena now occur in the different tissues, and we will briefly consider some of them: General enlargement of the lymphatic glands occurs — general adenopathy — as a result of (1) the proliferation of the cells carried to them by the blood, (2) the proliferation of their own lymphoid and connective-tissue elements under the stimulus of the infection brought by the syphilized cells, and (3) an accumulation of infected ger- minal material collected by the absorbents from the superficies of the body. Engorgement of the fauces and phar3mx now occurs, due to a localized cell- proliferation and accumulation in the rich net-work of lymphatics, which, as will be seen later on, is a marked feature of the anatomy of the fauces, tonsils, and phar3^nx. Mucous patches are likely to occur, and are simply quasipapules upon moist mucous surfaces, due to a circumscribed collection of the characteristic cells, — constituting syphilitic granuloma in whatever lesion it may be found. The same description will apply to the true papule upon the integumentary surfaces. This papule may have an excessive ac- cumulation of cells and become a tubercle, or from pressure upon and inter- ference with the nutrition of the normal tissue-elements by the cells in combination with their own tendency to retrograde metamorphosis, with or without complicating pus-infection, a pustule perhaps forms that may break and result in ulceration. Ixodes or peculiar periosteal, swellings occurring in syphilis are collections of proliferating syphilitic cells^granuloma. The syphilitic roseola has not been mentioned in connection with the syphilitic cell-proliferation because it is an exception to the rule. It is due, not to a localized accumulation of cells, but to vaso-dilation and stasis, with resultant transudation and liberation of blood-pigment. This condi- tion of vascular perturbation is probably due to the action of syphilitic toxins — elaborated by tlie micro-organism of syphilis — upon the sympa- thetic nervous system. Otis would undoubtedly have advanced this ex- planation rather than that of the action of the syphilized cell upon the sympathetic, if our knowledge of toxins had been developed at the period at which he presented his views. In any event, the cell may be the carrier of the toxins. What has been said serves to demonstrate, in a general way, the patho- logic importance of studying the syphilitic cell, by following it in its tour 352 SYPHILIS. of mischief and noting briefly its results. As already stated, this cell is not only important as regards the pathology of syphilis, but a knowledge of its properties and actions is absolutely indispensable to the intelligent applica- tion of remedies to the cure of the disease. The author will premise, with Otis,^ that:— The natural course of the syphilitic cell is to accumulate in and obstruct various tissues, thereby forming neoplastic masses very similar in structure to in- flammatory neoplasia, and finally to undergo retrograde metamorphosis and elimi- nation, ichich result eventually in the spontaneous cure of the disease. The danger of permanent injury to the tissues in syphilis is directly proportionate to the amount of the accumulated cells and the length of time they remain in contact with the normal tissues, thereby producing secondary changes in their structure. Understanding these facts, and with an eye to the probable germ origin of the disease, we most naturally seek for reme- dies the administration of which tends (1) to destroy or inhibit the germ- infection; (2) to eliminate and remove the effects of syphilitic toxins; (3) to remove new formations and cell-accumulations, by favoring or directly inducing retrograde metamorphosis in, and elimination of, such morbid material. These remedies will receive attention later on, as at this jDoint the author desires merely to emphasize the importance of an accurate knowl- edge of the pathology of syphilis in explaining the rationale of their action. The student will readily appreciate the fact that a careful study of the char- acteristic cell-deposit which constitutes the basis of all syphilitic processes will enable him to comprehend the principal manifestations of the disease. The manner in which syphilitic infection brings about the various changes characteristic of the disease will now be considered. As we have seen, the first manifestation of syphilis is a peculiar lesion characterized by induration. This is due to a localized accumulation of cells that are in- filtrated in the meshes of the connective tissue and tunica adventitia of the blood-vessels, forming a circumscribed mass. The cells vary somewhat in their general characteristics, those in the coats of the vessels being either round, spindle-shaped, or branched, but the bulk of the mass consisting of the characteristic round, multinucleated granular cell, already presented as an infected and transformed leucocyte.- These changes are very siinilar to those seen in simple dermatitis, excepting that there is no exudate, the in- duration being consequently dry and hard. This absence of fluid is due to the thickened walls and contracted lumen of the vessels, that render it diffi- cult for the serum to exude from them. For the same reason, there is anemia and innutrition of the neoplasm.^ ^Otis: "Physiology and Pathology of Syphilis." With regard to the local changes, Otis does not differ essentially from the generally-accepted views of syphi- litic neoplasm or granuloma. ^ Tide Besiadecki. LYMPHATIC CHANGES. 353 The small blood-vessels throughout the body are surrounded by peri- vascular lymijli-simces — it is even claimed that the tunica adventitia of the smaller vessels is really a part of the lymphatic system. The intimate asso- ciation of the blood and lymphatic vessels is thus readily imderstood. There is a constant current from the tissues to the lymphatics, and it is very evi- dent that after a time the morbid cells about the neoplasm — -or the micro- organisms they contain — must necessarily, as they extend, enter the lym- phatic circulation. This may explain the circumscription of the induration, the cells, after a certain time, being removed as fast as formed, thus limiting their local development. It will now be assumed that the first manifestations of S3fphilis are 2Durely local pathologically — as they certainly are clinically — and an attempt will be made to give a logical explanation of them along the lines laid down by Otis, with certain modifications that suggest themselves to the author as modernizing his theory. Evolution of Primary Lympliitis and Adenopathy. — Within a few days after the development of the initial induration of syphilis, or chancre, the lymphatic vessels leading from the infected surface begin to enlarge and become hardened, feeling often like pieces of pencil or wire under the skin. This is due to a low grade of inflammatory change, associated with localized cell-proliferation. It may seem strange that this alteration in the lymphatics does not occur immediately after the appearance of the chancre, instead of after an interval of some days, but this is probably explained b}^ the fact that the cell-accumulation constituting the chancre must extend until a l3miphatic vessel of some size is reached before the cells can enter the lymphatic current, the absorptive power of the smaller lymphatics being annulled by pressure and local irritation. A strong argument in favor of this view is the fact that the period of incubation is shortest, and the chan- cre smallest, in those parts most richly supplied with lymphatics. There is also less connective-tissue proliferation in such localities. An example of this is chancre developed beside the frenum preputii. The changes in the lymphatic vessels gradually extend along their course, the infection-bear- ing cells, or perhaps free micro-organisms, meanwhile traveling slowly on in the lymph-current, and finally reaching the lymphatic glands. Enlarge- ment of the glands — primary adenopathy — now occurs, those in closest relation to the primary sore being first to enlarge, but general syphilitic adenopathy eventually occurring, and each gland, however small, becoming consequently a depot for the production, storing up, and finally the dis- tribution of the infection. Each lymphatic gland, as the proliferation of infected cells goes on in its substance, becomes hard and woody to the touch, being nothing more nor less than a neoplastic growth precisely identic Avith the chancre itself, and presenting the same microscopic characters. The changes at the site of infection, and in the lymphatic glands first in- volved, have been most appropriately termed the "initiatory period" of 354 SYPHILIS. syphilis, a much more satisfactory nomenclature than "primarj^ syphilis." Xo eyidenees of hlood-infection have become manifest as yet, all the changes being aj)parently local. The infection and cell-migration having been traced to the lymphatic glands, their further consideration will be deferred until a little more attention has been devoted to the initial lesion and other im- portant points in the clinical study of early syphilis. Yakieties of Ixdueatiox. — The initial induration — initial sclerosis — may present itself under several different forms, a study of which is very essential. 1. The first form is what is termed the parchment induration. This usually underlies ulceration, and may escape notice altogether unless care- fully sought for by pinching up the lesion with the thumb and finger in such a manner as to press lightly upon its edges without bending it. This is the commonest form, according to some authorities, and is certainly so in hospital practice. In private practice, however, examples of the Hunterian chancre, or other marked forms, are more frequent in the author's experi- ence. 2. There is a variety of the parchment induration sometimes seen that is especially apt to escape attention, so insignificant does it seem. It con- sists in a very superficial cell-infiltration, presenting a very slight induration when lightly pressed upon. In appearance it is a slightly-brownish patch covered by very fine scales, not unlike a minute patch of psoriasis. This superficial induration is called by Otis the "dry scaling patch." The author would suggest as a better term "squamous induration." 3. The induration may be somewhat like a split pea beneath the skin, its convex surface being capped by ulceration. This induration is plainly marked and freely movable, with a feeling like wood or bone, or perhaps more nearly like cartilage. 4. The induration may be quite extensive and extend beyond the bounds of the ulceration, very often attaining the dimensions of a chestnut or almond. There may or may not be ulceration. ^Mien an induration of this description is ulcerated, its convexity is sometimes capped with a fun- nel-shaped ulcer, the whole constituting the so-called Hunterian chancre. In many cases there is merely a hard purplish lump with no ulceration, or at most a very superficial erosion capping the induration. In many cases the induration is irregular, sometimes presenting several distinct tumors, . or united by areas of less marked induration, giving, in the case of the penis, a "choked" appearance to the organ. 5. A very superficial infiltration may underlie a pseudomembrane of greater or less dimensions: "diphtheritic chancre." Loss OF Tissue ix Chaxcee. — The occurrence of ulceration in chan- cre is quite important, and, aside from the various sources of irritation that may act as exciting causes, is explicable by the histologic characters of the lesion. As alreadv noted, the chancre consists of localized cell-accumula- I CHAEACTEEISTICS OF THE IXITIAL IXDUEATION. 355 tion that not only presses upon the capillaries^, but actually invades their walls, thus causing a diminution of blood-supply and relatiTe anemia and innutrition of the neoplasm and the tissues involved by it. This innutrition gives rise to molecular disintegration of the superficial layers of the lesion, which break down and form an ulcerated surface. This process is termed by Besiadecki, "anemia of tissue," and by Virchow, "necrobiosis." The se- cretion of this ulcer is scanty when unirritated, for the same reason given for the hardness and dryness of the induration, viz.: absence of serous ef- fusion. It contains, however, the infectious principle of syphilis — the syph- ilitic microbe and its carrier, the germinal cell— and is highly contagious. Extent of Indukatiox. — The induration of chancre is variable in its extent, according to the tissues in which it is. situated, and within certain limits is proportionate to the extent of surface primarily infected, — e.g., when an extensive cut or abrasion is inoculated with the S3'philitic infec- tion the resulting chancre is likely to assume the size and conformation of the traumatic lesion. Chancres of the nipple, lips, skin, and behind the corona glandis are likely to be extensiA'ely indurated. Bernard finds in- duration most marked upon the inner surface of the prepuce and in the fossa glandis, and nearl}^, if not always, absent upon the body of the organ. In this latter statement the author does not quite agree, for, although true in a large proportion of cases, there still remains a certain number in which the induration is not only present, but quite plainly marked upon the body of the penis. It is usually, however, quite dry and often scaly, -resem- bling a patch of psoriasis — the squamous induration. Bernard also states that in females induration is most marked upon the nymplue. In a general way, it may be accepted that it is most pronounced when situated upon mucous membranes. In such spongy tissues as the glans penis the indura- tion is apt to be very slight. The sparsity of connective tissue beneath the mucous membrane of this structure, and the extreme tenuity of the mucous membrane itself, will perhaps serve to explain the latter fact. The in- fection of syphilis is pre-eminently a promoter of connective-tissue hyper- plasia, which explains the slight amount of proliferated cells in locations sparsely supplied with connective tissue. Atypic Indltratiox. — In quite rare cases of chancre, or apparently simple lesions followed by constitutional syphilis, induration appears to be entirely absent. This is perhaps due to the fact that it has been overlooked through carelessness, or co-existence with chancroid, or it is so slight that it escapes attention. After a chancre becomes phagedenic, induration shortly disappears. It is a peculiar, and at the same time unfortunate, fact that typically- indurated chancre is a rare thing in women. Yenereal sores appear and dis- appear, and contagion is spread about promiscuously in many instances, while the patient is entirely unconscious of her trouble. Seldom, indeed, does the physician have the opportunity of seeing a typic sore in a woman. 356 SYPHILIS. and the author's experience has taught him that most cases of syphilis in women follow very insignificant-looking lesions. We meet with a relatively large proportion of cases in which the patient is unaware of her disease until secondary symptoms prompt her to seek advice. If, at this time, the focus of infection be sought for, rarely, indeed, can it be found. While com- mitted to the view that in all cases of syphilis induration of greater or less degree must necessarily have existed at the atrium of infection, — i.e., at a point corresponding to the site of inoculation, — it is obvious, from what has just been stated in regard to chancre in women, that the original site of infection is not always easy to determine. The following case from private practice is a pertinent illustration of this fact: — Case. — The author ^vas consulted by a young man in regard to a sore upon his penis that proved to be a hard chancre, and was followed by secondary syphilis. After the local lesion had disappeared, at a time when he considered himself free from lesions and nothing could be detected upon either his penis or elsewhere, he resumed inter- course with a former mistress who was perfectly healthy. Within about eight or ten weeks after this the young woman presented herself with a characteristic roseola and sore throat. The most careful examination and inquiry failed to discover the slightest sign or history of a primary sore. In the progress of the case the woman went through a very severe and obstinate course of the disease. About four or five months after contracting her disease she brought her only child, a girl of seven, to the author for examination. The skin of the child was thickly studded with a maculo-papular eruption of a very suspicious appearance. Careful inquiry failed to elicit any history of a primary sore, and a most thorough examination gave a negative result. The author was in doubt about the diagnosis, although the lymphatic glands were moderately enlarged, until a characteristic mucous patch appeared upon the tongue. A course of gray powder cleared away the eruption very speedily, confirming the diagnosis. CouESE OF THE Indukation. — In simple chancre the induration most generally precedes the ulceration, but often follows it, coming on during the first week. The primary occurrence of ulceration is probably due to some local irritant acting chemically, or chancroidic or pus-infection occurring simultaneously with the syphilitic infection. This is the invariable course of mixed sores, and it. is highly probable that the majority of cases in which induration follows, instead of preceding, ulceration are primarily either chancroid, herpes, or simple ulceration from pus-microbes. The author is inclined to believe that this is alwa^^s the case, and we may accept the rule that syphilitic ulceration is always due to ''necrobiosis," or "anemia of tissue," unless there exists some source of irritation, simple or specific. This is em- phasized more particularly because this method of ulceration is the t^^pe of tissue-destruction seen throughout the entire course of syphilis. It should be remembered that ulceration of syphilitic lesions in general is primarily, in certain instances, the result of simple innutrition from pressure and tis- sue-obstruction, infection with pus-microbes being afterward superadded. It matters not whether the molecular disintegration produced by syphilitic INOCULABILITY OF CHANCRE. 357 neoplasia, or occurring within them, results in an open lesion, as an ulcer, or occurs in the form of a softening node or pustule, the process is the same throughout, being modified only by the presence or absence of secondary mixed infection. If this pathologic generality be remembered, the study of syphilitic phenomena will be greatly simplified. The induration of chancre may be transitory, and, as already indicated, may disappear so rapidly as to be overlooked. Cases have been observed in which it lasted only ten or twelve days, but such cases are exceptional, the ordinary duration being from one to three months, in rare cases lasting for some years. The author has met with several cases of long-persistent chancrous induration. In several instances excision became necessary, the induration in one case persisting for two years. In such cases intrinsic severity of the general infection is to be inferred. Seceetion of Chancee. — The secretion of syphilitic chancre is very scanty and sero-purulent for reasons already given, and retains these char- acters throughout unless the sore becomes inflamed, in which case it be- comes profuse and purulent, and perhaps bloody. Some cases of chancre appear to exhibit a marked tendency to bleed. A number of cases have oc- curred in the author's practice in which this symptom was quite persistent and recurred upon the slightest manipulation of the sore — the so-called "hemorrhagic chancre." CiCATEix OF Chancee. — The scar left by chancre depends upon the depth of the ulceration. In many cases nothing is left but a livid or "ham- colored" spot, that perhaps becomes of a coppery hue later on and finally fades completely. When complicated by other kinds of infection, chancre leaves a scar proportionate to the extent of destruction by the complicating process. Inoculability OF Chancee. — -The fact that syphilis is not autoin- oculable has already been alluded to, this being a very important point in the differentiation of chancre and chancroid. Many attempts have been made with syphilitic secretions, and especially the secretion of the chan- crous ulcer, but autoinoculation has thus far been found impossible, as a rule. When chancre is inflamed and secreting profusely, — containing toxins and pyogenic microbes — its secretion will produce a pustule if autoinocu- lated, acting like any other irritant. This pustule may be followed by ulcer- ation, but never by hard chancre. When the sore is mixed, autoinoculation is, of course, feasible. Van Boosbroeck long ago claimed that all pus is more or less con- tagious. While not an invariable result, it is undoubtedly true that inocu- lated pus will often produce more or less inflammation in tissues previously sound. This is more marked and more likely to be followed by suppuration in some persons than in others. The explanation of pus-contagion is simple enough in these days of pus-microbes. It has occurred to the author as probable that in very unclean persons 358 SYPHILIS. the secretion of chancre may evolve a germ-infection that is, in effect, identic with chancroid, and it seems plausible enough that some of the. cases of "mixed sore" are cases that have undergone a marked change — i.e., to a chancroidic character — as a result of the local circumstances of heat, moisture, filth, and irritation. It is questionable whether, if blood be drawn from an initial lesion be- fore ulceration occurs, — i.e., early enough in the course of chancre, — it may not be capable of inoculating the individual possessing the lesion; indeed, such an occurrence has been reported. This harmonizes Avith the theory that syphilis is primarily local. The following case bears directly upon this point : — • Case. — A large indurated penile chancre with slight attendant ulceration was ex- cised. The precaution M-as taken of waiting until the process was apparently station- ary and the chancre fully developed. The ulcer was first cauterized to prevent con- tamination of the wound by its secretion, after which the indurated tissue was thoroughly excised, the incisions being made well beyond the borders of the diseased tissues. An irregular wound was left that was closed with several catgut sutures. On the second day the wound had united and everything looked well; but on the fourth day induration of the edges of the wound began, and in a few days had involved their entire extent and the surrounding tissues for some little distance, finally attaining the size of an almond, being at least double the size of the chancre excised. The recurrence of induration in the foregoing case is certainly sug- gestive. x\ll the indurated tissue had been removed, and if constitutional syphilis already existed, no infection of the cut surfaces should have oc- curred. As there seems to be no other explanation, it would appear that the infection took place through the medium of the blood that escaped from the chancre. It is certainly peculiar that the resulting chancre should have been proportionate in extent to the cut surfaces and of similar shape. The speedy recurrence of the induration is noteworthy. Wallace cites a case in which he succeeded in inoculating a man Avith "syphilitic virus," producing a true chancre, when the patient was already in the eruptive stage of the disease. Fournier estimates that about 2 per cent, of autoinoculations of true chancre are successful, but presumably only when some inflammatory change in the sore exists. The author has already expressed the belief that a greater proportion might be successful if performed sufficiently early in the course of the disease. The practical rule, however, is that autoinoculation of true chancre is not feasible, although it may possibly succeed if done very early. When the syphilitic infection is inoculated upon a number of raAv sur- faces simultaneously, or after a few days' interval, chancre usually appears at each infected point at about the same time. This is a valuable point in differential diagnosis, for chancre, unlike chancroid, is usually multiple from the beginning, if at all, while chancroid may become multiple by auto- inoculation. A fcAv apparent exceptions to this rule have been noted. TYPIC COUESE OF LOCAL SYPHILIS. 359 In the stage of sequels— i.e., the so-called "tertiary period" — the secre- tion of chancre from another person may be inoculated, although rarely. Although the disease proper has disappeared, the patient is still relatively immune. Typic Couese of Local Syphilis feom Dieect Inoculation. — The course of syphilis following heteroinoculation is interesting. When any secretion containing syphilitic infection, such as discharge from a syphilitic chancre or mucous patch, or blood from a syphilitic subject, is inoculated upon a healthy individual, there may be a small pustule following, as from the prick of a septic lancet, due to pus-organisms; but this lasts only a few days, and is generally absent, there being nothing to indicate the site of inoculation, unless perhaps a speck of dried blood, until after a period of from ten to forty days, when an indurated papule appears. This becomes "ulcerated" most likely, but may not do so; the neighboring lymphatics be- come enlarged, and general syphilis follows. In vaccinal syphilis — i.e., syphilis acquired accidentally in the operation of vaccination — a somewhat different course is followed. The incubation period of vaccinia expires first, the characteristic vesicle appearing and running its usual course. After a time, however, the vaccine-vesicle becomes an ecthymic ulcer with an in- durated base, or induration appears and runs its course without ulceration. When a subject already syphilitic is vaccinated, we are likely to have a characteristic secondary syphilitic ulcer resulting after the typic vaccinal vesicles have first formed. Such an instance recently occurred in one of the author's patients, although under the influence of mercury at the time. A very important source of error with regard to vaccinal syphilis and one that should always be borne in mind, is that the local and constitutional dis- turbance produced by vaccinia is liable to develop latent S5^philis, whether hereditary or acquired, in which event the vaccinator will probably get the credit of having inoculated the disease. In such cases a more or less general eruption Avill usually be observed, commencing in the vicinity of the sore, instead of the typic period of incubation followed by typic induration, and after a variable time, by glandular enlargement and general syphilis. The following case reported by J. S. Prettyman is an excellent illustration of the course of vaccinal syphilis, but contains an unfortunate source of fallacy in the fact that the changes in the vaccinal sore are not described. Without typic induration such cases are open to question. In this instance the omis- sion was evidently unavoidable: — ■ Case. — Mr. N. T., aged 30, has been married nine years. His wife is healthy, has never aborted, and is entirely free from skin disease. They have two robust children, aged 6 and 8, who have always been well, but are subject to a "breaking out." Ten years ago the patient vaccinated himself directly from the arm of another, who, it was said, had been cured of a "bad disorder." In about two weeks an erup- tion appeared over the entire body and continued three months, disappearing and reappearing several times since. From time to time lumps have been noticed over 360 SYPHILIS. various parts of the body. He has never had ulcers in the throat, but the glands have been enlarged, and several times chronic abscesses have formed. He received no treatment except such remedies as he would apply locally. He presented himself with nodes, bullous sj^hiloderm, and ulcerations upon the neck, arms, back, and legs. He denied all possibility of contagion from any other source, and affirmed that previous to the vaccination and appearance of the eruption he had not even once indulged in sexual intercourse. It is self-evident that the accuracy of the diagnosis in the foregoing case depends upon the patient's Te^acit5^ CoMPAEATivE Feequexct OF Chaxcre axd Chaxceoid. — The rela- tive frequency of chancre and chancroid is variously estimated hy different observers. Thus, Fournier finds in his private practice that the frequency of chancre as compared with chancroid is about three to one. The statistics of ten years at one of the large Parisian hospitals show that chancroid com- prised about 80 per cent, of sores. From clinical experience the author is inclined to believe that these estimates are fair criterions of the relative fre- quency of the two varieties of genital sore as seen in both private and hos- pital practice. It must be remembered, however, that in hospital practice patients with atypic, and possibly mixed, sores are often lost sight of after they leave the hospital. Doubtless many of these afterward develop syph- ilis, thus cutting down the percentage of simple chancroid. IxFECTious Seceetioxs IX' Syphilis. — The consideration of the vari- ous secretions, physiologic and pathologic, that are capable of transmitting syphilis is very important. They have been exhaustively studied by different observers, among the most thorough of which have been Bassereau, Diday, EoUet, Fournier, and Clerc. These investigators have arrived at practically the same conclusions. Inoculations with the secretions of chancre, mucous patches — in short, all secondary cutaneous or mucous lesions capable of yielding a discharge, and of syphilitic blood have been made with entire success. Whether the blood is infectious between the periods of active mani- festations of the disease has not been determined by experiment, but from observations made upon vaccinal S3^philis it probably is. There would seem to be no logical reason why the blood should not be infectious at this time, inasmuch as each successive crop of lesions is not due to a new development of syphilitic infection, but to its renewed activity. The secretions of non- syphilitic lesions occurring upon a syphilitic are not inoculable unless mixed with the blood of the syphilitic subject: e.g., the secretions of gonorrhea and chancroid occurring in a syphilitic produce only gonorrhea and chan- croid unless there is an admixture of syphilitic blood. Diday inoculated pus from acne pustules produced by potassic iodid on a syphilitic subject, but with negative results. It is also probably true that vaccine-lymph de- rived from a syphilitic is not capable of producing syphilis unless it con- tains some of the patient's blood. This, however, should make the physician none the less cautious, for it is very easy for a small quantity of blood to be- IXFECTIOUS SECEETIOXS IN SYPHILIS. 361 come mixed with the Ijanph and remain undetected. ' The vaccine-scab from a syphilitic patient is always dangerous, as it invariably contains a certain proportion of dried blood in its composition. This view has been disputed, and in a most heroic manner, by an English physician, whose ex- periments, however, simply serve to confirm the opinion already expressed, inasmuch as it seems evident that in the last and successful inoculation the experimenter must have used lymph mixed with a minute quantity of blood. If this were not the case, how can the failure of the first three experiments be explained? The experiments were as follow: — With a desire to settle for himself the vexed question, Avhether vaccine-lymph taken from a syphilitic person, if unmixed with the blood of the vaccinifer, does not contain syphilitic virus, and is incapable of imparting syphilis by its inoculation. Dr. Cory made at intervals four separate experiments upon himself with lymph derived from obviously-syphilitic children. The last experiment was successful, and Dr. Cory had to endure all the pains and penalties of syphilitic inoculation. The committee appointed to investigate Dr. Cory's experiments, consisting of Drs. Bris- towe, Humphrey, Ballard, and Mr. Hutchinson, report that it is possible for syphilis to be communicated in vaccination from a vaccine-vesicle on a syphilitic person, not- withstanding that the operation be performed with the utmost care to avoid the admixture of blood.^ How was it possible for the committee to determine absolutely the ab- sence of blood? There is no account of a careful microscopic test having been made. The infection-bearing element of syphilitic blood is quite likely the white corpuscles, though no confirmatory observations have been made upon this point. The germs may exist free in the blood, although this is not probable. Inoculations with the secretions of tertiary lesions and with blood dur- ing the tertiary stage of syphilis are negative, although there have been apparent exceptions to the rule. Bumstead relates a case of inoculation of a surgeon's finger while operating upon a case of tertiary necrosis of the skull. The author will also cite the case of an intimate friend who in- oculated his finger in operating upon a rectal fistula in a patient suffering from tertiary S3^philis. In due time a chancre appeared, and was followed by a well-marked development of secondary manifestations. The gentleman finally died from cerebral syphilis. The possibility of such cases as those from whom these surgeons con- tracted syphilis being illustrations of reinfection of subjects suffering from sequels of a previous attack must be remembered, otherwise they would seem to refute the physiologic pathology. It is also to be considered that sub- sequent infection from some other source might have occurred in the wounds received while operating. In neither of the cases cited were the circumstances such as to preclude the possibility of such infection. ^ British Medical Journal, May 13, 1884. Dr. Cory has at least enrolled himself among the heroes of science. 363 SYPHILIS. The non-tran'smissibility of syphilis during the tertiary period of the disease is perhaps the strongest evidence in favor of the view that the lesions of this stage are not syphilitic at all, but are simply sequels. Patients suf- fering with tertiary manifestations may procreate healthy children, although they do not always do so. In many cases in which the children are fairly healthy and cannot justly be pronounced syphilitic, in the true sense of the term, there will be found some remote slight manifestations of hereditary taint, such as imperfect or irregular development of the teeth, or some other of the various manifestations of faulty nutrition that we are wont to. accept as evidences of a strumous diathesis. Hutchinson's experience regarding the efi&cacy of mercury and iodin in struma probably has a basis quite dif- ferent from the supposed "antistrumous" action of these remedies. The term "attenuated syphilis" would be fitting for many cases of so-called scrofula. As a rule, however, we may accept the statement that tertiary syphilis is not transmissible. The later the period of the disease, the less the liability to transmission, and it is also probable that the male loses the power of transmission before the female; this is certainly true of hereditary transmission. ISTone of the physiologic secretions, such as mucus, sweat, urine, milk, and semen, are inoculable, unless they contain either syphilitic blood or the secretion of a syphilitic lesion.^ The saliva, so often the medium of contagion, is innocuous unless mucous patches or other lesions exist in the mouth, in which case it is contagious in the highest degree. The syphilitic infection^be it cell or bacillus — must be present, else no secretion, ph3^siologic or pathologic, can transmit S3^philis.^ ^ It is obvious that if tlie assertions of von Xiessen sliould be confirmed this view of the normal secretions of syphilitic subjects will be refuted. " A proposition that is self-evident. CHAPTER XY. Methods of Acquieixg Syphilis — Yaeieties and Teeatment of Chaxcee — Peimaey Syphilitic Adenopathy. Methods of Acquieixg Syphilis.— The presence of the probably germ-bearing syphilitic cell or free bacilli is all that is necessary to render any secretion, whether physiologic or pathologic, extremely contagious, and in the absence of this infectious cell — unless the germ of syphilis exists free in the secretions, as is possible — no contagion can occur. Inasmuch as every morbid secretion produced by syphilitic lesions contains the syphilitic in- fection, either as germ-infected cells or free bacilli, and the lesions of syph- ilis are many and various, both as to form and location, the opportunities for transmitting the disease and the methods of its contraction are neces- sarily very numerous. The contagiousness of the blood of syphilitic sub- jects during the active period of the disease affords an additional danger, as there are several ways in which it may be accidentally inoculated. The initial lesion of syphilis or chancre may occur upon any portion of the human body, the only essential requisites for its production being a secretion containing the syjDhilitic infection — i.e., cell or germ — and a sur- face, integumentary or mucous, that has been deprived of its epithelium and is consequently capable of absorption of extraneous matter — i.e., an atrium for infection. In every method of transmission of syphilis, with the exception of two, the general disease is always preceded by chancre, and the existence of the latter may be inferred whether it has been detected or not. The circum- stances in which a chancre is never present are (1) the infection of the child w utero and (3) the infection of the mother through the medium of the child, the latter mode of transmission being still a subject of con- troversy. The first method has been positively demonstrated, and under either circumstance the syphilitic infection enters the blood-current di- rectly, and not through the medium of a localized process of infection and proliferation of cells followed by a roundabout tour of the lymphatics. Probably the same thing would occur if the syjahilitic secretion or blood were injected directly into a large blood-vessel. Where the father of the child is syphilitic and the mother healthy, the child may escape infection (1) because the virus is temporarily inactive in the father — either sponta- neously or from treatment; (2) he may have no infection-producing lesions; (3) the mother may present no atrium of infection: i.e., no surface capable of inoculation; or (4) the father's disease may be so far advanced in the period of sequels that it ceases to be transmissible. Excellent authorities deny that the child can be infected by the father directly, claiming that such infection can only occur through the medium of the mother. The (363) 36i SYPHILIS. author was formerly inclined to believe in the joossibilit}' of independent paternal infection, but increasing experience has led to the opposite view. This much, however, is certain, viz.: the svphilitic father may transmit to the child, independently of maternal infection, various dyscrasic conditions characterized by nutritional disturbances that, while not syphilitic in the literal sense, are nevertheless derivatives of syphilis. . It is highly improb- able that a healthy constitution of the spermatozoa can exist in a man who is jDrofoundh' impressed by syphilis. On the other hand, it is reasonable to supi^ose that the presence of active syphilitic infection in the spermatozoa would inevitably prove fatal to their vitality, and that consequently the child cannot become infected, save through the maternal circulation. AVhen the mother is syphilitic at the time of conception, or becomes so within seven months afterward, the child is invariably infected, unless a thorough course of treatment is instituted during the period of pregnancy, in which case it may possibly escape — apparently, at least. Oftentimes, however, the children of syphilitic women may not develop the disease until late in life, — syphilis Jiereditaria tarda, — thus leading to the supposition that they have escaped the disease. In such instances the disease expends its violence upon the maternal organism, jDrobably acting in a manner somewhat analogous to vaccinia. AATien the mother is infected after the seventh month of preg- nanc}", the child usually escapes: a point in verification of the views of the cell-pathology of syphilis already presented and which will shortly be dilated upon more fully. The second mode of contracting syphilis without the occurrence of chancre is the infection of the mother through the medium of the child. This, too, is denied by many authorities, even among those who accept the direct infection of the child through the father independently of maternal infection. That the author does not accept this view is a corollary of the opinion already expressed regarding immediate infection of the child by the father. It must be admitted, however, that the mother often apparently escapes the disease entirely or has very mild symptoms. Granting the oc- currence of independent paternal infection, there would be an explanation of this fact also in the possible analogy of fetal infection to vaccination first suggested by Hutchinson: syphilis in the mother being modified greatly, or entirely prevented by the infection of the child in much the same manner that variola is modified or prevented by vaccination. Theoretically the dis- ease expends its violence upon the child in utero, thus rendering the subse- quent infection of the mother comparatively mild, if, indeed, it occur at all. The converse of this hypothesis seems, however, the most logical view. The fetus in idero is organically an integral part of the mother, despite the ab- sence of direct nervous and vascular connection. The mother being in- fected in the usual manner, the disease may expend its violence upon the fetus as being relatively more susceptible than the maternal organism as a whole. The child is consequently profoundly impressed, while the mother's METHODS OF ACQUIEING SYPHILIS. 365 infection is overlooked because of the mildness or perhaps entire absence of symptoms. Argument aside, it is a clinical fact that infants with severe congenital syphilis are often born of mothers who are apparently healthy and who seemingly remain so. The following is a case in point: — Case.- — A young man under the author's care for severe secondary syphilis was engaged to a healthy, buxom young woman of German extraction. He was advised to break the engagement, which he did Avithout explanation. It subsequently transpired, however, that the young woman had notions of her own regarding the matter, and the patient, being nothing loath, fell in with her ideas, with the result that an illicit intimacy was established. The young woman became pregnant, and the couple were finally married. A male child was born in due time, that was apparently healthy at birth. Within three weeks, however, the characteristic "snuffles," and shortly afterward a marked general pafulo-bullous syphiloderm developed. The mother has never had, so far as can be determined, the slightest manifestation of disease. It has been stated that all that is necesary for the transmission of syph- ilis is the contact of a germ-laden secretion from a syphilitic lesion with an abraded surface. In many instances of infection no abrasion is perceptible, but it is to be inferred that it must necessarily have existed, inasmuch as the infection cannot be absorbed by an unbroken epithelial surface. AVhether the secretion containing the syphilitic virus may remain in con- tact Avith a sound surface of mucous membrane until maceration and re- moval of its epithelium with subsequent absorption occurs is not positively known, but this is highly probable and may undoubtedly occur in the case of secretion from a mixed sore, which is usually quite corrosive. Modes of C ontagion.—Th.e methods of contagion in syphilis are classi- fied as mediate and immediate. By the mediate method we understand the transmission of the disease through the medium of infected drinking utensils, tobacco-pipes, towels, etc. Chancroid is very rarely transmitted in this wa}^, but syphilis is quite often so transmitted on account of the multi- plicity of its lesions, that are sometimes apparently so insignificant, but none the less infectious. By the immediate method of contagion is implied the direct contact of an abraded surface in a healthy person with a secreting sj'philitic lesion or with syphilitic blood from a non-syphilitic lesion in a syphilitic subject. The type of this mode of contagion is, of course, infec- tion during sexual intercourse, but the disease may be immediately in- oculated in many other ways; quite often it is contracted by the physician or surgeon in operating upon or examining syphilitic subjects. Many prominent obstetricians anci gynecologists have had sad experiences in this respect. Chancre is sometimes contracted in kissing, a small, insignificant- looking — perhaps unrecognized — mucous patch upon the lips or tongue of the diseased person inoculating any slight fissure or abrasion that happens to be present upon the lips of the healthy subject. There are many very sad examples of this mode of contagion. The author has had a large num- ber of such cases under observation in private practice. Bulkley has col- 366 SYPHILIS. lected a surprisingiy large mass of clinical examples of syphilis in the inno- cent.^ Infants may contract syphilitic chancre from the nipples of syph- ilitic nurses, and, on the other hand, a healthy nurse may contract chancre of the nipple from a syphiHtic ijifant. CoUes's law, so called, that an hereditarily-syphilitic infant cannot infect its mother, depends simply upon the fact that the mother already has, or has had, syphilis. As already sug- gested, the possible analogy to vaccinia may explain it, the syphilization of the infant having afforded immunity for the mother — if the possibility of independent infection of the embryo by the father is accepted. Fig. 103. — Chancre of upper lip. (After Duraesnil.) Great care is necessary, when one member of a family is syphilitic, to prevent transmission of the disease to others. In the familiar intercourse existing between immediate relatives great danger of infection exists. This is well shown by several cases in the authors experience. In two instances a careless mother infected her little girl, who sulisequently developed marked secondary syphilis. In another, several members of a family were infected through careless handling of a syphilitic infant. There are many interesting examples of the mediate method of con- tracting s^'philis. Instances have been known in which a man with a long ^ L. D. Bulkley: "Syphilis in the Innocent.' METHODS OF ACQUIEING SYPHILIS. 36? prepuce has had intercourse with a syphilitic female and shortly afterward with his wife, infecting the latter, while he himself escaped the disease, the virus having been retained beneath the prepuce and subsequently deposited . in the healthy vagina. Again, the syphilitic poison may be deposited in the vagina of a female by her lover; her husband, embracing her shortly afterward, receives the souvenir the lover left him, while the woman herself escajDes. These facts must be born in mind, for a knowledge of them may be of great service in diagnosis. Tobacco-pipes, drinking-utensils, and the tubes used by glass-blowers are familiar media of syphilitic contagion. An instance is related in which a whole glass-blowing establishment became infected by the blow-pipe, as it was passed from mouth to mouth. One of the workmen had a few small, mucous patches in his mouth, and from this man the whole party contracted syphilis. Vaccination is also a familiar mode of contagion, less frequently, however, than is generally supposed, for if the taint of generations past should happen to manifest itself at the time of vaccination, particularly if humanized virus is used, the trouble is invariably laid at the door of the doctor. An interesting instance of the wide dissemination of syphilis by mediate transmis- sion is one in which an entire community was infected by an itinerant tattoo artist, who used his own saliva in mixing his inks. The usual ex- planation of mucous patches in the mouth holds true in this case. Kline has reported an instance in which thirty married women, nine husbands, and two infants either mediately or immediately contracted syphilis from a syphilitic midwife.^ A possible danger of contracting syphilis is said to be the custom prevalent among some cigar-makers, of biting the ends of cigars into shape and sticking the wrappers with saliva. Morrow reported a case of chancre of the chin from a scratch with a barber's razor. Taylor also mentions having seen such a case. Another interesting case has been reported in which a syphilitic patient cut off the end of a cigar, that he had previously held in his mouth, in a clip such as is seen in all cigar establish- ments; infectious material was left upon a cigar subsequently cut in the same machine by a healthy person, who in due time developed labial chancre and secondary syphilis.^ Duration of Chancre. — The duration of syphilitic chancre is variable. It may last for a couple of weeks, but in the majority of cases an eruption appears prior to the disappearance of the chancre. Numher of Chancres. — Chancre is generally single, but may be multi- ple, according to the number of points primarily inoculated. It is usually situated upon the genitals, especially often behind the corona glandis in the male, but its situation may vary greatly, as may be readily understood upon ^British Medical Journal, January 20, 188.3. • - To those especially interested in syphilis acquired in non-venereal ways — syph- ilis insontium — Dr. Bulkley's work, already mentioned, will be of great value. 368 SYPHILIS. considering its numerous methods of contagion. Chancres of the face, tongue, nipple, and fingers are not so very rare, and instances of chancre . of the tonsil have been reported. Urethral chancre is not uncommonly seen. Vaeieties of Chaxcke as a Clinical Extitt. — The various forms of induration of chancre have already been described, but a further descrip- tion of the initial sore, particularly of the ulceration, may be of service. Open chancre may present: 1. A superficial loss of epithelium without sup- puration, for a time at least; this is termed simple erosion. 2. A greater or less area of ulceration — saucer-shaped — incidental to irritation and sec- ondary pus-infection. 3. A deep ulcerative excavation with sloping edges. 4. Herpetiform and crustaceous chancre are exceptionally met with. 5. "When not open — i.e., when there is no loss of tissue — the chancre occurs in Fig. 104. — Hard chancre in the fossa glandis. (After Dumesnil.) the form of an indurated, non-secreting jDapule or tubercle. 6. Diphtheritic (diphtheroid) chancre. Erosion may be said to include about two-thirds of chancres, and is usually situated upon the mucous membrane, very often inside the prepuce in the male. In shape it is oval, or perhaps a trifle irregular, with a raw, polished surface of a wine-red color and sometimes a pultaceous base, but usually secreting a simple thin, sanious fluid, devoid of pus, or at least con- taining a very small amount of pus-corpuscles. These erosions are flat and may surmount a thin parchment induration, or ma}^ cap a hard tubercle as large as a marble. Superficial ulceration with sloping edges^the ulcer presenting a saucer-shajDe — is found with the parchment, but most often with the split-pea, induration. When this ulceration ea^^s a large mass of induration, it is likely to be quite deep and funnel-shaped from extensive necrobiosis, constituting the so-called "Hunterian chancre." The secretion from a chancrous ulceration is quite likely to be of a sero-purulent char- COMPLICATIONS OF CHANCEE. '669 acter. Herpetiform and crustaceous chancre may occur in any situation. The simple indurated papule or tubercle is usually found upon the skin, the integument of the penis, or even upon the prepuce itself Avhen it is short and dry. Ulceration of this form of induration might occur if it were kept moist, the conditions of warmth, moisture, and irritation com- bined being especially favorable to the production of ulceration. The parts upon which it develops are perhaps not so rich in lymphatic spaces as those in which a chancre is more likely to ulcerate, the collection of cells being consequently smaller and the tendency to necrobiosis less marked. Several unusual types of chancre have been described. French authors de- scribe a variety called the ''herpetiform." This would seem from its de- scription to be simply a lesion of herpes that becomes infected with syphilis and eventually indurates. In some cases the rationale of its formation is exceedingly simple. At the time of exposure to syphilis the subsequently- infected surfa'ce comes in contact with some local irritant. The patient being predisposed to herpes, one or more vesicles develop within a short time after exposure. The chancrous induration develops in the herpetic lesion later on — at the end of the period of incubation. Fournier describes a form of chancre that he terms "crustaceous chancre." This, he claims, may be confounded with scabies, which latter disease may present pseudo- induration and inguinal adenopathy. This condition yields to sulphur, which chancre does not. Fournier claims, however, that expectancy is the only recourse in the differential diagnosis of crustaceous chancre. The symptoms of urethral chancre, when too deep to be seen without the urethroscope, consist in a discharge coming on after the usual period of incubation, this discharge being thin, and perhaps sanious, but some- times creamy and thick. There is a painful spot in the urethra that is espe- cially noticeable during micturition and erection, with possibly a lump in the course of the canal, plainly perceptible on palpation with the thumb and finger in some cases. The character of the discharge depends upon the degree and character of the complicating urethritis. The characteristic symptoms of stricture may be present, produced by the pressure of the chancre upon the urethral lumen. By means of the urethroscope an ulcer may often be detected, and in a short time the general enlargement of the glands and other symptoms clear up the diagnosis. Great caution is neces- sary in making a diagnosis until these confirmatory symptoms appear. The author desires to call attention to a peculiar form of urethral chancre that may lead to grave errors in diagnosis. This appears as a slight erosion of a milky color, just within the meatus. Induration is not perceptible and the lesion looks not unlike an intra-urethral herpetic lesion. Complications op Chancee. — There are some complications of syph- ilitic chancre that demand attention: 1. First and simplest we have vege- tations or papillomatous growths: the so-called venereal warts. These re- sult from local irritation in combination with heat and moisture, and are 370 SYPHILIS. identic with vegetations occurring nnder otlier circumstances. Tliey liave already been discussed in a preceding cliapter under tlie liead of non-vene- real lesions of the penis. The author will reiterate his belief that, while simple genital papillomata are in no sense syphilitic, they, like herpes pro- genitalis, thrive best on syphilitic soil. Proper measures of cleanliness will usually prevent the formation of vegetations. When they do appear, as they will in some persons despite all care, caustics or, better, the scissors are necessary for their removal. 2. Inflammation of chancre — pus-infec- tion — sometimes occurs, giving rise to considerable pain and profuse puru- lent secretion. 3. Chancre may be complicated by chancroid — constituting "mixed sore," unless the two forms of disease appear in different locations. 4. Chancre may be attacked by phagedena or gangrene. Mixed Chancre. — When a chancre becomes inoculated Avith chan- croid, its ulceration deepens and it gradually assumes the general characters of chancroid, but unless phagedena occurs induration usually still persists. Oftener than is usually supposed, however, the chancroidic process inhibits the development of chancrous induration, or initial sclerosis — as a conse- quence, syphilis oftentimes follows an apparently-typic soft sore. Slight sclerosis is very apt to be melted away, so to speak, by the chancroidic in- fection, and thus escape attention. When chancroid develojjs primarily — from typic mixed infection — it generally runs its usual course, until the incubation period of syphilis has elapsed, when induration occurs. The secretion of the mixed sore is autoinoculable, and capable of transmitting either disease alone, or both together, to a healthy person. In some cases chancroid appears and rapidly heals, or the incubation-period of syphilis is long, and induration develops in the cicatrix of the chancroid after it has soundly healed. The test for mixed chancre is autoinoculation. Any indurated sore, the secretion of which is autoinoculable in the true sense of the word, and which is followed by constitutional syphilis, is a mixed chancre. By the term autoinoculable is meant a sore the secretion of which, inoculated in a new situation in the diseased individual, will produce typic chancroid. The methods of contraction of mixed chancre are tAVO, viz.: (1) both poisons may be contracted simultaneously, or (2) either variety of genital lesion may develop primarih', and subsequently become inoculated Avith the other form of disease. Typic syphilitic chancre — initial sclerosis — may undergo marked transformations: e.g., a chancrous induration, particularly when situated in a moist locality such as a mucous or cjuasimucous surface, may lose its hardness and at the same time become transformed into a quasimucous patch by becoming covered Avith a characteristic whitish pellicle. In some instances the sore acquires the form of the mucous patch yet retains its characteristic induration. MorroAv has described a "diphtheritic" A^ariety of chancre. It is possible that this may sometimes be the mucous trans- TEEATMEXT OF CHANCRE. 371 formation just described, and not a special variet}^ of lesion, but the author has met with cases corresponding exactly with Morrow's description. Phagedenic Chancke. — Phagedena may attack true chancre, and when it does so is quite likely to be of the gangrenous form. The pultaceous and serpiginous varieties are cjuite rarely seen under such circumstances. After phagedena has once invaded a chancre induration is no longer perceptible. If the sore be of the mixed variety, the pultaceous or serpiginous form of phagedena is then quite likely to develop. Such authorities as Bassereau and Diday think that the type of syphilis following phagedenic chancre is apt to be exceptionally severe. This is true in the authors experience, but is explicable by the fact that phagedena, per se, is probably due either to general debility or a peculiar diathesis that lessens both local and systemic resistance to disease and especially to syphilis, rather than by an extraor- dinary intensity of the syphilitic infection. The question of a special germ- infection in phagedena is still suh judice. Treatment of Chancre. — The treatment of syphilitic chancre is very simple when no comj)lications exist. The yellow or black wash may be ap- plied, and are the best aj^plications that can be used. According to the new pharmacopeia, the lotio flava, or yellow wash, consists of 18 grains of the bichlorid of mercury to 10 ounces of liquor calcis, and the lotio nigra, or black wash, of 30 grains of calomel to 10 ounces of liquor calcis. These preparations should be well shaken before being used, else very little of the salt of mercury, Avhich exists in the form of a precipitate, will be applied. The mild chlorid of mercury with zinc oxid forms a very efficient dressing. Europhen, nosophen, and, if the lesion is painful, orthoform, are useful applications. Cauterization of simple hard chancre should never be practiced, as it will simply cause painful inflammation and perhaps sloughing in an other- wise locally insignificant lesion. If, however, the sore is of the mixed variety, its chancroidic property should be destroyed by cauterization, after which iodoform in powder should be applied. All sources of irritation should be carefully avoided and perfect cleanliness insisted upon. The author believes that the internal administration of mercury should be begun as soon as the diagnosis of syphilitic chancre is perfectly clear. By follow- ing this course there are seldom any manifestations of the disease other than a slight roseola, with perhaps a few trifling mucous patches, during the entire course of treatment. It is very important to prevent eruptions, especially upon the face. Whenever, on the other hand, there is the slight- est doubt as to the correctness of the diagnosis, no mercury should be given until the question is decided by the appearance of symptoms unequivocally syphilitic. In a general way it is to be remembered that uncomplicated chancre is of little importance locally. It usually causes very little annoyance if not tortured by overtreatment. With the use of black or yellow wash, calomel, 372 SYPHILIS. nosojDlien, enrojjlien, or iodoform powder, or even absorbent cotton as a dressing, the induration ma}' nsuallj'' be left to take care of itself. Should the snrgeon wish to see by contrast the results of meddlesome ofhciousness, let him rub a hard chancre with pure nitrate of silver, and then apply some nasty, greasy ointment. The result will be a condition of affairs often seen in patients who have been treated in this manner by physicians, drug-clerks, or ver}^ often by themselves. Greasy applications and nitrate of silver should be avoided as abominations, else the patient's confidence will quite likely be lost. It, as in the case of mixed sore, it becomes necessary to cau- terize, the surgeon should use a caustic, and have done with it, and not apply an irritant like nitrate of silver, which sears, but does not destroy. Carbolic acid followed by the fuming nitric, pure bromin or the actual cautery should be used. The form of caustic is not so important as the manner of its use. The surgeon should select a caustic early in practice, and stand by it until he learns how to use it. The patient should be instructed in the matter of rest. Much may be accomplished by avoiding sexuality in thought and action, by taking very little exercise, abstaining from stimulants, and lastly b}^ handling the affected part as little as pos- sible. The oftener the patient examines himself to note the progress of the ease, the worse his chancre will eventually be. Occasionally a chancre will become phagedenic, in which event special measures of treatment become necessary, as seen in connection with phagedenic chancroid. Free stimula- tion and local cauterization with the actual cautery or pure bromin, followed by strict antisepsis, are the jDrincipal indications. Tonics and opium must be given. Opium was especially indorsed by Eicord. In the author's ex- perience it has seemed to be of service. It is certainly useful in relieving pain and nervous irritation in such cases. Mercury is necessary to combat the debilitating eff'ects of the constitutional syphilis in phagedena. It should be given very guardedly, howe^^'er, and in tonic rather than specific doses in most cases. Excision of Chancre. — There is one radical method of dealing with chancre that deserves special attention, viz.: treatment by excision. It is claimed by some advocates of this method that by it the general symptoms are modified and in some instances prevented entirely, not even the indolent glandular changes being perceptible. Theoretically, if the views of the pathology of the disease that have been presented in the ^^receding chapter b.e correct, excision of the initial sclerosis ought to prevent general infection completely, but unfortunately this has as yet to be proved to be the case in actual practice. The author has given the method some attention and has performed excision in selected cases whenever the patient's consent could be obtained. The cases thus treated number about sixt}^, some of which could be carefully followed thereafter, while others passed from under observation. In his earlier cases the author was inclined to believe that the operation was of benefit constitutionally. Subsequent experience, however, has seem- EXCISIOX OF CHAXCEE. PEIMAKY ADENOPATHY. 373 ingly shown that excision is of value only in meeting certain local indica- tions of a special character. Excision of chancre should be performed only after the induration has matured: i.e.; after it has attained full development and has remained in statu quo for some days. Otherwise induration is likely to recur in the edges of the wound. ^ There are several arguments that have been advanced in favor of excision which are in the main acceptable, viz.: 1. We thereby remove a constant focus of infection that is present so long as the induration persists. 2. We at once remove a large mass of syphilized cells that would otherwise only be removed by the slower process of fatty degeneration, ab- sorption, and elimination. 3. We obviate the possibility of the transmis- sion of the disease to others by means of the initial lesion — a point of great importance to married persons. 4. We lessen the danger of suppurating bubo, in case the chancre should become inflamed or pus-infected. 5. We remove a constant source of irritation and lessen the danger of phagedena and inflammation that might disable the patient. 6. The patient is able to resume his marital relations immediately the incision has cicatrized per- fectly.^ Why we cannot prevent constitutional syphilis by excision of chan- cre prior to local glandular changes is not clearly explicable, if we accept the view that the disease is practically local primarily. It is probable that the syphilitic infection, which begins at the moment of inoculation, has extended far beyond the limits of the initial lesion before the appearance of the latter. Then, too, improbable as it may appear, syphilis may possibly be a complex infection with both local and constitutional elements. Operation. — Excision of the chancre should be preceded by washing the parts in a solution of bichlorid of mercury 1 to 1000. If ulceration exists it should then be cauterized and dusted w4th calomel. The chancre should now be transfixed with a tenacrdum, raised from its bed, and the mass of induration quickly removed with a sharp scalpel or curved scissors. The incision sliould be sutured with fine catgut, dry dressings applied, and the patient kept at rest for a few days. Within forty-eight hours, as a rule, the wound will have united. In a week or two, if there is no penile lesion, the patient may resume his marital relations, providing some measure of pro- tection of the wife be adopted, such as the use of protectives or antiseptic unguents- and irrigations. Primaey Adenopathy. — The glandular enlargements that succeed the appearance of the initial sclerosis or chancre have already been noted. These are ordinarily termed "syphilitic bubo." The term primar}^ adenop- athy is more comprehensive and much more accurate pathologically. Pri- mary adenopathy may occur in any situation where there are lymphatic glands in the vicinity of a chancre, being therefore most often found in the ^ Xote case on page .358. ^Otis: "Class-room Lessons in Syphilis." 374 SYPHILIS. groin. The groups of glands involved vary according to the location of the chancre. In chancre of the penis, urethra, groin, buttocks, anus, lower part of the abdomen, scrotum, thighs, or rectum, the inguinal or femoral glands or both are involved. In chancre of the lips and mouth the submaxillary lymphatics, and in chancre of the face, the pre-aural glands are involved. When the finger is inoculated, we have enlargement of the glands in the axilla. The epitrochlear gland is not usually enlarged until secondary adenojDath)^ develops, for it connects only with the deeper lymphatic ves- sels. General glandular enlargement eventually occurs, but the changes are first evident in the contiguous glands, and they are always more markedly enlarged than any of the others. When the inguinal glands are implicated, they are grouped in a peculiar fashion. This group, termed, by Eicord, the "jDleiad," consists usually of one large gland surrounded by from two or three to six or eight of smaller size. The enlargement is generally not very extensive, but is peculiar in some respects. There is little or no pain or tenderness, and the glands are freely movable under the skin, being distinctly outlined and not matted together. As a rule, they have tbe hard woody feel observed in the chancre, but exceptionally they are softer and more elastic. Enlargement of the glands begins usually about the beginning of the second week after the ap- pearance of the chancre, and Fournier stjdes a case in which enlargement did not occur until the twenty-seventh day as unique. Instead of the peculiar group known as the pleiad, there may be only one moderately enlarged gland, or perhaps a single swelling, as large as a hen's egg, on one or both sides. Dissection shoAvs that, as originally claimed by Bassereau, such swellings consist of small glands matted together with enlarged lym- phatic vessels and firm connective tissue. Syphilis d'Emtlee. — The form of bubo without a pre-existing chancre, hubon d'emblee, — already expatiated upon in the chapter on bubo, — was for- merly much talked of in France. The syphilis following this variety of bubo has been termed syphilis d'emhke. Taylor very properly styles syphilis d'emhlee "a myth," but there are, nevertheless, occasional cases that are very puzzling at first sight. The author has seen a number of cases in which the first perceptible manifestation of trouble was in the inguinal glands, typic syphilis following in due course in each case. These patients were under constant observation and had inspected themselves regularly and carefully, yet absolutely no evidences of a local focus of infectioiL were discovered. The author does not believe that general syphilis can occur without pre- existing initial sclerosis of greater or less degree of development, but in such cases as those described it must necessarily be very insignificant as well as ephemeral. The important practical stand-point to remember in connection witb syphilitic bubo is that each individual gland is but a repetition of the neoplastic formation of which the chancre is the prototype. Its hard and PEIMAEY ADENOPATHY. 375 woody feel, comparative j^ainlessness, perfect circumscription and indis- position to suppuration, depend upon the same characteristic histologic features that have been studied in the initial lesion. Under the microscope there appears the same collection of cells of varying forms — the large round multinucleated granular cell being in preponderance — and the same pro- liferation of the surrounding connective tissue seen in a section of hard chancre. Primary adenopathy attains its full development in from one to three weeks, and may then remain stationary for some weeks or months. It may even last for over a year. It is usually present, and may suddenly increase in size when the earh^ eruptions appear. In exceptional instances it may speedily disappear from unknown causes. Suppuration rarely attacks syph- ilitic adenopathies, and when it does occur is the result of secondary mixed infection, favored by mechanic irritation or a strumous diathesis, and its pus is not autoinocuiable. When pus from suppurative adenitis is auto- inoculable, the primary sore must necessarily have been either a mixed sore or pure chancroid. Induration of contiguous lymphatic vessels and glands is so rarely absent in syphilitic chancre that practically it may be said to always exist. It is likely to be absent in cases of second infection, and, according to Eieord, is not present in phagedenic chancre. The author has seen several cases of phagedenic sloughing in hard chancre, in which pri- mary adenopathy did not appear, although general and inguinal adenop- athy developed in connection with the general symptoms. The author has no explanation to offer for this, and it must be confessed that it does not enhance the strength of the position assumed as to the pathology of the disease. Such cases naturally bring up a question to which allusion has already been made, viz.: whether there ma}^ not be two elements in the syphilitic infection, one local and the other constitutional — one acting via the lymphatics alone and the other through the general circulation. In cases in which there is considerable subcutaneous fat adenopathy may not be perceptible. As a rule, the enlarged glands gradually attain their maximum development, and as gradually disappear, either spontane- ously or under the action of mercury, in the same manner as the chancre itself eventually resolves. Although they never suppurate when uncom- plicated, these glandular enlargements are prone to caseous degeneration when the subject is of a strumous or tubercular diathesis. Bubo may recur during the active period of sj^philis and long after glandular trouble has apparently ceased. Eecurrent adenopathy has already been expatiated upon. The treatment of syphilitic bubo is that of general syphilis, unless sup- puration occurs, in which event it must be treated upon ordinary surgical principles. This subject has been fully expatiated upon under the special heading of "A^enereal Adenitis, or Bubo." CHAPTER XYI. Geneeal I>«rrECTio:bT of Syphilis. The most important subject in the consideration of syphilis is the period during which constitutional manifestations appear^, the period of systemic infection,, or, as Otis terms it, "localized cell-accumulation." The period covering the development of the chancre with its attendant and con- secutive Ijanphitis and adenitis, which we have termed the initiatory period, oi:, if we may use the expression, local syphilis, is more frequently known as primary syphilis. Congenital syphilis — so-called inherited syphilis — has no initiatory period, being general from its very commencement, but ac- quired syphilis has always a primary stage. This is of great practical im- portance, for wherever we meet secondary syphilis we can positively affirm that there must necessarily have been an initial sclerosis, of greater or less degree, somewhere, and this must have been attended by primary adenop- athy — adenitis — however obscure or slight the latter may have been. It is sometimes very important to decide where these local changes were mani- fest. The following is an illustrative case: — Case. — The author was consulted by a young woman who was suffering from active secondary syphilis the origin of which she professed to be entirely ignorant of. Her relatives seemingly had no suspicion as to the possible source of her trouble, and she was brought for consultation by the gentleman to whom she was engaged to be married. This gentleman had his own suspicions, but generously gave the woman the benefit of the doubt existing in his own mind, as to the possibility of her having contracted some simple disease by kissing, he himself having a sore mouth at the time. A careful investigation revealed the fact that she had never had the slightest trouble with her mouth or throat until the secondary pharyngeal manifestations appeared, and, in addition, she innocently stated that she had had, about a year previous to her consulting me, some small tender "lumps" in the groins. There had never been any "kernels," as she termed them, in the neck beneath the jaws. The throat and mouth lesions were typic mucous patches. These various points settled the question as to the locality primarily affected, and a candid statement of the case saved the young, man from a mesalliance. The woman is probably congratulating herself upon her success in duping her physician, but wondering at the disappearance of her affianced, he having withdrawn in the easiest manner possible by leaving the city. The initiatory period of syphilis terminates when the infection has traversed the lymphatics leading from the chanerous surface, entered the receptaculum ch3di, and from thence passed into the blood, through the medium of which it is disseminated throughout the system, giving rise to the peculiar changes characteristic of syphilis, in every tissue and organ, the changes being more marked in some organs perhaps than in others in different cases, but there being no tissue that enjoys complete immunity from the ravages of the disease. As will be seen later, the various bodily (376) PATHOLOGY OF GENERAL SYPHILITIC INFECTION. 377 functions may be impaired; the bones, viscera, and blood-vessels invaded; the special senses and sexual appetite destroyed, paralyses may occur, and even the intellect itself may be ruined by it. Pathology of Geneeal Syphilitic Infection. — As already seen, the period of local manifestations of syphilis is preceded by a period of in- cubation, lasting, on an average, twenty-one days. Following the initiatory period, with its initial sclerosis and primary adenopathy, there is another apparent period of incubation lasting, on an average, forty to forty-five days, and followed by general sj^mptoms. It would appear that these periods of quiescence are not true periods of incubation, but are periods during which there is an interference with the progress of the infection by "normal an- atomic and physiologic barriers." During the so-called second stage of incubation (this stage will shortly be subdivided into several incubative periods), which, as we have seen, lasts, on an average, forty to forty-five days, the syphilitic infection is slowly traversing the lymphatics and grad- ually making its way to the general blood-current.^ It is not fermenting, and thus preparing for an explosion, but is slowly traveling on through the lymphatic system, the cells that act as carriers proliferating and multiply- ing by the way, and not only changing themselves, but by virtue of the infection they bring exciting propensities for evil in the lymphatic and con- nective-tissue elements with which they come in contact, imparting to them their own infectious and other morbid properties, particularly their morbid activity and abnormal tendency to proliferation. Periods of JRetardation or Apparent Quiescence. — Generally — practically always in typic cases — only the chain of glands intervening between the local induration and the lymphatic reservoir or receptaculum cliyli are in- durated until immediately before, coincidentally with, or soon after the manifestations of general syphilis. Often, however, the general lymphatic sj^stem is involved some time prior to the appearance of the eruption, in which event there is an undoubted increase in size coincident with the erup- tion. jSTow, why is it that there is (a) an interval between the appearance of the local induration and the enlargement of the nearest lymphatic glands, (b) another between this glandular enlargement and general glandular hyper- plasia, and (c) still another sometimes betAveen the general glandular en- largement and the appearance of the eruption? Excellent hypothetic reasons can be given for these circumstances: In the first place, if it be granted that the cells alone carry the infection, as Otis claims, a certain length of time must elapse before they can leave the original focus of infection, — i.e., the chancre, — traverse the intervening lymphatic vessels, and arrive in the nearest lymphatic glands. Here the infection produces its characteristic ^ Otis insists upon this point with especial emphasis, laying stress upon the slow and systematic progress of the "germinal cells," for which the author has substituted the term infection. 378 GENERAL IXFECTION OF SYPHILIS. effects, as evidenced b}^ the deyelopment of primary adenopatli}^, and, wliile the glands become enlarged, some of the infected cells that have excited the morbid changes — with others that have joined them and become in- fected b}^ the wa}' — travel slowly on toward the receptaculum chyli and thence to the general system by way of the general circnlation. This re- qnires a certain interval of time, for no morbid manifestations can occnr nntil the infection has reached its destination. Geneeal Adenopathy. — As we have seen, the syphilitic infection eventually arrives at the receptaculum chyli, from which it is carried to the general circnlation and after entering the right heart is finally disseminated throughout the tissues generally, producing its characteristic effect of cell- proliferation, a first evidence of which may consist in a general glandular enlargement sometimes seen prior to the eruption. In cases in which general adenopathy occurs prior to the appearance of an eruption — the possibility of this is denied by some, good authorities claiming that glandular enlargement is always coincident with, or consecu- tive to, the eruption, the author's experience being that the glands often become enlarged prior to the eruption — there is a consequent interval be- tween general adenopathy and the syphilitic eruption. This is due to the fact that, although the infection arrives in other tissues of the body through the medium of the blood, quite as soon as in the lymphatics, the latter are likely to be the first tissues to respond to the infection by virtue of their relatively-greater susceptibility. The glands are not examined as often as they should be before the eruption appears, else they would be found to be more frequently enlarged prior to the eruption than is generally believed. If the lymphatic glands are already enlarged when the eruption appears, they immediately still further increase in size, the proliferation of cells being excited to renewed activity at this time. Theoretically, then, there would seem to be good and sufficient reasons for the three apparent periods of incubation, which, if correct, demonstrate that they are not true periods of incubation or quiescence, but are periods of retardation during which the infection is still slowly progressing and which are really necessary, in order that the infection-bearing cells maj^ reach the tissues that are successively involved. The first period of incubation occurring in the natural course of syph- ilis has not yet been discussed in detail. It can be explained along the same lines as the other periods of quiescence. This first period of incuba- tion is the most important of all the so-called incubative periods, and like the others is apparent and not real. This may be disputed even by those who are willing to accept the other stages of quiescence as only apparent. The period intervening between the inoculation with infectious material and the appearance of the initial sclerosis would certainly appear to be a stage of true incubation. It would seem from the long stage of quiescence that the infection of syphilis is undergoing a sort of development or fer- GENEEAL ADENOPATHY. THE EOSEOLA. 379 mentative change, at the culmination of which an explosion naturally follows in the form of a chancre. It is the author's belief, as formed from a careful survey of the investigations and teachings of Besiadecki, Baum- ler, Otis, and others, that local changes begin as soon as the syphilitic virus has been absorbed. These changes are very gradual, it is true, and probably consist, at first, of the incorporation of the syphilitic infection with the lymphatic elements of the infected tissues. Logically enough it may be inferred to be the incorporation of an infectious micro-organism with the normal cell-elements. A certain length of time is necessary before the infection reaches the lymph-spaces, and, again, some little time is necessary for its incorporation with the lymph-cells. There now begins a slow proliferation of the lym- phatic elements that are now syphilitic germinal cells possessed of new and morbid properties as well as an intensification of their physiologic proper- ties. The chief new and morbid property that they have acquired is in- fectiousness, and the normal properties already existing, but which now become intensified, are those of ameboid activity and power of prolifera- tion. The multiplication of cells becomes more active, the connective-tis- sue elements of the blood-vessels and lymphatic walls become involved, producing, as we have already seen, partial occlusion of their lumen and consequent "anemia of tissue." The smaller lymphatic vessels are now reached and the accumulation of cells is so extensive that perceptible in- duration is noticed. This area of induration increases in size until the cell- accumulation of which it is composed has free communication with the larger lymphatics and the smaller lymphatics regain their permeability. From this time on the cells are removed b}' the lymphatics as fast as formed. Finally, local proliferation having entirely ceased, the cells composing the induration are entirely removed by the absorbents or undergo fatty de- generation and resolution from the administration of mercury or potassic iodid. It will be observed that, including the primary stage of apparent quies- cence, four apparent stages of incubation have been described, while ordi- narily but two are described, one of which precedes the development of the chancre, and is universally termed a period of true incubation, and the other, deemed by some a true and by others an apparent period of incuba- tion, intervening between the primary and secondary syphilitic manifesta- tions. The author believes, however, that on careful consideration the intervals that have been described will be sufficiently plain. The Eoseola. — At the end of about forty to forty-five days, on the average, after the development of the initial sclerosis the period of "general S3^stemic infection and localized cell-accumulation" begins, the infection having now reached its final destination.^ The- first evidence of general ^ Tide Otis : "Class-room Lessons in Syphilis." 380 GENERAL INFECTION OF SYPHILIS. infection consists in the development of a peculiar eruption of rose-colored spots: the syphilitic roseola. Although this eruption may escape observa- tion, it is probably constant, being always present in a greater or less de- gree, in some cases lasting for a number of weeks, probably from two to eight, while in others it may last only a few hours. In its general appear- ance the eruption is not very unlike measles. The spots are of a dull rose- red hue, and disappear on pressure when recent, but later on leaving a coppery stain. Violent exercise, as in running or dancing, is liable to hasten or determine the eruption, as is true of simple roseola. There is usually no pain or other premonitory symptom with this eruption, although such symp- toms as facial neuralgia or severe pain in the chest may be observed, and in some cases general malaise, headache, and febrile movement may occur, these symptoms being supposed by some to be constant, and hence termed "syphilitic fever." The author has recently had a case in which severe facial neuralgia attended the roseola, and another in which all the sub- jective symptoms of an impending pneumonia were present, the thoracic pain being especially severe, these symptoms being followed by a classic roseola the next morning. In still another case systemic disturbance was ushered in by severe lumbar pain simulating lumbago. Sometimes the roseolous eruption consists of but a few pale spots, while in other instances it is general and well marked, being occasionally slightly elevated. The notion prevails quite generally that the syphilitic roseola is the result of local changes in the skin produced by the syphilitic poison, and, reasoning a priori from the line of argument already presented, the natural conclusion would be that the eruption is due to a localized cell-accumula- tion, the products of which, collecting in the skin itself, constitute the ex- anthem. This is not the case, however, and it is the only instance of the kind throughout the course of syphilis. The syphilitic roseola is due to dilation of the cutaneous capillaries, with subsequent stasis, and the ex- udation of leucocytes and red blood-corpuscles into the implicated integ- umentary area.^ The greater the degree of stasis, the larger the number of extravasated red corpuscles; and inasmuch as the staining of the tissues is due to changes in the blood-pigment, the greater the number of blood-cor- puscles extravasated, the deeper and more persistent this staining is likely to be. A similar staining is met with in any lesion, specific or simple, in which there has been long-continued congestion. This is illustrated by the changes in the superficial tissues resulting from non-syphilitic ulcers of the leg. It now remains to consider the origin of this capillary dilation, and inasmuch as the contractility of the blood-vessels is presided over by the sympathetic system, or more properly by the vasomotor fibers of the sympathetic, it is evident that vascular dilation in syphilis must be due to some peculiar influence wrought upon the sympathetic system by the ^ Biiumler. SYPHILITIC PEODEOMES. 381 syphilitic infection that causes a suspension of the contractile power of the vascular walls and leads to dilation and stasis at the periphery. That the caliber of the capillaries depends upon nervous currents from the sym- pathetic is illustrated by the familiar physiologic demonstration of section of the cervical sympathetic causing reddening and turgescence of the ear and various nutritive changes in the cornea of the rabbit, etc. It is pos- sible that the dilation and stasis are reflex phenomena due to reflected local irritation produced by the syphilitic infection or to a direct influence of the infection upon the vascular walls; but this explanation is hardly so rational as that involving a direct influence upon the sympathetic centers analogous to that produced by quinin, belladonna^, and various other drugs and by emotional disturbances. In the light of our recent knowledge of germ-infection and germ-products the author feels justified in the belief that the disturbing element in the action of syphilis on the sympathetic is a toxin or toxins elaborated by the syphilitic micro-organism. Analogic reasoning is not always satisfactory, but in this instance the analogy furnished by the untoward effects of drug and other toxic erup- tions appeals to one's sense of clinical discrimination most strongly. Apropos of toxin eruptions, attention may be called to the form that some- times appears in diphtheria — not the so-called scarlatinoid, in which a mistake in diagnosis and mixed infection are both possible, but the later type that heralds approaching dissolution. This is often a very fair imita- tion of the syphilitic roseola. Syphilitic Peodeomes. — Syphilitic Fever. — Something has already been said in reference to the so-called syphilitic fever. Among the phenom- ena that may be observed prior to the development of the roseola are malaise, headache, rheumatoid pains, anorexia, nausea, prostration, sleeplessness and nervous irritability, and in some cases quite sharp febrile movement, per- haps followed by j^erspiration. These are the symptoms several or all of which have been included under the head of syphilitic fever, or, as Diday more correctly terms them, "syphilitic prodromes." On reviewing the list of single symptoms that may occur it is evident that they may be dependent upon so many and various coincident disturbances that there can be no great constancy or certainty about their occurrence in syphilis. The term sj^ph- ilitic fever is therefore obviously inaccurate. Eicord denies its relation to syphilis, and claims that in every case it can be traced to causes independent, of the roseola. Otis indorses this view. Until recent years the author was inclined to agree with Eicord's view, for febrile disturbance is apparently exceptional and patients usually discover the roseola entirely by accident or in their daily examination of the surface of the body, and but rarely have the slightest objective symptom of constitutional disturbance. Very often the roseola escapes the patient's observation until his attention is directed to it, and then he is usually much astonished that he should feel perfectly well with such a prominent eruption. Since the advent of a more 382 GEXEEAL IXFECTIOX OF SYPHILIS. thorough understanding of germ-infection and coincident toxin poisoning, however, the author has come to regard many symptoms that were formerly attributable to coincidence as being without doubt attributable to S3'philitic toxins, this being especially true of early nervous phenomena. That such symptoms are not uniform in their occurrence suggests the possible ex- planation of (1) idiosyncrasy; (2) variations of excretory activity; (3) in- complete study of the case — and esjjecially the temperature — prior to the appearance of lesions perceptible to the patient. From personal observation the author feels warranted in presenting the following conclusions: 1. Syphilitic fever, so called, while an inconstant objective phenomenon — or series of phenomena — is present in a sufficient number of cases of syphilis to ^Dractically settle the question of the relation of cause and effect. 2. The symj^toms collectively designated as syphilitic fever are, in common with some other febrile constitutional disturbances, undoubtedly dependent upon the action of a special poison — a germ or its toxins — upon the sympathetic nervous system. 3. It is logical to infer from Avhat we know of the physiology of the sympathetic system, and particularly of those functions of the sympathetic which we term trophic, that the ma- jority of fevers — if not all — are directly dependent upon the action of the particular specific poison upon the S3an23athetic ganglia, Avhich action is manifested by disturbed metabolism and the resulting phenomena of fever. So, in the case of syphilis, the poison may produce such a profound im- pression upon the sympathetic ganglia that the trophic function of this jjortion of the nervous system is disturbed, with (a) an attendant perversion of tissue-metabolism, (b) a resultant excessive production of animal heat, and (c) the accumidation in the system of the toxic products of perverted physiochemic change in addition to germ-toxins. 4. The fact that the so- called syphilitic fever is not a constant phenomenon, but affects only a cer- tain portion of individuals attacked by syphilis, is explicable upon the ground of idios3mcrasy or defective elimination, or both. Its inconstancy may be more apparent than real. Careful study might show prodromes — especially fever — in all cases. The argument that the so-called syphilitic fever is the result of an im- pression produced by the syphilitic infection upon the sympathetic nervous S3'Stem does not necessarily impty — nor is it intended to do so — that any particular prodromal s3'mptom is a part of the natural course of the dis- ease. On the contrar3% the author believes many of the s3anptoms to be accidental and the result of idiosyncrasy. AYe know that dift'erent indi- viduals are variously affected by urticaria or erythema upon the ingestion of shell-fish, this result being especially apt to follow when the particular article of food is not perfecth' fresh or is not in an absolutely healthy con- dition when taken for food. Some persons are seriously affected by the in- gestion of certain vegetables — particularly if partial decomposition has oc- curred. Canned vegetables, particidarly tomatoes, are especially liable to PHAEYNGO-FALX'IAL IXFILTEATIOX. 383 impeachment upon this gronnd. If it is fair to infer that hy virtue of idiosyncrasy the nervous systems of certain subjects may be morbidly im- pressed by certain food-substances that are innocuous to the majority of in- dividuals, it is certainly logical to assume that in the case of so powerful an organic poison as that of s3qohilis, with which a large number of individuals are inevitably inoculated, certain special and exceptional phenomena might be produced in some persons. As already suggested, careful study of a large number of cases might show that, while prodromal symptoms vary in degree and kind, they are present in all cases. E elation of General Adenopathij to the Roseola. — With the roseola, or shortly after it, in cases in which glandular symptoms have not occurred prior to the appearance of the eruption, general enlargement of the lym- phatic glands — general adenopathy — occurs, the infection at this time not only having reached the general 15'mphatic system, which is extremely sus- ceptible to its morbific influence, but being, moreover, unusually active. Pliaryngo-faucial Infiltration. — About the time the roseola appears, sometimes shortly before or after it, we have the development of an inflam- matory engorgement of the tonsils, pharynx, and soft palate, involving usually the whole faucial surface. There should be some explanation of this localization of the effects of syphilis in the throat, and a simple one has been suggested by the anatomic peculiarities of the part. According to Frey, His, Eeeklinghausen, and Teichmann, the tonsil is a part of the general lymphatic system, representing the simplest form of 13'mphatic gland. There is no direct communication between the tonsillar follicles and the adjacent Ijmiphatic vessels, but each follicle is seen to be invested with an exceedingly dense net-work of fine lymphatic vessels, that are dilated in a peculiar fashion and cover in the follicle so completely that but one small jJortion of its surface is free, this being directed toward the mucous membrane. The entire pharynx is exceedingly rich in lymphatics, hence morbid changes in its structures might naturally be expected simul- taneously with those occurring in the general lymphatic system. This ar- rangement of the lymphatics also explains another phenomenon, viz.: the occurrence of those severe and often seriously destructive ulcerations ihat occur in this situation in late syphilis. These lymphatics are brought into much more intimate relations with the contiguous blood-vessels than are the lymphatics of a higher order, and are hence prone to true inflamma- tion and profound nutritive disturbances whenever they become crowded with syphilitic cells. The explanation of the involvement of the fauces and pharynx char- acteristic of secondary syphilis, upon the ground of lymphatic engorgement, the primary cause of which is the abundance and superficial character of the lymphatic capillaries of the affected parts, is quite plausible. It is a noteworthy fact, however, that there is but little swelling, joain, and tender- ness accompanying the syphilitic sore throat, providing ulcers be absent. 384 GEXEEAL IXFECTIOX OF SYPHILIS. There is also in the earl}' part of the disease little or no tendency to ulcera- tion in the majority of cases. There is comparatively little heaping np of syphilitic material as contrasted with some other lesions, — the papule, for example. These characters suggest that there is something behind the local- ized proliferation of cells— something too, that will explain the appearance of morbid phenomena at this particular point aside from mere anatomic peculiarities. For obvious reasons it has not been shown that the same efflorescence and engorgement does not occur throughout the entire alimen- tary canal in early syphilis. Admitting that there is a diffuse accumulation of cells in the pharyngo-faucial tissues, there should be something more than local anatomic peculiarities to explain it. May it not be a result of vasomotor changes similar to those prevailing in the roseola, due to the im- pression of the S3^philitic infection upon the central nervous system? The same condition, possibly, prevails in other portions of the alimentary tract, which are, as is well known, intimately associated with the sympathetic nervous system. It is only at this point, however, that the parts affected are so superficial as to be open to observation. At this point, moreover, causes of irritation are more prevalent than in other portions of the ali- mentary tract. The food that is swallowed, rapid changes of temperature incidental to respiration or the ingestion of fluids at various temperatures, the use of the voice, the contact of irritating secretions from the nose, and the inhalation of irritating substances from the atmosphere must certainly assist in localizing the syphilitic process in the throat. In the presence of such local causes of irritation vasomotor disturbance incidental to the impression of the syphilitic poison upon the central nervous system might be determined at this point, even though absent elsewhere. As will be seen presenth', the vasomotor impression underlying the roseola is substituted later on by a more or less pronounced trophic disturb- ance, manifested by the heaping up of neoplastic material, the development of pus, the occurrence of ulcerations, etc. Pari passu with the supervention of this trophic disturbance in the case of the skin we have a similar state of affairs in the pharynx and mucous membrane of the mouth, as mani- fested by the development of mucous patches, ulcers, and macular erup- tions, the latter being particularly marked upon the roof of the mouth. The apparent affinity of syphilis for the parts supplied by the fifth nerve will be discussed hereafter. It is sufficient to remark here that this special pre- dilection has an important bearing upon pharyngeal lesions. The Papulae Stphilide. — The next thing observable after the rose- . ola in the typic course of syphilis is the development of an eruption of true papules. This may appear when a roseola has not been noticed, thus seem- ing to be the first skin-lesion of the disease, or may even be coincident with it, but generally follows it after a variable interval, often some weeks or months. The papules are usually most prominent about the borders of the hair upon the forehead, forming a peculiar appearance termed the corona THE PAPULAR SYPHILIDE. 385 veneris or venereal crown, but may be scantily scattered over the breast^ back, and limbs. In still, other instances they may be thickly studded all over the body. This eruption lasts longer than the roseola, occasionally remaining prominent for a number of months. It is at first of a tolerably bright-reddish hue, but this gradually fades, leaving the characteristic ham color. The papules tend to exfoliate epithelial scales, especially at their bases, forming a peculiar appearance known as the collarette of Biette, a sign that is supposed by some to be pathognomonic of syphilis. It is un- doubtedly characteristic when present, but unfortunately it is oftener absent. This shedding of epithelial cells around the base of the papule of syphilis is due simi^ly to innutrition of the epithelial elements about the base of the papule produced by the heaped-up morbid cells within it. This process is precisely like that which causes loss of tissue in the initial lesion, viz.: necrobiosis, or anemia of tissue, from the pressure of abnormal cell-infiltration. According to Kohn, the papule is composed of a dense, circumscribed, cellular infiltration into the papillae and corium. This accumulation of cells is piled up in dense, regular layers around the vessels, and in the meshes of the connective tissue. These cells do not become permanently organized, but tend to undergo granular and fatty degeneration and finally disappear entirely, as a rule, the detritus pro- duced by their retrograde metamorpho- sis being removed by the absorbents to be eliminated by the various emunc- tories. Or the cells may become heaped together in large amount and form pus — which will certainly form if the morbific material becomes secondarily infected with pus-cocci. On section of the papule we find two lines of cells in the corium and papillary layer of the derma, which layers are glued to- gether quite firmly, the epidermis being tightly stretched over them. The hardness of the papule is due to the density and dryness of the accumulated cells, and its color to capillary stasis, effusion of coloring matter from the blood-vessels, and possibly to the color of the neoplasm itself. It will be Fig. 105. — Papular syphilide. (After Keyes.) 386 C4EXEEAL IXFECTIOX OF SYPHILIS. noted that the structure of a secondary papule is essentially that of the ini- tial lesion and the primary glandular infiltration. . It now remains to explain the cause of the circumscribed collection of cells constituting the S3'philitic papule. "We have already seen that the initial lesion is due to an accumulation of cells, which results from a ST ~ — 1 morbid impulse given to the normal leucocytes in loco by the syphilitic infection, and it would seem a very logical inference that there exists in the papule a similar process, and such is really the case. It seems pecul- iar that these cell-accumulations occur in the papilljEe and cutis rather than in other situations. However, by reviewing the anatomy and physiology of the skin a little, it is not difficult of explanation. The blood con- taining the nutrient pabulum upon which the repair of the tissues depends is distributed to the various tissues of the body by the arteries, and re- turns loaded with the products of retrograde tissue-metamor- phosis by way of the veins. There must, of necessity, be a certain amount of nutritive or germinal material taken to the tissues, over and above the quantity necessary for their re- pair, and there should be some physiologic means of restoring this to the blood. Such an arrangement does, in fact, ex- ist. Interposed between the arterial and venous systems there is a system of fine vessels, the lymphatics, the function of which is to collect all surplus germinal material and return it to the circulation. The nearest points of contact of the arterial, venous, and lymphatic vessels are at the superficies, — i.e., the periphery of the body, — where the capillaries of the general circulatory and lymphatic systems are in most intimate relation. Ym. 106. -Papulo-squaiiiuu^ (After Fox.) -ypii ilide. THE PAPULAR SYPHILIDE. 387 As it is here that the vessels are smallest, it is naturally in this situation that retardation of the circulation is most likely to occur, or an interference with the interchange of nutritive materials results from exciting causes of Fig. 107. — Pustulo-ulcerous syphilicle. (After Dumesiiil.) various kinds. It is here, therefore, that we sliould expect to find collections of surplus germinal material which from any cause have been forced to accumulate in the tissues and have failed to find an entrance into the lym- 388 GEXEEAL IXFECTIOX OF SYPHILIS. phatics. The structure of the papillEe of the cutis contains lymi^hatic capil- laries and blood-Yessels. According to v. Rindfieish, Teichmann, and others_, the lymphatic plexus lies in the center of the papilla, while the capillary blood-vessels wind around it, corkscrew fashion, until they reach the apex. Teichmann, in particular, has called attention to this peculiar arrangement These vessels vary in size from time to time, and vary according to the degree of vascular or hlood- pressure. It is in the spaces between these capil- lary loops and the central lymphatics that the accumulation of cells in the syphilitic papule takes place. x\n extra number of cells is brought to the part, and, in addition, there is an increased local proliferation that tempo- rarily blocks up the lymphatics or overcomes their power to dispose of sur- plus germinal material. The result is a heaping up of cells, with all those attendant morbid phenomena that have been studied in the initial lesion. Sometimes the papules are very fine, but the}^ may become large, sometimes by fusion. They may involve sebaceous and sudoriparous glands, — which have no lymphatics — simply matting them into the general infiltration of a number of papillae. Otis, following Besiadecki and others, has claimed that the evident predilection of syphilitic material for the papillse of the skin is due to the mechanic fact that — on account of the peculiar arrangement of their arterial, venous, and intervening lymphatic capillaries, already described — it is in the papillse of the skin that the narrowest points in the circulatory and lymphatic flow are to be found. The affinity of the syphilitic process for lymphatic structures explains the rest, and, as we have seen, there occurs at various points in the superficies of the body a localized heaping up of syphilitic cells. The roseola, however, as already stated, consists of localized and circumscribed jDhenomena that are not satisfactorily explicable upon mechanico-anatomic grounds. Why does not the roseola appear in one con- tinuous blush over the entire surface of the body? Is it not because the impression of the syphilitic infection upon the system is manifested through a vasomotor dieturbance of the function of the sympathetic ganglia at certain terminals in the skin? Otis accepts the neurotic origin of the roseola, and it is a matter of surprise that he should seek for local anatomic conditions, determinative of the syphilitic process in the papillge of the skin, as a cause for the development of the syphilitic papule. In view of the prob- able explanation of the roseola, would it not be fair to infer that a similar condition of affairs prevails in the case of other eruptions — i.e., that, as a consequence of an impression made by the syphilitic infection upon the sympathetic ganglia, their trophic functions are disturbed, with consequent disturbance of nutrition and perverted tissue-building at certain points upon the periphery or superficies of the body? The local anatomic arrange- ment would explain the rest. This hypothesis is at least worthy of thought as a possible logical explanation of the phenomena of syphilis. It would be particularly satisfactory if demonstrated to be true, for it covers not only TROPHIC CHARACTER OF SKIX-LESIOXS. 389 the roseola and papule, but every other lesion that may occur throughout the entire course of syphilis. The lesions of syphilis that succeed the roseola have been so posi- tively demonstrated to be dependent upon a localized deposit and prolifera- tion of syphilized cell-material that it would appear at first sight to be im- possible to apply the neurotic theory to them. It is only necessar}', how- ever, to direct attention to the marked symmetry characterizing the periph- eral phenomena of syphilis to demonstrate the plausibility of the view that there is a central nervous element in the production of the various lesions. It is, of course, admitted that a symmetric development of eruptive lesions occurs in some other affections. It will be found, however, that a nervous element is either positively demonstrable or the skin-lesions are so abundant and general that it would be impossible that they should be otherwise than symmetric. A most positive proof of the relation of eruptions of the skin to nervous disturbance of a presumably-trophic character is seen in herpes zoster. In this disease there is a fairly accurate delineation of the course of the affected nerve by the eruption, and a very manifest local disturbance of nutrition of the affected tissues. Generally some portion of but one side of the body is affected by this disease. It is sometimes bilateral and con- sequently of a more serious character than usual. Some of the later lesions of syphilis are unilateral and almost as plainly referable to the distribution of some particular nerve as herpes zoster. Recurrent herpes zoster is especially pertinent to the question of tropho- neurosis. This disease is usually followed by cicatrices. The first symptom is a burning sensation followed by severe neuralgic pains. Injury is often the exciting cause and it is frequently bilateral. Herpes progenitalis is often the result of syphilis, — being moreover a pure neurosis, due, first, to syphilis; second, to worry; third, to overactive therapeusis. These causes bring about disturbed innervation and nutritive disorder. It will be understood that the view that neurosis is a very important factor in the lesions of active syphilis in nowise contradicts the cellular pathology so far as its local phenomena are concerned. It has to do merely with the modus operandi by which these phenomena are brought about. The question is simply whether the various phenomena have their point of departure in an infection acting in loco or in local changes of a central neuropathic origin, the infection acting in some manner upon the sympa- thetic and, by disturbing its trophic function, exciting a morbid process of cell-accumulation in the superficies of the body. Syphilitic Alopecia. — During the period of general syphilis, usually during the early months of the secondary period, often co-existent with the papular eruption, falling of the hair, or alopecia, occurs. This results from derangement of nutrition in the hair-follicles. This lesion of early syphilis especially appeals to the author as a syph- 390 GENERAL INFECTION OF SYPHILIS. ilitic neurosis: a trophoneurosis, in brief. Tliis may be dangerous ground, for the close association of alopecia with tangible cell-deposit in other situ- ations has led to the tacit acceptance of this lesion as an evidence of the action of the materies morhi of syphilis in loco. Some authorities believe it to be due to local empoisonment of the hair-follicle with resultant nutritive perversion. ' Otis, following Baumler, and Besiadecki, thinks that alopecia sypli- ilitica is due to pressure-innutrition of the hair-follicles produced b}'' an ac- cumulation of syphilized cell-material, cure being induced by spontaneous or therapeutically-induced fatty degeneration and absorption of the infil- trated cells. The author himself long taught this view. Further study has brought conviction of its fallacy. The following considerations are impor- tant in this connection: — • 1. Lesions of the scalp of sufficient prominence to attract attention are rather exceptional in syphilitic alopecia, a few scattered papules and accumu- lations of epidermal cells or sebum being found in a certain proportion of cases. 2. Scarring is rare, and when it does occur permanent l^aldness of the affected area results, as a rule. 3. Tertiary syphilis, in which cell- accumulation is most marked, is rarely causative of characteristic alopecia. 4. Severe alopecia, not only areate but generalized, may occur without any other lesion — accompanying, preceding, or following. This could hardly occur if the alopecia were due to cell-deposit, inasmuch as in the early secondary period, when alopecia is most often found, the tendency to cell- deposit is quite generalized. Taking all the facts into consideration, the author has become convinced that syphilitic alopecia is a neurosis. If the mechanic theory be correct, it is strange that lesions of the scalp of sufficient prominence to attract attention, are so rarely associated with alopecia. A few small papules, pustules, and crusts are occasionally found, but hardly ever in sufficient amount to account for the extensive falling of the hair. It will, of course, be found that at the site of such lesions the hair invariably falls out. It would seem that if the syphilitic material had such an affinity for the scalp as would be indicated by the theory of localized cell-deposit, the cutaneous lesions of this portion of the integumentary sur- face should be especially pronounced. It is hardly probable that in the ■presence of such an affinity for the hair-follicles, a deposit of syphilitic ma- terial would accumulate to such an extent as would be sufficient to deprive the hair-follicle of nutrition and yet fall short of a sufficient amount to be perceptible externally. It is true that more or less accumulation of germinal material in the hair-follicles may occur, but it certainly cannot be sufficient to account for the alopecia, and there still remains the necessity for an explanation of its deposition in this location. Reasoning by analogy, we find much support for the neurotic theory of alopecia. The effects of fright, fevers, and head-neuralgias on the color and nutrition of the hair are well known. Leloir, Dumesnil. and others have SYPHILITIC ALOPECIA. 391 cited cases where traumatism of the sympathetic has jjrodiiced alojDecia. Joseph's experiments are quite significant in this connection. He divided the spinal ganglion of the second cervical nerve in cats and thereby pro- duced baldness. As a further illustration of the relation of malnutrition, probably dependent upon perversion of the functions of the sympathetic nervous system, to falling of the hair, may be mentioned the alopecia resulting from the excessive use of arsenic internally. The relative immunity that the beard of the male enjoys as compared with the hair of the scalp is probably dependent upon the greater intrinsic strength of the facial hair-growth and the higher vascularity of the face. Accepting the neuropathic character of the syphilitic roseola and alo- pecia, these lesions are very suggestive. If they are due to disturbance of the sympathetic we have only to imagiiie similar vasomotor and tropho- neurotic changes in the central and peripheral nervous structures to get a tolerably clear idea of more serious neuroses in early syphilis. The origin of the scalp neurosis under consideration is not far to seek. It is, without much doubt, toxins resulting from the evolution of the syphilitic microbe. Syphilis of the Nails. — The nails of the fingers and toes may become affected by the sjqDhilitic cellular infiltration and become brittle and luster- less, or from very great infiltration and consequent nutritive disturbances — and perhaps secondary pus-infection — the destructive lesion known as syph- ilitic onychia may occur. - , Precocious Skin-lesions. — As already stated, pustules^ or vesicles may form during the papular stage of syphilis. Ulcerations resembling tertiary or late secondary lesions may also occur. These constitute precocious syph- ilis. These changes apparently result from a lack of formative power in the lymph or a tendency to liquefaction of the hyperplasic materials, due to constitutional debility or lack of tone. Profound syphilitic toxemia may have much to do with these cases. Special Mucous Lesiojis. — There are several peculiar lesions occurring during the period of general syphilis that are both important and inter- esting, but which are really mere modifications of the syphilitic papule, de- pendent mainly upon their situation and surroundings. Mucous patches upon the various mucous surfaces or quasimucous surfaces, where they are constantly subjected to irritation from friction, heat, and moisture, are examples. These lesions are elevated plaques of a milky or grayish color, covered with a grayish exudate and are not greatly unlike the primary super- ficial erosion sometimes seen upon the genitals. When situated about the anus, upon the scrotum, vulva, or between the digits, these plaques muqueuse tend to become hjqDertro^jhied, forming broad papules or excrescences more or less elevated, sometimes covered with a quasidiphtheritic deposit, and usually secreting a foul-smelling serous secretion. These modified mucous patches are termed mucous tubercles, or condylomata. The existence of local 392 CtEXEEAL IISfFECTION OF SYPHILIS. irritation often determines the development of miicons patches, as is seen in the month from the contact of a pipe-stem or from irritation of the mucons membrane of the mouth or tongue by a broken tooth. Tobacco- smoke from either pipe or cigars and tobacco-juice will also produce milky- hued patches — plaqu&s opalines- — and it will be much easier to prevent them by removing sources of local irritation than to remove them when formed. Xon-syphilitic persons who smoke to excess are sometimes affected by a slow, chronic inflammation of the mucous membrane, with resultant whitish patches upon the cheeks, lips, and tongue, strongly resembling the mucous patch. This affection is completely curable by cutting off the source of irritation. Vidal has described a simple, non-syphilitic affection of the tongue that may be mistaken for syphilis. This he terms buccal, or lingual, leucoplasia. It consists of an epithelial thickening followed by papilloma- tous hypertrophy, and perhaps ulceration with consequent cicatrization. The spots of thickened epithelium resemble those caused by nitrate of silver, and may be detached in flakes. Post-syphilitic leucoplasia will be discussed later. Caspary, Unna, Parrott, and more recently Hack have called attention to a condition of excoriation of the tongue, superficial in character and char- acterized by deficiency of the normal papillae. This is independent of syph- ilis, is hereditary in origin, and has been traced by Hack through three generations in two different families. The possible occurrence of this con- dition is to be borne in mind. In the author's experience congenital aber- rations of papillary and epithelial growth affecting the lingual mucosa are by no means rare. Papillary hypertrophy of congenital origin is especially frequent. Visceral Involvement. — Visceral engorgements and infiltrations are by no means uncommon in syphilis, congestion characterizing the early secondary, diffuse infiltration the late secondary, and distinct gummy de- posit the sequelar period. Tenderness over the liver, spleen, and kidneys is occasionally observed. Transient albuminuria is not uncommon. Care is necessary to determine whether the disease or the treatment is re- sponsible for the albuminuria in each particular case. The author has long entertained the view that more or less transitory circulatory disturb- ance of the viscera is quite a constant feature of early syphilis. That this is due in early cases in any great degree to cell-deposit is doubtful; there is too little disturbance of function, as a rule. It would appear logical to infer that certain visceral areas are the seat of changes similar to those characterizing the roseola, at which time no cell-deposit may be manifest in any location. If the author's position be correct regarding the presence of a sympathetic neurosis produced by syphilitic toxins at this period, the vis- cera, bearing as they do so important a relation to the sympathetic, could hardh^ be expected to escape. As already remarked, there is usually no marked disturbance of function in early syphilis, but some striking excep- INVOLVEMENT OF SPECIAL TISSUES AND ORGANS. 393 tions to this rule are met with. For example, the author has seen severe Jaundice apparently due to hepatic involvement at a very early period of the disease. Albuminuria in early syphilis is, perhaps, like the nephritic disturbances of other infectious diseases: the effect of the direct action of toxins upon the renal epithelium. It is to he remembered that the later visceral disturbances are likely to be due to a diffuse syphilomatous infiltra- tion, which, organizing and contracting, may seriously impair the structural integrity of the organ. This is especially noticeable in the liver and kidney. Hutchinson admits that the early lung involvement of syphilis consists of temporary congestions, actual inflammations and infiltrations being re- served for a later stage. Aside from the possible existence of pulmonary vasomotor disturbance as the explanation of such phenomena, it is not be- yond the bounds of probability that in such cases the syphilitic toxins act in some peculiar manner upon the pneumogastric. Early Ocular Syphilis. — During the active period we often have ocular troubles that may prove of very serious import. An infiltration of cells into the iris and ciliary body often sets up an iritis at this time, this inflamma- tion being really in no way distinguishable from that produced in the same situation by rheumatism, trauma, or other exciting causes. There is, per- haps, a greater tendency to chronicity and plastic exudate with the forma- tion of adhesions or synechias, and the iris is possibly a trifle more cloudy and infiltrated than in the simple forms of iritis; but the differences, if any exist, are too slight, as a general rule, to be of very great practical impor- tance from a diagnostic stand-point. It has been claimed that iritis gener- ally occurs in both eyes (in 60 per cent, of cases) and that it passes unno- ticed in many instances, on account of absence of pain. This may be true pathologically, but clinically it is usually monocular. The local accumula- tion of cells in these cases sometimes forms a distinct nodule or tumor, often erroneously termed "gummy tumor of the iris," but which is in nowise different in structure from the syphilitic papule. This is especially apt to occur in late S3'philis, in which event it may perhaps be justly styled "gum- mous." Similar plastic nodules may form in the choroid at this period. Early Osseous Symptoms. — Bone-pains, usually localized, and localized subperiosteal accumulations of cells termed nodes frequently occur during early syphilis, although more characteristic of late syphilis. The pain in these instances is due to intra-osseous or subperiosteal pressure produced by the dense accumulations of cells. Sufiicient attention has now been given to the pathology of active or general syphilis to give a tolerably clear idea of its various phenomena, and to demonstrate one imjoortant point an acceptance of which will enable the student to understand syphilis in all the forms and varieties of its patho- logic phenomena, viz.: With few exceptions, the pathologic manifestations of syphilis occurring during the active period of the disease are due to a localized cell-accumulation and cell-proliferation, and to nothing else. An 394 GEXEEAL IXFECTIOK OF SYPHILIS. intelligent appreciation of this fact will alone form a rational basis for the treatment of the disease, Avhich is alike in every case and consists simply of all those means, whether general or local, that tend to produce fatty de- generation or retrograde metamorphosis in the hyperjilasic materials and induce their elimination from the body, while at the same time tending to improve the general health. This projjosition is, in effect, a resume of syph- ilitic pathology. The only distinguishing characteristic of the syphilitic cell as contrasted with the normal germinal cell is its contagiousness, — of jDrobable germ-origin, — which consists in its power of imparting to normal leucocytes its own tendency to proliferation. This rapid proliferation does not usually cause destruction of tissue, but gives rise to phenomena which, a priori, we might expect from an accumulation of surplus nutritive ma- terial. This cell-accumulation obstructs the tissues for a time in uncom- plicated cases, and then, from prolonged pressure, innutrition, and general causes, it undergoes fatty metamorphosis and is finally eliminated by the various emunctories. The only exce^Dtions to the rule that the lesions of syphilis are due to a localized cell-accumulation are those phenomena already alluded to as the result of toxins and neuropathic disturbance, such as the general symptoms of syphilitic invasion, roseola and alopecia, and certain nerve- and bone- lesions that Avill be discussed later on. DuEATiox OF IxFECTiON. — According to Baumler, the infection of syphilis lasts from eighteen months to three 3'ears, after which it is ex- hausted. Following the cessation of the active period of S3^philis, the blood and the secretions of open lesions cease to be contagious, and it may also be stated that in by far the greater jiroportion of cases, especially if they have been properly treated, no further manifestations of syphilis are ever experienced. Eeasoning from these facts, it is quite logical to infer that the so-called tertiary period of sj^Dhilis, to which attention will hereafter be directed, is not a "stage'^ of the disease at all, but simply a period of gen- erally-unnecessary sequels, and, indeed, such is now the teaching of our best authorities upon the subject. Hutchinson. Lee, Lome, Baumler, Besia- decki, Otis, and many others incline to this view. The author believes, furthermore, that the j^rojDortion of cases of tertiary syphilis or sequels may be considerably abridged by remembering that some of them are probably suffering from the excessive or injudicious action of mercury rather than from sequels of s^qDhilis. Lessened Vital Resistancy in Sypliilis. — The existence of severe syph- ilis, while it may not be intrinsically dangerous to life, must necessarily lessen vital resistancy and enhance the danger of intercurrent disease. Dujardin-Beaumetz states that it is a common saying in the Hopital Cochin that a patient with typhoid fever engrafted upon early active syphilis is a doomed man. This lessened resistance during active syphilis should be espe- cially noted by examiners for life-insurance, as it is a question with which the examiner is often confronted. The risk is always increased to a greater LESSENED VITAL EESISTAXCT IX SYPHILIS. 395 or less degree, and, irrespective of the apparent physical health of the ap- plicant, this is worthy of most serious consideration, especially where it cannot be shown that the patient has been thoroughly treated for the re- quired time. It must he admitted, however, that an attack of syphilis is often conservative in its effects. The rigorous regimen, abstinence and hygienic ]3recautions necessary in a thorough course of antisyphilitic treat- ment are often so beneficial that the subject is in better general condition in the end than he was before he contracted syphilis. This will be touched upon again in connection with the relation of S3'philis to life-insurance. Syphilis in its Relations to General Surgery. — The relation of syphilis to surgical diseases and operations is a very practical point for consideration, especially as regards the influence of the constitutional infection upon the healing of wounds and the repair of fractures. To avoid a lengthy discus- sion of the subject the author will present the conclusions drawn from his clinical experience, embracing a fairly extensive field of general operative work extending over a period of twenty years. 1. Early mild syphilis in patients in good general health does not im- pair the healing of wounds, jDrovided they be aseptic and free from sources of irritation. 2. Early severe syphilis does not interfere with wound-healing when the patient is under proper treatment and the wound surgically perfect. 3. "What has been said of wounds in the foregoing conclusions also applies to fractures. 4. Injuries and surgical diseases involving prolonged irritation are 396 GENEKAL INFECTION OF SYPHILIS. usually retarded in healing by constitutional syphilis. Thus, open wounds, ulcers, inflammations, and compound fractures — especially if septic — are likely to do badly. Proper treatment for the syphilitic infection is a sine qua non for repair. 5. All surgical injuries do badly, on the average, in the syphilitically- cachectic and mercurially-debilitated, especially in sequelar syphilis. 6. Summing up, it is to be understood that syphilis retards the re- covery of surgical diseases and the repair of wounds in direct proportion as the patient is suffering from nutritional perversions and defects inci- dental (a) to the duration of syphilitic blood-taint, (6) to the cachexia 23roduced by syphilis, (c) to the debility produced by excessive or incorrect treatment, and (d) from a greater or less degree of irritation of the injured part, which is ojDerative in developing the local syphilitic influence in direct proportion to the duration of the irritation. Peognosis of Syphilis. — The prognosis of syphilis as regards cura- bility has already been touched upon. The prognosis of the disease as regards the life of the patient is a matter difficult to determine, as is obvious when the obscurity and wide variation in type of the more remote conditions produced by syphilis are taken into consideration. Fatal results from syph- ilis are usually incidental to sequelar lesions of the arterial or cerebro-spinal systems or the viscera. They occur, as a rule, at a period so remote from the original infection, and the symptoms are so obscure as regards the specificity of their origin, that it is practically impossible to determine the primary cause of the condition in a very large proportion of cases. This much may be said, however, namely: syphilis is a disease that is essentially benign so far as danger to life is concerned. It is probable that in well- treated cases the average longevity is not seriously diminished by the dis- ease. In cases in which treatment has been insufficient, injudicious, or altogether neglected, longevity is unquestionably diminished, to what ex- tent it is impossible to say, as there are no data to be obtained. Consider- ing the apparent seriousness of the manifestations of syphilis, it is rather remarkable that fatalities immediately attributable to the disease so infre- c[uently occur. A point that has been fairly well established is that patients who have had syphilis are more likely to develop general paresis under nervous and mental strain than non-syphilitics. It does not often occur; but when it does, it is usually before middle age. It is a notable fact that fatalities from syphilis are almost entirely limited to the period of sequels. Cases of death from the lesions of the active period are very rare. In twenty years' experience the author does not recall a single case of the kind. Prognosis from the Life-insurance Stand-point. — The author has very frequently been asked for an opinion upon the relation of syphilis to life-insurance. A few words upon this subject may be serviceable to those engaged in life-insurance examinations. In a general way, the author be- PKOGXOSIS OF SYPHILIS. 397 lieves that insurance companies entertain a mistaken idea of the manner in which syphilis modifies the risk of insurance. In most companies the risk is accepted after a certain number of years following the primary infection, this period being in most instances ten years or less. In the author's opinion the years immediately following the period of active in- fection in the class of persons most often ap^olying for life-insurance, espe- cially for large amounts, are the safest from the "risk" stand-point. The average individual in comfortable circumstances, and especially those of such a conservative turn of mind as are most of the applicants for life- insurance, submits himself to thorough and prolonged treatment for syph- ilis when he is so unfortunate as to acquire that disease. He is quite likely to follow his physician's directions, and, in so doing, reforms and regulates his habits of life in such a manner that, as already remarked, he is often healthier, from a general stand-point, at the end of his treatment than he was prior to infectio^. He is likely to take excellent care of his health for many years after his disease is apparently cured, appreciating, as he does, the necessity of care and watchfulness in guarding against the return of a disease a cure of which cannot possibly be guaranteed him. Individuals who die as a result of syphilis — i.e., of sequelar lesions — are usually beyond middle life, most frequentl}^ past the age at which insurance i& likely to be applied for. At this time the individual is quite likely suffering from a combination of the remote nutritional effects of syphilis and senile degener- ation. Under such circumstances, the applicant for insurance is a hazardous risk in direct ^^roportion to his age, the risk being disproportionately great as compared with healthy individuals of the same age. The author would advise extreme care in insuring risks beyond middle life, and would suggest that the danger is compounded very rapidly after that period. As for per- sons of early adult age who have suffered from syphilis and have been well treated, the author firmly believes that, other things being equal, a hundred such individuals may be insured at least as safely as a hundred who have not contracted the disease. The percentage of deaths at the end of twenty years is not likely to be greater in syphilitics than in non-syphilitics. The exceptional cases of death attributable to syphilis have been a great bugbear with insurance companies. As compared with persons who have had syph- ilis without serious results, however, they amount to but little. It would be interesting to know how many accepted risks have lied to the examiner. The insurance company, strange to say, is often in the position of discrimi- nating against honesty. Another point that the companies might consider with advantage is the fact that a history of a mild attack of syphilis is not necessarily a criterion of the safety of the risk. The quality and dura- tion of treatment is a much safer standard for judgment. Insuring subjects with active syphilis, or within two or three years after infection, is, of course, not to be thought of, for, as already noted, syphilis lessens vital re- sistancy and thus enhances the danger of intercurrent diseases of all kinds. CHAPTEE XVII. Early Bbaix and Xerve Syphilis. The various nervous manifestations of early syphilis have been the subject of special study on the part of the author, and have been considered important enough to merit se|3arate and detailed consideration. Involvement of the nervous system in late or sequelar syphilis is so common that all practitioners of experience have met with syphilitic nerve- phenomena of varying types. Nervous phenomena occurring as a part of the clinical picture j^resented by the secondary, or active, period of the dis- ease, while not rare, are often overlooked and even discredited as syphilitic possibilities by physicians in large practice. On the other hand, surgeons of extensive experience in the treatment of syphilis, with the best opportunities for the study and systematic man- agement of the disease, have come to regard early nerve disease in syphilis as so frequent as to be of special pathologic and clinical importance. Hutchinson and Fournier, in particular, have expatiated u^Don this point, the former having described some beautifully-typic examples of nervous disease occurring within the first year or two of syphilis. In one of his earlier communications Fournier described a very peculiar form of anes- thesia or analgesia occurring coincidently with the roseola. That instru- ment of diagnostic jorecision, the ophthalmoscope, has demonstrated beyond peradventure of doubt the occasional occurrence of syphilitic retinitis within or shortly after the first year of the disease. Some of Hutchinson's cases are by no means indubitably syphilitic; others, however, are so marked as to be beyond controversy. Apropos of the clinical reports of this admittedly-distinguished authority, the majority of conservative diagnosticians will agree that he takes much for granted. Some of the cases of nervous syphilis that he reports are substantiated by the authoritative weight of an eminent opinion, rather than by clinical data. Such cases aside, however, enough clearly-cut cases remain to demonstrate the accuracy of his conclusions upon the general question of the early occur- rence of nerve syphilis. It has been the fortune of the author to meet with a number of cases of varying types of nervous phenomena occurring in the early months of syphilis. Some of the manifestations observed are quite common and would deserve no attention were it not for the fact that their neuropathic origin is not generally understood, although the phenomena presented are a matter of common and daily observation. These simpler and more common phe- nomena have already been alluded to as part of the so-called syphilitic fever, embracing slight neuralgias in different situations, varying degrees of (398) MICROBIAL ORIGIN. 399 cejDhalalgia, extreme mental depression, and rheumatoid pains in different parts of the body — symptoms that may occur at any time during active syphilis independently of syphilitic fever. The various forms of nerve and brain disease of syphilis have received attention chiefly as phenomena of late syphilis, and even in the late cases it has been considered sufficient to classify them as nervous lesions without attempting a critic study of the varying conditions underlying them. The terms diffuse and circumscribed gummy infiltration have covered a multi- tude of pathologic conditions of widely-varying types. There is, to be sure, more uniformity in the pathogenesis of late nerve disease than in the early forms; yet, in a general way, what will be said of the precocious forms will apply in a certain degree to the more systematic later types. There is often in the later forms a very important plus factor in the etiology due to ex- cessive drugging and the syphilitic cachexia. This factor may exist in early cases, but is exceptional. The prognosis in all forms of nerve syphilis is fairly good, if we except the debatable cases of tabes and general paresis. With early and thorough treatment the prognosis is much more favorable than is usually believed even in the sequelar types. It is worthy of note that the more typic the lesion in late syphilis, the better the prognosis; thus, a definite gummatous deposit may always be expected to yield to judicious treatment. Unyielding symptoms are due to lesions that may be termed post-syphilitic, in the true sense of the term, or to nutritional disturbances produced, not by the action of syphilitic poison in loco, but by the pressure and irritation of products that have usually long since lost their infectious properties. The author believes that all tertiary changes are essentially post-syphilitic, and cannot regard tabes and paretic dementia in any other light, where there is reason to accept them as syphilitic in origin. The prognosis as regards recurrence is excellent, in well-treated late cases of gummous nerve disease. This is apparently not so true of the early cases. It may be that the necessity for vigorous treatment is not so well appreciated in the earlier periods; but be that as it may, the occur- rence of neuropathic disturbances in early syphilis is likely to be a pre- monition of future and more serious nerve trouble. In the author's opinion, a clear understanding of the principles of pathogenesis underlying the early nerve phenomena of syphilis can only be obtained by regarding the disease as microbial. Independently of the question of the known or unknown character of the germ, analogic reason- ing alone should convince the intelligent observer of the logic of this view. Having accepted this premise, another point is to be considered, viz.: the modus operandi of the germ. In a general way it may be stated that the germ of syphilis follows a very regular and systematic evolution or life- history. As with all pathogenic microbes, therefore, we must take into con- sideration (1) the soil, (2) the action of the germ per se, and (3) the action 400 EAKLY BRAIX AXD XEEYE SYPHILIS. of certain toxins that it produces (a) by its own excretory functions; (h) by the morbid changes that it excites in the tissues in which it operates. The action of the germ may be said to be, in brief, the excitation of morbid impulses and new properties in certain anatomic tissue-elements — the cell-elements. These new properties are, as noted in the preceding chapter: (1) a tendency to rapid proliferation; (2) a tendency to fatty de- generation; (3) infectiousness. In time, as the life-history of the germ is completed, the property of infectiousness disappears from the morbid tis- sues, but the other evil properties remain so long as the leasi trace of the syphilitic impress exists. The effect of the toxins may still remain, though no new ones are formed, save by the cell-changes themselves, — metabolic toxins. The tissues know the germ-toxins no longer, save, perhaps, by their effects. The action of the early toxins may lay the foundation for cell- changes occurring long after the germ has fulfilled its mission and disap- peared. The relation of such debatable diseases as tabes and paretic dementia to early intoxication of the brain and cord is yet to be shown, but it is prob- able that such early nerve-intoxication may have much to do with these late j)henomena. What Hutchinson terms "vulnerability"' may thus be ra- tionally explained. The author will state, in passing, that most physicians seem to regard syphilis in the light of a tissue-destroyer, the syphilitic poison being sup- posed to roam about like the traditional lion, seeking innocent cells and fibers to devour. This is a serious error, and has been responsible for much wild pathology and still wilder therapeutics. Syphilis is a builder of tissue, — such as it is, — and destroys, not by corrosion, but largely by press- ure-innutrition. Perhaps some of the severe lupoid, necrotic, and phage- denic lesions of tertiary syphilis may be quoted in contradiction, but it is easy to show their fallacy. As a matter of fact, the disease is only apparently destructive, and even its apparent destructiveness is generally manifested after the germ has probably disappeared. With reference to prognosis, there is this to be said, viz.: if the syphilized cells constituting syphilitic neoplasia — whether situated in the nervous system or elsewhere — be removed before pressure-innutrition and absorption of the tissue- elements have occurred, perfect recovery ensues. The more delicate the structure, the more quickly must the removal be accomplished. The practi- tioner must beware of delay in those obscure cases of sudden deafness, certain cases of disseminate or patchy choroiditis and neuro-retinitis occur- ring in syphilitics. These affections when neglected in the slightest de- gree — and often ab initio in neuro-retinitis — rank witli tabes and general paresis with respect to their curability. The practitioner should remember that his remedies may effectually cure syphilis, yet fail to remove the ruins produced by it. If we examine a scar left by subcutaneous resolution and absorption of a syphilide and EAELY BKAIN AND NEEVE SYPHILIS. 401 then imagine a similar scarring of nerve-tissue or arterial wall — if the ex- pression is permissible — some obscure points in syphilitic neuropathology and therapeutics are at once made clear. Apropos of this proposition, the author's position regarding the administration of mercury in some forms of nerve syphilis may be readily surmised. The failure of mercury and the iodids in tabes and paretic dementia has often been used as the chief argu- ment of those who deny the specific origin of these diseases. As well say that a long-standing case of paraplegia cannot possibly be of specific origin, be- cause, forsooth, mercury and iodin fail to cure it. Another point: Mercury and iodin may remove the adventitious deposit very quickly, yet fail to im- press the now fully-organized connective tissue that has been thrown out as a consequence of the irritation induced by the syphilitic neoplasm. To the neurologist there may be nothing novel in this view; yet how few general practitioners understand it. As is readily apparent from what has already been said, syphilitic toxins occupy a very prominent position in the etiology of early syphilitic nerve disease. They also bear a more remote relation to some of the later types of nerve-phenomena. It now remains to consider how they act. Apparently in several ways, viz.: — (A) By direct intoxication of nerve- ! ' tissue 2. Ganglionic. I 3. Perij)heral. (B) By the induction of vasomotor f 1. In the vessels of the central changes via the sympathetic gan- ! nerve-system, glia or the so-called monarchical } 2. In peripheral vessels, vasomotor center in the medulla I 3. In visceral vessels. (C) Direct intoxication and irritation K^ 't-. . ,- „ 1 , • 1 ■ .12. rassive congestions. of vascular tissue producing m < „ t ^ , . „ , ,, , 3. Innammations ot a low type, the nervous system , tt -, ■ 1^ 4. Hyperplasias. The question at once suggests itself: If toxins are present in syphilis and they are so variously and multitudinously pathogenic, why do not all syphilitics present such results in greater or less number and severity? To the philosophic clinician such a query would never suggest itself; but the practitioner who is impressed with the typically-specific character and routine effects of S5''philis on the average might well be expected to be a doubting Thomas. The plus factors in syphilis are too little appreciated even by the expert. The physician who sees nothing peculiar in the de- termination of a mucous ulcer by the irritation of a jagged tooth or tobacco- juice, is at once at sea when confronted with a syphilitic nervous disorder. The relation of cause and effect is, it is true, not so easily determined in 402 EAELT BEAIX AXD XEEYE SYPHILIS. the latter, hut it is none the less definite. Throughont the course of syph- ilis we find lesions that are determined hy very simple and common factors. Thns, long-continned mncons irritation determines mucous plaques, ulcers, papillary hypertrophies, fissures, tuhercles, and condylomata. Gouty and rheumatic irritation of muscle, tendons, ligaments, and s3movial memhranes determines so-called syphilitic and mercurial rheumatism. Gout and rheu- matism jn'edispose to iritis, neuralgias, and infiltration of arteries. Just so surely do such sources of irritation as alcoholism, sexual excess, the gouty and rheumatic diatheses, mental overexertion, or worry determine nervous disease of a type corresponding to the seat of irritation. This applies not only to the toxin neuroses, but to phenomena due to structural changes: i.e., to those characterized by syphilitic new growth. The element of hered- ity is of importance, but, as we well knoAv, a neuropathic tendency may exist without it. Acute complicating diseases are not usually credited with the power of aggravating syphilis; but the fact none the less remains that general or local impairment of nutrition is likely to determine syphilitic action. The more prolonged and irritating the process, the better the prospect of an outcropping of the specific taint. There is no disease, perhaps, that more actively predisposes to nervous disturbance in syphilis than grip. The author could, from his own clinical experience, formulate quite a lengthy dissertation on syphilo-grippal neu- roses. In general, there is no condition more troublesome than a combi- nation of grip and syphilis — grippo- and syphilo- toxins. One of the most important factors in nervous vulnerability in syphilis is defective elimination. Xot onl}^ do the S3'philitic toxins give rise to serious results under such circumstances, but the patient shows intolerance of antisyphilitie remedies. The so-called idiosyncrasy that makes mercury and the iodids obnoxious to certain patients often means defective elimina- tion. Iodic! intolerance may signify a sluggish or damaged kidney. The influence of trauma in the determination of syphilitic processes must be ad- mitted; this applies to nervous as well as to other lesions. A clean incised wound in a syphilitic will heal readily, but prolonged irritation develops a syphilitic element that interferes with repair. From this brief survey of the determining factors of syphilitic phe- nomena, it is evident that the question of vulnerability of tissues and organs, and especially of the nervous system, is of great practical importance. The author has admitted, for the sake of argument, that all syphilitics do not present early toxin neuroses, for the routine neuroses described in the pre- ceding chapter are not generally accepted as such. To sum up the question of toxins in early s3qDhilis, the author is of opinion that they bear a most important relation to the cephalalgias, neu- ralgias, bone-pains, myalgias, paralyses, and rare cases of mental disturbance found in early syphilis, which affections for the most part are an evidence EAELY BEAIN AND NEEVE SYPHILIS. 403 of the action of toxins on tlie nervous system — botli central and periph- eral — and especially upon the sympathetic. These disturbances are often transitor}', independently of treatment, but they leave behind them a vul- nerability of nerve-tissue that may determine much more serious trouble later on. Precisely how the toxins act we do not know — we are as ignorant here as in the case of many other organic poisons. That vascular changes bordering on inflammation of nerve-structure and its envelopes occur in some cases is probable enough, but difficult of proof. The earlier the dis- turbance, the less likely it is to be due to organic cell-deposit. In concluding the subject of the relation of toxins to syphilitic nerve and brain disease, the author desires to call attention to one point involved in the views of Bannister to which he must take exception.^ This distin- guished authority believes in the syphilo-toxic origin of some cases of general paresis, but holds that the toxin remains latent in the system for a prolonged period. He does not believe that the toxins prepare the way for paresis, but that they exist and are operative at the time the paresis begins. With the latter point the author cannot agree. It is more probable that with the cessation of bacterial evolution the toxins are eliminated and not stored up for future morbid action. Bacterial evolution probably ends with the ces- sation of the active period, long before general paresis develops. Cerebral syphilo-toxemia may pave the way for paresis, but it probably does so by profoundly perverting the biochemism and, possibly in a minor degree, the structure of the cerebral tissues. This impression produces no very disas- trous results in the early history of the case, but later on, as nutrition be- comes relatively impaired by advancing age and directly impaired by inter- vening pathogenic factors, serious trouble results. It is a fact well known in pathology that early damage to tissue may not reveal itself for many years — this aside from disease due to germ-infection. This is even true of some cases of malignant disease of late clinical development. In studying the nervous phenomena inferentially due to cell-infiltra- tion in early syphilis, it is to be understood that it is difficult to difEerentiate them from the toxin variety. The later the development of the phenomena, the greater the probability of the existence of definite organic lesions. In late secondary and tertiary lesions these may be well marked. In a general way, the toxin neuroses have their point of departure during the first three or four months of syphilis, the later varieties being of neoplastic origin, but perhaps complicated by toxinsi The younger and more active the germ, the more virulent and abundant its toxins. In the true sequelar period the syphilitic germ and its toxins are probably no longer a factor in syphilitic neuropathology, save as respects the tissue-vulnerability and mor- bid cell-impulse already described. The exceptions to the general rule regarding the dependence of the H. M. Bannister: Journal of Nervous and Mental Diseases, .Januaiy, 1894. 404 EAELY BBAIN AXD NEEVE SYPHILIS. very early nerve disturbances upon toxins are chiefly cases in which hemi- plegia or some severe forms of paralysis develop; in hemiplegia especially the inference that a localized cell-accumulation exists is usuall}^ justifiable. Organic or functional nervous disturbance is produced by syphilitic new growth in numerous ways, viz.: — 1. By invading the lymphatics surrounding nervous structures. 2. By involving the tissues, chiefly the lymphatic vessels, surrounding the blood-vessels supplying or draining the part. 3. By invading the arterial walls. 4. By infiltration of connective and other tissues about nervous struct- ures. 5. By involvement of the nerve or brain parenchyma proper. 6. By involving nerve-sheaths or the cerebro-spinal meninges. These various conditions act by producing:— 1. Irritation. 2. Pressure-innutrition, and occasionally degenerations. 3. Passive hyperemia and edema from venous obstruction. 4. Localized anemia (ischemia) from arterial obstruction. 6. Blocking up of the affected area by lymphatic obstruction. It is rare that extensive destruction of tissue from breaking down of the neoplasm occurs in the earlier nervous lesions. It is to be remembered, however, that gumma may develop at an early period from the intrinsic malignancy of the disease. The predilection of syphilitic cell-growth for lymphatic glands and capillaries has already been expatiated upon. That most of the neoplasia of syphilis are essentially processes of lymphatic infiltration and obstruction is not only true of the active, but also of the sequelar, or gummy, period. In the latter, however, the process is largely one of lymphatic obstruction and congestion, while in the former essential infiltration of lymphatic structures exists. The difference between the two may possibly be explained by the hypothesis that the gummata are chiefly due to old-time injury of lymphatic tissue by essential tymphatic infiltrations incidental to the active period. Vascular involvement — direct or by the pressure of syphilitic cell- growth — is probably the most important factor in the etiology of organic nervous disease in early syphilis; as already remarked, however, the more remote the period after the chancre, the more likely the process is to be due to arterial disease. The apparent predilection of the sj^philitic process for arteries of medium size, and especially those of the brain, is well recognized, but has not been satisfactorily explained. A brief reconsideration of a special anatomic point — that still further emphasizes the importance of lymphatic pathology in syphilis — makes this circumstance fairly intelligible. The perivascular lymph-spaces are an integral eleinent of the lymphatic EAELY BEAIN AND NERVE SYPHILIS. 405 system, and share in its special susceptibility to syphilitic involvement. Pressure upon and inelasticity of small- or medium- sized arteries quite seriously disturbs the nutrition of the supplied area, with consequent aberra- tion of function in the latter. This is a very important matter as regards the brain. The perivascular spaces of the large trunks are involved, it is true; but the resultant pressure and inelasticity are a trivial matter in com- parison with the resisting power of the large arterial tubes and the relative quantity of fluid forced through them. Another vital point is this: the tunica adverititia of the vessels is probably a part of the lymphatic system; it certainly is extensively involved in early syphilis. Hutchinson seems to believe that the tunica intima is primarily involved, the adventitia sometimes, and the middle coat only secondarily; but, despite so weighty an opinion, the author inclines to the view that the point of departure is the adventitia. Apparent evidence to the contrary probably depends upon the fact that most of the cases studied have been late cases in which serious and extensive secondary changes have occurred in the vascular walls. Hutchinson says that syphilitic arteritis does not produce aneurism. This is true as regards the early stages, but the endarteritis of late syphilis is a most prolific cause of those miliary aneurisms that bear so important a relation to cerebral disease, especially of the apoplectic variety. With reference to Mr. Hutchinson's opinions of vasculo-cerebral syph- ilis, it is a peculiar fact that some of the cases that he records are directly opposed to his own views regarding the point of departure of the pathologic process. He quotes a case reported by Sharkey, in the transactions of the Pathologic Society of London, of a man who died of vasculo-cerebral dis- ease in the seventh month of syphilis while still covered with a secondary eruption. The disease was symmetric, affecting both middle cerebrals. ''The process had begun in the tunica adventitia cvnd had spread inward.'''^ Both arteries were occluded, the right completely so, and the areas supplied by them were softened. The patient had suffered from headache and was under treatment for syphilis when he suddenly passed into a semicomatose condition, with convulsions of the extremities; in this state he remained until his death, one week later. Another case quoted is from Dr. Clifford Allbutt, of Leeds. The age of the patient's syphilis is not given. In the brain were found scattered masses of syphilitic neoplasm involving the smaller arteries; these varied from the size of a pea to a walnut and were somewhat indurated. "Microscopic examifiation shoived that the process began ivith cell-exudation and proliferation in the perivascular canals, finally causing great perivascular thickening.'''^ The support afforded by these cases to the view the author has ex- ^ Italics the author's. ^ Italics the author's. 406 EARLY BKAIX AXD XEEYE SYPHILIS. pressed regarding the relation of tlie tunica adrentitia and the perivascular lymph-spaces to the initial arterial lesions of syphilis is very noticeable. It would appear that Hutchinson has formed his conclusions mainly from cases of late syphilis in which the point of arterial departure is often lost in the extensive gummy changes and secondary degenerations of this period. The earlier vascular changes that are really at the bottom of the difficulty have usually disappeared, the later changes that replace them being given credit for the entire field of pathologic change. In the presence of large diffused gummata, with or without degeneration of the inner tunic of the vessels, it is by no means surprising that the earlier changes are masked, imderestimated, or entirely overlooked; even though they have not com- pletely disappeared, they might be expected to have done so. Early peri- vascular exudate, especiallv, may produce most disastrous effects on vascular wall-nutrition and yet be removed in due time. Its presence in tertiary cerebral syphilis would be conclusive; its absence, however, argues little. It is probable that the arterial changes of early syphilis are chiefly operative in the production of ischemia of the brain- and nerve- tissue, with resultant loss of function. Vicarious hyperemia from obstruction of certain areas, and compensatory pressure in others supplied by sound vascular twigs from the same vessel, are possible elements. Passive congestion and edema from venous involvement are additional possible factors. Hutchinson has called attention to a peculiar form of periphlebitis due to syphilis; this may occur in the brain. It is not beyond the bounds of logic to assert that all of the conditions described may possibly co-exist, and that intoxication by syphilitic toxins may be superadded. Hemorrhages, distinct tumors, embolism, thrombosis, vascular ulcera- tions — softening of the tunica intima — are not to be expected in this early stage. Intracranial nodes, while possible, are certainly rare at this time. Meningeal infiltrations probably occur, but, as a rule, do not seem to excite symptoms. Such damage as may be done early in the disease mani- fests itself by symptoms at a relatively much later period. It is obvious, from what has been said, that the changes mentioned as characteristic of syphilitic cell-deposit are much more likely to be localized than those due to a universally-circulating toxin. It is to be remembered, however, that the toxin may cause symptoms referable to a particular area of nervous distribution, by producing aberrations of vasomotor impulse through its action on the sympathetic. Involvement of nerve- and brain- tissue proper by neoplastic deposit has been mentioned as occurring in very early syphilis, but it must be very rare. Such invasion as does occur must be slight, and acts merely by laying the foundation for later gimimy disease. It will be understood in this connection that the possibility of precocious gnmmata of the brain is not denied. In such cases, however, there are abundant extracranial evi- EAELY BKAIN AND NEEYE SYPHILIS. 407 dences of malignancy. In a general way it will be found that large circum- scribed gumniata are characteristic of the period of sequels, while those of the earlier jDeriod are not only small, but disseminate. The disseminated lesions of early involvement of the choroid fairly illustrate what may be expected in the brain in early syphilis. The cases of early nerve-syphilis that have been reported by different authors, among whom Hutchinson, Kiernan, Bannister, Moyer, and ISTor- bury occupy prominent positions, can hardly be classified arbitrarily. Those observed by the author may be fairly divided into: (1) cases in which toxin poisoning was the chief factor; (2) cases in which organic cell-deposit existed and was the main element; (3) mixed cases in which both factors were probably well marked. That these conditions are often absolutely independent of each other during the active period is hardly credible. The author will again direct attention to the fact' that the probability of the presence of organic cell-deposit is in direct proportion to the duration of the case. Some of the very early nerve-phenomena are distinctly toxemic; a little later there is a mixture of both elements, although either may greatly jjredominate; later still, the toxin factor is of secondary importance. Xerve- phenomena associated with a simple typic roseola may be accepted as prob- ably toxic. The existence of eruptions consisting of cell-deposit enhances the probability of cell-infiltration of nervous tissue or the vessels supply- ing it.^ Several of the author's cases have been fair examples of the effects of syphilitic toxins upon the brain. Not only were the meninges directly intoxicated by the products of syphilitic germ-evolution, but there was, in all probability, a vasomotor neurosis that constituted a still more powerful source of cerebro-meningeal hyperemia. The line between such conditions and actual inflammation is difficult to draw, but. Judging by the effects of known syphilitic ]3achymeningitis later on, it is questionable whether actual inflammation is present in these early types of head disturbance. Its occur- rence would, however, not be surprising, Judging by the effects of other poisons — that of rheumatism, for example — upon the meninges and brain. Pericranial involvement ma}^ in the author's opinion, be laid aside in these cases. When we consider the excessive engorgement of the pharynx in sec- ondary syphilis we ought not to be surprised at the occasional occurrence of severe symptoms referable to meningeal engorgement. The faucial hyperemia has been, it is true, referred to actual cell-deposits; but, as stated in the preceding chapter, the author believes that vasomotor dis- turbance has much to do with it. ^ The author's paper on this subject, read before the Chicago Academy of Medi- cine, appeared in full in the Journal of the American Medical Association in March, 1895. It contains the report of twelve personal and a number of quoted cases. 408 EAELY BEAIX AND NERVE SYPHILIS. It Avould appear that mental disquiet was important in the determina- tion of head-symptoms in the author's cases. This is an important practical point as tending to show that syphilis alone may be a quite different matter from syphilis plus anxiety, brain-fag, or any condition that tends to disturb cerebral circulation and nutrition. One case' of severe cephalalgia in a chlorotic female syphilitic clearly illustrated what may occur when diathetic conditions and blood-impoverish- ment are superadded to syphilitic infection. It has seemed to the author that rheumatism, gout, tobacco, and alcohol are somewhat alike in increas- ing vulnerability of nerve- and brain- tissue with respect to both syphilitic intoxication and cell-growth. i\_lcohol is especially open to impeachment by virtue of its pernicious effect, not only upon the brain-cells, but also upon the cerebral circulation. ISTumerous cases of spinal neuralgia — intercostal, lumbo-abdominal, and general — occurring in early syphilis have demonstrated the selective action of syphilitic toxins upon the posterior spinal nerve-roots. One of the author's cases, a young man in his early twenties, suddenly developed hemiplegia and aphasia in the early eruptive stage of syphilis. Such cases sometimes arise very suddenly, after drinking, sexual excitement, or other source of cerebral excitation, demonstrating very conclusively that syph- ilitic brain disease may remain latent for some time, only to develop upon the supervention of some exciting cause. Whether this is true only of the early disturbances of syphilis is open to question. It is a fact, however, that in early cerebral disturbance — due either to toxins or gradual diminution of vascular caliber, or both — the onset is apt to be insidious, with premoni- tory symptoms of vertigo, slight aphasia, impairment of memory, cephal- algia, sense of head-fullness, melancholy, irritability, or perhaps muscular spasm. The final stroke may be sudden; but some of the foregoing symp- toms are likely to have preceded it. The exceptionally-sudden development of several of the author's early brain cases is a feature of great interest. Later cases, that may be due to thrombosis, embolism, or hemorrhage, are, of course, very sudden. Bannister relates a very interesting case with features somewhat simi- lar to several of the author's: — Case. — I was called into a large store to see a man who had been seized with an apoplectic attack. I found a gentleman, between 30 and 40 years of age, completely hemiplegic on the left side. He had not lost consciousness, and, while mentally some- what disturbed, was capable of giving a clear account of himself, which was verified by his friends. He had been well, prior to the attack, with the exception of a chancre contracted four months previously. I had him taken in a carriage to his boarding- place as he requested, prescribed, and promised to call the next day. The next morning to my surprise I found him up and dressed; all motor paralysis had dis- appeared, but he was completely aphasic and could only partially express himself by signs. I learned that his hemiplegia had left him during the night, to be followed by his present condition. This also passed off within twenty-four hours; but his EAELY BEAIX AXD XEEVE SYPHILIS. 409 mind Avas left markedly affected: a condition of mild depression and partial hebetude remained which continued until he left the city and passed out of my knowledge. Bannister considers this case to have been one of incipient paretic de- mentia due to toxic cerebral disturbance, and in this opinion the author is inclined to agree, but with some qualifications.^ It is quite unfortunate that the age of the patient, his previous habits of life, heredity, and sub- sequent history were not definitely known. These points would possibly afford additional support to Bannister's theory of the case, by removing certain features of doubt. As to the cerebral intoxication, it was doubtless a very important factor in the case; but there were certain other elements requiring due consideration. In the first place, cell-deposit was to have been expected at the time the hemiplegia developed; vasculo-cerebral changes were probably present, with resulting relative ischemia and de- fective nutrition of the brain. The toxins undoubtedly did their full share in perverting nutrition and inhibiting cerebral function; but the sudden paralysis was probably explicable by their vasomotor rather than by their direct effect. The speedy recovery of the hemiplegia, and the apparent alteration of the morbid process from right to left, as suggested by the aphasia, which replaced the left hemiplegia, tend to show this. Temporary vaso-contraction of arteries the lumen of which was already diminished by syphilitic infiltration would serve as a logical explanation. The resulting mild dementia was probably due to the combined effects of the temporary ischemia and the syphilitic toxins. Typic examples of early syphilitic hemiplegia afford, when well treated, ample evidence of the favorable character of the prognosis. A very im- portant point in this connection is the fact that such cases should rarely occur. We cannot avoid in some cases — possibly in the majority — the early toxin-phenomena, for the reason that treatment may not have time tS thoroughly impress the patient before the symptoms of toxin nerve disease develop. When, however, we have several months' leeway, we should always be able to prevent early symptoms due inferentially to arterial disease, pro- viding the patient be intelligent and conscientious. Eecovery does not ensue, even in early syphilitic brain disease, unless the toxins and syphilitic neoplasm be removed before permanent changes in the affected tissues have occurred. The syphilitic factor in such cases may be swept away easily enough, but we must be very prompt and radical in our therapeutics, else nerve-ruin will be left behind. It must be -remembered that the pathologic ^ (a) "Statistic Note on Two Hundred and Thirty-four Cases of Paretic De- mentia, with Especial Reference to Etiology." H. M. Bannister, Journal of Nervous and Mental Diseases^ 1891. (ft) Thesis before the Chicago Academy of Medicine, by H. M. Bannister, en- titled "Paretic Dementia : A Toxic Disease." .Journal of Nervous and Mental Diseases, January, 1894. 410 EAKLY BEAIX AND KEETE SYPHILIS. process in some cases may be precocious, verging upon gumni)^ change; herein lies a source of danger. In a case of early hemianesthesia of the author's the character of the lesion is an open question. Cerebral hemorrhage should be rare in such early cases, the thickening of the vessel-walls and perivascular tissue pro- tecting the arteries from rupture rather than otherwise. Collateral vascular strain and hyperemia induced by venery and alcohol might have been the essential factor. It will be understood that the probability of a small ex- travasation in such cases is not denied. The author simply desires to assert its rarity at so earl_y a period of syphilis. Its occurrence, however, might show that the localization of vasculo-cerebral syphilis depended upon some antecedent non-syphilitic disease. This is not likely in a relatively-young subject. The occurrence of acute ischemia of the affected area is not im- probable. The affected area probably accommodates itself, as a rule, to the gradual diminution of the blood-supply incidental to the encroachment of the syphilomatous process. When, however, from any cause the vessels are suddenly occluded the result is well known. The mechanism of this occlu- sion in early syphilis is not so easily explained. Embolism is possible, but is not to be expected in early syphilis. Localized vasomotor disturbance is also possible. The toxin element does not enter here, save as a complicating factor; that it is the essential feature of the case is not likely. After a care- ful survey of the pathologic possibilities in the case under consideration the author inclines to the ischemic view of the cerebral disturbance. The loca- tion of the lesion in the internal capsule or its immediate vicinity may be taken for granted. The subsequent recovery and prolonged good health of this patient typify the favorable ultimate prognosis of many cases of nervous syphilis. ^ Among the author's most interesting cases — a man of middle age — ^was one of combined grip and the first efflorescence of syphilis. Severe spinal neuralgia with symptoms suggestive of involvement of the spinal meninges developed and proved most trying and obstinate. Some months later this man developed severe paraplegia. A prominent factor in this case was excessive sexual indulgence even after the syphilitic eruption appeared. The case quite forcibly illustrates three important features of syphilitic neuropatholog}^, viz.: — 1. The acutely pernicious action of syphilitic toxins upon the nervous system. 2. The vulnerability of nerve-tissue produced by this early intoxication. 3. The importance of such conditions as grip and possibly the influ- ence of sexual excess in determining neuropathic phenomena. The early nerve disturbance in this case the author believes to have been due to the following factors: (a) direct irritation of nerve-tissue and spinal meninges by the syphilitic toxins; (b) circulatory disturbance — probably hyperemia — of the same tissues and especially of the posterior roots of the spinal nerves. EAELT BEAIN" AND NEEVE SYPHILIS. 411 produced by syphilitic intoxication of the sympathetic. The paraplegia that occurred later on was, in all probability, due to actual cell-infiltration of the motor tracts determined by the perversion of nutrition left by the toxins. For that matter, the paraplegia did not occur late enough to exclude toxin action at the time it developed. Even if the toxins were the point of departure, however, cell-infiltration was probably the essential factor at this time. Grip was a very important factor in the early symptoms. This dis- ease is itself a powerful toxin-elaborator. Sexual excess, perhaps, had much to do with the spinal determination of the syphilitic poison. The author is inclined to the view that the causative influence of syphilis in tabes is often operative chiefly through the secondary factor of sexual excess. Hutchinson reports a case in which acute myelitis was precipitated by sexual indulgence, the patient being well along in late syphilis. It is, of course, recognized that the relative importance of syphilis in the etiology of tabes has not been definitely settled. Alcohol bears a somewhat similar relation to tabetic etiology: it is probably the determining factor that develops morbid changes in the spinal cord in syphilitics, from which abstainers would prob- ably escajDO. The author's cases comprise several involving the nerves of the head and face. One case, in which the fifth nerve was affected, is an illustration of a form of syphilitic nerve disease which, while it can hardly be said to be very rare, is yet sufficiently infrequent to be of great interest. It would appear that syphilis has something of a monopoly in the production of paralysis of the fifth. Hutchinson states that he has never seen this form of paralysis except from syphilis. The author is not in a position either to verify or contradict this assertion. JSTeurologists of large experience are much more competent to judge. It is to be remembered, however, that Mr. Hutchinson's clinical experience has been enormous. The only cases of trifacial paralysis that the author has seen — two in number — were due to syphilis; but, strange to say, neither of them bore out Mr. Hutchinson's favorable prognostic opinion of such cases. He says: "I do not recollect a single case of syphilitic paralysis of the fifth nerve which was permanent." The apparent contradiction in the author's cases was probably due to the late period at which proper treatment was begun. In neither of the cases Avas the cornea involved, the superior division of the nerve probably escaping involvement. Hutchinson has several times removed the eyeball in cases of total involvement of the nerve, the anes- thesia from the nerve-lesion being so complete that anesthetics were un- necessary in operating. As a rule, only one nerve is involved, cases in which bilateral paralysis of the fifth or coincidental involvement of other cranial nerves being exceptional. Hutchinson believes that the want of symmetry and strict localization of the lesion shows that the trunk or ganglion rather than the origin of the nerve is affected. A most interestino; feature of one of the author's cases was unilateral 412 EAKLY BEAIX AND XEEVE SYPHILIS. deafness. So rare is this condition that Hntcliinson states that he has never seen an example of it. Partial deafness in one or hoth ears, generally tem- porary, is by no means unusual in early syphilis. Tinnitus aurium is an- other aural phenomenon that is not infrequent and is likely to be very stubborn, but may not be accompanied by the slightest inhibition of audi- tion. In the eases in which absolute deafness occurs the process is not only bilateral, but may be fulminant. Unless mercury be vigorously used, incurable deafness is very likely to develop in an incredibly short time. We are almost in the dark regarding the pathology of these cases. Deafness develops during the first year of syphilis, as a rule; is rarely, if ever, sequelar; and seems to be almost identic in acquired and heredi- tary syphilis, in which latter condition it is very frequent. The severity and rapidity of the process in connection with the total abolition of hearing that usually results warrants its classification among the nerve-phenomena of syphilis. A disturbance of the relations of the arteries to their bony investments by virtue of loss of elasticity, thickening, and narrowing of the vessel-walls probably explains some of the slighter cases of deafness and tinnitus. Some transitory cases are doubtless due to a syphilotoxic vasom- otor neurosis. Where cell-infiltration in or about the auditory nerve occurs, the press- ure and counter-pressure on the delicate nerve-fibers must be very great, be- cause of the unyielding nature of its osseous investments. The syphilitic neoplasm may, as usual, be quite speedily removed, but jDressure and toxic innutrition have done their work, and permanent and functionally-fatal injury has been produced. The author sees no other logical explanation of these cases. There is certainly no explanation that could more power- fully emphasize the necessity for early and radical treatment. A final point of interest is the fact that facial hemiatrophy, which occurred in one of the author's cases, is exceptionally preceded by neuralgia of the fifth. In the case under consideration it was very severe. Facial paralysis from syphilis is very rare, while it is very frequent from other causes. The possibility of coincidence is therefore to be taken into serious consideration in suspected cases. Hutchinson, with his vast experience, recalls only two or three examples of facial paralysis from syph- ilis, and in these cases other cranial nerves were also involved. He quotes Buzzard and Hughlings-Jackson as having recorded examples of it. In a case of the author's there was no change for the better until full mercurial treatment was instituted: a point in favor of the diagnosis of sj^philitic dis- ease of the seventh nerve or its root. In cases of early cord symptoms where tabes develops at a remote period, it would be difficult to prove the connection of the early tabetic symptoms of undoubted specific origin, with the later manifestations of typic tabes. The inference of a causal relation of the early symptoms to the later incurable cord disease is, however, apparently fair. At this junct- EAELT BEAIN AND NEEVE SYPHILIS. 413 lire it might be well to again suggest that, in many cases of tabes with a syphilitic history, early cord intoxication without symptoms may have laid the foundation for later changes. H. N. Moyer has observed a case which is very pertinent as bearing upon early spinal-cord involvement in syphilis. His report of the case is as follows : — Case. — I was called to see a woman, about 30 years of age, who was said to be suffering from an obscure nervous trouble. The disease had begun some weeks before I saw her, with severe pain in the back and shooting pains in the legs. These symp- toms had gradually increased until within a few days of the time when she came under observation, at which time she was compelled to take to her bed. At the time I saw her she was apparently very sick and suffering excruciating pains, particularly in the legs, and a dull, heavy aching in the back. She was very restless and sleepless. The pains were described as shooting or darting up and down the limb: the feet were especially painful and there was a feeling as though hot sand were applied to the soles. On examination, there was no special atrophy, though there was, perhaps, some loss of power in the legs. She was able to stand with the eyes open, but with them closed she would immediately pitch forward. The knee-reflexes were completely abolished. There was impaired tactile and temperature sense in the lower extremities. At this examination I detected a diffuse macular and papular eruption pretty gener- ally distributed over the entire body and which up to that time had not attracted the attention of the attending physician. The eruption also was present upon the palms of the hands. Suspecting the specific nature of the eruption I immediately questioned the husband, who admitted that about ten months before he had been infected, but after six months' treatment his physician had advised him to marry, and he had done so. To my mind, there was no question that the specific infection was directly responsible for the acute ataxia in which I found the patient. An examination of the genital organs did not reveal any primary sore. I saw the patient on one or two occasions after this visit, and I learned subsequently from her physician that imder free use of the iodids, with mercurial inunction, the pains rapidly disappeared and the patient made a quick recovery. Within three or four weeks she was going about attending to her ordinary household duties. It would be interesting if at this time I could see and examine the patient, but unfortunately I do not know where she is. It is the earliest case that has ever come under my observation. It has not been the author's fortune to observe cases of early brain syphilis with mental symptoms as the predominant element. A number of such cases are on record. Most of these cases have been collected by Kier- nan, in a brief yet comprehensive survey of the literature of the subject of early syphilitic psychoses.^ Wille, several years ago, made an exceedingly valuable analysis of the psychoses due to syphilis, which he found were divisible into the following classes: (1) irri- tative psychoses based on cerebral anemia following syphilitic infection even from its very beginning: (2) simple inflammatory psychoses due to meningitis and cere- bral softening; (3) neoplastic psychoses proceeding from cerebral meningeal gum- mata. Griesinger states that, when acute mental disease affects patients during the ^ James G. Kiernan, Journal of ISTervous and Mental Diseases, July, 1880. 41-i EAELT BEAIN AXD XEETE SYPHILIS. secondary stage of syphilis, it will be chiefly those whose brain is organically affected, who have previously presented symptoms of abnormal cerebral activity, or who come from neurotic families. Wille says that mental symptoms may appear two months, or even two weeks, after infection, certainly with the onset of the secondary symptoms. Hildebrand has had very similar experience. Leubuscher was the first to establish the existence of mental symptoms during the secondary period. Prior to his article these had been regarded as tertiary acci- dents. Berthier some twenty-seven years ago reported several acute cases of insanity occurring during the secondary j^eriod. Fournier has described several cases of insanity due to secondaiy syphilis, vaiying in type from confusional insanity to cataleptoid states. Mickle has observed several cases of insanity due to secondary syphilis in which the psychic effect of syphilis was similar to that of alcohol. Clouston substantially agrees with Wille. He says the jDsychoses occur in the secondary stage of the dis- ease, coincidently with the eruption, and are curable and rare. C'adell reports a case characterized by mental excitement and restlessness, which reached its height seven months after the initial lesion and five months after the appearance of the secondaiy symptoms, with the onset of which the mental symptoms began. This case consisted of a confusional delirium. The patient slept but little, but rode recklessly about at night. A year later melancholia had set in, accompanied with paralysis of energy, so that the patient scarcely left his bed. He at length made a good recovery. Regis states that the psychoses of secondary syphilis occur on the appearance of secondaiy accidents accompanied with fever, principally at the time of the eruption. The onset is more or less brusque, and takes the form of acute or subacute mania or melancholia, preferably mania; it is sometimes of a circular type. It is usually of short duration, disappears with the febrile manifestations to which it is due, and readily yields to mercurial inunction. Luys, admitting that mania, melancholia, and hallucinatory confusion can occur, asserts that these are but the epiphenomena of a morbid process in evolution. Several of Kiernan's own cases are of great interest. The histories of two of them are herewith presented: — Case 1 was that of a 35-year-old Canadian, a periodically-drinking tailor, of criminal antecedents and parentage. A sister and an aunt are prostitutes. One brother is idiotic and one a professional burglar. Foiu- weeks before admission he had contracted a chancre, which healed without treatment. Two weeks before coming under care he was very morose and irritable, felt chilly sensations all over the body, and was very languid. Six days before coming under care he was attacked by a very intense fever, and on the following day complained of insects crawling beneath his flesh, and of men being at the Avindow with guns to shoot him. He was markedly terrified. When he came under obserA^ation he had a temperature of 104.9°. He was markedly agitated, constantly in motion, and had an expression of extreme terror. Sedatives had no effect on the mental symptoms of the fever. On the third day the histoiy already narrated was obtained, whereupon mercurial inunctions were ordered. During the following night the patient Avas less agitated, but retained his delusions, and Avas A'ery little inclined to remain alone. This treatment continued tAAO days, the temperature and mental state remaining the same. The third day after this a roseolaceous eruption appeared on the forehead and neck. This was at EAELY BEAI^' AXD XERVE SYPHILIS. 415 fii'st a simple roseola, but in twenty-four hours became pustular and gradually melted down into dark-brown crusts, flattened and depressed, Avhich, when removed, showed a grayish film bathed in pus underneath. The attendant, soon after the appearance of the eruption, neglected to rub in the mercurial ointment, whereupon the patient's temperature rose to 103.6°, and he became violently excited, rushing wildly from one room to another, saying that he was about to be shot and that spiders were "eating his brain." His countenance expressed terror and he was always in motion. As a means of restraint and to secure treatment, a sheet was smeared in mercurial ointment, the patient was wrapped in this, and then confined in a camisole. The next day his temperature fell to 101.7°. Although still retaining his delusions, he was much more at ease and less agitated than he had been since his admission. Treatment was continued three weeks. The mental disturbance became less and less marked. The eruption began to cicatrize, and finally healed up in places, leaving thin, red lines radiating from the center. The delusions grew less and less vivid until they seemed to the patient but dreams of an unpleasant nature through which he had passed. He retained some gruffness and irascibility, but this was evidently natural to him and not insanity of manner. He made a good recovery and remained in good health. Case 2. — A baker, 25 years old, a moderate drinker, had a brother who died insane and a sister under treatment in an insane hospital. When he came under observation he was very much agitated and had well-marked auditory and visual hal- lucinations. He saw spiders crawling over him, and guns protruded from holes in the wall to shoot him. He heard wolves and lions howling and roaring at him. He kept always in motion, but by dint of great effort could control himself and give a few relatively rational answers to questions. After recovery he gave the following history: Four weeks before coming under treatment he had contracted a chancre. About the beginning of the fourth week after this he had a distinct chill, followed by a high fever. Believing this to be the onset of malaria, but feeling unac- countably depressed, he took 10 grains of quinin and visited Central Park. While there he was so frightened at the howling of the wolves that his companion was obliged to draw him away to avoid attracting attention. This scene was repeated before the lion's cage. He was not afraid of the animals, but of their howling. On his return home he became exceedingly delirious and cried out about wolves and lions. In two days hospital treatment became necessary. On admission he had a temperature of 104°. He Avas fairly well nourished. He was rather loquacious, which loquacity was at times broken in upon by his hallucinations. He was ordered seda- tives as in the previous case, also without effect. The fourth day of treatment a roseolaceous eruption made its appearance on his forehead around the roots of his hair. The patient was ordered a mercurial ointment applied as in the other case. In twenty-four hours his temperature fell to 99.8°. He was much quieter, but retained his delusions and hallucinations. The next day a similar eruption to that described appeared on the arms and trunk, which gradually formed flat pustules. These became covered with greenish-brown crusts, which, when removed, showed a grayish-red ulceration beneath, and Avere surrounded by a copper-colored areola. The delusions and hallucinations grew less viAid for the next two Aveeks. By the time of the total disappearance of the eruption (at the beginning of third Aveek) they disappeared also, leaA'ing the patient in a dazed condition. He remained relatiA^ely stationary for about tAVO Aveeks, Avhen he gradually brightened up and reeoA'ered, four months after admis- sion. In the author's opinion, the toxin A'ieAv of such cases as Kiernan's is the most logical one. Indeed, they seem to he typically toxic. An insta- 416 EAKLT BKAIK AXD XERYE SYPHILIS. bility of cerebral structure and function, moral and mental influences, alco- hol and previous cerebral irritation from any cause whatever, may act as factors that determine the toxemic process to the brain; but cerebral in- toxication by syphilitic toxins is none the less the essential factor. Some cases in which brain-symptoms develop a year or two after the chancre must still be classed as early psychoses of syphilis, if associated with typic secondary lesions. It must be remembered, in this connection, that the duration of the disease is not always a criterion of the period at which the evolution of syphilis has arrived. Eruptions characteristic of the sec- ondary period may appear very early, or they may be retarded until long after their usual period of evolution. The point to which the evolutionary progression of S3q3hilis has arrived is often a better criterion of the patho- logic age of the disease than the period of time since infection. CHAPTER XVIII. The Period of Sequels, oe So-Called Tektiart Syphilis. Having finished the description of the lesions of the secondary, or active, period of syphilis, and considered the physio-pathologic explanation of the various phenomena presented by general constitutional infection and localized cell-accumulation, it now remains to consider the period of sequels: the so-called tertiary stage. The Tubercular Syphilide — Gummy Infiltration. — One of the most frequent and important of the tertiary lesions or sequels is the tuber- cular eruption. This has been said to be due to a localized accumulation of morbid cell-material in the tissues — so-called "gummy infiltration" — that is the type basis of all tertiary lesions. This gummy material is termed by Wagner "syphiloma," and is described by him as an infiltration of cells and nuclei, the cells not being capable of differentiation from the normal white blood-cell or leucocyte and the nuclei themselves presenting no character- istic appearances. He states that their morbid effects are due to a mere interference with the function and nutrition of affected parts by simple pressure. Baumler also claims that the histologic elements of syjDhilomata lack specific microscopic characters. The tubercular, or gummy, lesion may develop in any situation, its favorite locations being the cellular tissue, skin, bones, liver, testes, brain, and kidneys, and, in children especially, the lungs. This gummy material is a grayish -red, homogeneous mass of greater or less consistency, that may be found in the parenchyma of any organ or tissue of the body, either as a diffused or circumscribed infiltration, but never incapsulated. When this accumulation of morbid material is superficial and exposed to unequal press- ure, and when it is excessive or involves the walls of the blood-vessels, thus giving rise to localized innutrition from pressure or vascular obstruction, the whole mass is liable to disintegrate and form an open lesion, or break down into pus, or puruloid material that may absorb through fatty or gran- ular degeneration without ulceration. As we have already seen, the lesions now under consideration have no specific inoculable properties, this view being supported by Eicord, Diday, Barensprung, and Baumler. This is the only difference, so far determined, between the histologic elements of the tertiary and those of the secondary lesions, save, perhaps, the greater tendency to destruction of tissue in the former. It has been demonstrated that the longer the duration of the active period, and consequently the more pronounced the changes in the lymphatic structures produced by its lesions, the greater the liability to tertiary lesions " (417) 418 PEEIOD OF SEQUELS. of a severe type. As the cells composing gummata are not infectious and are less active than the true sj^philitic germinal cell^ they are probably not the result of the influence of an active infection upon the normal tissue-ele- ments, but are due to lymphatic obstruction, being no more nor less than an accumulation of normal embryonal cells that are prone to undergo and pro- duce various .degenerative changes through nutritive disturbances. The Ij^mphatic obstruction giving rise to this accumulation of embryonal cells is probably the result of injury to the absorbents produced by the lesions of the active stage. Eindfleiseh, who is unexcelled as an authority on patho- logic questions, says: — "Luxurious new formations, catarrhs and surface secretions of various hinds must he produced when the lymph-conveyance is hindered." The results of careful investigation tend to show that the new forma- tions and surface secretions of tertiary syphilis are all due to an accumu- lation of normal germinal material, and, if this be true, how can we account for it except by the existence of lymphatic obstruction? The author accepts this view of mechanic l3^mphatic conditions as ex- planatory of the accumulation of lymphatic germinal elements at certain points, but believes that the same nervous influence lies behind some sequelar lesions as has been suggested in explanation of the phenomena of the active period. This nervous influence — trophoneurosis — is more difficult of ex- planation than in the active period, for the germ and its toxins are prob- ably gone. Permanent derangement of nervous structure and function affecting the sympathetic system produced b}^ the lesions of the active stage is, however, a rational explanation. Why tertiary lesions should occur at one time rather than another is difficult to say. Accepting the view of the forma- tion of the gummata or syphilomata that has been set forth, the term "gummy period" is inaccurate. The term "period of lymphatic obstruc- tion," suggested by Otis, is more comprehensive because indicating the actual pathologic condition and the exact manner of its production. After the removal of the cells by fatty degeneration there is always a tendency to recurrence. This explains the difficulty of curing the disease at this period. This tendency is due to an increased injury to the lym- phatic structures already greatly impaired by the lesions of the active stage of syphilis. This impairment consists in the formation of fibrous tissue, as a result of low inflammatory action mechanically set up by the cells. This fibrous formation, of course, interferes, in a measure, with tissue- nutrition in diff'erent localities, by producing changes in the vascular walls. It has been claimed that a great deal of the trouble in so-called tertiary syphilis is due to wide-spread fatty degeneration caused by vascular con- traction. In any event these vascular changes do produce innutrition and a tendency to destructive changes in those parts supplied by the affected vessels, and nutrition is still further impaired by local pressure from accumu- lation of lymphatic elements. THE TUBERCULAK SYPHILIDE. 419 It is well known that fatty and purulent degeneration are more likely to occur in some subjects than in others, and are most likely to supervene in individuals who are cachectic or debilitated from any cause. Debility would, of course, be produced by a prolonged and severe active stage, and, indeed, Hutchinson claims that "the liability to, and severity of, tertiary lesions are in direct j^roportion to the duration and severity of the secondary stage." He also asserts with great positiveness that tertiary syphilis com- Fig. 109. — Ulcerous late syphilide. (After Dumesnil.) prises the sequels of syphilis, and not the lesions of syphilis proper. The author believes there are some sequels that are not due to lymphatic obstruc- tion, and, also, that there are many apparent exceptions to Hutchinson's rule. The most important exceptions are certain phases of osseous and nerv- ous syphilis that will receive attention later. The practical conclusion at which we may arrive after a careful con- sideration of all the facts thus far presented is that the various lesions and 420 PEEIOD OF SEQUELS. different degrees of severit}^ of tlie plienomena of the so-called "tertiary stage of syphilis" depend upon (1) the amount of damage produced by the lesions of the active period of the disease and its duration, (3) the con- stitutional condition of the individual independently of specific infection. Late, or Sequelae, Xeeve and Beain Syphilis. — The term "nerv- ous syphilis" has been applied quite generally only to those disorders of brain and nerve — organic, presumably — met with in late syphilis. The nervoiis lesions of late syphilis are more severe, and the prognosis much graver, than in the case of the early nerve-phenomena discussed in a preceding chapter. The reason for this is quite obvious. The accumu- lation of neoplastic material in and about the delicate nerve-structures, occurring in late syphilis, is associated with and probably dependent upon: 1. The local damage inflicted by the lesions of the active stage in the form of a low grade of inflammation with connective-tissue proliferation, vascular and lymphatic obstruction. 2. The debilitating effects of prolonged sypli- ilization and the prolonged treatment necessitated by it. 3. Prolonged mental worry, with or without alcoholic or other excesses. 4. In some cases resistance to remedies occasioned by their prolonged use. It is probable that the nerve and brain lesions of the sequelar period act entirely by producing mechanic and nutritional disturbance, the syphilitic infection proper having long since become exhausted. What role, if any, is played by metabolic toxins is, of course, problematic. That true syphilitic toxins are no longer formed the author believes. Taking everything into consideration, however, the disastrous effects and unfavorable prognosis of late nerve syphilis are not surprising. The manifestations of sequelar nerve syphilis are many and various, although the local lesions are tolerably uniform in character and few in number. Parah^ses — such as hemiplegia, paraplegia, and monoplegias of different kinds — are apt to occur, and are due either to localized deposit of syphiloma external or internal to the structure involved or to diffuse interstitial de- posits and proliferation of obstructive connective tissue. Gummy tumors may occur in the brain proper or its membranes, or ihe latter ma}' undergo a chronic thickening resembling chronic meningitis from other causes. The pathologic results and symptoms produced vary with the location and func- tion of the structure involved. Gummy deposits in and about the vascular walls interfering with the cerebral circulation are prolific causes of paralysis. The thickening from syphilitic deposit during the secondary period is apt to S0 pervert the nutrition of the vascular walls that atheromatous and calcific degeneration, with subsequent rupture and apoplectic effusion, occur later on during the period of sequels. This same vascular degeneration is often the cause of those miliary aneurisms the rupture of which is at the bottom of many cases of apoplexy and hemiplegia. It is well to remember that the amount and severity of eruptions experienced in the active period LATE NERVE AND BEAIN SYPHILIS. 421 of syphilis is often inversely to the danger of nervous sequels. Dumesnil, in particular, has called attention to this.^ The disease often expends its violence upon the nervous and vascular systems, while the skin and mucous membranes escape. The various cranial and spinal nerves are likely to become involved in sequelar syphilis. This involvement may be central, involving the brain origin of the nerve, with or without a greater or less degree of coincident brain-involvement, or it may be peripheral, affecting any part or all of the distribution of the nerve. As with the brain, the nerve-lesion may consist (1) of a circumscribed or diffuse gummy deposit; (2) of sclerotic changes produced (a) by lesions of the active period or (b) by sequelar gummy deposit; (3) of destruction of normal tissue-elements. Sclerotic changes — incidental to connective-tissue proliferation and contraction — and destruction of normal tissue-elements are the explanation of the incurability of a large proportion of cases of nervous disease in late syphilis. Nutritional perversions incidental to permanent disturbance of lymphatics and blood-vessels explains the tendency to relapse in cases that apparently yield to treatment — as all cases do prior to local tissue-destruc- tion and sclerosis. This point emphasizes the necessity of haste in removing syphilomatous nerve-deposits by proper remedies. Unlike the early nerve- lesions, which 23romptly manifest themselves by symptoms, as a rule, those of late syphilis are very insidious, and may do great and irreparable damage ere symptoms lead to their detection. The author desires to emphasize especially the fact that the unyielding character of the symptoms may mislead as to the diagnosis. The resistance of the symptoms to vigorous treatment is often taken as evidence against syphilis. The consideration of the permanent damage — the scarring, so to speak — produced in the nervous system by sequelar syphiloma shows the fallacy of such illogical reasoning. A special predilection for the nerves of special sense is often manifested in syphilis. The author has at present under observation a most interesting case of permanent anosmia, coming on suddenly in a syphilitic. It is asso- ciated with defective taste. While in a general way the danger and severity of late lesions are pro- portionate to the severity of the active stage, — as has already been re- marked, — it is none the less true that in some cases the external evidences of syphilis are not faithful criterions for an opinion as to its severity. Exter- nal manifestations may be slight, the disease apparently expending its violence upon the circulatory and lymphatic systems. This explains those otherwise-mysterious cases in Avhich objective secondary symptoms are skipped, yet terribly-destructive sequelar lesions develop many months or ^ Dumesnil does not vouchsafe an explanation of the phenomenon, but emphasizes the clinical fact. 422 PEEIOD OF SEQUELS. even years later. A recent case of the author's is a sad and instructive example of this: — - Case. — A young and active man occupying an important mercantile position con- tracted syphilis for which he was treated most systematically for full three years or more. His habits were unexceptionable. During the treatment he was absolutely free from symptoms save the first eruption of roseola, a few mucous patches early in the case, and the usual amount of primary and general adenopathy. Being apparently cured, the patient passed from under observation. Ten years later he developed neu- ritis of the right brachial plexus. This was treated by a distinguished nerve-specialist as rheumatism. >Seven months later cerebral symptoms, and finally general paresis, develojjed. Death finally occurred despite vigorous antisyphilitic treatment. Pressure upon a nerve or nerve-center produced by syphilitic deposit may give rise to certain special symptoms: e.g., joressure upon the optic nerve will produce blindness of the corresponding eye, pressure upon the origin of the olfactory nerves Avill impair the sense of smell, pressure upon Broca's center will produce aphasia, pressure upon the fifth cranial or its branches will produce severe neu.ralgia, and so on ad infinitum. Some rare illustrations of nervous sj'philis are noted in both typic and precocious cases of the secondary period. This has already been exhaustively discussed. IxFLUEXCE OF SYPHILIS 0^^ THE Spixal Coed. — There has been some- thing of a controversy as to the influence of syphilis upon the spinal cord. It is well known that gummy infiltration and localized deposits with con- sequent paralysis occur in the cord, but the etiologic relation of syphilis to locomotor atax}^ has been disputed. Erb maintains that 61 per cent, of cases of locomotor ataxy are due to syphilis. Fournier claims a syphilitic origin in the "enormous majority of cases." In regard to this question the author can only say that, while the statements of these authorities may be exaggerated, clinical experience seems to prove that quite a proportion of cases is due to syphilis. Taylor opposes this view. Beyond doubt, however, some cases are curable if treated early by the iodids and merciiry. The theory of the causal connection of syphilis with locomotor ataxia is by no means new, having been first suggested by Duchenne many years since. It was advocated by Yirchow, Wunderlich, and Eomberg at least thirty years ago. The principal foundation for opposition to the luetic tlieory of tabetic etiology is the incurability of the majority of cases of locomotor ataxy by antisyphilitic treatment. This, in the author's opinion, is a fallacious argument. The spinal cord is a very delicate structure, and it does not require very marked nor prolonged j)athologic changes to produce perma- nent nutritional changes in it. As has been already stated, it is probable that insidious nutritional cord-changes without symptoms in the active period are often responsible for locomotor ataxy developing in the period of sequels. The peculiar tendency of syphilis to produce sclerotic changes must not be lost sight of. Obviously, treatment relieves symptoms pro- TBOPHOXEUEOSIS IN SYPHILITIC SEQUELS. 423 diiced by syphilitic toxins^ syphilized cells, and true syphiloma, only to the extent that they are dependent upon nerve-empoisonment or neoplasmic deposit. "Xerve-scars" cannot be removed. Peognosis of Late IsTeeve-lesions. — The prognosis of late nerve and brain syphilis is notoriously bad, but in many cases more hopeful than some authorities would have us believe. The author once heard an eminent authority say of a serious case of late brain syphilis: "This man will surely die very soon. Such cases all go that way." But the patient did not die. He got well under enormous doses of iodids. A short time since the author saw a case in consultation with Dr. Haerther, of Chicago, that illustrated this point very forcibly: — Case. — The patient was in his fourth year of syphilis. He had hemiplegia — with facial jiaralysis — extensive gummy ulcers on the extremities with bone-involvement, and was aphasic. Emaciation was extreme, and, taken altogether, the ease was most unpromising, especially as treatment had not so far been well tolerated. An unfavor- able prognosis was given, with the proviso that the ease might be an exception to the rule, like the one previously described. This man recovered, and when last seen was apparently as healthy and hearty as could be desired. Teophoneueosis in Syphilitic Sequels. — In studying some of the late or sequelar lesions of syphilis, particularly those involving changes in the osseous structures of the head and face, the author has been forcibly impressed by certain characters of the lesions that seem to depend upon a mere occult series of pathologic changes than those to which they are usually accredited. Some of these characteristics pertain also to many of the lesions of the active or secondary period of syphilis, and have already been dis- cussed in connection with the syphilitic fever, roseola, and other lesions. As already indicated, the relation of certain syphilitic phenomena to organic or functional disturbances of the nervous system — and particularly the S3anpathetic system — is manifested here and there along the whole line of morbid phenomena developed by the disease. It would appear that syphilitic infection not only has a peculiar affinity for the sympathetic nervous system, but that this affinity is particularly marked in the case of the upper or cervical portion of the sympathetic. The proportion of lesions aljout the head, face, and mouth is relatively much larger, even under the best of treatment, than in other portions of the body. The parts supplied by the fifth cranial nerve appear to be especially sus- ceptible to late lesions, although the nerve itself is rarely affected. Most cases met with in private practice escape general cutaneous eruptions and bone-lesions under appropriate treatment. Few, indeed, no matter how thoroughly they may be treated, are not affected at one time or another with lesions of the oro-pharyngeal mucous membrane and alopecia of greater or less degree. This is more especially true of the active period, but even in the late and sequelar syphilides this same predilection for the structures of mouth and throat is manifest. Cases are frequently met with in which the 424 PEEIOD OF SEQUELS. initiatory and active jDeriods of the disease have been passed through without serious trouble, when suddenly and without warning, serious destruction of the nasal, palatal, and maxillary bones has developed. Many cases of serious destructive ulceration of the pharynx are met with as remote manifestations of syphilis in cases in which lesions have been escaped during the earlier periods of the disease. The affinity of the syphilitic process for the iris may possibly be ex- plicable from the important function of those filaments of the sympathetic system supplied to this part. In other words, the local accumulation of cells in the iris may be incidental to disturbance of nutrition dependent upon the impression of the syphilitic infection upon the central sympathetic system. Even in congenital syphilis evidences of trophoneurotic disturbance are met with. The peculiar affinity of the syphilitic process for the epiphyso- diaphysial junction of the long bones in infants and children is strikingly suggestive. It is here that the processes of growth and nutrition are most active and tissue-building most rapid. It is consequently at this point that disturbance of the trophic function of the sympathetic, which presides over the physiologic processes of nutrition and growth, is most likel}^ to be mani- fested by pathologic change. A perversion of the function of the sympa- thetic would result in imperfect differentiation of the cells of the part, and, as the rapidity of proliferation of cells is inversely to their degree of dif- ferentiation, a heaping-up of young material is to be expected. Associated with this imperfect differentiation of cells we have a tendency to degenera- tion, for it may be formulated that the tendency to degeneration is also in inverse ratio to the degree of differentiation. This imperfect differentiation with consequent tendency to degeneration of young germinal material is the characteristic feature of all lesions and all periods of syphilis. The physiologic effects of the remedies upon which we depend for the cure of syphilis are, so far as they go, evidences of the neurotic element in syphilitic phenomena. It is shown that mercury and potassic iodid, al- though very efficacious, are in no sense directly curative, their beneficial effects being dependent upon their power of inducing fatty degeneration and elimination of the neoplastic and toxic products of the syphilitic process rather than upon any special controlling or antidotal effect upon the poison per se, whether this poison be a virus, microbe, or infectious cell. The elimination of those elements of the infection which act upon the nervous system, may be the all-important factor in treatment. In reviewing the opinions of our best syphilographers regarding the treatment and prognosis of syphilis, one is impressed with the idea that syphilis is a disease that runs a natural course in spite of treatment, the physician being incapable of doing more with his remedies than to remove the effects of the disease as fast as they appear, — i.e., melt down deposits, neutralize and eliminate toxins, — thus preventing, so far as possible, permanent damage to the af- TEOPHONEUEOSIS IN" SYPHILITIC gEQUELS. 425 fected tissues. So far as aborting the natural course of the disease is con- cerned, we are absolutely helpless, and apparently our success in the treat- ment of the disease is inversely to the vigor of our attempts to antidote or "stamp it out/' If the neurotic theory of the modus operandi of syphilitic infection be correct, we have, in our efforts to discoverer a specific remedy for syphilis, been necessarily led away from those lines of research that would lead to a proper therapeusis. The severity of the results of syphilis would appear to depend (1) upon the individual susceptibility of the nervous system of the patient; (2) upon his constitutional condition at the time of infection and, incidentally, on the resisting power of his tissues; (3) upon the action of remedies — this being by no means the most important consideration. Careful observation of successive crops of lesions in syphilis shows that the tendency to destruction of tissue and involvement of various important bodily functions increases as the case progresses. We see, therefore, in watching a case from its inception, the gradual supervention of a trophic upon a vasomotor disturbance, and as the case progresses this trophic aber- ration becomes more and more pronounced, until finally in the period of sequels there is marked tissue-destruction in various situations — a destruc- tion so marked as to have led to the belief that the syphilitic infection produces in such instances corrosion of the tissue. Inasmuch as the in- fectious property of syphilis decreases as the case progresses, and the amount of tissue-destruction increases, the only logical explanation of the serious effects of late syphilis — in the admitted absence of a corrosive power of the syphilitic infection — would seem to be trophoneurotic disturbance. Glancing at the series of morbid general phenomena occurring in a typic case, the plausibility of the trophoneurotic theory is at once appar- ent: A macular eruption or perhaps an erythematous efflorescence of the skin first develops, which is but slightly, if at all, raised above the surface. This — the roseola — does not produce any destruction of tissue, nor does it contain cell-deposit. Later on papules develop. Next, in the natural order of succession, come pustules, perhaps followed by ulceration. Still later, marked ulceration of an ecthjmiatous or perhaps rupial character occurs. Interspersed with these various later lesions, or occurring alone, there may be scaly lesions — sometimes tubercular syphilides.. Coincidently with the papules sore throat appears, followed later on by mucous patches, and per- haps mucous ulceration. As the case progresses, the bones may be affected; iritis may occur, and well along in the period of sequels necrosis of the bones may develop. It will be found that, as the intensity of the infection diminishes, the tendency to suppurative processes and destruction of tissue increases. The later lesions are found to be frequently associated with dis- turbance of a known nervous character, cerebral syphilis in its various forms being quite apt to occur. The excejDtions to the gradual increment of severity of syphilitic lesions 426 PEBIOD OF SEQUELS. are so unusual that they have come to be designated as precocious. Malig- nant or precocious cases of syphilis are explicable, in the author's opinion, upon the theory of idios3^ncrasy or some unknown constitutional condition that enhances susceptibility. This, again, is explicable upon the ground of peculiarit}'' of nervous structure. It is in the late secondary and sequelar lesions of the disease that the apparent trophoneurotic character of syphilitic manifestations is most pro- nounced. The author has long been impressed with the peculiar course of some of the osseous lesions of late syphilis, particularly those affecting the head and face. The destructive effects of the morbid process upon the bony tissue seem to be greatl)^ disproportionate to the objective and subjective phenomena that precede actual destruction. For example, the objective l^henomena preceding the necrosis en masse of various portions of the palate, superior maxillar}^ and nasal bones are comparatively slight considering that the vitality of affected bone is entirely destroj'ed. The first objective phenomena in necrosis of these parts are incidental, not to bone-death, but to Nature^s attempts to rid the tissues of foreign material. The greater por- tion of the palate may be destro3'ed with few or no symptoms until sup- puration occurs. The first symptom is likely to be a small point of ulcera- tion of the superimposed soft parts, and the discharge of a small quantity of pus — a quantit}' entirely disproportionate to the extent of the morbid process. On passing a probe into the small sinus thus formed, a large por- tion of the bone is found to be dead and perhaps loose in the tissues. It will be found, upon observation of non-syphilitic processes that pro- duce osseous necrosis or caries, that bone-death is preceded b}^ marked ob- jective phenomena in the way of pain, swelling, and deformity — symptoms indicating the existence of proliferated inflammatory material which subse- quently produces, by simple pressure, destruction of the vitality of the bone. Those syphilitic processes that involve bone or periosteum early in the dis- ease are accompanied by relatively more prominent objective phenomena than the late lesions now under consideration; yet, at the same time, they are rarely followed by caries or necrosis. Destruction of bone, it seems, is reserved for the late secondary or sequelar period of the disease. Thus, it will be seen that, although the local process is apparently more severe in the early cases, destruction of the vitality of the bone is not so likely to occur. There is a marked difference between the nodes and diffuse sub- periosteal swellings of early syphilis, and the condition of the bone and periosteum that precedes necrosis en masse, or, for that matter, caries, in the late stages of the disease. Besides the disproportion between the degree of destruction of bone and the objective phenomena preceding such destruction, another sug- gestive point is the fact that late syphilis possesses the power of dissecting out definite portions of osseous tissue, apparently by cutting off their nutri- tive supph' — as cleanly as it could be done by the knife. Thus, the author TEOPHOXEUEOSIS IN SYPHILITIC SEQUELS. . 427 has numerous specimens of the intermaxillary hone, portions of the alveolar process of the maxillas, the malar, and the ossce nasi which became necrosed, loosened, and were removed from cases of late sj^philis. These fragments of bone present as natural a conformation in most instances as in their healthy condition. As already noted, there seems to be a special predilection of late syph- ilis for the parts supplied by the fifth nerve, indicating that the ganglia and filaments of the sympathetic system presiding over these parts are particu- larly sensitive to the syphilitic impression. In some instances the tendency to unilateral destruction of osseous tissue is particularly marked. Thus, the palatal process of the superior maxilla, or the alveolus in either jaw, may necrose and give way without the corresponding portion of bone becoming affected. Usually, when necro- sis attacks the facial bones it is im230ssible to check it until the line of de- markation represented by the anatomic outlines of the affected bone has been reached. The peculiar manner in which one-half of a structure may be dissected away by the sequelar lesions of syphilis is exem^olified by a case of syphiloma of the tongue that recently came under the author's observation in which unilateral sloughing of the organ was sharply limited by the raphe. In several of the author's cases the portion of the superior maxilla cor- responding to the intermaxillary bone was dissected out by the sequelar syphilitic process with loss of the incisor teeth, the remainder of the jaw remaining intact. There appears to be a peculiar predilection of late syph- ilis for this portion of the jaw. Caries often occurs in this situation, caus- ing the loss of one or more perfectly healthy teeth. These cases appear so characteristic that the author regards loss of the permanent incisor teeth without apparent cause as almost positive evidence of syphilis. The following case illustrates the unilateral limitation of some late lesions of syphilis: — Case 1. — A gentleman of 30 had an obscure history of syphilis, dating some years back. Several years before coming under observation ulceration began at the roots of the molar teeth upon one side and extended inward to the palate. When the case was first seen the ulceration had extended inward upon the hard palate for about three- fourths of an inch and forward to the median line, where it abruptly stopped. The appearance of the ulceration was quite typie. There was no disease of the teeth or jaws to account for it. Healing was rapid under appropriate antisyphilitic treatment. The following is an interesting case of a somewhat similar character: — Case 2. — A gentleman of 40 had had syphilis seven or eight years previously. For the last three or four years occasional symptoms of the disease had developed. A few months since ulceration occurred about the roots of the upper incisor teeth. This was attended with slight caries of the intermaxillary bone. The process was checked by appropriate treatment, the teeth, which were loosened, finally becoming perfectly solid. About six or eight weeks after the ulceration was healed the patient consulted 428 PEEIOD OF SEQUELS. the author for supra-orbital and infra-orbital neuralgia and hemicrania. This resisted all treatment except antisyphilitic remedies, yielding readily to potassie iodid in large doses. Within a few days the patient has again applied for treatment for paresthesia of the right side of the face noticed for the first time while being shaved. His face having previously been excessively tender, he soon observed the lack of sensibility under the razor. Associated with this paresthesia there is obscure pain, which he locates back of the eyeball. The ensemile of symptoms in this case points to central disturbance and evidences a manifest predilection of the sequelar lesion for the fifth cranial nerve. The frequent association of obstinate tubercular sypliilides with, late nervous syphilis is striking. It seems that the danger of involvement of the central nervous SA^stem is often directly proportionate to the severity of other sequelar lesions. In considering the trophoneurotic character of the late lesions of syph- ilis the author does not ignore the fact that syphilis may act directly upon the nervous system in several different ways, which, although already out- lined in a general wa}', will bear repetition: — 1. By the direct effect of syphilitic deposit upon the nerve-cells or nerve-fibers or membranes of the brain and spinal cord. 2. By secondary changes in the brain and cord membranes. 3. By deposits in and about the blood-vessels, inducing circulatory disturbance. 4. By a proliferation and condensation of interstitial connective tissue that remains after the syphilitic material per se has been removed. There is probably a difference in the late and early forms of syphilitic lesions in the manner in which the trophoneurotic element is brought about. Thus, it ma}^ be due, in order of succession as regards the period of the dis- ease, (1) to a direct impression of the syphilitic poison upon the sympathetic nervous system; (2) to direct pressure upon the nervous structures (late sec- ondary and early sequelar lesions); (3) to a disturbanoe of function and nutrition of the nervous structures incidental to interference with blood- supply from vascular damage done at an earlier period (late sequelar lesions). This division is, of course, not arbitrar}", but is fairly practical. It is probable that mercury acts upon the nervous system in very much the same manner as syphilis. It is very difficult to differentiate late syph- ilitic lesions of the bones and mucous membranes from those directly due to mercury. That mercur}' exerts a powerful effect upon the sympathetic nervous system is shown by ptyalism, which cannot be accounted for solely upon the theory of salivary irritation. The well-known power of mercury over the secretions is probably due to its influence upon the S3''mpathetic ganglia.^ "When the injurious action of mercury is superadded to syphilis, there is a more marked tendency to trophoneurotic phenomena than in well- ^ This, of course, does not agree with Clevenger's ingenious theory upon this par- ticular point, as will be noted later. CLINICAL STAGES OF SYPHILIS. 439 treated cases of the disease. Indeed, the excessive use of mercury often seems to determine the predilection of late syphilis for the bones of the head and face. It is quite as capable of producing necrosis or destructive ulceration of these parts as is syphilis per se. In considering the question of trophic disturbances in their relation to destructive syphilitic processes it is well to again remember the familiar physiologic experiment of section of the sympathetic in the neck of the rabbit. The same experiment is also interesting as bearing upon the faucial congestion of early syphilis. The reddening of the ear of the rabbit and the inflammation and sloughing of the cornea incidental to section of the sym- pathetic are certainly suggestive. To carry the analogy of this physiologic demonstration a little further, the serious corneal trouble that sometimes results from herpes frontalis seu orbicularis should be borne in mind. Positive demonstration of the dependence of the phenomena that have been outlined, upon nervous disturbance, is, of course, difficult, but the in- ferences drawn appear logical. Symptomatic Division of the Stages of Syphilis. — A knowledge of the ordinary division of syphilis into stages is essential to a clear clinical understanding of the disease. As already stated in a general way, syphilis is ordinarily and somewhat arbitrarily divided into the so-called "primary," "secondary," and "tertiary stages." By some an "intermediary" stage is described which comprises the lull, or, at most, the period of almost insig- nificant lesions following the active period, and preceding the development of the tertiary stage. Primary syiDhilis, of course, implies the initial lesion with its attendant glandular enlargements — i.e., the initiatory period. Secondary syphilis comprises the earlier affections of the skin and mucous surfaces, and many of the lighter changes in the eye, testis, and other glands, with some forms of nervous phenomena — i.e., the symptoms of the active period of syphilis. Tertiary syphilis comprises the later severe ulcerative skin-lesions; the deeper lesions of connective tissue, bone, muscle, cartilage, and viscera; and all the severe lesions — i.e., sequelar lesions — of the eye, testis, and brain; in short, all of the many and various changes characterized by the so-called "gummy deposit." The line between the two stages is not always clear, but in typic cases the lesions, at first superficial, gradually increase in severity until the destructive pathologic changes of the so-called tertiary stage, or period of sequels, develop. Some of the lesions properly belonging to the secondary group are liable to crop out with the tertiary lesions, and rarely, on the other hand, nodes develop in the secondary stage. Osseous and subperiosteal swellings do develop during the secondary stage, but characteristic nodes are exceptionally seen. Quite rarely the secondary stage may appear to be omitted entirely, destructive lesions ordinarily characterizing the tertiary period appearing within a few months after the chancre. These varieties of cases comprise the cases of so-called irregular, precocious, and malignant syphilis. 430 PEEIOD OF SEQUELS. Secondary syphilis lasts often a year and sometimes two or more. As already stated, the active period of syj)hilis has a duration of from eighteen months to three years, hut there need not necessarily be any mani- festations of the disease during that time. The division of the stages or periods of S3^philis involved in the physiologic pathology of Otis is based upon the sequence and character of the pathologic changes altogether, and not upon mere symptomatology, as is ordinarily the case. It will be seen, Fig. 110. — Squamous syphilide — so-called syphilitic psoriasis — of palms. (Author's case.) therefore, that the so-called secondary stage, as ordinarily understood, is merely that portion of the active period during which actual lesions are present. The division of the disease into primary, secondary, and tertiary stages depends upon the form of the lesions, and is, therefore, necessarily inaccurate and unscientific, while the more rational division — ^^into (1) the initial, (3) the active periods, and (3) the sequelar period — ^is founded upon a knowledge of the natural course of the disease in the tissues, the lesions being dependent upon this natural course, and not vice versa. CLINICAL STAGES OF SYPHILIS. 431 Tertiary syphilis — so-called — does not commence until one year after the initial sore, excepting in cases of malignant syphilis. As already shown, it is not a necessary stage of syphilis, and does not appear in by far the large number of cases. It may, however, appear after years of apparent good health. The whole active — i.e., secondary — stage is sometimes skipped, especially under treatment, no manifestations of general syphilis appearing until suddenly some sequelar^t.e., tertiary — lesion of greater or less severe Fig. 111. — Early squamous sypliilide — so-called syphilitic psoriasis- palms. (Author's case.) -of type develops. Such cases are rare, and it must be remembered that there is a possibility of even some of these being due to the excessive administra- tion of mercury. The author has recently seen two cases of extensive gummy ulcers in which three and nine years, respectively, had elapsed since the primary sore, during which time no secondary symptoms had ever appeared. In another case a man presented himself, by the advice of his physician, for the purpose of having a supposed extensive epithelioma of the ]3arotid region 432 PEEIOD OF SEQUELS. removed. This proved to be an ulcerating gumma, and was completely cured by a six weeks' course of the iodids. This patient had had a chancre twenty years before while in the army, but from that time until the gumma appeared had not experienced a single manifestation of the disease. The Syphilides. — The most prominent of the manifestations of syphilis are the eruptions of the skin. These are termed "syphilides/' or "syphilodermata." The syphilides are many and various, often confusing; but their classification may be rendered quite simple; thus, if papules are the essential feature of a syphilitic eruption it may be termed a "papular syphilide." In the same way the eruption may be designated as vesicular, pustular, tubercular, scaly or squamous, crustaceous and ulcerative syph- ilides, and such combinations as papulo-pustular, papulo-squamous, and so on, the first part of the combined term being made to correspond to that feature of the mixed eruption which is most prominent. Ulcerative syph- ilides may be designated as superficial, deep, serpiginous, or perforative, as the case may be.^ The principal distinctive lesions of syphilis that occur at various periods during its course, are: macules, papules, mucous patches, mucous tubercles, condylomata, vesicles, pustules, bullse or blebs, rhagades or fissures, gummy tubercles, and diffuse gummy deposits and infiltrations. Dependent upon some of these lesions, different forms of deep and superficial ulceration, attended or followed by peculiarly-formed crusts and scars, may occur — syphilitic ecthyma and rupia — ulcero-crustaceous syphilides. Squama or scales in various forms and locations may develop. Physical Characters of the Syphilides. — The most important point with reference to the syphilides is the consideration of their general character- istics. These characteristics are: (1) polymorphism of all lesions, including the chancre; (2) rounded form of the eruptive lesions and ulcers; (3) lividity or "ham color," becoming coppery, then grayish, and finally white and shining as cicatrization occurs; (4) absence of pruritus and pain ex- cepting in hairy regions, and, with respect to pain, in the bones; (5) svm- metry, generalization and superficial character of the early eruptions in all save precocious or malignant cases; (6) tendency to grouping of the later eruptions, which involve the true skin and tend to scarring; (7) tendency to circular arrangement; (8) scales comparatively thin, white, generally superficial and non-adherent; (9) crusts irregular, thick and adherent, and either of a greenish or black color from admixture of disorganized blood; (10) abrupt edges of both skin and mucous ulcerations, which are not under- mined, are sluggish, and bleed easily (the chancrous ulcer, it will be remem- bered, has sloping edges): (11) the rounded, depressed appearance of cica- trices, which are thin, movable upon the sublying tissues, pigmented at first ^ Tide Van Buren. THE STPHILIDES. 433 sometimes, but eventually becoming white and shining. These scars are often crescentic or horseshoe shaped. In addition to the foregoing special characters of the lesions of syphilis we have attendant symptoms, such as the so-called syphilitic fever in some cases, alopecia, headache, osteocopic pains worse at night, analgesia, anes- thesia, indolent lymphitis, iritis, sore throat, and mucous patches. The term "polymorphous" is applied to the syphilides because there is no form of skin-lesion that may not occur in syphilis. Indeed, no single form or type of lesion is usually present: e.g., a papular syphilide is rarely purely papular, vesicles, pustules, or erythematous patches being usually found at the same time, and the eruption being named from the lesion that predominates. The tendency of the syphilides to arrange themselves in a rounded form is peculiar and well marked, the later syphilides being especially dis- posed to circular grouping. The color of the syphilides is not an inflammatory red, but is a vinous or purplish red, resembling the color of raw ham, the color gradually pass- ing by pigmentation into a coppery hue, or more deeply to a brownish or black color. The pigmentation may last for years, but finally clears off gradually from the center toward the periphery, the cicatrix or spot becom- ing eventually white and shining. There is a peculiar feature of syphilitic eruptions that is often of value in diagnosis. It will be found that the syphilides appear more prominent when inspected at a moderate distance than when the patient is near the eye. The author has frequently demonstrated this singular feature of the syphilides to his classes at the clinic, and it has been readily appreciated by the students. When an eruption of syphilis is more or less blurred and indistinct, — as, for example, when mixed with acne, — the patient should be asked to step awa}^ ten to fifteen feet. It will be found that while the sim- ple eruption becomes fainter, the syphilitic lesions stand out in bold relief, and appear larger than when near at hand. The papular syphilide sometimes assumes a circinate form closely re- sembling tinea circinata, or ring-worm. The author has observed this peculiar form in several instances. In one case the eruption was situated upon the forehead and neck, and had been treated for ringworm; in an- other the circinate lesion was located upon the hard palate and subsequently became transformed into an ordinary mucous patch. A third case was recognized as a cutaneous syphilide from the beginning. Atkinson^ and Dumesnil have reported similar cases. Pain and pruritus are rarely present in uncomplicated syphilides, ex- cepting when irritated or inflamed. In dependent portions of the body, as on the legs, or in such situations as the throat, which are subjected to con- ^ I. E. Atkinson, Journal of Cutaneous and Venereal Diseases, October, 1882. 28 434 PEEIOD OF SEQUELS. stant irritation, ulcerations are liable to be quite painful. When an eruption that is evidently syphilitic gives rise to pain and itching, we can usually find some cause of irritation independent of the syphilide. The patient may, perhaps, have an irritable skin and a pruritus that constantly troubled him prior to the development of syphilis. Contrary to the general rule, how- ever, the early, eruptions of the scalp are often attended by pruritus. The same is true of other hairy parts. The earlier syphilides are superficial, leave no cicatrices, — save when precocious, — and are symmetric, appearing upon the flanks and sides of the trunk, the sides of the neck, forehead, etc. The later eruptions are Fig. 112. — Early circinate syphilide. (Author's case.) grouped and not generalized, and are characterized by destruction of tissue, as evidenced by the resulting cicatrices. They may leave scars even if no ulceration occurs, which is true of no other lesion excepting skin tuber- culosis, of which the lupus non-ex&dens is an example, but which leaves an irregular, burn-like scar, totally different from syphilitic cicatrices. In some cases of lupus, however, the scars are smooth. The scales of the squamous syphilide are very thin and non-adherent, not at all like the thick, imbri- cated scales of psoriasis. The scabs of the ulcerative syphilides are thick, rough, and adherent; dark, of a greenish-black color usually, but sometimes pale if the lesion be simply pustular. THE SYPHILIDES. 435 Two important varieties of nlcero-crustaceous syphilide are syphilitic ecthyma and syphilitic rupia. The first consists in an eruption of large pustules that soon scab over with a characteristic dark-greenish crust. On lifting this crust a characteristic sharply-cut circular ulcer will be found. Syphilitic rupia is an advanced stage of the same ulcerative process, in which as the crusts form, they are pushed up and replaced by accumulations of material from beneath, and, the ulceration gradually extending at its periphery, the lesion soon presents a peculiar appearance, quite like an oyster-shell upon the skin. The crusts are piled up in imbricated layers, which when lifted from their bed expose the results of tissue-destruction Fig. 11.3. — Circinate syphilide. (Author's case.) in the shape of extensive ulceration. These rupial crusts may become very large, and when numerous form a most disgusting spectacle. The pustular and ulcerative skin-lesions in rare cases become phagedenic, perhaps serpig- inous, constituting a very formidable condition. Death may result from exhaustion in such cases. Eruptions of this kind are most apt to follow phagedenic chancre, not because of intensity of infection, but from inherent lack of vital resistance. It has already been stated that the ulcerations of syphilis are round, clear cut, and not unlike chancroid. They are sluggish like any chronic ulcer, and painless, unless greatly congested and inflamed, or located over a bone the periosteum of which is involved. 436 PEEIOD OF SEQUELS. Cicatrices remaining after destruction of tissue by the syphilides, whether there has been ulceration or not, are usually rounded, thin, de- pressed, and movable, not adherent. They are at first pigmented, especially in brunettes, but eventually clear up and become white and shining. In strumous subjects, in whom the lesion is likely to be a combination of struma and syphilis, tlie resulting cicatrices are apt to be puckered and irregular. They are often cribriform, on account of the persistence of ducts in the affected skin and the extreme tenuity of the lesion. In some cases they are horseshoe or crescentic shaped. DuEATiON or Syphilis. — There is no disease the duration and course Fig. 114. — Ulcerous late syj^hilide. (After Dumesnil.) of which are so, uncertain as those of syphilis. It is impossible to state arbitrarily in any given ease that the disease has or has not terminated. This is more especially true when we consider that it may permanently modify the constitution of the individual, even though no typic manifesta- tions of the disease appear after a certain time. None of the methods of blood-examination thus far suggested to determine the existence of syphilis have proved reliable. The disease may manifest itself as a series of mild secondary eruptions followed by apparent recovery, or it may afford no evidence of its presence after the initial sore until late in life, when suddenly tertiary lesions— 7. p., sequels — crop out. CURABILITY OF SYPHILIS. 437 CuEABiLiTY OF SYPHILIS.- — Although it must be acknowledged that in a large number of cases syphilis causes a permanent modification of the patient's constitution, still the evidence shows that syphilis can be cured. In the author's opinion it is a perfectly curable affection in by far the greater proportion of cases, providing the patient be intelligent and the physician conscientious. We have proof of this in the cases of second attacks, cited by reliable authorities, and we have 'already seen that what- ever the possibilities of tertiary lesions, they are not necessary and are un- doubtedly sequels. It has been found that patients with sequelar syphilis may procreate healthy children, and that the blood and secretions of tertiary lesions are no longer inoculable. If the microbial character of syphilitic in- fection be admitted, the spontaneous tendency to cure of syphilis is almost beyond controversy. It is part of the life-history of the germ. Fig. 115. — Secondary circinate syphilide. (After Dumesnil.) As found among the better classes, syphilis is often a very insidious dis- order. We often meet with respectable women complaining of various symptoms, vaguely described and as vaguely treated as neuralgic or rheu- matic, that are no more nor less than slight manifestations of this jorotean disease and by which the patient perhaps comes honestly enough. Children may have obscure symptoms that mislead both parents and physician, and are conveniently termed "scrofula" in some instances. Paterfamilias for- gets a "little sore" that he once had, and never dreams of attributing the ailments of his wife and children to those dimly-rememljered and as lightly- weighed wild oats that he once sowed. But, whether remembered or not, the harvest garnered as the fruit of that sowing is none the less certain. When may a Syphilitic Marry? — The practical question now arises: "When is it safe for a person to marry after having had a chancre?" Our 438 PEEIOU OF JiEQUELS. best authorities assert that, on the average, marriage is safe at the end of three years. More rationally, from a clinical stand-point, the period may be fixed as eighteen months after the disappearance of the last syphilitic lesion, providing three years have elapsed, the patient being meanwhile nnder careful treatment that is to be persisted in until after the birth of the first child.. During the three years of probation symptoms may crop out at any time, but under careful management they are usually slight, and, whether we can Justly claim a cure or not, the virulence of the disease seems to be exhausted in cases of mild or moderate severity so managed in about three years. If the patient be addicted to excesses of any kind, if he does not take a steady and efficient course of treatment, but treats himself or is treated — perhaps to excess — at spasmodic intervals, his chances are, of course, not very good. Fournier gives the following requirements for the guidance of syphilitics contemplating marriage^: — 1. Present freedom from specific symptoms. 2. Advanced period of the disease. 3. A considerable period of absolute freedom from symptoms since the last specific manifestation. 4. A mild type of the disease. 5. Prolonged and thorough treatment. These requirements contain in a few words all that it is necessary for us to impress upon syphilitic patients who consult us with reference to their matrimonial prospects. Should they refuse to be guided by the physician, the responsibility must rest upon their own consciences. It is tmfortunate that so many persons are willing to assume so grave a responsibility. A man who Avill deliberately condemn an innocent woman to the dangers of syphilitic infection is beneath contempt, yet such men are met with in the practice of every physician. In the case of women, a still longer period of probation should be en- joined. The syphilized female is much more dangerous to the offspring than the male. It is fortunate, perhaps, that syphilis in the mother so often causes her to abort, thus preventing great disaster. Sooner or later, how- ever, she is liable to bear a living child, and this child will almost inevitably show signs of syphilis of a greater or less degree of severity. The author desires to state, in passing, that the ph3^sician should never give a patient assurance of absolute safety in marriage. Under no system of treatment can there fail to be an element of doubt. This should be plainly stated to the patient. The author has had but one case in which a patient, well-treated and without symptoms for over three years, claimed to have infected his wife shortly after marriage, and in that case there was probably deceit on the part of one or the other of the contracting parties. The bare possibility of such a case, however, should make us conservative. ^ A. Fournier: "Syphilis et Mariage." PEOGNOSIS OF SYPHILIS. 439 Peognosis of Syphilis. — • The severity of syphilis depends mainly upon the constitution and hygienic condition of the patient. As we have seen, we do not have at the present day, as a rule, such severe cases as in former years. In the better classes it is a very mild disease by comparison with the lower walks of life, in which we still meet with frequent cases exem- plifying its serious character. Even among persons who are constitutionally and hygienically well circumstanced, we sometimes see cases of the most malignant type, as illustrated by the following case: — Case. — A fine-appearing and exceptionally well nourished man, whose ciix-um- stances were the very best that could be desired, consulted the author in regard to a small abrasion upon the glans penis. This had appeared a day or two after a suspicious exposure and had probably resulted from friction during intercourse. He was told that, while the sore had nothing at all alarming about it, it would bear close watching. At the end of two weeks from the date of exposure the sore became slightly indurated, constituting the parchment variety of chancrous induration. This chancre disappeared in a very short time, but was followed by a most malignant course of syphilis. Apparently tubercular lesions appeared in various situations, and deep ulcerations developed and ran their course inside of three months, the patient barely escaping with his life. The severity of the syphilitic infection cannot be prophesied from the character of the primary sore. The foregoing case serves as a very forcible illustration of this observation. Cases of this sort are seldom seen in private j)ractice, and only those practitioners who are so fortunate as to enjoy the privileges of the large general hospitals are likely to realize the severity of syphilis in its more marked and serious phases. The following cases illustrate the occurrence of obstinate solitary lesions of a peculiar or severe character, in occasionah cases of syphilis under the most careful management: — Case 1. — The author was consulted by a young man in good circumstances, 24 years of age, in regard to a genital lesion that was apparently chancroid. This healed in about two weeks; but about the second week thereafter induration appeared in the cicatrix. This was followed by a t}T)ic roseola, but there has never appeared a lesion of the skin or mucous membranes since, with the exception of the lesion about to be described: About two years after the contraction of syphilis, and at a time when he was still under treatment, his tongue began to trouble him. The lingual mucous membrane became greatly thickened and fissured, constituting the con- dition known as "syphilitic psoriasis of the tongue." This persisted in spite of treatment for some months, when it finally yielded to hydrotherapy and large doses of iodids. This case is interesting from the fact that the lingual lesion was the only source of discomfort during the entire course of the constitutional dis- ease. Case 2. — This is similar to the preceding case, so far as the lingual lesion is con- cerned, but differs from it in that the patient has been afl^icted with alopecia, severe mucous patches, tubercular and squamous syphilides, and severe nodes, with their accompanying osteocopic pains. This patient is 28 years of age and has been afflicted with syphilis for ten years. He has taken the best of care of Jiimself, being treated 440 PEEIOD OF SEQUELS. off and on for the entire period since he first contracted the disease. He has done well under systematic treatment -with the exception of lesion of his tongue, and this absolutely refuses to yield to treatment. Prolonged residence and treatment at Hot Springs has been of little or no service. The administration of iodids in tremendous doses does not affect the lesion appreciably, and mercury is not tolerated at all. The microscope does not show malignancy. Case 3. — In this case thorough treatment has been giA-en continuously for two years, and, until recently, with apparent success. Within a few weeks, however, syphilitic onychia of the left index finger and the great and little toes of the right foot has appeared, and bids fair to prove exceedingly obstinate. Case 4. — This gentleman Avas referred to the author by Dr. S. S. Vaughn, of Hot Springs, where he had been sojourning for six weeks. He had improved, but the case was at a stand-still and the patient was obliged to come home. At this time he had tibial osteitis and several large gummy ulcers of the leg that were excessively painful. Treatment had been continuous for over a year, but with little effect. Large doses of iodids finally brought about recovery of the lesions and the case is now doing well. Case 5.- — A young married Avoman contracted syphilis tAvo years ago and has been under treatment CA'er since. She has had a typic . course of syphilis, Avith about all of the secondary lesions possible. She is noAv, for the first time since" its commencement, apparently free from symptoms of the disease. Little or nothing, howeA^er, can be claimed for her treatment. Perhaps the case may have been Avorse without it, but that is doubtful. x^lthough, as just stated, it is, as a rule, impossible to predict the se- verity of syphilis from the character of the primary sore, this statement re- quires some qualification: e.g., in cases of phagedenic chancre a severe course of syphilis is to he expected, not because of any intrinsic severity of the in- fection, hut because the constitution is at fault. This constitutional per- version will have the same influence upon the general symptoms as upon the primary lesion in inducing phagedena. It is probabl3\ as previously suggested, some peculiar condition of trophoneurotic instability of nutri- tion, ycleped by courtesy "idios3mcrasy." The character of the earlier eruptions should influence the prognosis somewhat. The milder and more insignificant these are, the more benign the subsequent course of the disease is apt to be, and vice versa. This is exemplified in cases of malignant syphilis, in which the earlier lesions are deep and destructive. Vesicular, and more especially pustular eruptions, indicate a severer type of the disease than do papular and erythematous lesions. In considering this point it is to be remembered that generalization and severity are two different -qualities of syphilides. Thus, a severe type of lesion may be scanty in number, while a mild t3^pe may be generalized and abundant. Serious nerve and brain lesions are more apt to occur where the S5^philides are discreet and of severe type than where they are both severe and abundant. The author believes that DumesniFs view, already pre- sented, is really intended to cover this point, although that gentleman does not explicitly so state. EELATION OF SYPHILIS TO CAJ^TCEE. 441 The BeJation of Syphilis to Malignant Disease. — The possibility of a combination of late syphilis and carcinoma has recently suggested itself to the profession. It has even been claimed in certain quarters that trans- formation of a syphilitic into a cancerous process is possible. The first cases of combined cancer and syphilis were reported by Jonathan Hutchinson, and, following him, Langenbeck directed attention to this unusual class of cases. Lang, of Vienna, recently exhibited a very interesting case of this kind: — Case. — A middle-aged woman had suffered from syphilis for a protracted period. Scars of former syphilitic processes were present upon the trunk and face, the palate being perforated and the upper lip having suffered considerable loss of substance. At the time she came under observation most of the ulcers were cov^ered with a white scab, the histologic examination of which did not reveal any sign of diagnostic im- portance. About a month later, however, a small white indolent ulceration appeared upon the hard palate. A small portion of the involved tissue was excised and upon microscopic examination was found to be epithelioma. Lang states that he had observed three other very similar eases, the development of the carcinoma upon the syphilitic soil being demonstrated in each instance by microscopic examination. The first ease that came under his observation had suffered from a characteristic course of syphilis, including numerous relapses of iritis and gummatous ulcerations that had cicatrized with the exception of one which became transformed into a "cancroid" of the skin. The second case was that of a man, aged 46, who had suffered from various syphilitic ulcerations on different parts of the face and body. After anti- syphilitic treatment one ulcer, located beneath the tongue, proved resistant to treat- ment and became transformed into cancer. In the third case a syphilitic infiltration located in the lower lip underwent a relapse at the end of a year and assumed a carcinomatous character. It is unfortunate that the profession has not more carefully noted the cases in which carcinoma has developed in syphilitics. There are many cases in which careful study might demonstrate the causal relation of syph- ilis to malignant disease. A case that the author had the opportunity of observing was one the progress of which he had studied for a protracted period; hence there is no doubt as to the primary condition upon which the malignant disease that eventually destroj^ed the patient^s life was ingrafted. In recognizing the transformation of syphilitic processes into cancer, the author does not wish to be understood as claiming that the histologic elements of syphilis are ever transformed into those characteristic of cancer, but that, the ele- ments of syphilis having been removed, the tissues are left in such a dam- aged state that continued irritation may result in cancerous degeneration. On the other hand, a syphilitic process may recur so frequently, and be so obstinate to treatment, that the irritation thereby produced is capable of causing cancer. It is as yet too soon for us to discuss the question of the existence of special bacilli in syphilis and cancer for the purpose of disproving the pos- sibility of the transformation of the one into the other. It is conceivable 443 PEBIOD OF SEQUELS. that both cancerous and syphilitic deposits may act in the same manner as other irritating processes in the tissues. It is to he presumed that, if a can- cer were present in the month of a syphilitic subject, syphilitic processes would be more apt to develop in the vicinity of the malignant disease than elsewhere. A somewhat similar relation exists between an existing syph- ilitic lesion and the development of carcinoma. Whether actual transforma- tion can occur or not, it is certain that cancer may develop in tissues that .are indubitably affected by syphilis, and that the cancer may go on to de- struction of tissue and finally prove fatal. This may occur without any Ijreliminary change in the physical appearance of the tissues affected by syphilis prior to the development of cancer. The author feels warranted in speaking thus positively from experience with the case herewith presented. In regard to the bacilhis of cancer, it is as yet an unknown quantity. So far as the bacillus of syphilis is concerned, no one has thus far been able to positively demonstrate that the supposed bacillus of syphilis is really the specific bacillus. That S3'philis is a specific disease is not open to question; that it is due to a microbe is well-nigh certain. A demonstration of this, however, demands the fulfillment of all the conditions imposed by Koch in proving the bacillus tuberculosis. To put the matter of the transformation of syphilis into cancer con- cisely, the author does not believe that syphilitic cells can possibly be trans- formed into cancer-cells, but holds that the irritation of the tissues pro- duced by the former may, in the presence of favorable constitutional and local conditions, develop a new process of tissue-building or neoplastic de- posit resulting in the formation of cancer-cells. Case. — A man, 29 years of age, contracted syphilis at the age of 18. He stated that the resulting chancre inflamed and caused paraphimosis, which lasted about a month and left the mucous membrane of the penis in an irritable condition that resulted in the frequent appearance of fissures and ulcerations — some of which de- veloped from time to time after he came under the author's care. Secondary symptoms appeared about four months after the initial lesion, and, according to the description, a pronounced papulo-pustular eruption appeared and resulted in considerable scarring of the skin. Mucous patches presented themselves in successive groups and were very annoying, especially those upon the tongue. After the secondary period became manifest his physician put him upon mercury, a thorough course being given for about three months, after which he went to the Hot Springs. He remained at the springs for three months, was rubbed with an enormous amount of mercury, and badly salivated twice. He went home and at the end of two months eruptions again appeared upon the body with larger mucous patches than before, his tongue at this time giving considerable trouble from general soreness of the organ. At this time an old eczema of the hands, that had troubled the patient off and on all his life, developed, and in combination with the syphilis gave him a great deal of trouble. He again went to the springs and remained there for eleven weeks, during which time he took mercury internally quite freely. He returned home and was apparently well for three months, when mucous patches and eruptions appeared, sores appearing at this time upon the penis. About five years after the beginning of the syphilis the patient fell under the care of a physician who again rubbed him freely with mercury, TEAXSFOKilATIOX OF SYPHILIS IXTO CAXCEE. 443 the treatment being continued for about six months. He improved for a time and then quit treatment, as such patients frequently do, but, growing worse, went back to the same physician, and for at least eighteen months took mercury in consider- able quantity. He was then advised to go to Mount Clemens, Michigan; he remained there about fifteen months, and while there became entirely well of his eczema, the syphilis, however, never leaving him entirely. In 1884 the patient consulted the author for the first time. He had then un- equivocal cerebral syphilis, and tuberculo-squamous syphilides in considerable number were scattered about the forehead, forearms, and thighs, with a few scattered squamas upon the trunk. Scars of former pustular syphilides were visible upon the forehead, forearms, and legs; the tibias and sternum were excessively tender, and considerable pain was experienced at night. Cephalalgia was a constant symptom and gave the patient intense suffering. An apparently gummy ulceration with several fissures existed upon the penis just back of the corona. The tongue was rough, and coated with a thick, dirty, yellowish-gray fur, with marked dryness in the center and posterior part of the organ. Several tubercular nodules were also observable, one in the center of the tongue and the others near its base, those upon the right side being especially marked. On inquiry it developed that the tobacco and alcohol habits had been persisted in for a greater portion of the time that he had been under treatment, and, strange to say, he stated that his 23hysicians had not restricted him in the matter of either indulgence. The treatment at this time Avas very vigorous; codliver-oil and iron were ordered on account of the patient's marked debility. The mixed treatment and potassic iodid in saturated solution were given, the iodid being run rapidly up to a dose of 300 grains per diem, and maintained at that point for three weeks, the disease being completely resistant to treatment until the end of that time. Local applications of acid nitrate of mercury were made to the tongue from time to time, with apparent benefit. As soon as the symptoms began to yield to treatment the dose of the iodid was diminished to about 60 grains per day, the tonics being meanwhile continued. At the end of three months the patient was free from trouble, with the exception that his tongue was more thickly coated than ever (psoriatic), and the nodules upon its surface were still perceptible. No amount of care and treatment ever caused this condition of the tongue to Qisappear entirely, and as the history will show, it subsequently became the source of terrible trouble. The case remained comparatively well for some months, the tongue creating some uneasiness from time to time on account of com- mencing ulceration of the nodules upon its surface, but yielding rapidly to treatment. On each occasion, however, the nodules and furring of the tongue became more promi- nent, and remained so in spite of treatment, the furring becoming a sort of mem- branous deposit like wet chamois-leather, that reformed as fast as it was removed. At this time while at the Hot Springs under the care of Dr. S. S. Vaughn, the tongue began to swell, and assumed a threatening appearance; the nodules began to ulcerate, and at one time a severe hemorrhage occurred. After all means of treatment had been tried for two months without avail the case was pronounced probably cancerous by the attending physician and several others who saw it in consultation. At this time Dr. Vaughn refen-ed the case to the author with a view to possible excision. Upon examination the tongue was found filling the mouth and pressing upon the teeth in such a manner that it had become eroded and ulcerated by them. Salivation was profuse; a deep ulcer existed at the center and back part of the organ ; the enlargement seeming to be rather more marked upon the right side. There were no other lesions present upon any part of the body. Microscopic examination at this time failed to demonstrate the presence of cancer. No further examination of the tissues was made until after the tongue had been excised. 444 PEEIOD OF SEQUELS. As the patient experienced great difficulty in masticating and swallowing, he was subsisting entirely upon fluid food, and not being very robust primarily had become greatly emaciated. The treatment instituted was chiefly a tonic one, in con- junction with an alterative mixture containing sodic iodid and the chlorid of gold; milk-punches were allowed and the patient instructed to take as much sweet cream and milk as he could without creating digestive disturbance. Local applications were made of a compound of carbolic acid., iodin, and menthol in mild strength. Improvement was at first very rapid, and at the end of a week the tongue was nearly reduced to its normal size. In a few days, however, it again enlarged upon the right side, this enlargement being peculiar in that it was limited by the raphe, the tongue being at least double the thickness upon the right side that it was upon the left. The appearance was precisely the same as that presented by certain cases of acute glossitis, a condition that it strongly resembled in the rapidity of its appear- ance, the increased thickening having come on within twenty-four hours. This condition of the right side of the tongue soon subsided, but was succeeded by enlargement of the tubercular nodules previously mentioned and by the appearance of several new nodules. These appeared, not upon the margin of the tongue, but upon its upper surface. Within a few days the left side of the tongue underwent a diiTuse enlargement, similar to that which had occurred upon the right, and in the same way subsided and was succeeded by the development of tubercular nodules. The whole tongue now gradually increased in volume and became so large that it hung over the edges of the teeth and protruded through spaces left by extracted teeth. There was little or no pain, and such as there was was referred by the patient to the "holes," as he expressed it, worn in the tongue by the teeth. The case went on from bad to worse, many different plans of treatment being tried without avail. The sloughing continued until the tongue was in such con- dition that even if healing had been possible the organ would have been practically useless. The base of the tongue was a foul mass of hyperplastic ulcerating tissue, the odor and secretion from which were not only offensive to the patient, but prominent factors in producing the constitutional disturbance. There seemed to be no hope of benefit from either internal or local medication, and in addition the malignancy of the process appeared to be now clinically established, although microscopic evidence was by no means satisfactory. As the patient was anxious to have something done to remove the foul and stinking mass from his mouth, excision with the galvano- cautery was proposed: an operation to which the patient readily consented. At the end of a Aveek the eschar produced by the caviterization became detached and left a surface of fairly healthy appearance; the fetor of the breath was gone and the sloughing at the base of the tongue had ceased. The floor of the mouth healed nicely and remained in a tolerably healthy condition for several weeks. The general con- dition of the patient improved considerably. About a month after the operation, however, the submaxillary glands became enlarged and quite tender. There was comparatively little pain save a moderate amount of cephalalgia and otalgia. The ulcerative process on the floor of the mouth recurred, but did not progi'ess rapidly nor ulcerate extensively. A small ulcer formed upon the right pillar of the fauces. These symptoms practically settled the question of malignancy. Dr. I. X. Danforth having examined the specimens excised informed me at this time that the case was of a sarcomatous character, but from his report it would be inferred that it did not present typic characters. About two months after the operation an abscess formed in the submaxillary glands. This, when opened, gave exit to a thin, sanious fluid. Pain at this time was very severe. At the end of about three months an occasional slight hemorrhage from the mouth occurred. The patient finally died about four months after the operation from a sudden hemorrhage occurring during the night. SEQUELAE LESIONS OF THE MOUTH AND TONGUE. 445 This imfortimate case is in many respects unlike any others on record. The literature of the subject is very meager. During the course of the dis- ease there were present distinctive features of several forms of glossal affec- tion. During the four years that the patient was under observation, the tongue presented gummy nodules and ulceration, lingual psoriasis, diffuse syphilomatous deposit, and latterly attacks of subacute glossitis. At various times before coming under observation, and once afterward, as shown by the history, mercurial stomatitis occurred and formed an important feature of the case, particularly as regards the etiology of the process that finally necessitated removal of the tongue. Prior to extensive destruction of the organ these various conditions merged into a general hypertrophy, the tongue becoming extremely indurated. These various features must be taken into consideration in studying the case. Macroglossia, or hypertrophy of the tongue, of a simple character is very rarely seen; a few cases of congenital origin are on record. x4.ccording to Fairlie Clark,^ hypertrophy of the tongue occurring later in life may arise "spontaneously" (?), or from wounds, mercurial salivation, or as a conse- quence of diffuse inflammation from scarlet and other forms of fever. The author will add to these causes constitutional syphilis. Attrition against the teeth in these cases of macroglossia produces from time to time attacks of acute or subacute glossitis, each of which leaves the tongue more enlarged than before.- This was a prominent feature of the case at present under consideration. The continued use of alcohol and tobacco in combination with the irritation produced by diseased teeth completed a chain of circumstances which, in combination with the syphilitic cachexia, favored the development of the malignant process in the tongue. Sequelae Lesions or the Mouth and Tongue. — Lesions of the mucous membranes in early syphilis are so characteristic and so intimately related to the active period of the disease that even general practitioners are more or less familiar with their pathologic characters and treatment. The sequelar, or so-called tertiary, mucous lesions are, however, not well understood, despite the fact that they are of far greater importance, inas- much as the earlier lesions have -an intrinsic tendency to recover, other things being equal, while those of a later period are characterized by extreme chronicity and a stubborn tendency to recurrence. Certain lesions of the mucous membranes late in the history of syph- ilitics are the most typically sequelar of all the late lesions of the disease, inasmuch as they are the result, not only of syphilis per se, but of numerous other factors to which the mucous membranes are exposed during the active period of the disease or during the intermissions between the active mani- "Diseases of the Tongue." ' Koenig, "Lehrbuch der specielen Chirurgie," 1878. 446 PERIOD OF SEQUELS. festations. The jaost-syphilitic character of the lesions in many instances is so marked that ordinary antisyphilitic treatment either has no effect what- ever or is injurious. These lesions occur in the form of hyperplastic infil- trations of greater or less extent of the mucous and submucous tissues. These have been classed by different authorities as leucoplakia^ by others as leucoplasia — terms that are intended to convey the characteristic whitish appearance of many of them and their tendency to arrange themselves in distinct hyperplastic plaques. The term post-syphilitic leucoplasia is prob- ably as comprehensive and accurate as any that have thus far been sug- gested. The terms psoriasis, ichthyosis, tylosis, leucokeratosis, diskeratosis, and hyperkeratosis serve simply to add confusion to the subject. Perrin believes that: — 1. The white hyperplastic plaques, presenting themselves as syphilitic or post- syphilitic phenomena, have for their elementary characters functional and organic disturbances of the epithelium. 2. They may occur as a consequence both of the syphilis and antisyphilitic treatment. 3. In some instances there exists some peculiar morbid constitutional condition or diathesis as the predisposing cause of leucoplasia. 4. Such conditions are peculiarly liable to occur in both syphilitic and non-syphilitic patients Avho are addicted to tobacco. 5. There is a large number of cases of mixed character in which the condition is excited by syphilis and tobacco combined in gouty or rheumatic subjects. It may be doubted whether leucoplasia should be classified as a distinct pathologic entity, but most of those who have studied such cases will hardly question the assertion that these lesions present traits that are sufficiently characteristic to warrant such classification. From a clinical stand-point there can be no question of its accuracy. With reference to the relation of syphilis to leucoplasia, however, the occurrence of the latter independently of the former must be taken into consideration; indeed, when we consider the large proportion of patients who indulge in tobacco and liquor, with or without overactive mercurial therapeusis, it is rational to infer that, even in cases in which syphilis appears to be primarily responsible for leucoplasia, the affected individual must be possessed of some peculiar predisposition that differentiates him from the average syphilitic. In several instances the author's attention has been directed to the question of idiosyncrasy as an explanation for the oc- currence of leucoplasia by the occurrence of such lesions in syphilitic blood- relations. Post-syphilitic leucoplasia derives its chief importance from the fact that, while its dependence upon syphilis is usually recognized, the mistake is made of believing that the lesions should be quite as tractable under anti- syphilitic treatment as other lesions of the mucous membranes occurring in this disease. As a matter of fact, these lesions must be regarded essentially as non-syphilitic neoplasms occurring upon a syphilitic foundation. With this in mind the practitioner may perhaps readily comprehend the correct POST-SYPHILITIC LEUCOPLASIA. 447 principles of treatment. Forgetting this^ he is likely to do the patient in- calculable injury through misguided and enthusiastic efforts to cure the lesions by strictly antisyphilitic treatment. Ordinary local treatment simply aggravates the difficulty, as a rule, and only the most radical measures are likely to be effective. A further reason for regarding these lesions as important, per se, is the indubitable fact that they may assume a malignant character. The condition known as ichthyosis, or psoriasis, of the tongue, more properly termed leucoplasia, is due to the same causes as generalized glossitis, and is really a similar process in which the inflammation is localized upon the surface of the mucous membrane. According to Hulke, ichthyosis— i.e., leucoplasia — of the tongue con- sists essentially in hypertrophy of the epithelial and papillary elements of the mucous membrane.^ The relation of this condition of the tongue to syphilis and cancer is very important. All authorities unite in acknowledg- ing its relations to syphilis, — although it may occur in non-syphilitics. In appearance it resembles in some cases a deposition of wet chamois-leather upon the surface of the tongue which rapidly reforms after removal. In other instances it resembles a thin layer or film of coagulated albumin, and in these cases each successive deposit is more dense and adherent than the preceding. That the condition is prone to develop epithelial cancer Weir has shown most conclusively by the history of 68 cases, of w^hich number 35 eventually developed epithelioma.^ Hutchinson has also advanced the opinion that cases of syphilitic dis- ease of the tongue are especially prone to develop epithelioma later in life. The condition underlying leucoplasia does not always develop distinct white plaques of hyperplastic epithelium. Some local perversion of nutri- tion may develop fissures of greater or less depth and extent, with margins of hyperplasic epithelium, or the edges of which may have become trans- formed by atrophy, presenting a smooth, glazed, and dry appearance, the characteristic papillated appearance of the tongue being replaced by a smooth, quasimucous surface. In other instances distinct ridges of greater or less extent present themselves, particularly along the tongue or the inner surface of the buccal mucous membrane at the point of contact of the tongue and cheek with the teeth. This form of epithelial hyperplasia is particularly apt to occur in patients who have been overtreated with mercury. We find in other instances the classic type of leucoplasic forma- tion in which more or less elevated, distinct, whitish plaques of epithelial overgrowth are noted. These plaques may undergo transformation, and pre- sent the smooth, reddened, glazed appearance already described in connec- tion with fissures. The cases in which the epithelium is transformed in this ^ "Clinical Society Reports," vol. ii, p. 1. ^ New York Medical Journal, March 18, 1875. 448 PEEIOD OF SEQUELS. manner are characterized by extreme irritability, lesions that are trivial in appearance giving rise to considerable irritation and pain. Excessive smok- ers are particularly apt to present lesions of this character. The more for- midable variety of post-syphilitic neoplasm occurs in the form of distinct, circumscribed nodules of greater or less extent that have a tendency to de- velop along the margins of the tongue, but are often seen upon one or the other side of the lingual raphe, and in some instances limit themselves en- tirely to the base of the tongue upon one or both sides. These lesions are very apt to' be mistaken for gummata. Doubtless nodular gummy infiltra- tion is the point of departure for the lesion in some instances, but instead of resolution, suppuration, or necrosis occurring, the gummy deposit is ap- parently removed or transformed — at least, it is replaced by a distinct con- nective-tissue new growth. This may subside to a certain extent, but is very likely to remain permanently and enlarge from time to time, each successive exacerbation being followed by an increase of permanent enlargement. Such nodules are to be regarded as extremely dangerous, as it is this form of post- syphilitic mucous lesions that is most likely to undergo malignant trans- formation. The lesions above described have long been regarded by the author as evidence in favor of the theory that post-syphilitic phenomena are largely trophoneurotic. Trophoneurotic disturbances of a permanent char- acter associated with various causes, such as local irritation affecting the mucous membrane, etc., should be all-sufficient to explain the peculiarities of the lesions under consideration. Even a superficial study of these lesions should convince the practical clinician that it is but a step between these benign overgrowths of epithe- lial and connective tissue and malignant neoplasm. The author regards the nodular variety of the affection as essentially precancerous. In this view alone lies the safety of the patient. In the treatment of leucoplasia of the mucous membranes several fac- tors must be taken into consideration, viz.: — 1. The possible existence of a certain degree of activity of the original constitutional trouble — syphilis. 2. The question whether syphilis per se has not long since been eradi- cated, as a consequence of which antisyphilitic treatment will simply add fuel to the fire. 3. The relation of previous antisyphilitic treatment — particularly in the direction of overdosing with mercury — to the lesions present. 4. The existence of trophoneurosis, as a result of syphilis, treatment, or most probably of idiosyncrasy. 5. The relation of local irritants, such as tobacco, liquor, highly-sea- soned food, and the application of caustics. 6. And most important of all, the circumstance that the lesion may re- quire attention as a neoplastic entity independently of its relation to any of SYPHILIS OF SPECIAL STEUCTUEES. 449 the foregoing factors^ with the distinct object in mind of preventing trans- formation into malignant disease. Effect of Syphilis upox Special Stehctuees. — At this juncture it may be profitable to review briefly the more important effects of syphilis upon some of the special structures of the body. Mucous Membranes. — The initial sclerosis may or may not be situated upon a mucous surface. Following the primary sore, mucous jJatches appear upon the mucous or quasimucous surfaces, the circumstances favoring their development being (1) heat, (2) moisture, (3) local irritation, and (4) filth. They consist of slightly-elevated grayish plaques, presenting something of the appearance of a superficial diphtheritic deposit. The}^ may vary in size from the dimensions of a split pea to a penny. Occasionally — especially about the anus, scrotum, and female genitals — they undergo hypertrophy Fig. 116. — Dactylitis syphilitica. (After Berg.) or hyperplasia, forming mucous tubercles or condylomata. The mucous patch is most often seen in the mouth. Its development is favored by the irritation produced by the food, carious teeth, and, above all, by tobacco. It may undergo ulceration. Diffuse congestion or hyperemia of the faucial mucous membrane is a feature of secondary syphilis. The vocal apparatus may be involved, causing hoarseness or even aphonia. Gummy ulceration of the mucous membranes may occur in late syphilis. SMn. — The lesions of the skin are those that have been already de- scribed as the syphilides or syphilodermata. These embrace almost every known form of skin eruption and are hence designated as polymorphous. Thus, syphilis may present every variety of skin-lesion from a simple macular efflorescence to extensive ulceration. Ecthyma is a late eruption of large pustules followed by small circular ulcers covered with greenish crusts. 450 PERIOD OF SEQUELS. Eupia consists of larger ulcerations covered by imbricated crusts resem- bling an 03'Ster-sliell. These eruptions have already been described in detail. The Hair and Nails. — The epithelial appendages of the skin are peculiarly susceptible to derangements of nutrition in syphilis. Alopecia syphilitica and onychia have already been expatiated upon. A brittle con- dition of both nails and hair is a frequent concomitant, or, more especially, a sequel of syphilis. Dryness of the scalp with a dry, brittle condition of the hair is often seen after the syphilis proper is apparently cured. The hair becomes more or less thinned, but does not shed in the characteristic areate form of the earlier period. Sometimes all of the hair is shed from the entire bodv. Fig. 117. — Dactylitis syphilitica with absorption of boue. (After McCready.) The Fingers and Toes. — The digits are occasionally the seat of a pecul- iar spindle-shaped enlargement, — syphilitic dactjditis, — due to thickening of the bones and periosteum of the phalanges from cell-deposit. Caries or necrosis occasionally ocurs. Absorption of the affected bone ^yithout caries sometimes occurs. Syphilis of Connective Tissue. — Whether subcutaneous or in the vis- cera, syphilis of connective tissue presents itself as gummy infiltration, diffuse or circumscribed. Its results depend on the structure and functional importance of the tissue or organ involved. Male Sexual Organs. — Besides the chancre and the mucous patch, there may develop in this locality flat condylomata and, in the late secondary SYPHILIS OF SPECIAL STEUCTUEES. 451 or tertiary period, severe and destructive gummy ulceration. Chronic infil- tration of the corpora cavernosa may develop. The urethra may be the seat of patches, ulcers, or condylomata. The testes may be affected in one of two ways, viz.: by diffuse syph- ilomatous deposit, or by circumscribed syphiloma or gumma. The diffuse form gives rise to the painless enlargement fallaciously termed syphilitic sarcocele, or, more inaccurately still, "syphilitic orchitis." The gummy de- posit may resolve or it may suppurate. Female Sexual Organs. — Chancre may occur on the vulva, vagina, or cervix uteri. Mucous patches are frequent and are the principal factors in transmitting the disease. Condylomata are especially apt to develop in women. Destructive gummy ulceration may cause atresia of the vagina in late syphilis. Anus. — The anus may be the seat of mucous patches, huge condylo- mata, ulceration, and fissure, and sometimes the primary sore. Oro-pharynx. — The mouth, gums, lips, or tongue may be the seat of the primary sore, and, later on, of patches, ulcers, or gumma. Chancre of the tonsil, while rare, is sufficiently frequent to demand attention. Leuco- plasia of the mouth and tongue has been exhaustively discussed. Nose. — In the earlier stages a catarrhal discharge, with or without mucous patches, may occur. Later on, ulceration and necrosis with offensive discharge — ozena — may occur and the bones may be destroyed, with conse- quent flattening of the organ. Larynx. — The larynx may be affected early by diffuse congestions; later on, by ulcerations that may impair the structure and function of the vocal cords. Complete aphonia may occur. JEyes. — Iritis from early cell-deposit and later from gummy infiltration of the iris may occur. Circumscribed gummy deposit and resulting hypo- pyon or pus in the anterior chamber may be observed. Choroiditis and retinitis are occasionally seen. The retina may be involved in diffuse in- filtration. Bones. — The bones and periosteum are often affected by cell-deposit, with resulting severe pain in the secondary stage. In the late secondary and tertiary periods, bone-swellings, termed nodes, subperiosteal suppura- tion, and caries or necrosis may be seen. These changes are most often seen in exposed and flat bones: e.g., the tibias, sternum, cranial bones, and clavicles. Liver, Spleen, and Kidneys. — These organs are often the seat of dif- fuse or circumscribed syphiloma. In the diffuse form organization and contraction — cirrhosis — of the new tissue may result. Amyloid degenera- tion of these organs is usually associated with necrosis of bone in late syphilis. Cerebrospinal Axis and Nerves. — The brain and cord may be the seat of diffuse or circumscribed gummy deposits. When situated in the 452 PEBIOD OF SEQUELS. brain, the results may be pain, sleeplessness, disturbed intellect, paralysis, aphasia, epilepsy, coma, and death. The cerebral vessels may be occluded or atheromatous, causing apoplexy or softening. Gummy deposit in the cord gives rise to nervous disturbance depending upon the portion of the cord affected: e.g., in the cervical region, respiratory paralysis and death may ensue, while in the lower portion of the cord paraplegia and paralysis of the bladder and sphincter ani may result. Neuroma, meningitis, and neuritis are sometimes observed. Nervous symptoms due to syphilitic toxins may occur, especially in early syphilis. Synopsis of a Typic Case of Syphilis. — It may be serviceable to the student to present a brief synopsis of the course of a typic case of Fig. 118. — Showing cranial hyperostoses from tertiary syphilis. Exostosis in right orbit shows clearly. The ramus of the right side of the inferior maxilla shows syphilitic necrosis. Note the overgrowth and destruction of bone associated in the same subject. This skull is very dense and heavy. (Author's specimen.) syphilis: The patient has exposed, himself to infection by a suspicious 'in- tercourse, and during the performance of the act causes a little abrasion upon the penis — or possibly he still farther irritates or abrades a pre-ex- isting abrasion or patch of herpes. This abrasion may heal in a day or two — or may escape his attention entirely, for that matter — or may persist. In about two or three weeks a little hard lump or nodule appears on the site of the abrasion. This gradually enlarges until it attains the size, per- haps, of a filbert. In a few days — say five to eight — small lines of hard- SYPHILIS OF SPECIAL STBUCTUKES. 453 ness appear beneath the integument of the penis leading from the indura- tion^ and, in a few days more, small, hard, and freely movable lumps appear in the groins. These phenomena constitute primary syphilitic lymphopathy and adenopathy. There is now an interval of perhaps six weeks, after which an enlargement of the cubital or epitrochlear glands at the elbow over the internal condyle is noted. This is quite characteristic, and is succeeded or attended by enlargement of the general sj^stem of lymphatics. Within two or three days — perhaps at the same time — an eruption of erythematous spots, macules or fine papules resembling measles, develops, the lesions being scat- tered over the surface in variable amount. This eruption may appear simul- Fig. 119. — Showing osteoporosis and carious destruction of frontal region from tertiary syphilis. Hyperostosis at site of irregular prominence above right orbit. This skull is phenomenally light and fragile. (Author's specimen.) taneously with general adenopathy and is attended by a still further increase in the size of the lymphatic glands. Sore throat may now be complained of. A varying degree of toxemic symptoms may occur at this time — -head- ache, bone-pains and muscle-pains, and perhaps fever. After a variable interval of some Aveeks or months an eruption of prominent papules appears. This is most prominent about the roots of the hair on the forehead: the venereal crown. The papules may become vesic- ular or pustular, according to the intensity of the infection and the con- stitutional condition of the patient, and may appear before the roseola has 454 PEEIOD OF SEQUELS. gone. Sore throat is frequently experienced shortly after the appearance of the roseola, but most often with or soon after the papular eruption. Iritis is likely to occur at any time after the appearance of the papules. Late in the disease the iritic inflammation takes on the so-called "gummy" or nodular form, when it is quite characteristic, but the early syphilitic iritis is practically indistinguishable from the rheumatic form. During the latter part of the first year bone-pains and nodes are apt to develop; but they may appear earlier. Areate falling of the hair occurs usually during the early months if at all, and, in common with the form of lesion known as the mucous patch, is most likely to develop during the papular eruption. General shedding of the hair may be a late phenomenon. Dryness and brittleness of the nails are apt to occur as late secondary or sequelar lesions, even when the patient has otherwise suffered very little from his disease. Should the matrix of the nail become infiltrated, onychia syph- ilitica is likely to result and is exceedingly tedious. Pustular and ulcerative lesions begin to appear during the latter part of the first year or eighteen months, and are succeeded by ecthyma, rupia, and tubercular or gummy lesions of the bones, skin, brain, and other viscera. Various nervous lesions may crop out from time to time during the patient's future existence. They may be delayed until very late in life. Death may eventually occur from profound pathologic changes in the cere- bro-spinal axis or abdominal viscera. As illustrative of the ravages that a severe case of chronic syphilis and its sequels are capable of producing, a case under the author's care at the iSTew York Charity Hospital cannot be excelled. Case. — A Mexican, 40 years of age, had contracted syphilis five years before, and at the time he entered the hospital was in as deplorable a condition as could be imagined. He was lame from osseous complications, and had but one arm, the other having been amputated for syphilitic necrosis. His bodj' was covered with cicatrices from former ulcerative syphilides, and his hair had nearly all fallen out several years before. There was double suppurative inflammation of the middle ear, and secondary to that upon the right side was a large abscess beneath the scalp posterior to the auricle, from which was evacuated at least eight ounces of as foul-smelling pus as ever saluted a surgeon's nostrils. The tongue was shortened and bound down to the floor of the mouth by adhesions from old ulcerations, and there was a large cavity in the superior wall of the pharynx that had been produced by ulceration, but which had cicatrized. The epiglottis had been destroyed, and a small circular open- ing represented the glottis. The jaw was partially ankylosed from old inflammation of the articulations. To crown all, the patient's vision was impaired from old iritic adhesions. The facetious diagnosis given by one of the hospital staff, "shattered," quite aptly expressed the poor patient's condition. Happily for him, meningitis super- vened in a few weeks and ended his miserv. CHAPTEE XIX. CONGEXITAL SyPHILIS — ACQUIEED StPHILIS IX ChILDEEN. Although not entirely neglected by the more systematic works upon syphilis, the subject of congenital and infantile syphilis is not usually pre- sented in a practical and sufficiently comprehensive manner. Congenital syphilis should be differentiated from infantile syphilis in general, for the reason that children may acquire the disease in a number of ways inde- pendently of hereditary transmission. When thus acquired, the course and various phenomena of syphilis are in nowise different from the same affec- tion in the adult. A child may become inoculated with syphilis by kissing persons with oral or labial syphilides, such as mucous patches, fissures, and ulcers, or it may acquire it from nursing its syphilitic mother or nurse. The possibility of acquiring the disease by vaccination must also be remem- bered, although at the present day non-humanized virus is almost exclu- sively used, and such an accident can only occur through the grossest and most culpable carelessness. There is also the possibility of contamination through criminal assault, perpetrated by either male or female examples of depravity. The author has seen four cases of syphilis in children acquired in this manner. These instances have, however, no bearing upon congenital syphilis, save that great care is to be exercised in differentiating the two. An error in diag- nosis in a ease of this kind might seriously compromise an innocent person, on the one hand, or allow a guilty one to escape, upon the other. In the case of alleged vaccinal syphilis great care should be taken, else an innocent operator may be held responsible for the sins of the child's parents. It is to be remembered that a diagnosis is difficult without a knowledge of the natural course of syphilis. A more or less typic course of syphilitic phenomena, following a chancre, or, at least, following primary adenopathy, is the only positive proof of acquired syphilis, be the subject old or young. Methods of Acquieing Congenital Syphilis. — The methods of ac- quiring syphilis by heredity have already been studied to some extent. It is held by many that either parent may transmit syphilis to the child, al- though, so far as the father is concerned, the question of his power to procreate a syphilitic child without first infecting the mother is still suh juclice. The presence of the syphilitic microbe is probably incompatible with the life of the spermatozoa; but, until the germ of syphilis has been absolutely demonstrated, we can only claim theoretically its necessity in this particular method of transmission. The most plausible view is that, (455) 456 CONGENITAL AXD ACQUIEED SYPHILIS IN CHILDREN. while the jDresence of the syphilitic germ is necessary in order that the semen should be inoculable, its presence is "unnecessary in order that the father should impress the fetus with conditions which, while not specifically syphilitic, are none the less derivatives of that disease. This results from the fact that the spermatozoa of a man who is in the full flower of syphilis have been so modified that they are incapable in most instances of gen- erating a healthy child. This is still more pertinent when the father is in the stage of sequels. The child need not necessarily be affected by the ordinary phenomena of syphilis, but may present certain perversions of growth and nutrition not ordinarily considered to be syphilitic. That syphilis may so impress the spermatozoa that the child may be cachec- tic and ill nourished, although not actually syphilitic, is probably true. It is probable also that the syphilitic impress is liable to appear as rickets or scrofulosis — and perhaps a tubercular tendency — in the child. Inde- pendently of theoretic reasoning, it is a positive fact that the children of apparently healthy mothers, by syphilitic fathers, are often affected by certain conditions of malnutrition that are singularly benefited by antisyph- ilitic treatment, and which are probably "attenuated syphilis." That the mothers are not really syphilitic, is, of course, an open question, but in a large proportion of cases the evidence is in their favor. As already indi- cated, if the child really has unequivocal syphilis, the author believes that it has become infected via the maternal circulation. He cannot accept "conceptional syphilis" as described by Fournier^: i.e., infection of the mother via the ovum. It is an indisputable fact that, when the mother is syphilitic at the time of conception, the offspring rarel}^, if ever, escapes. Her power of transmitting the disease lasts much longer than that of the father, as may be readily explained if we stop to consider the intimate anatomic and physio- logic relations existing between the fetus in ute.ro and its mother. The exception of the mother who becomes pregnant while healthy, and does not become infected with syphilis until the seventh month, is to be borne in mind in considering the probability of the mother's infecting her child. ^ It is claimed by some that syphilis acquired at any time during pregnancy cannot be conveyed to the fetus in utero. Taylor says upon this point that "the syphilis of the mother cannot be conveyed to the fetus through the utero-placental circulation."^ The author does not accept this. A case recently observed by the author supports the contrary view. In this instance the father developed syphilis at the third month of his wife's pregnancy. He communicated the disease to her and she ran a typic course of syphilis. The child was still-born at the seventh month, and ^ "Syphilis et Manage." - Diday, "De la Syphilis des Noiiveaux-nes." ^ "Venereal Diseases/' Bumstead and Taylor, p. 805. METHODS OF ACQUIRIXG COXGENITAL SYPHILIS. 457 presented indisputable evidences of syphilis. A case recently reported hj Ziessl is of similar character.^ It was essentially as follows: — Case. — A young married man in the commencement of the month of April had connection with his wife for the last time. The menses remained away, and the wife proved to be pregnant. On the 12th day of April he had connection with another woman, and contracted syphilis from her. The sore healed rapidly, but an induration developed which remained a considerable time. As he believed that without a sore he could not infect, he, on the 25th of May, recommenced intercourse with his wife. She contracted syphilis, and on the 31st of December was delivered of a child. It showed indisputable evidences of hereditary syphilis, and died soon afterward. It has been demonstrated that the female may procreate syphilitic children long after she has lost the power of infecting a healthy man. As a matter of practical importance it had best be remembered that, while it remains to be positively shown that either parent may infect the child independently of the other, cases sometimes occnr that seem to prove its truth, and until the question is absolutely settled it is best to be cautious, and remain upon the safe ground of conservatism. Inasmuch as such diseases as small-pox have been communicated through the mother to the fetus in utero, there would seem to be no good reason why syphilis cannot be transmitted in like manner. One of the best articles so far published, bearing upon the possibility of syphilis acquired during pregnancy affecting the fetus, was from the pen of 8imes.^ This author has presented his views so clearly and forcibly that they are Avell worth quoting verbatim: — The existence of the hereditary form of syphilis was first definitely pointed out by Paracelsus, in the year 1536, and since then it has received most careful consideration at the hands of numerous writers. In fact, its study, owing to the many differences between the hereditary and acquired forms of syphilis, has become almost a special branch of investigation. In considering the etiology of this affection it is found that many and various explanations had been given by the early writers. Even at the present time several points are still undecided. Much of the diversity of opinion is due to the many difficulties and peculiar nature of the investigation. The following conclusions, however, have been reached: — 1. A syphilitic father may procreate a syphilitic child. 2. A syphilitic mother may give birth to a syphilitic child. 3. Both parents being syphilitic, their offspring will probably be syphilitic. 4. The mother contracting syphilis during gestation may transmit the disease to the fetus, provided constitutional contamination has occurred. The first of these propositions has not been generally accepted; the second and third are accepted without question, providing, in the case of conclusion I^o. 3, the mother is infected before conception occurs; the last conclusion has not been so favorably received; more especially as it is denied by Kassowitz, wdiose investigations into the etiology of ^ Wiener medicinische Presse. -J. H. C. Simes, The Polyclinic, Philadelphia, December, 1883. 458 COXGEKITAL AND ACQUIEED SYPHILIS IN CHILDKEN. hereditary syphilis liave been very elaborate. He concludes, from the study of many cases, that a mother acquiring syphilis during gestation does not transmit the disease to her healthy fetus, and he also claims that this view is much strengthened by the circumstance that his investigations in • the opposite direction led him to the conclusion that a non-syphilitic mother is capable of giving birth to a syphilitic child. The fetus, he says, -'cannot transmit syphilis to the mother through the placental circulation, and in all cases where the mother becomes syphilitic during pregnancy, the disease originated in some other manner." The opinions advanced by Kasso- witz upon this subject have not, however, been accepted by most writers. Their objections are based largely upon clinical observation: i.e., upon cases ' in which the history has been known from the beginning to the termination. Simes says upon this point: — It is just here, however, that the most experienced are liable to, and frequently do, fall in error, not in any way due to their want of skill, but owing to deception, or, at times, no doubt, to ignorance, on the part of the individual. Where the nature of the investigation is of so peculiar a character as endeavoring to ascertain the etiology of a disease which is considered by those contracting it a disgrace, deception is not to be wondered at, and, where the early symptoms of the disease are fre- quently so slight and imperceptible that not only the patient, but the surgeon himself, may overlook them, ignorance of their existence is possible. Therefore it must be admitted that in the most carefully reported cases there is frequently room for con- troversy. After duly considering both sides of the subject, I am inclined to the opinion that syphilis contracted during pregnancy may be transmitted by the mother to a previously-healthy fetus, provided the affection in the mother has passed beyond the initial lesion and is made manifest by constitutional symptoms. This conclusion has been reached from a physiologic and historic study, rather than from clinical observation on the subject. In order to make any reasoning in this matter secure, it would be necessary to establish the nature of the syphilitic virus, and here it must be admitted that much diversity of opinion exists among the most reliable authorities. I agree fully with those who hold that this virus is a material, and probably a demonstrable, substance, but its exact nature I am not at present able to describe; it may be a diseased cell, an infected particle of protoplasm, or a micrococcus; but that it is some degraded anatomic element of the organism, either holding or con- stituting the virus, and having the power of transmitting it to another organism, all clinical experience and experimental pathology lead me to infer. It is beyond doubt that the blood of a person affected with constitutional syphilis contains the virus, and is capable, when inoculated upon a non-syphilitic individual, of producing the disease. This virus being, as I believe, a material substance, it must exist in the blood, either as a separate element or an organism. In either case the inherent power possessed by the white blood-corpuscle of surrounding or incorporating within itself any material substance with which it comes in contact, leads me to conclude that these corpuscles are the chief, if not the only means, by which the virus is transmitted from one organism to another. When the anatomic and histologic rela- tions of the placental and uterine connection are examined, it is seen, from the most recent investigations, that no direct communication exists between the circulation of the placental and maternal blood. From the anatomic structure of the parts, it has been considered impossible for a material virus to pass from mother to fetus. That a direct communication is necessary, in order that a material substance may be conveyed from mother to fetus, I do not believe. METHODS OF ACQUIEIXG COJs'GENITAL SYPHILIS. 459 Eeferring again to the white blood-corpuscle- — the probable carrier of the infection — it is known to possess the vital property of movement or migration, and also has the power of penetrating and passing through the protoplasmic wall of the blood-vessels. These physiologic and histologic conditions existing and being capable of demonstration, a direct communi- cation of maternal and fetal circulation is not required in order that a material virus may pass from one to the other. The white blood-corpuscles, containing, or constituting, as the case may be, the morbific germ of syph- ilis, may pass directly through the vascular wall and infect the fetus. The ])ossibility, or rather the certainty, of the white blood-corpuscle's having the ]30wer of carrying material substances from the maternal to the fetal cir- culation has been demonstrated by the experimental researches of several investigators. When minute insoluble particles, such as cinnabar or indigo, are injected into the blood-vessels of a living pregnant animal, and the animal killed after a varying period, an examination of the fetuses within the uterus shows the white corpuscles of their blood to contain some of the particles that were injected into the blood-vessels of the mother. Simes says, anent this question: — Therefore, if it is possible for such comparatively-large and appreciable particles to pass from one organism to another, through the placenta, it is not unreasonable to conclude that it is possible, or even very probable, that the virus of syphilis, which has as yet escaped our observation when sought for with the highest powers of the microscope, may in a similar manner be transmitted. These experiments would certainly indicate that it is immaterial whether an immediate and direct vascular communication does or does not exist between mother and fetus, although this question seems to be the only one which investigators have endeavored to determine, in order to explain fetal infection. The vital ameboid movement, the inherent power of incor- porating within itself foreign substances, and the acknowledged power of passing through the protoplasmic wall of the blood-vessels, are all attributes possessed by the white blood-corpuscle, and are, I think, sufficient to explain the manner and possibility of fetal contamination. Morrow's conclusions upon hereditary syphilis are as folloAv: — 1. A syphilitic man may beget a syphilitic child, the mother remaining exempt from all visible signs of the disease; the transmissive power of the father is, how- ever, comparatively restricted. 2. A syphilitic woman may bring forth a syphilitic child, the father being per- fectly healthy; the transmissive power of the mother is much more potent and pro- nounced, and of longer duration than that of the father. 3. When both parents are syphilitic, or the mother alone, and the disease re- cently acquired, the infection of the fetus is almost inevitable; the more recent the syphilis, the greater the probability of infection and the graver the manifestation in the offspring. 4. While hereditary transmission is more certain, when the parental syphilis is in full activity of manifestation, it may also be effected during a period of latency when no active symptoms are present. 5. Both parents may be healthy at the time of procreation, and the mother may contract syphilis during her pregnancy and infect her child in ntero. Contamination 460 CONGENITAL AND ACQUIEED SYPHILIS IN CHILDEEN. of the fetus during pregnancy is not probable if the maternal infection takes place after the seventh month of pregnancy. Fetal and Placental Changes from Syphilis. — The changes in the fetus resulting from the sypliilitic infection or impression are of vital im- portance, and often decide the cjuestion as to the birth of a living syph- ilitic child. The ovum may he blighted early in the course of utero-gesta- tion and be cast off, or absorbed, or it may develop to a greater or less ex- tent, according to the severity with which the syphilitic infection manifests itself. The disease may manifest itself in several ways, and sometimes in a rather obscure fashion. A general shriveling or dwarfing of the structure of the fetus may occur, with resulting death and consequent abortion. Serious visceral lesions sometimes occur and destroy life: e.g., the author recalls a case in which a woman miscarried, and was delivered of a still- born child whose liver was so enormously hypertrophied as to cause serious difficulty in delivery. Intra-uterine hydrocephalus is an occasional result of syphilis. The author has had occasion to perform craniotomy upon a case of this kind. He also had the privilege of assisting Dr. Munde in a similar operation at the New York Maternity Hospital some years ago. Disease and malformation of the infantile osseous system are frequent results of syphilis, and it is the author's conviction that many congenital deformities depend upon imperfect development, resulting either from dis- tinct intra-uterine syphilis or the nutritive perversions produced by "attenu- ated syphilis." These, however, are the more obscure manifestations of the disease. Apoplectic effusions often occur in the syphilitic fetus, and, if all aborted syphilitic children were examined critically, much light might be shed upon the effects of syphilis upon the vascular system. Well-marked eruptions are apt to occur upon the fetus in utero, and most syphilitic fetuses will present some unmistakable external lesion. It is exceptional that a woman in full syphilis succeeds in carrying a child to term, even when under quite active treatment. x\bortion usually occurs, and is perhaps most often due to death of the fetus, which then acts as a foreign body and is cast off. It is not unusual, however, for abortion to occur as a result of placental changes. Placentitis hemorrhagica, fatty and waxy changes in the placenta, all interfere with its uterine attachments primarily, and secondarily affect the vitality of the fetus by interfering with the interchange of nutritive material necessary for its sustenance. Placental apoplexy is especially apt to bring on abortion, particularly when the blood extravasates upon its attached surface and detaches it to a greater or less extent. When the hemorrhage is parenchymatous, abortion is not so likely to occur. Syphilis is one of the most potent and frequent causes of abor- tion, and when a female, however healthy, aborts frequently, a suspicion of syphilitic taint is justifiable. The treatment of syphilitic abortion is of necessity the administration SYPHILIS HEEEDITAEIA TARDA. 461 of mild mercurials throughout the course of pregnancy. It by no means follows that, because a woman aborts as a result of syphilis, she must neces- sarily give birth to a syphilitic child; hence it is always Just and consci- entious to try to carry the pregnancy to full term if possible. The better the apparent health of the mother, and the later the period of the disease, the more eminently proper such a course becomes. When a syphilitic child goes on to full term, which often occurs, it may be born a^Dparently healthy and well nourished, but, as a rule, it de- velops symptoms of inherited syphilis within a few weeks. In the majority of instances syphilis develops before the child is three months old. In some cases, however, some years elapse before symptoms are discovered, and then they are more or less marked. Cases have been related in which lesions of the pharynx, viscera, and bones occurred in adult life for the first time, the childhood of the patient having been apparently healthy — syphilis hered- itaria tarda. It is probable, however, that in these cases symptoms have existed at an earlier period, but have been overlooked. There is some clinical testimony, of more or less doubtful character, to the effect that an entire generation may be skipped before the syphilitic nutritive impression mani- fests itself. Obviously, such cases are not really syphilis, but remote results of the disease. Syphilis Heeeditaeia Taeda. — In a series of lectures at the Hopital St. Louis, Fournier called especial attention to late hereditary syphilis. He gives the following interesting cases in support of his view that the first manifestations of hereditary syphilis may be after the period of infancy and even during the period of adolescence: — 1. A case of interstitial keratitis and double sarcocele in a child 4 years of age. 2. A case of a child, aged 7 years and 6 months, born of parents both of whom were syphilitic, who suffered from brain syphilis which yielded to the iodid of potassium. 3. A case of a man, 24 years of age, who had mucous patches soon after birth, but no other symptoms until the age of sixteen, when he developed syphilitic gumma of the testis of a diffuse character (i.e., sarcocele). At the age of 24 extensive syphilom- atous deposit occurred in this patient's tongue. These cases are of great interest, but the classification and description of the various lesions seen late in life and attributed by Fournier to late hereditary syphilis, are, in general, certainly overdrawn. Were they true, there are very few persons with peculiarities of cranial or nasal structure who would be free from suspicion of hereditary taint. Many patients with precisely the same congenital characteristics described in some of Fournier's cases are met with who are suffering from severe acquired syphilis, which, while not impossible, would not be very likely to occur were the patients congenitally syphilitic. In determining the question of late hereditary syphilis it is, of course, necessary to inquire most minutely into the family history. IsTot only the 462 COXGEXITAL AXD ACQUIRED SYPHILIS IX CHILDREX. parents, but the brothers and sisters must be examined in order to arrive at a rational conclusion. The necessity for this careful inquiry has been shown quite plainly by the observations of Hughlings-Jackson, Avho has demonstrated conclusively that hereditary syphilis may be plainly marked in one member of a family, while the brothers and sisters show absolutely no traces of the disease. As has been already asserted, many cases of disturbed nutrition termed struma or scrofulosis are probably syphilitic. Astley Cooper tacitly ad- mitted this in his day. His favorite remedy for ''scrofula''' consisted of mer- cury bichlorid in Huxham's tincture of cinchona-bark. Hutchinson appar- ently entertains a similar view. In the majority of instances the syphilitic child is indelibly stamped with the hereditary impress. As a rule, it is remarkable for its pinched, shriveled appearance, due probably to a lack of fatty tissue from malnu- trition. The newborn baby has the look of an old man, and, if it lives long- enough, has often the most supernatural look of intelligence that could be imagined. This wise little old man is as remorseless as fate in divulging the sins of his parents. He says little, but expresses much, and is a burden greater than the "Old Man of the Sea" so long as he lives. He is literally persona non grata to all concerned. Lesions of Congenital Syphilis. — If not present at birth, lesions of various kinds develop from time to time. The author has delivered children with a well-marked roseola. Chaps and excoriations of the quasi- mucous surfaces about the genitals, anus, and mouth are apt to develop, and may form true plaques muqueuses or even condylomata. A "scalded" appearance of the anus is quite characteristic. "Snuffles" develop after a time, and the nares become so clogged up that respiration and nursing are interfered with, and nutrition still further impaired. Ozena may de- velop and lead to necrosis of the nasal cartilages. There is no symptom of hereditary syphilis that is considered so characteristic in the minds of the mass of the profession as snuffles. Apropos of this, the author desires to warn the young physician that, if he begins diagnosing hereditary syphilis from this symptom alone, there will be breakers ahead. A great number of young children, especially in such climates as that of our lake-region, are affected by catarrh or coryza that presents an excellent imitation of syphilitic snuffles. A diagnostic mistake in these cases will surely cause serious trouble, and it is safer for the physician to diagnose all cases as catarrh, meanwhile treating them as he sees fit, than to run any risks in diagnosis, especially where an accurate diagnosis might be unwelcome. A livid macular eruption is sometimes seen, and ulcerations may form about the mucous orifices. Papular and pustular lesions are not infrequent, and quite characteristicly affect the palms and soles in certain instances. Subcutaneous tubercular lesions may be seen in some few cases. A very peculiar eruption occasionally occurs in syphilitic children that SYPHILIS HEEEDITAEIA TARDA. 463 is quite identic in its pliysical characteristics with ordinary pemphigus in the adult. This "infantile pemphigus" is an unmistakable evidence of syphilis. It consists of an eruption of bullas or blebs, sparsely distributed over the skin. Sometimes but one or two buUas are present. It is especially apt to affect the palms of the hands and soles of the feet. The blebs are filled with fluid that varies in its physical characters from slightly-turbid serum to pus, and is sometimes bloody. When the cuticle ruptures, the fluid dries into a greenish crust and ulceration occurs beneath, precisely as in syphilitic ecthyma or rupia. It has been claimed that infantile pemphigus may result from simple cachexia, but the evidence of this is dubious, and it may be generally ac- cepted as a positive evidence of syphilis. When a syphilitic child develops pemphigus, a severe type of disease is evidenced, and the case is usually hopeless. A severe case in a 3-month-old infant recently seen by the author made, however, a good recovery. The epithelial appendages of the body, such as the hair and nails, are not so likely to become affected in congenital syphilis as in the adult, but a brittle, lusterless condition of the nails is occasionally noted. As Hutchin- son has shown, the nails may be repeatedly shed, or they may split and be- come ragged in appearance. They may even become affected by suppura- tion or onychia.^ It has been generally accepted that the osseous lesions of children are insignificant as compared with the same changes in the adult syphilitic. This, however, is a mistake. The author has been so fortunate as to observe a considerable number of bone-lesions in children. One of the most fre- quent lesions observed in the cases of congenital syphilis at the N. Y. Charity Hospital was syphilitic "inflammation" of the bones. It was the exception, rather than the rule, that serious visceral lesions were unaccom- panied by osseous troubles. Taylor has called especial attention to lesions of the bones in congenital syphilis.^ He has shown that the most frequent seat of the osseous lesions is the diaphyso-epiphysial junction of the long bones, certain bones, however, being affected with especial frequency. This is explained by the fact that the processes of growth and nutrition are most active at the junction of the diaphysis and epiphysis of all bones. The possible dependence of certain cases of rickets upon hereditary syphilis is a question which, although as yet sub judice, is of the greatest interest and importance. Parrot even goes so far as to claim a syphilitic orip-in for all cases of rickets. While this proposition is untenable, the author is inclined to believe that syphilis is responsible for quite a proportion of cases. It is certainly not fair to ignore Parrot's series of one hundred cases of rickets, of which ninety-one were unequivocally syphilitic. Kassowitz ^ Hutchinson, "Pathological Transactions," xii, 259. = R. W. Taylor, "Bone Syphilis in Children." 464 COXGEXITAL AXD ACQUIEED SYPHILIS IX CHILDKEX. and several other German authorities claim that nearly all syphilitic chil- dren become rachitic, and Fournier, of the French school, believes that syphilis has much to do with the etiology of rickets. If this theory be well grounded, — and it must be admitted that syphilis and its derivatives pro- duce profound nutritive perversions, — congenital syphilis and the inherited syphilitic diathesis are necessarily responsible for many deformities. In syphilitic osteitis in infants the bones are usually more or less uniformly enlarged, although in certain instances the periosteum seems chiefly afEected. Suppuration is infrequent, but is described by Bouchut as a result of softening of the cartilages of the epiphysis.^ Xecrosis is not very infrequent. The most important of all the manifestations of hereditary syphilis are the lesions of the viscera. The processes of growth and nutrition in the infant are very active, and constructive changes are especially favored. These circumstances are particularly conducive to the proliferation of young connective tissue about the parenchyma of the viscera. These interstitial proliferations are usually diffuse, circumscribed cell-deposits being excep- tional. Such cases, however, have been observed. Any or all of the viscera may be involved, the connective-tissue changes being especially apt to affect the liver, spleen, and kidneys. There is in syphilitic newborn children a marked tendency to apoplectic effusions in various situations, particularly in the meninges of the brain and probably also the cord. The condition known as cephalhematoma is especially apt to occur in syphilitic children, in whom the vessels seem to be characterized by great tenuity. If labor be at all difficult, or if forceps be used, there is great danger of intracranial or sitbpericranial effu- sions. The author has noted 5 cases of meningeal hemorrhage in new- born syphilitic children — verified by autopsy — and 6 cases of cephalhema- toma, 4 of which were undoubtedly syphilitic. In 1 case the child developed a cephalhematoma soon after birth that absorbed in a few weeks. During the fourth week the child developed convulsions and died. On autopsy extensive changes in all the viscera were noted, and upon the surface of the brain a large clot from a ruptured meningeal vessel was found. In 1 of the author's cases of meningeal hemorrhage the child was found dead by its mother's side, and a suspicion of foul play was entertained. The autopsy, however, sjiowed an extensive meningeal hemorrhage. Cases of sudden death in syphilitic children have been occasionally noted by other observers, but there seems to have been no autopsy in the majority of instances, at least no explanation for these cases has been given, so far as the author is aware. It is probable that some of them have been due to meningeal hemorrhage. This is of medico-legal importance, and should be remembered. Bouchut: "^Maladies des Enfants Xouveaux-nes." SYPHILIS HEREDITAEIA TAEDA. 465 An hemorrhagic tendency has been noticed in another form in syph- ilitic children: — Case 1. — Andronico reports the case of an infant born of a woman who, in the second month of pregnancy, had a chancre on the vulva. From the first days of life the child had coryza and marked icterus; soon afterward numerous points of a copper-red color appeared on the skin, and obstinate hemorrhage took place from the umbilical cord. The child died on the ninth day.^ Another case is reported by de Lnca: — Case 2. — A woman acquired syphilis from her husband, and some years later gave birth to a child. The infant suffered from pemphigus, and soon after the bullae became filled with blood, and petechias appeared on the legs. Finally, uncontrollable hemorrhage took place from the gums of the lower jaw, the umbilical cicatrix, and the intestines, and the child soon died.^ Children are apt to develop hydrocephalus as a result of syphilitic in- heritance. The author recalls to mind a family in which two successive children died of this disease as a result of congenital syphilis. The so- called rachitic appearance of the skull is often a manifestation of syphilis. The extreme pathologic conditions of the brain in congenital cerebral syph- ilis are well shown by the following case reported by Dr. Angel Money^: — Case. — Chronic syphilitic meningitis, arteritis, cerebral atrophy, and sclerosis in a boy aged 4: He was first seen at the age of eleven months, suffering from hydro- cephalus. The skull was natiform, the root of the nose depressed, the spleen enlarged, and there were signs of disseminated choroiditis. Syphilitic taint was discovered in every member of the family. The boy improved and seemed to be almost well until August 18, 1888, when left spastic hemiplegia developed. On October 11 he lost his speech and developed right spastic hemiplegia, and on the 19th he died. At the necropsy the brain and dura mater were found to be adherent everywhere, but the adhesions could be separated. The arteries were much diseased, so was also the brain- substance. The atrophy and sclerosis were most marked in regions supplied by the diseased arteries. The dura mater was four lines thick in the temporal regions, and , resembled a fibroma in structure. The ependyma was granular in appearance, due to the formations of granulations composed of small, round nuclei; and the structure was of considerable density. Dr. Money also exhibited the brain of a microcephalic child, showing atrophy and sclerosis of the left hemisphere without disease of the arteries or membranes, but yet of syphilitic origin. The child could not stand, sit, or talk, and all the limbs were weak and spastic, but the left arm least so. Death oc- curred at the age of sixteen months, and the brain weighed fourteen ounces. It is probable that congenital syphilis has a more or less marked in- fluence in the causation of tubercular meningitis. The congenital taint may not give positive evidence of its presence by a development of un- equivocal syphilitic disease, and yet may so impair nutrition as to favor the development of tubercle, in case of exposure to infection. The syphilitic ^ Giornale Italiano delle Malattie e della Pell., August, 1886. - Giornale Italiano delle Malattie e della Pell., August, 1886. ' "Transactions of the Pathological Society," London, 1888. 466 CONGENITAL AND ACQUIRED SYPHILIS IN CHILDEEN. soil is one in which the tubercular bacillus will flourish, and the remote conditions of malnutrition inherited from syphilitic parents are therefore a constant invitation to tubercular infection. Geneeal Chaeactees. — The most accurate description of the symp- toms of congenital syphilis that has ever been given is that of Mr. Jona- than Hutchinson. The syphilitic countenance as described by him is quite characteristic, and his description of the teeth in congenital syphilis is classic. The evidences given by the teeth cited by him are not pathogno- monic nor are they always present even when positive signs of syphilis exist, but in general they are very valuable. The permanent teeth, instead of being regular and symmetrically de- veloped, are irregular, notched and pegged in appearance, and the con- formation of the alveolar arch is imperfect. The two upper central incisors are Hutchinson's "test teeth." They are short, vertically notched, narrow, and rounded at their corners. Hutchinson further says: — ' • Next in value to the malformation of the teeth are the state of the patient's skin, the conformation of his nose, and the contour of his forehead. The skin is almost always thick, pasty, and opaque. It also shows pits and scars, the relics of former eruptions, and at the angles of the mouth are radiating linear scars, running out into the cheeks. The bridge of the nose is almost always low, and broader than usual; often it is remarkably sunken and expanded. The forehead is usually large and protuberant in the region of the frontal eminences; often there is a well-marked broad depression a little above the eyebrows. The hair is usually dry and thin, and now and then the nails are broken and splitting into layers. Interstitial keratitis is pathognomonic of inherited taint, and, when coincident with the syphilitic type of teeth, puts the diagnosis beyond doubt. There is one peculiarity about badly-nourished syphilitic children that has especially impressed the author, and that is the appearance of the hands and feet. These members are scrawny and wrinkled, and resemble in min- iature those of an aged person. The skin has the appearance presented by the integument of a part that has been overdistended from edema, after the serous effusion has become absorbed. Should the syphilitic child live, it will be observed to have a marked tendency to splay-foot, talipes, and such deformities. The general dusky appearance of newborn syphilitic infants is also quite striking in most cases, and is due to a generally defective vas- cular tonus. Peognosis. — The prognosis of congenital syphilis is very unfavorable — fortunately so, in the author's opinion. The earlier the eruptions or other symptoms appear, the greater the danger. Marked eruptions occurring shortly after birth indicate a fatal prognosis. Severe and early ozena in badly-nourished children is of like import. Marked visceral lesions and apoplectic effusions are always fatal. Lesions of the bones, if unaccom- panied by marked visceral changes, are not so serious. In cases of enteritis TREATMENT OF CONGENITAL SYPHILIS. 467 syphilitica, a lesion first described by Lancereaux, there is no hope of saving the child. In the face of the unfavorable prognosis of hereditary syphilis, it is some consolation to know that, as a rule, a syphilitic child is better dead, for it is a constant danger to its friends, and its life is, at best, but a miser- able one. Sometimes, however, a syphilitic child becomes fat and healthy under proper treatment, and sometimes without it. This is borne out by the following case of the author's: — Case. — The male child of parents who were both syphilitic presented the char- acteristic aged appearance of the syphilitic infant at birth. Double talipes was present, and altogether there seemed to be a most deplorable prospect for the child. An un- favorable prognosis was given, and as it seemed useless to prescribe for the infant — which was in nowise suffering — nothing was prescribed save inunctions of codliver-oil. The child is now 6 months old, and the author was greatly surprised when, a day or two since, the little patient ^%as brought in by its mother. The infant was not only apparently healthy and well nourished, but its feet were very nearly normal in appearance, as a result of persistent manipulation by the mother. Treatment. — The treatment of congenital syphilis is to be carried out in two ways, according to the age of the child, viz.: 1. By direct medication of the child. 2. Indirect medication through the system of the mother. The best internal remedy for the child is the hydrargyrum cum creta in doses from 1 to 3 or 4 grains three times daily. In very young children inunctions of mercurial ointment or the oleate of mercury in very mild strength must be depended upon. A good plan is to spread a piece of blue ointment, the size of a large filbert, upon the fiannel binder once daily. The delicate skin of the child absorbs this quite readily. Daily cleansing with soap and water, and frequent shifting of the position of the band, are necessary to avoid irritation. The soles of the feet, axillae, and flexures of the joints are also eligible situations for inunctions. In older children the bichlorid of mercury may be given in small doses, in combination with some vegetable bitter, like Huxham's tincture. Tablet triturates — mercury with chalk, protiodid, mild chlorid, or, best of all, the tannate — are also useful. The general condition is always to be borne in mind in treating con- genital syphilis — anemia especially must be guarded against. Codliver-oil and iron will always be of benefit. The syrup of the iodid of iron is the best preparation. Young children absorb codliver-oil readily when given by inunction. The oleate of mercury may be combined with the oil. Good and sufficient nourishment is always required, but the child should not nurse from its mother, unless it is positive that she not only has or has had syphilis, but is in fair general health.^ A syphilitic child should never be ^ While the author does not believe the fetus can be infected with syphilis save through the medium of the mother, such infection has been asserted by good authori- ties; hence it is not conservative to allow a syphilitic child to be nursed by an apparently-healthy mother. 468 CONGENITAL AND ACQUIKED SYPHILIS IN CHILDREN. reared by a nurse who has not had syphilis. In general, pure cows' milk is best for the child. When the child is nursed by its .mother or by a wet-nurse it may be treated through the medium of the breast-milk by the administration of potassie iodid. This drug is eliminated in great part by the mammary glands, which physiologic fact is of great therapeutic service in hereditary syphilis. From 5 to 10 grains may be given four or five times daily, care being exercised in regard to the production of gastro-enteric irritation in both mother and child. The local management of congenital syphilis is often of importance. Perfect cleanliness is a paramount indication. Ulcers and excoriations should be kept clean and dry, and dusted with calomel, oxid or stearate of zinc. Condylomata are to be treated as in the adult, but with milder ap- plications. Ozena requires local treatment, and a nasal douche of some anti- septic solution is useful. Seller's tablets and the preparation known as listerin are useful for this purpose. The listerin should be diluted with about 3 or 4 parts of water, and used three times daily. Harsh applications should be avoided in syphilitic lesions of children, as their delicate skins are very intolerant of irritants of all kinds. In all cases of congenital syphilis the physician should warn the relatives and friends of the danger of contagion. Failure to do this may result seriously, as is illustrated by the following case of the author's: — Case. — A young man contracted syphilis during the sixth month of his wife's first pregnancy. At about the seventh month a chancre appeared upon her right labium minus, and shortly after her child was born characteristic secondary syphilis developed. This first child was born healthy, a fact that is important as bearing upon the theory that the child escapes infection when the mother is not syphilized prior to the seventh month of utero-gestation. The child died of bronchitis at about the age of two years, having meanwhile presented no evidences of syphilis. Fifteen months later a second child was born that presented positive evidences of syphilis. This child died in about three weeks, during which time it was under the care of its grandmother and aunt. These benighted females caressed and fondled the infant incessantly, the family physician having failed to apprise them of the danger of infection. Within about two weeks after the death of the infant both ladies developed labial chancre which Avas in due time followed by secondary syphilis. As a final com- plication of the infection of this family, the grandmother subsequently infected her husband. Thus the infection of one individual was responsible for the syphilization of five persons. Had proper caution been observed, the disease might at least have been confined to the syphilized infant and its parents. CHAPTER XX. Teeatment of Syphilis. Constitutional Treatment. — The treatment of syphilis can be in- telligently conducted only when based upon a clear conception of the patho- genesis of the infection itself and the lesions produced by it at each period of the disease. There is room for great difference of opinion as to the cor- rectness of the pathologic views set forth in the preceding chapters, yet the author believes that they will be acknowledged to be a rational foundation for the therapeusis of the disease. Errors more serious in their effects than the disease itself are often committed by those whose treatment of syphilis is not founded upon a rational pathologic basis. Mercury in Syphilis. — Syphilis has long been treated upon the prin- ciple that there is present a constitutional poison which must be antidoted and that mercury is the antidote. Hutchinson has taught that this drug has the property of neutralizing the specific virus upon which syphilis is supposed to depend. The antidotal theory of the action of mercury has been accepted by some of our best syphilographers. In accepting the anti- dotal doctrine, however, they have seemed to consider it all-sufficient, and have failed to explain the physiologic action of the drug. Mercury has therefore been given empirically: i.e., solely because experience has proved it to be curative in syphilis. Now, it will be found that even when the system has been completely saturated with mercury, perhaps to the extent of producing severe ptyalism, the disease returns directly the drug is with- drawn, thus showing that the syphilis has in no sense been antidoted. On the contrary, the case is usually worse than ever. On the other hand, we find that the slow, continuous, and moderate use of mercury, for a period corresponding to the maximum time of the normal duration of the disease as nearly as may be, and without at any time producing its full physiologic effects, will bring about a cure that can be accomplished in no other way. It is well known that mercury has the power of inducing fatty degen- eration and elimination of inflammatory products, or "of relieving tissues encumbered with superfluous and obstructive material." This condition of the tissues is precisely what exists in syphilis, and as mercury is the best remedy at our command for the correction of such a pathologic state, irre- spective of etiology, it should be administered throughout the natural course of the disease, not to antidote a poison, but to remove the morbid results produced by it, as fast as they are formed, until finally the syphilitic im- pression upon the organism has naturally exhausted itself. We have already seen that the infection of syphilis, whatever its material substance, prac- tically consists in the influence of infection on healthy cells, causing their rapid proliferation and obstructive accumulation. That the peculiar prop- (469) 470 TEEATMENT OF SYPHILIS. erty of the infection is due to a pathogenic microbe of as yet unknown form is probable; but whether the morbific principle be a germ, virus, or "degraded cell/^ the result is the same. It is a rather peculiar fact that every method of treatment for syphilis that has been advocated for the last two or three centuries has comprised such measures as tend to produce rapid tissue-change, and, more especially, elimination. The sweating cure; the use of hot baths, as at the Hot Springs of Arkansas; the purgation and starvation cures, Boeck's method of syphilization, and the treatment of pustulation with tartar emetic, all of which have been recommended by various authorities at different times, are chiefly active through their power of inducing fatty changes in the tissues. In the various methods of hydro- therapy the benefit is secured by increasing elimination. This is especially important in view of the toxins elaborated by the microbe of syphilis. The action of mercury upon the system has been the subject of con- siderable controversy, particularly as regards the form in which it enters the blood and its modus operandi after entering the system. Text-books upon materia medica and therapeutics are notoriously de- ficient in their presentation of the subject of mercury and its therapeutic uses and action. Empiric observation appears to be the basis of most of the so-called studies of the drug. Special consideration of this subject seems, to the author, to be singularly appropriate in connection with the therapy of syphilis. That it is not a work of supererogation is well shown by the statement of Bache: — Of the modus operandi of mercury we know nothing, except that it acts through the medium of the circulation and that it possesses a peculiar alterative power over the vital functions which enables it in many cases to subvert diseased actions.^ Such rubbish as this, while it may reconcile one to the lucubrations of theosophy, merely clogs the wheels of scientific progress. The most logical and scientific contribution to the study of physiologic and therapeutic action of mercury thus far made is the series of essays of S. V. Clevenger.2 The author takes the liberty of quoting the main points made in Clevenger's most recent paper in fulP: — Investigators of the action of mercury seem to have been lured away from evident and fundamental principles in imagining no connection between the easily- discernible physical properties of mercury and its therapeutic effects and assigning the drug occult, catalytic properties. Physiologists do not disregard the mechanic properties of water, yet mercury has never been considered from this stand-point. Both water and mercury are ^ "United States Dispensatory." ^Chicago Medical Gazette, February 20, 1880. Chicago Medical Journal and Examiner, April, 1880. American Journal of Microscopy, June and July, 1880. Chicago Druggist, 1881. Gaillard's Medical Journal, March 17 and 24, 1881. ^ "The Mercurials," S. V. Clevenger, Journal of the American Medical Association, February 22 and 29, 1896. COXSTITUTIONAL TEEATMEXT OF SYPHILIS. 4T1 fluid at common temperatures; both vaporize at all temperatures; both change their specific gravities in passing from solid to fluid and thence to vapor; both main- tain extreme division of their particles under certain circumstances, and by loss of heat or under compression cohere in drops and fall. The great difi'erence is that mercury is fourteen times heavier than water and has a different solidifying point. 1 claim that the simple mercurials, such as pil. hydrargyri, unguentum hydrargyri, hydrargj'rum cum creta, emplastrum ammoniaci cum hydrargyro, emplastrum hydrargyri, unguentum hydrargyri compositum, linimentum hydrargyri, suppositoria hydrargyri, and the oleate of mercury depend for their medicinal properties upon the metal's being flnely divided, and in proportion to the extent to Avhich this division is carried the therapeutic effects of the drug are augmented. A grain of mercury undivided may have no physiologic value, but when separated into a hundred thousand globules and held by an excipient from forming large particles, as in blue mass, the well-known effects of this drug are obtained, and, the more potent the pill, the greater has been the division of the metal. The confections, fats, oils, and other substances with which the mercury in this is blended by the pharmacist, impart nothing to it that changes its character. Though occasional oxidation may occur, it will be seen that this is of no consequence whatever. My experiments prove that mercury undergoes no change in the system after ingestion, and that it is fully capable of producing all its therapeutic and poisonous effects by circulating in or obstructing the microscopic channels of the body. The first eight mercurials mentioned above contain globules of the metal rang- ing from one five-hundredth to one one-hundred-thousandth of an inch in size, mixed with substances more or less inert. The first numbers one hundred thousand globules and upward to each grain of mercury in the mass; the second is much more finely divided; the third is badly divided, some of the globules being quite large, as the chalk does not prevent confluence, and it is therefore an unreliable form for adminis- tration. The "oleate" contains A^ery minute globules reduced by the oleic acid from the yellow oxid with which it is incorporated. The metal constantly precipitates from this form until very few globules are suspended in the oil. The other mer- curials vary more widely in the quantities of mercury they contain, but none of them convey mercury into the system in any other than the metallic condition. No other metal is capable of comparison with mercury in its mechanic prop- erties and physiologic effects. It is the only metal fluid at common temperature; it resists separation into smaller masses and tends to form larger globules when divided, unless held apart by some substance that will coat each particle separately. Each minute sphere will adapt itself to the shape of the tubular or intercellular space through which it may pass, and will by virtue of its superior gravitating power cleanse many of the parts through which it circulates. The myriad of globules released in the stomach and intestines permeate the glandular structures, blood- vessels, and lymphatics, and act as "alteratives," as we could imagine a foreign body, having its weight and adaptabilities, would act when introduced into circulating channels. The distances between the globules prevent the larger-sized masses from forming, and even when lying compactly an albuminous coating will effectually pre- vent cohesion until such covering is broken. I kept for a month a mass of globules shaken up in albumin, and found, after having given a dose to a frog, that the globules maintained their sizes in the tissues of the animal, and that but few had run together by rupture of the enveloping albumin in the stomach, this being easily recognized by the larger-sized globules and the silvery luster of the metal which the coating had previously dimmed. No one disputes the fact that blue mass contains minutely-divided mercury, but nowhere have I found any opinion as to the probability that the mercury alone thus given produced its well-known effects. Histologic tissues and a flnelv-divided 473 TREATMEXT OF SYPHILIS. metal have not been considered as amenable to mechanic principles. Both, being microscopic, are at once relegated to mysterious modes of working, though a billionth of an inch is as much an entity as a billion miles. When the metal, in an undivided or uneombined state, is administered, it rapidly passes through the intestines, without any apparent affect. The cohesive properties of its component particles resist sepa- ration. The metal must be well triturated with an excipient to reduce it to globules; shaken up in water, a temporary, uneven, yet pretty-fine division may be made, but the water opposes only very temporary resistance to the metallic confluence. Honey, fats, oils, confections, etc., when mixed with the fine globules, tend to keep the particles separate. Albumin and glycerin effect a separation better than many substances. Finely-divided mercury presents a grayish appearance, passing into black as the division is made extreme, this condition favoring the reverberations of light from par- ticle to particle until no rays are reflected to the eye. The microscope shows that no change from the metallic state has occurred in reducing the metal to this form. To count the globules in a gram (15.4 grains) of blue mass I spread it mixed with water over a square decimeter of surface and found an average of 2000 visible under a very low magnifying power in an area of a square centimeter, which would make 200,000 of these globules in a gram. But under an objective magnifying seventy diameters more than ten times as many became apparent. The size of these globules is from one six-thousandth of an inch to sizes almost immeasurably smaller. In a gram of pill mass there is '/a of a gram of mercury, which would cubically measure one- fortieth of a cubic centimeter. Taking 0.01 millimeter (Kolliker) as the average diameter of the capillaries, the division of this mass into twenty-five million globules would suffice to reduce all the mercury to capillary sizes. But all are not so reduced, though many are divided up very much smaller. Carpenter^ asserts that metallic mercury, finely divided, can be absorbed by the blood-vessels from the alimentary canal. If these minute globules drop unchanged into the glandular tubules and force their way to the blind extremities, the expulsion of less-heavy contents from these tubules would occur necessarily Avithout reference to whether such contents were morbid or normal. In this manner a deobstruent action is obtained by as simple and effectual means as by cannon-balls dropped into a large pipe. Peristalsis would assist in passing the same globules onward to other secreting and excreting surfaces, and a few globules of the proper size would thus change the conditions of a large area of minute tubules. After passing the pylorus the simple follicles and duodenal glands are affected as were the gastric tubules, and, by thus cleansing glandular structure, we restore normal secretion, or, in some cases, induce hypersecretion. The intestinal villi and lacteals pass the metal into the circulation, while the portal vein carries most of it direct to the hepatic parenchyma. Somewhat as the direct aortic connections with the carotid render embolismus most frequent in the left cerebral artery, the peculiar relationship of the inferior dental arteries with the external carotids facilitates mercury-accumulation in the cancellated tissue of the inferior maxillary bone, with resulting tenderness and sponginess of gums. The minute globules find easier ingress to, than egress from, the dependent portion of the lower jaw-bone, where they accumulate to exert a slow, but sure, disturbing effect upon the gums and incisors, and finally the molars. The irritation of the globules upon the peripheral nerves of the salivary glands, together with the detersive influence of the metal itself, already mentioned, accounts for the activity of the sublinguals, sub- maxillary, and parotid glands in ptyalism. The question arises: why does not catharsis continue during ptyalism if all glandular structures are affected, the liver being caused to secrete more bile as the maxillary glands are stimulated to salivary 'Physiology," p. 138. THE ACTION OF MEECUKY IN SYPHILIS. ' 473 excretion? In the first place, the innervation of all glandular structures is not alike, hence they are not comparable in their actions; next, ptyalism succeeding catharsis shows that, while the liver and intestines evince the first effects of mercurial in- gestion, the superior glands, are reached later through the circulation. From this it may be reasoned that mercurial inunctions impress the general system rather than the liver or alimentary canal, and this has been proved clinically. Mercurials load the circulation and emunctories with effete matter because of their deobstruent effects and ability to insinuate their particles among all tissues, separating some morbid or ulcerated portions from the healthy, by the great and universal laAV of heavy bodies acting in the line of "least resistance." If the bile is improperly diverted or suppressed, it restores it, by opening the channels through which it normally flows; if superabundant from organic obstruction it would regulate its quantity in the same way by affording exit for morbific causes. Its aplastic action is due to tiie capillary and lymphatic cleansing it produces, the million minute globules pushing open circulatory channels and preventing accumulation, as well as affording means for absorption. Provisional callus and wound-healing is interfered with by the globules' breaking up new tissue and interfering with its formation as would any foreign substance. Mercury has been distilled over in considerable quanti- ties from the bones of those who have died from mercurial cachexia, the little par- ticles finding stopping-places in the cancellated tissue removed from more active cir- culatory influences, and, in excess, doubtless dissecting away the periosteum, filling the lacunse and canaliculi, thus producing caries. Eld, Buchner, Cantu, Jourda, Anduoard, Fourcroy, Gmelin, Byanon, Mayengon, Bergeret, Sakowsky, Osterlin, and Heller have found mercury, regardless of the form given, in the blood, urine, serum and pus of ulcers, saliva, feces, seminal fluid, and aborted fetuses of salivated women, in every conceivable secretion and in every tissue. Naunyn^ says: "It has been proved by good observers that mercury is of relatively-frequent occurrence in the bones in quantities readily discernible to the naked eye. Years after mercurial treatment I have found it in biliary calculi. . . . If an albuminate be formed it must be again decomposed, for elimination of mercury sometimes occurs in non-albuminous urine, while albuminous urine sometimes con- tains free mercury. Mercury is also eliminated by the bile, saliva, and sweat. In the finest globules, it is to be found in the bile, urine, and feces after inunction." Taylor- recovered mercury-globules from the brain and liver which averaged one-twenty-six-hundredth of an inch, while those recovered from the kidneys were still larger. As he states, the word mercury is often used in a loose way by authors to include the salts as well. In most cases the usual chemic tests were evidently applied for the base, and the radical was undetermined. The microscope would have been effective enough for the discovery of the metal, but nowhere does any use appear to have been made of this instrument in these investigations. Clevenger claims that an occasional tonic influence of the metal fol- lows wherever glandular obstruction is superinducing diminution of the red blood-corpuscles. Mercury, he says, is not a tonic; but — as it increases secretion, removes obstructions, and sets the corpuscular manufactories in "Ziemssen's Cyclopedia," p. 615. "On Poisons," p. 389. --■ 474 TREATMEXT OF SYPHILIS. order, as it does the biliary — it induces tonicity.^ But lie further says that mercury also causes anemia, which might be expected from persistence in its use, when its occlusive powers, in closing the minute passages and tubular structures, — from which, in medicinal quantities, it removed pre-existing obstructions, — are remembered. Mercury in large doses diminishes red blood-corpuscles, produces anemia, emaci- ation, ulceration, and febrile symptoms, witli a peculiar "jerking, thready" pulse. Obviously a salutary effect upon the glandular system, wrought by small doses, be- comes pernicious by overdoses, and hematosis is seriously disturbed by vascular stasis induced by mercurial plugging of the arterioles and venules. Any irritation causing perversion of the hepatic and splenic functions is certainly followed by hemic degeneration, and the pulse characterizing hydrargyria is, in my opinion, due to the iiTegular, but frequent, propulsion of blood by vis-a-tergo clearing of the lesser vessels where the metallic globules had for awhile backed up the current till forcibly overcome. This leads to the consideration of the nervous phenomena among its toxic effects. Mercury produces ulceration, neuralgia, paralysis agitans, epilepsy, often melancholia, all of which can be produced by thrombus, embolus, passive or active cerebral or spinal congestion, or resultant anemia directly wrought in the way mentioned. Take any treatise on nervous diseases, and wherever the words clot, thrombus, and embolus occur, substitute mercurial accumulation, and the cause, in my opinion, is fully explained. Accumulation in the terminal twigs of the cerebral cortical arteries would induce paralysis, paresis, softenings, tremors, hemiopia, amblyopia, etc., according to location, and whether the basilar or carotid supply contained the larger quantity of mercury. Should the middle cerebral artery be the meeting-place of the molecules, according to subsequent arrival of the metal thence, aphasia, hemi- plegia, or anesthesia will supei-A'ene, singly or together, depending upon whether the gyrus operculum, insula, optic thalamus, corpus striatum, crus, or internal capsule had become congested or deprived of blood by this interference. Bumstead relates a case of epilepsy as due to syphilitic neurosis, which can be better accounted for as mercurialization.- The patient had been subjected to a long coiu-se of mercury, and manifested neuropsychoses quite compatible Avith the sup- position that the taercury was their cause. Bumstead gave more mercury with iodid of potassium and was gratified by immediate benefit. The iodid alone would have been the better remedy, as iodin unites directly with mercury to form mer- curous iodid. That mercuric iodid is not formed is evident from absence of the physiologic effects of this active compound. The less soluble mercurous iodid is carried back into the circulation from the bony or vascular recesses in which the iodin united with the mercury, and, decomposing, leaves the mercury to reproduce the same phenomena as when first ingested, with the advantage that the excretory channels have a better chance to eliminate the mercury while circulating than when lying dormant in inaccessible places. This explains why the iodids resalivate the mercurialized. Finding the metallic mercury "in every conceivable tissue and fluid of the body" warrants the supposition that diabetes, vomiting, gastric and pulmonary irri- ^ This is begging the question somewhat. If mercury produces "tonicity" it is truly a tonic, irrespective of its modus operandi. ^ This assertion of Clevenger's is open to doubt. The epilepsy may have been due to syphilitic toxins. The toxemic theory has even been advanced as explaining ordinary epilepsy. THE ACTIOlSr OF MEECUEY IX SYPHILIS. 475 tation following hydrargic exhibition are owed to nerve-center irritation, meclianic and direct, in the floor of the fourth ventricle, or to interference with its blood- supply. At this stage an augmentation of the salivary flow by irritation of the chorda-tympani nerve might also be expected, and this may be among the initiatory sialagogic causes. This irritation is exerted upon the nerve-centers by the heavy globules of the metal, exactly as serous or purulent accumulations are mechanically productive of nervous and mental derangements, or that mercurial interference with the circulation thereabouts would be followed by such neuroses. The elimination of mercury from the system seems to be principally through the kidneys; but gold rings, brooches, or necklaces, in contact with the person, will become covered with mercury-films during a course of hydrargic treatment.^ Con- sistently with its vaporizable tendency increasing with heat-elevation, warm baths help its passage through the sudoriparous channels, and it is well known that nearer the tropics greater immunity is enjoyed from the effects of large doses. Clevenger directs attention to the harmony of the mechanic view of the action of mercury with the pathology of the disease as presented by Otis, Biiumler, and Wagner and adopted in the preceding chapters of this work. Baumler formulated the pathologic principle npon which Otis based his entire teaching of syphilitic phenomena, when he supported the view that the characteristic feature of the active syphilitic cell is the possession of ability to set up in other cells, through contact, its own disposition to rapid proliferation.- These cells not only obstruct tissues, especially lym- phatic structures, but they undergo degeneration and elimination. Otis has especially insisted that the syphilitic tubercle, in common with all syphilitic sequels, is a deposit of arrested normal material, the favorite seats of which, according to Baumler and Wagner, are in the subcutaneous cellu- lar tissue, the skin, in and upon the bones, the liver, the testicles, brain, kidneys, and infiltrations — of microscopic size — scattered through the parenchyma of an organ. The cause of the accumulations, Rindfleisch claims, is interference with the lymphatic circulation; the natural channel through which the nutritive material exuded into the tissues in excess of the necessities of growth and repair is returned to the general circulation.^ This point has been sufficiently expatiated upon, and is reverted to in this connection simply to show how beautifully Clevenger's researches harmonize with the pathologic doctrines of syphilis advanced in the preceding chap- ters. The newer points brought out by Clevenger in his most recent paper are of absorbing interest. His theory that mercury exerts a phagocytic action in syphilis is most fascinating, and harmonizes perfectly with the microbial hypothesis of syphilitic pathogenesis. ^ Clevenger evidently ignores the fact that this is due, in cases where inunction treatment is used, largely to the mercurial A-apov arising from the skin. It occurs, however, where the drug is only given int-ernally. This clearly demonstrates elimina- tion by the skin. ^ "Ziemssen's Encyclopedia." ^ Rindfleisch. 476 TEEATMEXT OF SYPHILIS. Reverting to the observation that mercury attaches to itself fine particles of dust that are with difficulty separated therefrom, the behavior of the metallic globules in the physiologic channels may be justifiably compared to that of phago- cytes. If a micro-organism is eventually established as the cause of syphilis, the antagonism of mercury for the disease may be found not only in its assisting elimi- nation generally, but through phagocytic action of the globules in enveloping the morbific organism, as the wandering cells of the circulation are known to load themselves with bacteria, micrococci, etc. In this manner the adjacent tissues would be kept from infection and the globules of mercuiy could carry away, through the emunctories generally, the microscopic cause of syphilis. Clevenger holds that all the evidence thus far obtainable goes to show that the therapeutic action of mercur}^ is, in the main, mechanic. As water enters and issues from hydrants unchanged, so mercury enters the Ijody and leaves it jDlainly as mercury; and yet speculation has been rife as to some undemonstrable chemic change occurring in transit, notwith- standing that the bodies of mercurialized animals have been repeatedly opened and mercury found in the various organs en route toward excretion or dormant in the tissues. Salivation occurs through accumulation of the metal in the terminals of the dental arteries by gravitation to the most dependent portions of the jaw. Accumulation in the cancellated tissue, gums, and salivary glands would fully account for ptyalism, the earliest effects being manifest in the lower incisors — most apt, from their position, to be affected. Fournier claims that mercurial ulcerations are situated al- wa3^s on the edges of the tongue, and on the side on which the person has been accustomed to lie when sleeping. This supports the theory of the gravitating tendency of the globules. It must be remembered, how- ever, that the gravitation of the tongue itself down upon the teeth, where it remains for some hours, may have much to do with the localization of mercurial ulcers of the tongue. Another point is the gravitation of irri- tating fluids to the edge of the tongue, which remains bathed in them for hours at a time. The pivotal point in Clevenger's theory of the action of mercury, as demonstrated by his exceedingly-interesting experiments, is the conclusion that all the mercuric and mercurous preparations decompose in the body into mercury-globules the sizes of which determine much of their effects. The experiments Avith blue mass may be accepted as the standard demonstra- tion of the mechanic action of mercury. Clevenger first placed the web of a normal frog's foot under a ^/^ inch objective, magnifying seventy-five diameters. He thus acquainted himself as thoroughly as possible with the peculiarities of its blood-vessels, pigment-granules, and appearances by re- flected and transmitted light. He then gave the frog 5 grains of blue mass. Twenty-four hours afterward the frog was examined and little globules of mercury were found mingled with the mucus secreted by its skin. These were brushed off and its feet again placed under the lens. The blood-vessels Avere found to be choked with metallic mercury. Aneurismal and varicose THE ACTION OF MEECUKY IN SYPHILIS. 477 pouches were distended with mercurj-, and a great number of the so-called pigment-granules had changed to a yelloW;, metallic luster; these spots reflected the light as would mercury, when examined by direct rays. As many as twenty of these lacunse, or star-shaped bodies, could be counted between two toes, and altogether there were about a hundred on each foot. The close resemblance between the lacunse thus injected and Strieker's description of the lymphatic sacs in the course of the lymphatics of the frog led Clevenger to believe that he had observed mercury in the lymphatic channels of the frog. Two little tubules choked with mercury presented a singular phenomenon. Under the power used the tubes appeared blind, but a little globule of unmistakable mercury lay upon the surface of the web at the outer end of one of the tubes. Watching this globule intently for ten minutes, it suddenly increased in size, and the tube collapsed, having emptied its mercurial contents outward. The globule thus formed was twice as large as the characteristic blue-mass globule, and was easily removed from the web by a camel's-hair pencil. The other similar tube was more curved, and at its outer end had two such globules, both of which increased slowly in size, and in half an hour had grown very large at the expense of the tubular contents, the tube disappearing as did the first mentioned. Nowhere could anything like foreign particles circulating in the blood be seen. The white and red blood-corpuscles were distinctly visible, but in one capillary was a small dark particle gradually accumulating similar particles near it; these were apparently minute mercury-globules; they accumulated against the current, and the blood passed around them freely; suddenly the down- stream end of the mass broke away and apparently washed away in the blood out of sight. This was repeated several times while the mass, in this way, Avas proceeding up stream. In one vein a large globule of mercury lying motionless could be plainly seen, while the blood-corpuscles changed positions to pass by it in the vessel, which they did as rapidly as ever. Some of the exuded mercury-globules on the web furnished good compara- tive measurements. Six globules together measured the diameter of a small capillary, and could easily have passed through this blood-vessel abreast. The experiment was repeated on a smaller frog by anointing the chin, • axillge, and thorax with oleate of mercury, with the same result. To a large frog was given 10 grains of blue mass and as much blue ointment. Twenty-four hours later the lymphatic sacs were engorged, but the blood circiilation was undisturbed. In all the frogs so treated, where unavoidable lacerations of their feet occurred in manipulating, there oozed from the torn edges minute globules of mercury. The last frog shed his skin in three days after the dose, but otherwise none of them underwent any ap- parent change in health or vigor. The skin must have afforded the main means of exit for the metal. There was not a fragment, however small, of this discarded cuticle that did not exhibit plainly the metallic globules. Dissecting the frog last mentioned, the stomach was found coated with the 478 TEEATMEXT OF SYPHILIS. globules; but ten days having elapsed since the dose, no mercury was found between the intestines and the skin except in the derma, and probably in the liver. This organ was apparently choked with sacculations of an opaque substance, which proved to be aggregations of metallic mercury in the hepatic channels. In the hope of discovering the course of the metal through the frog's body, a gram of finely-divided mercury, in albumin, was given to a male frog. In five hours globules appeared on its back. Dissection showed that the intestines, renal and portal circulation, heart, kidneys, and even the testes contained numerous globules of mercury, and the lymphatic passages were beautifully injected with globules much more finely divided. Apparently the lymph-channels had chosen the lesser particles, or the metal had undergone further division in absorption into the passages. Experiments with calomel and other preparations of mercury have shown, according to Clevenger, that all preparations of mercury are reduced to a finely-divided metallic form before entering the system. The pancreatic fluid has a marked action in reducing calomel to the metallic state. Clevenger touches upon one very important point in the clinical use of calomel in the following words: — From remote periods it has been supposed that salt and acids converted calomel into corrosive sublimate in the stomach, though this has been repeatedly shown not to be the case. One of the denials was made from numerous experiments by Verne^: "No poisonous compounds are generated from calomel in combination with such bodies as salt, sugar, citric acid, etc.; and whenever such mixtures have been followed by alarming symptoms the calomel must have been an impure article. The protochlorid of mercury is really a more stable compound than ordinarily considered, and it would appear that bichlorid is more easily converted into the proto combina- tion rather than vice versa." Upon testing the stocks of calomel in a dozen drug-stores in Chicago I found corrosive-sublimate traces in nearly all, and in that of a few manufacturers the amount to the ordinary dose must have rendered this chlorid far from "mild." So, as Verne notes, when calomel acts harshly it is probable that it is impure by contain- ing the bichlorid. Further, as to the mistake that a higher salt may be formed from a lower mercurous compound, Wurtz- says: "Bichlorid of mercury is easily reduced to the monochlorid or even the metallic state by many agents. Light will precipitate calomel from an aqueous solution, and many organic substances reduce the bichlorid to calomel or even to quicksilver, especially under the influence of light." In the face of these facts it can hardly be logically maintained that calomel shows a tendency to assume a higher state of oxidization. It also appears absurd to prohibit the consumption of acidulous food Avhile administering calomel, the more so when we consider the presence of free hydrochloric acid in the stomach, and remember that this acid reacts with calomel only at a boiling temperature. The author considers the foregoing argument based upon chemic ^ "Repertoire de Pharmacie," June, 1879. ^ "Dictionnaire de Chimie." THE ACTION OF MEKCUKY IN SYPHILIS. 479 facts, as convincing enough regarding the chemistry of calomel, but as a matter of clinical observation it is unsafe to base our practice upon such deductions. It is possible that the speedy occurrence of salivation after the administration of calomel and acids in succession is due to impurity of the mercurial, and is a mere coincidence, so far as the acid is concerned; but such accidents occur so often that we are not justified in assuming such a skep- tic position in practice. It by no means follows that calomel is not reduced by ingested acids in the gastro-intestinal tract, even though such reduction does not take place outside the body. Chemic evidence to the contrary not- withstanding, the author would advise a conservative course: i.e., abstinence from acids while taking mercurials. The general conclusions arrived at from his observations are recapitulated by Clevenger as follows: — 1. Mercury acts mechanically as a deobstruent upon the glands and lesser tubular structures, by virtue of its unstable chemic properties, its volatility, and great weight. 2. Its condition in the fluids and tissues is that of finely-divided globules of the metal numbering upward of one billion to the cubic centimeter, and as vapor of the metal. In whatsoever form it may be taken, it is quickly precipitated as mercury, and without change is excreted or retained in the system, mainly in the bones. 3. It cleanses the intimate visceral tissues by projecting from them materials of less weight, and in this way breaks up, removes, or prevents morbid accumulations. In excess it occludes the tubular parts, and may produce any of the phenomena attending stasis of vital operation anywhere about the body, such as ulceration, con- gestion, paralysis, anemia, etc. 4. The liver and inferior maxillary region — for anatomic, and the former for physiologic, reasons — receive most of its primary influences. 5. It can be given in larger doses in warm weather or climates because heat favors its elimination, systemic efl'ects decreasing necessarily in proportion. 6. Its antiphlogistic properties are merely deobstruent and detergent. 7. Its value in syphilis is owed to its acting in the line of least resistance, break- ing up any nidns the disease may form. The ability of the metal to envelop and carry micro-organisms gives it an ameboid or phagocytic value. In phagedenic ulcer- ative processes it would be contra-indicated, because the degeneration is too rapid to be effectually reached by mercury, which is not the case in slower-forming specific ulcerative stages. Its administration in these diseases could be regulated by the rapidity of degradative processes. Comparatively slowly acting morbid centers or those of a congested nature could be improved by mercury where the drug would only accelerate rapid tissue-destruction. 8. It is tonic, by increasing red blood-globules whose formation has been pre- vented by glandular perversion, the metal removing the obstructions toward their formation, while in overdoses anemia is produced by occluding the vessels it, in small doses, cleansed. 9. The solubility and consequently superior penetrating power of the bichlorid is probably productive of characteristic merciu'ial effects which seem out of propor- tion to the amount of metal in doses of this salt; but it is not to be denied that chemic or direct neurotic influences co-operate with the metal in the more active preparations, and thus possess features of their own. 10. Experimental evidence is opposed to the probable formation of any compound in the body, and supports the belief that decomposition invariably and almost in- 480' TEEATMEXT OF SYPHILIS. stantaneously follows its ingestion, with the j)recipitation of mercury as minutely- divided globules from any preparation of which it fonns the base. A careful survey of Clevenger's experiments cannot fail to impress one with their conscientiousness and, in general, with the logic of his con- clusions. In order to demonstrate that mercury acts only mechanically, however, it would he necessary hy experiment on animals to show that all of the mercury introduced into the system can be collected again in the metallic form from the animars secretions, excretions, and tissues. This condition is, of course, difficult of fulfillment. Again, it is questionable whether mercury in so fine a state of subdivision as is demonstrated by Clevenger would not be subjected to a certain amount of chemic change in the tissues. The potency of bioehemism is an unknown quantity, and may be a much more important factor in the physiologic action of mercury than Clevenger seems to believe. The author freely admits, however, that the mechanic action of the metal is paramount, and that it alone seems sus- ceptible of experimental proof. The authors view that mercury acts, to a certain extent, in the form of varying chemic compounds of a more or less soluble character, is sub- stantiated by the fact that mercury is eliminated in its non-metallic form by the kidneys, and may be separated from the urine in the form of a sulphid by proper tests. Admitting the mechanic action of mercury, the author is inclined to believe that the drug acts to a certain extent by blocking up the capillaries supplying the areas affected by syphilitic infiltration. The syphilitic neo- plasm being of low vitality, it takes but little to enhance its innutrition and produce fatty degeneration — in sort, to hasten the normal process of reso- lution and elimination. This condition the mercury furnishes by im- peding blood-supply. The ferret-like action of the drug in driving mor- bific material before it perhaps comes into play later, when the neoplasm has undergone softening and is ready for elimination. Under such circum- stances the minute mercury-globules probably act by pushing the degenerate cell-material before them into the various eliminative areas of the body, where the morbific matter is expelled, along with the free mercury. A moment's thought is sufficient to impress the importance of this deobstruent action upon the mind of one familiar with the pathology of syphilis as pre- sented in this work. One criticism that the author would make upon Clevenger's views is that he does not lay sufficient stress upon the circulatory vis a tergo in explaining the career of mercury in the blood and tissues. Obviously, such pliable, plastic, fine globules as those of metallic mercury can penetrate and traverse the finest capillaries. This, in fact, occurs, and the blood-power behind them drives them on and on, until some obstruction is encountered. This obstruction is furnished (1) by the lymphatic tissues, (2) by neoplastic EFFECTS OF MEECURY UPON THE BLOOD. 481 formations, (3) b}' adventitious connective-tissue organization, (4) by com- Ijressed or contracted blood-vessels, and (5) by gravitation, which specially tends to cause its accumulation in certain localities. The relative importance of the hearths action, the elasticity and con- tractility of the arteries, muscular contraction, and the aspirating power of the chest are obviously the same with respect to propelling mercury through the tissues as in the physiologic propulsion of the blood-corpuscles. Effects of Mercury upon the Blood. — The action of mercury upon hema- topoiesis is a most important point for consideration in the therapeusis of syphilis. The action of mercury upon the blood is of great practical interest, inasmuch as by its use diametrically-opposite effects may be produced, ac- cording to: (1) the dose used, (2) the duration of its administration, (3) the constitutional condition of the patient, and (4) the stage of the disease. Knowledge of the varying effects of the drug upon the blood is of so great importance that the physician who does not understand them is hardly to be trusted with the management of syphilis. Every practitioner worthy of the name is familiar with the variations in the effect of mercury upon the gastro-intestinal tract. That large single doses will act as a cathartic, and moderate doses as a laxative, is as familiar as the fact that by small and fre- quently-repeated doses, for from twenty-four to thirty-six hours, severe stomatitis and ptyalism may be produced. If the drug be given in a less vigorous fashion for a longer period, pallor and debility may result, due to depreciation in the quantity and quality of the red blood-corpuscles, de- fibrination of the blood-plasma, and increased tissue-waste. A certain degree of these effects is unavoidable in the treatment of syphilis; but it should be our chief aim to keep them within bounds and thus avoid the danger of pro- ducing permanently-injurious effects. Such effects as great pallor, wasting, and debility, pustular or vesicular eruptions, with fever known as "mercurial fever" and marked tremors, may result from the action of mercury, and that too, without the occurrence of ptyalism. On the other hand, small doses of mercury, in various cachectic or anemic conditions, particularly during the sequels of syphilis, stimulate hematogenesis and rapidly and markedly increase the quantity, while improving the quality of the red corpuscles and fibrin, thus lessening hydremia. This statement is supported by the experiments of Keyes with the hemometer, and, moreover, by clin- ical observation of the action of the drug. The question of the possible accumulation and prolonged retention of mercury in the system has been considered to be suh judice, the weight of opinion being in favor of the view that proofs of such a result of the drug are wanting. The author has not yet seen any bugaboo cases in which portions of bone are found to be "full of metallic mercury." That metallic mercury may be found in the tissues during a prolonged and thorough course of the drug is true, but that such a condition prevails for years after the treatment is not so certain. Alleged cases of this character have probably been under more recent mercurial 483 TREATMENT OF SYPHILIS. treatment than they acknowledge or perhaps are aware. They may have been innocently taking medicines of mercurial composition.^ In a series of elaborate experiments Schuster, of Aix-la-Cliapelle, has shown that elimination of mercury by the feces is by no means inconsider- able.^ The method of administration was by inunction. Some of his con- elusions are of interest: — 1. Elimination of mercury by the feces is regular and continuous. 2. Elimination after thirty to forty-five days' mercurial inunction is complete in six months. 3. Consequently^ persistence of mercury in the organism cannot occur. This conclusion is important as bearing upon the cumulative action of mercur}^, but is obviously fallacious. lodin in Syphilis. — There is another remedy that experience has shown to be curative in syphilis, and which is second onl}^ to mercury. lodin, in the form of the iodids, especial^, is invaluable, — in fact, well-nigh in- dispensable, — more particularly in late syphilis. The iodids — of which potassic iodid is the type — act in two ways in the cure of, syphilis, viz.: firstly, by their own intrinsic power of producing fatty degeneration and elimination of morbid products, especially toxins; and, secondly, by liberat- ing, exciting to renewed activit}', and eliminating the mercur}^ that is stored up in the tissues, thus assisting its action. It is evident that the first of these effects is the most important, for the iodids have a most powerful effect in resolving the products of inflammatory changes, or of adventitious deposits, irrespective of their cause. This in the face of the argument that iodin can cure syphilis only by liberating mercury from the tissues, and that it is the mercur}^, and not the iodids, that produces the curative effects. That this is incorrect is shown by the beneficial effects of potassic iodid in cases of late syphilis in which mercury has never been administered.^ When to begin Treatment.- — Having decided upon the administration of mercury in the constitutional management of syphilis, when shall we begin its use? It is claimed by some that it is not good practice to begin treat- ment until secondary symptoms develop, until, in short, the case is ma- tured, as mercury will have little effect prior to that time. It is the au- thor's opinion, however, that it is our duty to begin treatment just as soon as the diagnosis is established, as the duration of the initial lesion is thereby shortened, and secondar}' sj'^mptoms moderated, if not prevented. To save ^ ClcA^enger quotes the instance of a cadaver exhibited at an eclectic college, the skin of which was full of mercury-globules. As Clevenger did not himself see the cadaver, the ease is by no means proved. ^ Journal of Cutaneous and Venereal Diseases, September, 1883. ^ In the British and Foreign Medical Review for October, 1845, Hassing, of Copen- hagen, reported 195 cases of syphilis, 70 of which were cured by potassic iodid alone, without using mercury at any stage. These experiments have since been frequently repeated by various observers, with like results. SELECTION OF MEKCUEIALS. 483 the patient from lesions npon the body or face, that he who runs may read, is very desirable, and is only to be accomplished by early treatment. It must be acknowledged, however, that those cases in which treatment is not begnn until pronounced eruptions appear sometimes seem to respond more readil}^ and to give rather less annoyance during the active period than where mercury is given as soon as chancre develops. Whether the prospect of a permanent cure is brighter is questionable. Dumesnil opposes very strongly the practice of giving mercurials before secondary eruptions ap- pear, no matter how plainly marked the case.^ The difficulty of diagnosis is one of the most powerful arguments advanced by him, and is presented so clearly and forcibly that one can hardly offer a criticism. There are, however, many cases that are so plainly marked that this argument falls to the ground. In quite a proportion of cases the diagnosis is doubtful and the conscientious physician must necessarily wait. Kegarding such dubious cases, there should be no difference of opinion. Dumesnil further claims that by the administration of mercury secondar}^ symptoms are not pre- vented, but are mereh^ delayed. This statement is rather too sweeping. It is true that secondary symptoms are rarely prevented entirely, but is not their severity usually markedly moderated? What is to be said, moreover, respecting those cases in which no symptoms whatever follow the primary sore until, perhaps years after the disease was forgotten, severe sequels ap- pear? According to Dumesnil, the non-appearance — or apparent non-ap- pearance — of secondary symptoms would indicate that in such cases syph- ilis did not exist. In some cases secondary symptoms are ven^ slight and likely to be overlooked by the patient. In such cases the necessity for con- stitutional treatment might be first announced by severe sequels at a period too late to warrant a hojDC for a permanent cure. The author believes that in doubtful cases delay, as suggested by Fournier, is most proper, but, on the other hand, holds that, whenever an unequivocal diagnosis of syphilis has been made, treatment should be begun at once. Selection of Mercurials. — Having determined upon the administration of mercury, it remains to select an eligible preparation. The mildest and least irritating form of the drug is the mercurous iodid, or, as it is some- times termed, the green or protiodid. It is best given in pill form, in doses of, on the average, ^/- grain, thrice daily. This dose is to be continued for several days, and then increased one pill per day — still in divided doses — until the gums become somewhat tender or the stomach and bowels are dis- turbed. The author generally gives the drug until the gums are slightly affected, and then gradually lessens the dose until the patient is taking about half the amount necessary to produce slight physiologic effects. This, as Keyes terms it, is the patient's average dose, and is usually from two to four ^ "When to Begin the Treatment of Syphilis," A. H. 0. Dumesnil, St. Louis Med- ical and Surgical Journal, August, 1883. 484 TEEATMEiS^T OF SYPHILIS. pills, of the strength mentioned, daily. This should generally be continued — with certain intervals of rest — throughout the course of treatment. It is often well to substitute from time to time some of the other mercurials for the mercurous iodid. It is well to bear in mind the possibility of injurious effects from the cumulative action of the drug, and also the fact that it is likely to lose its effect upon the disease after a time. The author's plan is to omit the mercurous iodid at intervals of two to three months, and give potas-. sic iodid pretty freely for about four weeks. In this way any mercury that may be stored up in the tissues is liberated, rendered active, and eliminated. The system is again susceptible to its action by the time the pills are re- sumed. In addition, the special action of iodin is obtained. By proceed- ing in this manner the possibility of injuring the patient with mercury is practically avoided. There are various other eligible forms of mercury. The bic3i'anid has been known to agree when no other preparations could be tolerated. Clevenger alludes to the eligibility of this salt when others produce gastric irritation.^ The red iodid has been especially recommended in the late scaly eruptions. Its superior merit, however, is not obvious. A well-known preparation, called Zittman's decoction, was formerly much used in Germany. It contains mercury in combination with sarsaparilla and aromatics. It is often a matter of great difficulty to induce patients to take med- icine for a sufficient length of time to effect a cure. They are prone to find fault with the physician if he is honest with them, and suspect him of sordid motives if he attempts to coerce them into prolonged treatment. It is a peculiar fact that most people try desperately to compel the physician to be dishonest with them in self-defense. They misinterpret honesty as lack of skill, and will more readily pay the quack huge fees for false prom- ises and blatant pretenses than the scientific physician a moderate amount for skillful treatment. They have always at their tongue's end a long list of their friends who were cured of a bad case of syphilis (?) by Dr. So- and-So in three months. In spite of this perverseness of human nature, however, it is the jDhysician's duty to tell his patient that if he wishes to get well he must take medicine for at least three years, and if any doubt exists at the end of that time he had best add another year, especially if he has matrimonial intentions. As already stated, no syphilitic patient should be permitted to marry under three years from the appearance of the chan- cre. In the case of women a still longer period is advisable. Another difficult item in the management of most cases of syphilis is convincing the patient that it is absolutely necessary for him to avoid the use of liquor and tobacco for an extended period, and that he must abstain from the various dissipations and excesses to which he has been accustomed. This point must be insisted upon, however, and, with good conduct upon S. V. Clevenger, op. cit. TKEATMEXT OF SYPHILIS. 485 the part of the patient assured, half the battle will have been gained. The late Willard Parker used to say to his syphilitic patients: "Yon are pos- sessed of three devils, — rum, tobacco, and syphilis. If you will rid your- self of the two former, I will rid you of the latter." Some patients do not tolerate mercury well, diarrhea or gastric dis- turbance following the slightest attempt at pushing the drug. In this event, ^/s grain of extract of hyoscyamus should be added to each pill. Another good plan is to give the patient a few 10-grain powders of bismuth sub- nitrate, with instructions to take one whenever the stomach or bowels be- come troublesome. In other cases the patient tolerates a large amount of mercury. The author has repeatedly given several grains of the protiodid daily for some weeks, without affecting the gums or digestive tract in the slightest degree. In such eases the large dose should be kept up for a few weeks, and then diminished to about four or five pills daily. In some cases the pil. duo. introduced by Bumstead is an excellent preparation, especially if the patient is anemic and debilitated. The pil. duo. contains gr. ij of pil. hydrarg. and gr. j of ferri sulph. exsiccat. It should be given precisely like the mercurous iodid. It usually produces constipation; hence an occasional dose of Apenta, Hunyadi, or Friederichshalle water may be necessary. When a patient fails to respond readily to the internal administration of mercury, or when gastro-intestinal irritation is marked, the drug may be used by inunction. Were it not for its uncleanly features, this method would be best of all. It certainly is the most useful method for a short, relatively vigorous course of treatment. The oleate — a minute subdivision of mercury in oleic acid — is the best preparation, although too expensive for some patients. A 5- to 10-per-cent. solution should be used, and about 5] rubbed into the axillse, morning and night. As the axilla become irri- tated, the rubbing may be done at the flexures of the joints, where the skin is thin and absorption readily occurs. The mercurial ointment, though less elegant, may be used as a substitute for the oleate. It may be rubbed in or spread upon a white flannel band kept in contact with the abdomen, the band being shifted about occasionally and the skin kept clean by daily washing. Another good plan in hospital practice is to rub the ointment upon the soles of the feet and have the patient wear heavy woolen socks. In some cases mercurial inunctions or mercury-vapor baths must be wholly depended upon, and it may be said, in this connection, that both are very efficacious in obstinate skin-lesions. The general dissemination of mercurous vapors over the surface of the body explains, in great part, the beneficial action of the inunction method. A simple method of giving a mercurial bath is as follows: A small tin plate supported by a tripod, an alcohol-lamp, and a pan of boiling water are all the necessaries. The patient, being stripped, seats himself in a cane- bottomed chair and wraps the chair and his body thoroughly in blankets. About 20 grains of the mercurous chlorid is placed upon the plate, the lamp 486 TEEATMEXT OF SYPHILIS. is lighted, and the whole ajjparatns placed under the chair. In a few minutes the calomel is vaporized, and, with the steam from the boiling water, is deposited upon the skin of the patient. In fifteen minutes the lamp may be extinguished, and after ten minutes more the patient should wrap himself in a dry blanket and go to bed. In the morning he may rub himself with- dry towels, the mercury having become, in great part, absorbed. About three baths jDer week are necessary. Calomel is the best jDreparation for fumigation, because of its freedom from irritating proper- ties and the readiness with which it volatilizes without reduction to the metallic condition. The red oxid also volatilizes readily, but its fumes are more irritating to the respiratory tract. It is sometimes necessary to bring a patient under the influence of mercury very rapidly: e.g., in cases of syphilitic iritis, in which a few hours' delay might be fatal to the integrity of the eyes. In such an event calomel, in doses of ^/^o grain every hour, will accomplish the desired result; and, if necessary, ptyalism can be produced in this manner within twenty-four to forty-eight hours. Another rapid and eflficacious method of introduction of mercury is b}^ Lewin's method of hypodermic injection.^ From ^/m to ^/g grain of mercury bichlorid, in combination with ^/^^ grain of morphin and a small quantity of sodium chlorid, is dissolved in 15 minims of distilled water, and injected into the cellular tissue, preferably of the buttock,^ once or twice daily; a minute dose of cocain may be advantageously combined with the injection. There is a vast difference in the susceptibility of differ- ent patients to these injections. The author has never seen an abscess pro- duced by them, but some patients complain bitterly of the pain following their administration. In others, hard and painful indurations follow their use. If the precaution is taken, however, of introducing the needle well into the cellular tissue before injecting the fluid, very little trouble will be caused in the majority of cases. It is probably the best treatment for syphilis, in a certain proportion of cases where the patient can be induced to attend strictly to treatment. As an adjunct to internal treatment, mild injections are excellent. There is one point to which the author especially desires to call attention, viz.: the bichlorid makes the needle very brittle, and, unless it is frequently changed, it may break off in the tissues, an accident that the patient is quite likely to criticise. For the average patient in the hands of the general practitioner, Lewin's method is inferior to the internal use of the mild iodid. Abadie urges the advantages of his method of subcutaneous injections of mercuric bichlorid in the late ocular lesions of acquired syphilis and constitutional S3'philis: — ^Lewin, "Behandlung der Syphilis, mit Subcutaner Sublimat-injection."' Berlin, 1869. -Stern (Progres Medical, Paris, 1878) expresses a preference for injecting the tissues of the back. TREATMENT OF SYPHILIS. 487 These lesions are characterized by their complex nature and the slowness of their evolution. Chororetinitis is frequently accompanied by chronic iritis, and even by parenchymatous keratitis. Many of these cases heal spontaneously without treat- ment, Avhile others show a very disquieting tenacity, Avhich resists all treatment until the hypodermic mercurial injections are employed. This latter method of treatment also gives good results in certain forms of chororetinitis limited to the region of the macula. In cases of isolated paralysis of the cranial nerves or twigs of nerves, without cerebral complications, the extreme rebelliousness of the trouble is success- fully conquered by the hypodermic method of treatment. For this purpose I employ a solution of mercuric chlorid, 1 part; sodic chlorid, 2 parts; and distilled water, 100 parts. I inject 20 drops of the solution beneath the skin of the back on alternate days, and make gentle massage over the spot afterward.^ An interesting method is the treatment of syphilis by intramnscnlar injections of mercnry. Mr. J. Astley Bloxam states that over fifteen hun- dred patients were treated by this method at the Lock Hospital and else- where dnring eighteen months^ with the best results. The solution for injection contains 6 grains of the bichlorid to the ounce of distilled water, and of this 20 drops constitute a dose. The sore generally begins to heal very promptly after one or two injections, the secondary symptoms are markedly modified, and after a course of treatment extending over a year, more or less, the patient is enabled to discontinue his attendance. Toward the latter end of the course of treatment the injections may be given less frequently, and, as a general rule, not more than from 8 to 12 grains of the perchlorid are injected in all. It is undesirable to repeat the injections oftener than once a week, as otherwise salivation might be induced, and the quantity injected each time (Va grain) is found to be quite suffi- cient until the next time. There are several advantages attending this method of exhibiting mercury. In the first instance, it is only necessary to see the patient once a w^eek, when sufficient mercury is injected to last until the following week; secondly, salivation is not produced, as is apt to happen when the patient continues to take mercury for a whole week while away from the supervision of his medical attendant; thirdly, the gastric derangements that are so apt to follow the administration of mercury by the mouth are by this means avoided; lastly, the ease and certainty of administration which enable the surgeon to do his own dispensing with a minimum of trouble. A little quinin is generally given during the course as a tonic, but no other form of mercury is administered. The injections are made preferably deep into the muscular mass of the glutei. The pain following is slight and soon passes away, and there is no danger of abscess.- Hypodermic injections of calomel as originally recommended by Sca- renzio and Eicordi, over thirty years ago, have been highly extolled by numerous writers. It is asserted that the insoluble salt is slowly transformed by the alkaline juices of the tissues and the blood into the soluble mer- curic chlorid. From 1 to 3 grains may be given suspended in aseptic albolene or glycerin, twice weekly. Taylor advises a mixture of calomel and sodic chlorid, 5 parts of each, suspended in 50 parts of distilled water. Of this fluid an ordinary hypodermic svringeful may be injected every ^ Abadie, Annales d'Oculistique, May, June, 1886. = New York Medical Journal, October 23, 1886. TEEATMENT OF SYPHILIS. eight or ten days.^ The sides of the buttocks and the back beneath the shonlder-blades are the best sites for the injections. Care should be taken to have both skin and syringe aseptic. The needle should be larger than the ordinary hypodermic variety. The calomel injections are often painful, and sometimes followed by painful swellings and abscesses — despite all care. Their field of usefulness, therefore, comprises emergency cases onlj^, as a rule. For routine use they are hardly satisfactory. In the case of females with very weak stomachs, and in children, the gray powder or hydrarg. cum creta is an excellent mercurial preparation. If it becomes necessary to push the mercurial, it should be done by super- adding fumigations or inunctions, rather than by increasing the internal dose. A preparation highly lauded abroad is the tannate of mercury; — hydrargyrum tannatum oxydulatum, — which is justly claimed to be perfectly unirritating. The hydrargyrum formidatum is also serviceable. The pep- tonate is another fanciful preparation used by our French confreres. UxTOWARD Effects of the Mercurials. — Many of the disagreeable and injurious effects observed from the action of mercurj'' are due to the tend- ency upon the part of most teachers of therapeutics to dwell only upon the good effects that result, or are supposed to result, from the administration of various drugs. A certain amount of discussion is usually given of the im- mediate or remote toxic effects of the drugs per se. The relation of the method of administration and the disease conditions under which the drug is given to its untoward effects are insufficiently considered. Although confessedly a champion of the mercurial treatment in syphilis, the author is fully aware that many evil effects are liable to attend its administration where due consideration is not accorded its intrinsic toxic qualities. The reputation of mercury as a remedy has been injured chiefly at the hands of inexperienced and careless practitioners — ^more especially those who have treated syphilis upon the antidotal principle. Much of the popular preju- dice against mercury has resulted from observation of patients treated by this class of practitioners. We meet with a decided and, it must be con- fessed, fairly well-grounded prejudice against the use of mercury existing in the minds of the laity, the principal reason for which has just been stated. It is a self-evident fact that many of the alleged evil results of mercury are due to the circumstance that its use has not been faithfully persisted in for a sufficient length of time; but, notwithstanding this, there is un- doubtedly a certain proportion of cases in which serious injury to the sys- tem of the patient may be justly attributed to the drug itself. With proper care, however, the author ventures to assert that there is no drug that is safer or more reliable, and he has yet to see a single case of permanent in- jury resulting from the drug when properly used. ^ "The Venereal Diseases/' E. W. Taylor. UNTOWARD EFFECTS OF MERCUEY. 489 Mercurial Depression. — Cases are occasionally met with in which mer- cury has a yery unsalutary effect upon the patient, in the form of intense mental and emotional depression, even when very moderate doses are given. In such cases it may be necessary to give tonics and even stimulants, in order to counteract this condition. Or it may even he necessary to stop the mer- cury entirely, and depend upon potassic iodid. Coca-wine or fluid extract and quinin will be found useful in such cases. Ptyalism. — One of the most frequent of the injurious elfeets produced by mercury is ptyalism. Salivation in any marked degree is always injuri- ous, and no more pronounced effect should ever be produced than a slight increase in the salivary secretion, a coppery taste in the mouth, a slightly- bluish tint at the margin of the gums, and — what is often a good indication to diminish the amount of mercury — a sensation as if the teeth were too long. This latter symptom is of especial value. Ptyalism may go on to acute stomatitis. Ulceration of the cheeks or gums sometimes occurs with- out previous salivation; but this is quite rare. To prevent these annoyances, the mouth and teeth ought to be put in perfect order by the dentist, prior to beginning treatment. Tartar should be removed and the teeth cleaned, and all those that are decayed either extracted or filled. The causes of salivation are idiosyncrasy or excretory inactivity with moderate doses of mercury or large doses without idiosyncrasy. Diseases of the mouth and gums predispose to it, and sometimes exposure to cold and wet during a mercurial course will bring it on. The elimination of mercury from the system being chiefly through the medium of the bowels, skin, sali- vary glands, and, in slight amount, the kidneys, ptyalism and other cumu- lative evil effects of the drug may be best guarded against by the adminis- tration of diuretics, laxatives, and the use of hot baths. Ptyalism is not likely to occur so long as the eliminative areas are not inhibited in the per- formance of their functions. The dicta of various authorities regarding the channels by which mercury is eliminated from the body appear to the author to be very unre- liable. It has been so often asserted that mercury is chiefly eliminated by the kidneys that the profession has taken it for granted, and writers upon therapeutics and materia medica have gone on repeating the mistaken notions of our medical forefathers, much to the disadvantage of scientific therapeutics. The experiments related in so important a work as Blyth, on "Poisons," are as vague as possible. For example, after asserting that the main channel by which absorbed mercury passes out of tlie body is the kidneys, Blyth substantiates his claim by quoting from Bynssen, who — after experimenting with mercuric chlorid — -came to the conclusion that "it could be detected in the urine in about two hours, and in the saliva about four hours after its administration." Bynssen considered that elimination was complete in twenty-four hours. The amount of mercuric chlorid given is stated, but nothing is said 490 TEEATMEXT OF SYPHILIS. about the quantity recovered nor the form in which it appeared. It was recovered as a sulphid, but the form in which it existed in the urine was undetermined. That a certain amount of mercury is discoverable in the urine during the administration of that drug is probably true. It is hardly possible that so many experimenters as have investigated this subject could have been deceived. So far as the treatment of syphilis is concerned, the mercuric chlorid — the most soluble form and therefore the form that is most likely to be eliminated by the kidneys — is exceptionally given. The mercurous iodid, mercurous chlorid, tannate and hydrarg. cum creta, and ung. hydrarg., convey mercury into the system in a form that is eliminated chiefly by the bowel, the kidney playing a secondary and minor role. As already intimated, the presence of mercury in the urine in any other than the metallic form shows conclusively that Clevenger's theory, while prob- ably in the main correct, is, as already intimated by the author, insufficient to explain the jDhysiologic action of mercury entirely. If mercury Avere eliminated in the metallic form in the urine to any extent, it would accumu- late in greater or less amount in the bottom of the bladder, or in any vessel into which the urine might be ejected. Its presence in the urine in soluble form shows that it acts upon the system chemically as well as mechanically. Potassic iodid assists in the elimination of mercury, chiefly through its deobstruent action upon the tissues and by increasing secretion and excre- tion. Exposure to cold and wet during a mercurial course causes ptyalism, through the reflex hyperemia and consequent inhibition of function of the eliminative areas incident to cold-taking. Treatment of Ptyalism.- — Obviously, the first step is to stop the mer- curial. Potassic chlorate may be given internally, and a mouth-wash used, composed of potassic chlorid and tincture of myrrh, in the proportion of 5ij of the potassic chlorid and .^ss of tincture of myrrh to ^iiiss of water. Glycerin may be added if desired. The chlorid of potassium, and not the chlorate, should be specified in this mixture. In some severe cases of sali- vation the patient cannot swalloAv solid food, and, whether this be the case or not, fluid aliment is -indicated. As already noted, the skin, kidneys, and more particularly the bowels require attention. The kidneys may be assisted in the performance of their function by Turkish baths and Jaborandi. Chlo- rate of potassium in doses of 10 grains every three hours is very useful. The kidneys should be flushed by copious draughts of hot water in combination with potassic citrate. It is not wise to give potassic iodid at first, as it may enhance the difficulty by liberating and making active any mercury that has become stored up in the system. As the case improves the iodids may be given with great benefit. A single case of mercurial salivation is suf- ficient warning against the abuse of a really excellent drug. The fetor of the breath in these cases is something horrible, and is due to the presence of decomposing fat in the saliva produced by the action of mercury upon the tissues and eliminated bv the salivarv glands. In some cases of mer- UNTOWARD EFFECTS OF MEECUEY. 491 curial stomatitis the cheeks, tongue, and lips are fearfully swelled, perhaps ulcerated, and covered with a yellowish pultaceous deposit that is eminently characteristic. In certain instances chronic pains of a rheumatic character, muscular and articular, result from mercury. Experience shows that when a patient who is taking mercury begins to complain of vague pains in the forearms and legs, it is time to stop the mercury and give iodin. A fact that is worthy of mention is that some patients complain bitterly of pains in the heels, and sometimes the soles of the feet, similar to that which occurs in gonorrheal rheumatism. This is probably due to mercury. When the patient complains of his feet's being tender, the dosage of mercury should be lessened and iodids given. There is a serious question in the author's mind whether some of the ulcerations of the mouth and tongue in the later periods of syphilis may not be due to injudiciously-given mercury. There are many such cases in which the continued use of the drug appears to make matters worse. When iodids are substituted improvement at once occurs. This has been attributed to the action of the iodin in liberating and revivifying, so to speak, the latent mercury; but this is not a sufficient explanation of the beneficial action of iodin. Chlorate of potassium is also effective. Cases of syphilis are occasionally met with in practice that put the surgeon at his wit's end for suitable remedies. The following is an illus- trative case: — - Case. — A woman, aged 26, has been suflfering from an attack of syphilis for over a year. She has gone through successive eruptions, with their concomitant mucous lesions, Avhile under active treatment. Thus, she has had the roseola, followed by a papulo-squamous syphilide with mucous patches of a severe type, a tuberculo- squamous eruption followed by ulcerations and accompanied by condylomata, and two attacks of iritis. Experience has shown that this patient is made worse by mercury. Unfortunately, however, her stomach is so irritable that iodids are not tolerated for any length of time, and the author has therefore been forced to rely, for the most part, upon tonics, coca having acted best of any that have been tried. The use of the iodids in syphilis requires some special notice. The active element in these salts is supposed to be the free iodin that is liber- ated in the system; but there seems to be some difference in the degree of effect exerted by the various salts. The potassic iodicl is the most powerful, but is most liable to produce gastro-intestinal irritation. This does not, however, impair its usefulness to any great extent; hence it is the most generally used of all the preparations of iodin. The sodic salt is milder, and is a useful substitute for the potassic iodid where the j)atient has a feeble or irritable digestive apparatus. The iodids are often and success- fully used in combination, the ammonium iodid being combined with the iodids of potassium and sodium. Pure iodin is useful, but usually too irritating to the digestive tract. The iodid of starch is valuable where the 492 TREATMENT OF SYPHILIS. stomach is extremely irritable. An excellent plan is to have the patient follow the potassic iodid by a copious draught of dilute starch-water. Cal- cium iodid is valuable, especially where debility is a prominent factor in the case. • This salt deserves more extensive trial. Where a rheumatic or gouty diathesis complicates syphilis, the preparation known as the "tri-iodids" has proved very valuable.^ This preparation is a legitimate one, containing iodin in combination with vegetable alkaloids. In passing, the author desires to state that the gouty or rheumatic taint often complicates S5^philis, and is responsible for many painful muscular and bone symptoms usually attributed to the syphilis itself or, what is more likely, to mercury. It is an almost universal custom to use iodin and its preparations only in the late periods of the disease, and chiefly in tertiary lesions; but it will be found that many cases of obstinate secondary lesions will not yield until the iodids are given. As already stated, it is well to give a few weeks' course of the iodids from time to time, throughout the course of mercurial treatment. A small amount of the nascent mercuric iodid — mixed treatment — may be given at the same time if thought best. In precocious syphilis, in which destructive skin-lesions and mucous lesions or nerve-changes come on early in the disease, the iodids are sometimes our chief reliance. It is in late syphilis, however, that the iodids will be found most reliable, especially if combined with mercury in the form of "mixed treatment." Gummy lesions require an excess of the iodids; but, in all cases after the lesions are under control, a prolonged mild mercurial course should be instituted. This is the proper method of treating the deeper lesions of the brain, spinal cord, bones, viscera, testicle, etc.; tubercular lesions of various kinds; the various scaly eruptions; and those later syphilides that tend to aggregate themselves in groups or become particularly obstinate. As an example of the mixed treat- ment, the following is an eligible formula: — IJ Hydrarg. bichloridi gr. iv. Ammon. iodidi 3iij. Kalii iodidi 3v 9 j. Tr. cinchon. co., or Syr. sarsap. co §iv. M. Sig. : 3j in a wineglass of water after each meal. Where it is desirable to use an alterative tonic in combination with the iodids the author frequently gives the "elixir of the three chlorids." This is a very reliable and elegant mixture.^ The formula contains in each dram : — Protochlorid of iron, gr. Vs; bichlorid of mercury, gr. V128; ehlorid of arsenic, gY. ^/eso; combined with calisaya, alkaloids, and aromatics. A desirable formula is as follows: — ^ The "tri-iodids" and "three chlorids" are prepared by the Henry Phamiacal Co., of Louisville, Ky. EFFECT OF THE lODIDS. 493 IJ Kalii iodidi 3ii3ij. Ammon. chloridi 3ii 3 ij . Liq. fenisenici (Henry) Biv. M. Sig. : 3i to 3ij after each meal. When it is necessary to stop active treatment the author frequently gives a tonic course of the elixir of the chlorids alone. Potassium chlorate is often of great service in the treatment of syphilis. The occasional alternation of a two or three weeks' course of this drug with the routine mercurial course often gives excellent results, especially where lesions of the mouth exist. Gunn's "three-eights" mixture is an excellent one for the administra- tion of iodin. It is as follows: — I^ lodinii resubl » gr. viij. Potass, iodidi 3viij. Syr. sarsap. co , §viij. M. Sig.: 3j dose. Patients should be impressed with the necessity of freely diluting iodin or iodid preparations before taking, as they are all more or less irritating to the stomach. So far as possible, they should be taken after meals. In some instances, however, in which the patient's digestive organs are not very sensitive, the iodids may be taken with advantage while fasting, especially if combined with a vegetable bitter like quassia or cinchona or with some carbonated water such as the sparkling Garrod spa or apollinaris. In the formulas given for the mixed treatment the combination of incompatibles and the irritating bichlorid seem greatly in evidence, but the ingredients are rationally compatible, although not chemically so. There is a chemic reaction in the mixture that results in the formation of the biniodid, which is very active by virtue of its nascent condition. When it is necessary to push the dose of the iodids, this may be done by adding a saturated solution of sodic or potassic iodid, in doses of 10 drops (or 5 minims, representing 5 grains) thrice daily to begin with, to be subsequently increased 2 drops, or 1 minim, daily per dose until the limit of tolerance has been reached or the symptoms yield, when the dose may be reduced, the favorable result meanwhile continuing. It is sometimes necessary to use mercurial inunctions in addition to the iodids, and the local application of the oleate is often of great assistance in the cure of obstinate skin-lesions. The deep-seated ulcerations — especially those of the throat, syphilis of the bones, and syphilis of the brain and cord — often require enormous doses of the iodids before they exhibit any signs of yielding. During the author's service in the venereal wards of the New York Charity Hospital a daily dose of 200 or 300 grains of potassic iodid was nothing unusual, and Van Buren relates a case in which 900 grains were given daily for eleven days. The author has had a number of eases in 494 TEEATMEXT OF SYPHILIS. priyate practice in which, the drug was increased to a daily allowance of from 300 to 600 grains. Much depends upon the purity of the drug. Potassic iodid is often largely adulterated with potassic hromid, which makes the supposed iodid readily tolerated. Making due allowance for adulterations, however, the doses tolerated hy some patients are amazing. There is great variation in the tolerance of different patients for the iodids. Some will take several hundred grains daily for weeks, while, on the other hand, cases are met with that will not tolerate the most minute doses of the iodids. The degree of tolerance of potassic iodid exhibited by different patients greatly depends upon the general management of the constitu- tional condition. The iodids produce great debility and wasting when given in large doses, unless great care be used. Many cases of late syphilis are suff'ering with two conditions, viz.: the debility produced by long-continued syphilis, and the malnutrition and anemia incident to injudicious mercurial treatment. Great care is always necessary in such cases to keep up general nutrition. If the syphilis per se be treated, injury is apt to be done; but, if the syphilis be relegated to the background and the patient himself attended to, much good may be accom- plished. Some patients who have sequels of syjDhilis and who have taken more or less mercury in times past, state that they "cannot stand mercury." To such patients the physician may usually safely say that they not only can tolerate mercury, but that they probably can take it and grow fat at the same time. Mercury produces effects that vary greatly according to the idiosyncrasy and resisting power of the patient, and the dose, prep- aration, and method of administration of the drug. Given in minute doses in combination with the iodids, it acts as a powerful tonic. The proper method of administration of potassic iodid in late syphilis is in the form of the saturated solution, as already designated. At the same time, the formula for the mixed treatment, with a dose of the bichlorid not to exceed ^/ga of a grain, should be given. The dose of the iodid can be in- creased by drops as required. Codliver-oil and iron are alwa3^s necessary in these cases. The oil may be given as an emulsion, and the iron in the form of the diah'zed iron or syrup of the iodid. As illustrative of the ex- cellent effects of this method of management, the following cases are in- structive, although in no sense remarkable: — Case 1. — A physician, 35 years of age, contracted syphilis at the age of twenty- eight, and went through a more than ordinarily severe course of the disease. Two years after the commencement of his trouble extensive ulcerations appeared upon his right leg, and, as the veins of his limb were varicose, the lesions proved very obstinate, and had never perfectly healed. In the meantime the patient had be- come thoroughly disgusted with mercuiy on account of injudicious treatment early in the case. At the time he Avas first seen debility was quite marked. Potassic iodid in increasing doses, with ^/ss grain of the bichlorid, Avere ordered, and, later on, a mixture of syr. ferri iod. and ol. morrhuae. Antiseptic strapping constituted the local treatment. The oil and iron were ordered in shen-y-wine after meals, and the UNTOWAED EFFECTS OF lODIX. 4:95 patient was as much surprised as gi-atified at this prescription. Improvement was rapid, and the patient gained fourteen pounds in weight in about four weeks, the ulcer nieanwliile cicatrizing completely. Case 2. — A Avoman of 30 consulted the author in regard to necrosis of the palate and nasal and superior maxillaiy bones. Small portions of necrosed bone were removed from time to time. Tonic doses of mercury with increasing doses of potassie iodid, in combination with oil and iron were given. Although she was much debili- tated, the dose of iodid was increased until 180 grains per diem were taken, and with the best results. The nose and throat improved, the necrosis ceased, and the patient gained about twelve pounds weight in the course of a month. Case 3. — This case was that of a man of 33 years who had lesions of the nose and pharynx similar to those of Case 2. Anemia was not marked, but wasting was quite pronounced. The patient stated that he could not take potassie iodid, as it disturbed his stomach and made him thin. Under the treatment already recommended this patient was finally given nearly 200 grains of jaotassic iodid daily, for at least two weeks. At the end of six weeks' treatment he had gained seventeen pounds in weight, and returned to his home in a neighboring city in better health than at any time since he contracted his syphilis. A number of similar cases might be described, but the histories above given are sufficient to illustrate what judicious treatment can do in late syph- ilis, and are consequently as valuable as a larger number would be. Untowaed Effects of Iodix. — Like the unpleasant effects of mercury, those of iodin require more than casual attention. In the first place, the iodids may cause sudden and severe ptyalism in patients who have been taking mercury freely, simply by suddenly liberating and rendering active the latter drug. On this account, caution should be exercised in the use of the iodids in such cases as have been under a prolonged course of mercurials. It will also be found in every case that iodin has a special action upon the salivary glands, whether the patient has been taking mercury or not. "Within a very short time after taking a full dose of potassie iodid the iodin can be distinctly tasted, and the saliva, and mucus from the nasal passages, will exhibit a decidedly yellowish tinge. The nasal mucus, espe- cially, will be greatly increased in amount. lodism. — The most important of the evils that may be caused by the iodids is the condition known as "iodism." This consists in a feeling of depression and malaise, nervous irritability, tinnitus aurium; neuralgic or rheumatic pains in various situations, especially in the bones and muscles; and irritation of the various mucous surfaces, especially those of the eyes and nose. The latter symptom may be merely a mild coryza or may amount to a very severe inflammatory edema of the conjunctiva and nasal and lacrymal apparatuses. Violent diarrhea and vomiting, with severe griping pain, may occur from the irritant action of the drug upon the gastro-in- testinal mucosa, and may necessitate its complete suspension for a time. Often, however, the treatment may be continued by substituting the sodic for the potassie salt, limiting the diet to rice and milk, and giving large doses of subnitrate of bismuth. When given as already suggested, by be- 496 TEEATMEXT OF SYPHILIS. ginning with small doses and gradually increasing until the limit of toler- ance is reached^ there is usually little difficulty in administering large doses of the iodids. An excellent method for the administration of the iodids in cases of intolerance is to mix the drug with a large quantity of lithia-water. Twenty to 60 grains of sodic or potassic iodid may be dissolved in 2 to 4 quarts of water and drunk during 'twenty-four hours. The eliminative ac- tion of the water itself is of great benefit in syphilis. There is no better adjuvant to treatment than drinking large quantities of pure water. lodin Eruptions. — Some persons are the subjects of an idiosyncrasy that renders them peculiarly liable to eruptive phenomena, even when small doses are given. The author has a patient at the present time who cannot take potassic iodid in 10-grain doses for a day without the development of multiple, red, painful swellings — erythema — upon his limbs. Some pa- tients are liable to extreme iodism from very small doses. A professional gentleman of the author's acquaintance cannot tolerate the drug in doses of 2 or 3 grains without the development of a severe coryza within a few hours. In another case a ^/4-grain dose causes typic iodism. There are three principal forms of eruption that may result from iodin and the iodids, viz.: acne, erythema, and purpura. Of these eruptions acne is the most frequent, and may be slight or quite extensive, the pustules varying from the size of the head of a pin to quite extensive phlegmonoid abscesses. Iodin erythema is usually situated upon the nose, cheeks, or forehead, and is followed by branny desquamation. It may, however, merge into eczema. Any of these forms of eruption may be attended by consider- able heat and itching. Severe and well-marked purpura hemorrhagica is occasionally noted in cases of syphilitic sequels treated by large doses of potassic iodid. Such patients suffer from the combined evil propensities of the syphilitic cachexia and large doses of iodin. This explains the profound blood-changes to which the purpuric extravasations are attributable.^ Fatal cases of iodin poisoning have been reported; hence a certain amount of caution must be exercised in cases in which there is a marked contra-indicating idiosyn- crasy. A case is reported of a man with cardiac hypertrophy and subacute renal disease who died as a result of the administration of 30 grains of potassic iodid during a period of about thirty-six hours. It is quite easy to explain the manner in which idiosyncrasy acted in this case. The abnor- mally irritating effect of the iodid completely suspended the action of the kidneys, these organs being already impaired by disease. Such cases serve as a warning against giving iodin freely to nephritics until we are certain that no idiosyncrasy exists. Eenal disease alone is not necessarily a contra- indication for the iodids. On the contrary, they are often of great value in the treatment of the renal disease itself. ^ Otis claims to have seen, as a result of the iodids, patches resembling diph- theritic deposit upon the mucous membrane. NEW EEMEDIES FOE SYPHILIS. 497 All of the evil effects of the iodids rapidly disappear upon the cessation of the drug and the administration of such tonics as quinin, iron, and cod- liver-oil, with free doses of such diuretics as the potassic citrate or acetate. The cause of the evil phenomena described is usually defective action of the kidneys, — i.e., defective elimination; hence the advisability of pro- moting free diuresis during a course of the iodids. Acne, in certain special cases of idiosyncrasy, may be prevented by the administration of Fowler's solution of- arsenic, conjointly with the iodids. Neiv Remedies for Syphilis.- — There is a tendency on the part of the profession to recommend various new and questionable preparations in the treatment of syphilis. Certain vegetable preparations have enjoyed a more or less long-lived popularity in this respect. Sarsaparilla was long thought to be a specific. Among the new preparations are cascara amarga, berberis aquafolium, and stillingia, alone or in combination. A trial of these things demonstrates their unreliability and shows more plainly than ever the value of iodin and mercury. As bitter tonics the vaunted vegetable preparations are all more or less useful, but as specifics they are arrant humbugs. A certain quasiproprietary medicine composed of various vege- table ingredients was introduced as a specific a few years since, and unfortu- nately fathered by no less a man than the elder Sims. As a matter of fact, it is a fairly eligible combination of vegetable tonics, useful enough as such, but without the slightest justifiable claim as a specific therapeutic agent. Tayuga, another remedy of doubtful origin that was recommended as a spe- cific some years ago, has been given a fair trial in syphilis, but with negative results. The bichromate of potassiiim has been recommended, but the author has had no experience with it. This drug was first introduced as a remedy for syphilis by Gtintz, of Dresden, who claims surprisingly good results froni its use. He at first gave gr. Vis i^ combination with potassium nitrate, three times a day, but subsequently obtained better effects from what he styles "chromwasser," which consists of a solution of potassic bichromate in carbonic-acid water. With this preparation, he claims to be able to give 3 ^/2 grains of the drug daily, the quantity of carbonated water necessary being about 6000 grammes. The remedy is to be given after meals. Giintz •claims that this remedy is curative in syphilis on account of its powerful oxidizing properties. While it is undoubtedly best to be liberal with respect to the various new remedies for syphilis and give different remedies a fair trial, irrespective of their origin, the proportion of cases of syphilis that is curable by the judicious use of mercury and iodin is so large and so gratifying that the practitioner is hardly warranted in wasting much time upon new and strange drugs.^ ^Taylor estimates the proportion of cures under mercury and iodin at about 95 per cent., but this is probably too optimistic. 498 TEEATMEXT OF SYPHILIS. Two remedies that have been decidedly beneficial as tonics in syphilis, in the authors experience, are the fluid extract of coca and iodoform. Coca is an excellent tonic when used conjointly with strictly antisyphilitic treatment, and tends decidedly to relieve the nervous depression from which most syphilitics suffer. It may sometimes be combined with sherry or port wine with advantage. Tajdor also praises the erythroxylon coca as follows: — Its marked tonic effect upon the heart, nervous system, and capillaries, and its power to invigorate the system, improve nutrition, and sustain life is so great that its use in syphilis, secondary to that of mercury and of potassium iodid is attended by results which no other agent known to us possesses. It is especially useful in the anemia and cachexia of the secondary period, and in marked debilitated and cachectic conditions at all stages of the disease. Iodoform will be found quite useful in cases that do not tolerate mer- cury and iodin well, and should be combined with the exsiccated sulphate of iron or iron by hydrogen, the latter, perhaps, being the most useful and convenient. Ferratin and peptomangan, new preparations of iron, are very useful. It is pleasant and readily assimilable. There are two other drugs which, while not in any sense curative, are very beneficial in S3q3hilis. These are the potassic chlorate and amnionic chlorid. The former in doses of a tablespoonful of the saturated solution thrice daily seems to act very well when conjoined with the regular mercurial course, particularly when oral or faucial lesions are prominent symptoms. The amnionic chlorid assists in dissolving the young connective tissue or plastic deposit that forms the bulk of syphilitic lesions. It has seemed especially useful in nervous syphilis. It is best given in combination with the ordinary mixed treatment. Du- mesnil also claims excellent results from this drug. The internal administration of gold has been vaunted in the treatment of some phases of syphilis. Xo preparation of gold has in the slightest degree a specific effect, unless combined with mercury. Gold, per se, is, however, of value in the syphilitic cachexia, and in some of the nervous sequels of s^'philis. The combinations of gold and arsenic and, more espe- cialh', of gold and mercur}', devised by Barclay, and Clark's solution of the chlorid, are, so far as the author is aware, the only ^ireparations in which gold is present in an assimilable form. These formulas often give excellent results. Local Teeatmext of Syphilis. — Before leaving the subject of the treatment of syjihilis the author desires to call particular attention to cer- tain items in the local management of the disease that have proved of great service in his own practice. There is little to add to what has already been said regarding the treat- ment of the chancre itself, save in the way of recapitulation, but some of the skin-lesions and mucous lesions demand more exhaustive consideration. Local Treatment of tlie Chancre. — First principle, avoid caustics. LOCAL TREATMENT OF SYPHILITIC LESIOXS. 499 Second principle, avoid grease. Third principle, keep the part dr}^, as a rule, and perfectly clean. A clear understanding of the merits of the chancre per se will prevent many foolish patients from applying caustics, liniments, and filthy salves prescribed by their friends or by various doctors to whom they apply, one after the other, in search of the impossible— a three days' cure. It would seem unnecessary to warn physicians against the use of caustics in syphilitic chancre; but the specialist — who sees so many cases of chancre tortured into serious inflammation, and perhaps sloughing, by copper sulphate or silver nitrate in the hands of general practitioners and drug-clerks — knows full well the practicality and importance of such warning. A very important point in the management of severe chancre is the maintenance of rest. Movement and friction are often responsible for serious complications of chancre. That sexual intercourse should be inter- dicted goes without the saying. Eegarding the latter point, the patient should be duly impressed with the danger of contagion. He should under- stand that the slightest abrasion upon his penis, occurring at any time within three years after infection, may infect the female. The married man who understands this and is careless must assume all responsibility for evil results. The only exceptions to the rule regarding caustics are mixed sores, with a minimum of induration, and exulcerated sores that become sluggish and refuse to heal after induration has nearly or q^uite disappeared. In the first instance pure carbolic acid followed by fuming nitric acid is admissible, but the galvanocautery, preceded by cocaine, is better. In sluggish ulcers stimulation with silver nitrate may be warrantable. The exception to the rule regarding grease is the application of iodo- form ointment to sluggish or painful sores. The following formula will be found to be excellent, the odor of the iodoform being well disguised. The author attributes this property to the menthol. IJ Mentholis gr. v. lodoformi 3iv. Cetacei alb. ._ 3ij. Cerati q. s. ad Bj- M. Sig. : Apply on lint. Oil of mirbane may be used in lieu of menthol, but is more irritating and less effective when used in ointment. Where there is considerable pain, cocain and extract of belladonna may be added: — IJ 01. mirbani m. iv. Bals. Peru 3iij . lodoformi 3ij. Vaselini q. s. ad §j. — M. The old-time black and yellow washes are serviceable, although the part cannot be kept dry under their use. A solution of mercuric chlorid 500 TEEATMEXT OF SYPHILIS. 1 to 1000 is very useful. A plan recommended for the application of the bichlorid is to wash the lesion with a weak solution of common salt. Calomel is now sprinkled upon the part, a small amount of nascent and active bi- chlorid being thus formed. The author has used this plan for condylomata quite successfully. The best absorbent for the dry treatment is the pow- dered oleate or stearate of zinc. A useful combination is the following: — IJ Bismutlii subnitratis 3iij. Ac. salicylatis gr. ij. Zinci oleatis q. s. ad §j . — M. Simple calomel is also serviceable. Turpeth mineral affords a very de- sirable method of applying a mercurial in a dry form. Oxid of zinc and lycopodium are also very good, used in equal parts. The part may be kept dry by absorbent cotton. Cumbersome dressings must be avoided, especially such as require for their retention constriction of the penis. Pronoimced induration often persists for months without ulceration, or after a concomitant ulcer has healed. Bathing in hot water, with fric- tions of hydrarg. oleat., 5 per cent., will usually resolve them after a time. The easiest and best method is excision. There is often no objection to early excision of clearly-cut chancres upon the prepuce or integument. Care should be taken, however, never to excise them until they have become stationary, else recurrence is almost certain. Local Treatment of Shin-lesions. — The roseola seldom requires atten- tion. If, however, pigmentation is marked and lasting, hot baths with fric- tions of 20-per-cent. oleate will be serviceable. In ordering the oleate Squibb's should be specified. There may be others quite as good, but not to the author's knowledge; certainly there are none better. Papules, tubercles, squamas, and other dry lesions can be controlled and rapidly resolved by applications of the following formulas. Care should be taken in the selection of the proper strength — ^blistering may result, and, though sometimes beneficial, is likely to cause the patient to lose confidence. There is great variation in integumentary susceptibility. The collodion preparation is the one that is most likely to blister:- — IJ Hydrarg. bichloridi gr. v to gr. x. Collodionis Bj. M. Sig. : Apply Avith eamel's-hair pencil. ij Hydrarg. bichloridi gr. v to gr. x. Tr. benzoini co §J. M. Sig. : Apply. Tincture of Tolu is also an excellent vehicle for the local application of mercuric chlorid. The results obtained by these preparations are often remarkable. They are of especial value in removing facial blemishes; they hasten removal of pigmentation very niarkedly. Their efficacy is easily tested by contrast- LOCAL TEEATMENT OF SYPHILITIC LESIONS. 501 ing the course of facial lesions treated by them with that of other integu- mentary lesions upon the same patient. The solution of bichlorid in compound tincture of benzoin is often better than the collodion solution. It is less apt to blister and may be intrusted to the patient for application. It is, however, rather disagreeable in that it discolors the skin, and is with difficulty removed. The oleate of copper, recommended by Shoemaker for freckles and other pigmentary lesions of the skin, seems to act well in removing the discolorations left by the syphilides. Soaps containing mercury bichlorid are also useful. In ecthymatous or rupial ulcerations applications of the oleate of mercury or mercurial plaster are beneficial. Crusts and squamas, if thick, are benefited by applications of ung. hydrarg. nitrat. to the sublying lesions. The ammoniated-mercury oint- ment is useful in some instances. Where the lesions are very obstinate, an occasional application of the pure acid, hydrarg. nitrat. after removal of the crusts will hasten resolution. Ulcers require especial care. Ointments of iodoform, hydrarg. oleat., ung. hydrarg., the citrin and white-precipitate ointment are all of service in different cases; one failing, another should be used. Occasional stimula- tion with argent, nitrat. or even the acid nitrate of mercury may be re- quired. Should ulcerations be attacked by phagedena, Eicord's paste, bro- min, or the actual cautery may be used. The author's preference is for pure bromin. Applications of the potassio-tartrate of iron — 20 grains to the ounce — are effective in some cases. Ulcers may require excision of under- mined edges and curettement. Nodes and diffuse osteoperiosteal swellings may usually be resolved by frictions of ung. hydrarg., hydrarg. oleat., or ung. iodinii co. The author has obtained good results from hypodermics of a solution of the bichlorid immediately contiguous to the swelling. A blister, followed by ung. hydrarg., is often efficacious in disposing of obstinate nodes. The tincture of iodin is also useful. Necrosis of the bones in various situations is often encountered in late syphilis: i.e., the period of sequels. An effort should be made to determine whether the osseous troubles are due to syphilis or to mercury. Whether syphilitic or not, however, such cases must be treated largely upon general principles. Tonics are always indicated. The iodids are our main reliance, mercury, if given at all, being indicated only in tonic doses. The following case is a fair illustration of the destruction sometimes produced by necrosis in late syphilis: — Case. — A young man of 30 vras referred by his physician for a possible operation upon the naso-pharyngeal cavity for the removal of dead bone. The palatal and nasal bones were found to have been entirely destroyed. Destructive ulceration had already attacked the vault of the pharynx and was threatening the osseous structures at the base of the skull. Mercurial treatment had been persisted in for the entire 502 TEEATME'S'T OF SYPHILIS. course of the disease, which had been contracted nine years before. A few small scales of necrosed bone that Avere partially detached were removed, and the patient put upon tonics and increasing doses of the iodid. Improvement was quite rapid, the lesions healed, and the patient was sent home at the end of six weeks in compara- tively good health. The obstinate headaches of both late and early syphilis, whether asso- ciated with cranial bone-lesions or not, are benefited by frictions of the scalp with hydrarg. oleat. — 10 per cent. The nng. hydrarg. is also serviceable. In obstinate cases a blister to the nncha, followed by mercnrial plaster, is quite effective. There are occasional cases of cephalalgia associated with the cachexia sypliilitica where the galvanic current is of great service. Bromids in large doses sometimes act well. Leeches are often useful. The possible indication of elimination of toxins should be borne in mind. Mucous Patches. — Mucous patches sometimes give great annoyance, and refuse to yield to purely-constitutional treatment, becoming sluggish and indolent. In such an event the pure acid nitrate of mercury will be found to be the best application. Before applying it the lesion should be dried with a piece of bibulous paper or absorbent cotton. The surface should then be thoroughly cauterized, after which it should be again dried. The nitrate of silver may be used in the same manner. Sometimes cauter- ization is not tolerated, the lesion becoming inflamed and irritable. In such cases the tr. benzoin co., either alone or in combination with the mercuric chlorid, will be found most effective. . It coats the lesion with a deposit of gum benzoin, and, in addition to its mildly stimulant and antiseptic action, protects the surface from irritation. When mucous patches hyper- trophy and form tubercles or condylomata, an application of hydrarg. bichlor. in collodion, 4 to 20 grains to the ounce, will be found to remove them very rapidly. Calomel, zinc oxid, salicylic acid, and iodoform are also quite useful aj^plications. Salicylic-acid ointment or plaster and chrysarobin are very useful appli- cations in the scaly syphilides and syphilitic "psoriasis." The following formula is useful in the latter condition: — B^ 01. cadini '. . . . 3ij. Ung. hydrargyri §ss. Lanolini q. s. ad Bj. M. To be used by inunction, morning and evening, for syphilitic psoriasis of the palms and soles. Washing the ^jarts in salt solution, followed by the application of calo- mel is also of service, as nascent bichlorid of mercury is formed and acts very powerfully upon the lesions. Very obstinate skin-lesions will often be found to improve rapidly under mercurial fumigations, after all other methods of treatment have proved inefficacious. LOCAL TREATMENT OF SYPHILITIC LESIOXS. 503 Continuous applications of oleate of mercury or mercurial plaster are beneficial. Gummy ulceration, especially when situated in the mouth or pharynx, is hest treated by the application of benzoin co. Iodoform is also quite effectual, but unpleasant, for most patients do not like to have such an odorous application in so close proximity to their nasal and digestive organs. The following formulas will be found quite effectual in lesions of the throat and nose: — IJ lodoformi, Camphorse of each 3iij. Morphise gr. ij- Pulv. acacise 3ij. Ac. tannic! gr. x. Bismuthi subnitratis 3iv. M. Sig.: Use with poAvder-blower. IJ lodinii puri gr. xx. Kalii iodidi gr. Ix. Ac. carbolici 3ss. Olei eucalypti 3j. Boroglyceridi 3iij. Olei menth. pip • m. x. Glycerin, tannat q. s. ad 5j- M. Sig.: Apply with a probang or camel's-hair pencil. Iritis. — The therapy of this complication of syphilis merits special con- sideration. In this disease synechias or adhesions form ver}- rapidl}" and treatment must be correspondingly vigorous. Where possible, the responsi- bility should be divided with a competent ophthalmologist. The patient must be brought under mercury as rapidly as possible. Either hypodermic injections of the mercuric chlorid or minute doses of calomel frequently repeated are excellent methods. A combination of inunction and internal administration is usually effective. Leeches should be applied to the tem- poral region, and cathartics administered to secure the benefits of derivation and local depletion. Either hot or cold apijlications may prove beneficial. Most important of all is dilatation of the pupil by atropin. A solution of from 4 to 8 grains to the ounce should be instilled into the eye several times daily until dilatation is complete. Weak collyria containing bichlorid, 1 to 20,000, are of value. Concomitant herpes progenitalis is a common feature of syphilis, oc- curring most often as a sequel. As stated in the chapter on that subject, the author regards syphilis as a frequent cause of herpes. The oleate and stearate of zinc are most useful applications for this condition. Alopecia is greatly benefited by the following: — 504 TEEATMEXT OF SYPHILIS. IJ Hydrarg. bichlor gr. xx. Tr. canthar §ss. Tr. eapsici Bss. Glycerini Bj- 01. ricini §j. Sp. colognensis q. s. ad Bviij. M. Ft. lotio. Sig. : Eub in scalp night and morning. IJ Hydrarg. biniodidi gr. v. 01. verbenge m- ij- Vaselini §j. M. Sig.: Eub well into the scalp at bed-time. Treatment of Post-syphilitic Leucoplasia. — In deciding the question of the administration of antisyphilitic treatment in leucoplasia, considerable discrimination is necessary, particularly in the direction of estimating as accurately as possible its relation to other factors than syphilis. It will be found in these eases that, as a rule, the proper course of antisyphilitic treatment is tonic rather than radical. Small doses of mercury bichlorid in combination with tincture of cinchona-bark are much safer, particu- larly when used tentatively, than the larger doses commonly given in the earlier and more active periods of the constitutional infection. It may be found that even a modern amount of mercury will aggravate the lesions, and under such circumstances tonics combined with the mercurials are in- dicated. The various preparations of gold are useful as tonic alteratives. The liquor arsenii et hydrargyri bromidi (Barclay) is an excellent prepara- tion. A very excellent combination of alteratives and tonics is the prepa- ration already alluded to — the "three chlorids" (Henry). The dose of mer- cury in this preparation is so small that its specific effect may be disregarded, its tonic action only being worthy of consideration. Where syphilis is be- lieved to be still active, the author inclines to inunctions of mercurial oint- ment in combination with large and increasing doses of the potassic iodid given with great caution, particularly as regards its possible debilitating effects. It Avill be found that the majority of eases are anemic; consequently all radical measures of treatment should be carefully guarded by the judi- cious administration of nutrients and tonics. Codliver-oil in combination with a pure wine, or in some cases a moderate amount of good brandy or whisky, may be indicated. There are occasions where alcoholics are highly advantageous, even in active syphilis. This is too often disregarded. The key-note to the treatment of all post-syphilitic and late syphilitic phe- nomena is, in many cases, the administration of tonics rather than vigorous antisyphilitic treatment. With regard to the use of tobacco and liquor — with the possible exception above mentioned — there should be even less compromise than in active syphilis. With reference to the application of caustics in leucoplasia, any form TEEATMEISTT OF EAELT STPHILITIO NEUEOSES. 505 of caustic that is not immediately and thorouglily destrnctive simply acts as an irritant and aggravates the pathologic condition. Superficial caustics, such as the nitrate of silver, should be avoided. Antiseptic and astringent washes are often beneficial, and unless used in too great strength cannot possibly be harmful. So far as the various forms of antiseptics and astrin- gents are concerned, there is practically little choice so long as the prin- ciples of antisepsis are observed. From clinical experience, some of which has been of a rather un- pleasant character, the author has concluded that in obstinate cases of leu- coplasia and those that recur only one form of treatment is to be considered, and that a most radical one — viz.: free excision with the knife or scissors, followed by the actual cautery. In some cases the author has used the actual cautery alone. There should be no hesitancy in the thorough application of these measures, and from an operative stand-point it is best to regard these lesions as essentially malignant, complete and thorough destruction or ex- cision being consequently indicated. Half-hearted destruction or excision is worse than no treatment at all, as is true of genuine malignant neoplasms. Should a case present itself in the transition stage, or after malignant char- acters have asserted themselves, the lesion should be treated as is malignant disease elsewhere. There is a question in the author's mind whether these cases are not often more unfavorable than ordinary malignant disease of the mucous membranes of the mouth, on account either of the syphilitic dys- crasia or the post-syphilitic anemia and debility that are so characteristic of overdosed patients. Treatment of Nerve Disease in Early Syphilis. — The treatment of nerve disease in early syphilis is, in the main, that of the specific affection upon which it depends; hence a discussion of the therapeutics of the subject may seem superfluous. There are, nevertheless, numerous practical points that demand special consideration. Prophylaxis of nerve disorder is an important feature in all cases of syphilis. It is to be remembered that the nerve disturbances of the early period are not only important per se, but they lay the foundation for later and more serious disease. It is well, also, to bear in mind that certain factors may cause nervous disturbances that do not at the time produce symptoms, but which none the less pave the way for serious organic nervous disease at a later period. Inasmuch as vasomotor neurosis is probably an important factor in syphilitic nerve phenomena, avoidance of all causes of disturbance of the sympathetic is a prime indication. Instability of vasomotor equilibrium may often be avoided. Most surgeons are aware that tobacco and liquor are injurious to syphilitics, but comparatively few appreciate other than em- piric reasons therefor. The toxiceffect of these drugs upon nerve-protoplasm and the sympathetic ganglia is a very powerful predisposing factor in brain and nerve disease in syphilis. By them the foundation is often laid 506 TEEATJIEXT OF SYPHILIS. for sulDsequent disease of a very serious or even fatal character. Mental "worr}^ or overstrain, mental excitement, and sexual excesses constitute powerful jDredisposing causes — especially of cord disease. If the patient be given a clear understanding of the true reasons for abstinence from these injurious factors, he is likely to be much more tractable. In cases with a distinct neurojoathic taint, hereditary or otherwise^ the points that have been made are of special importance. The curative treatment of early nerve symptoms is, in the majority of cases, mercurial, first, last, and all the time; but there are certain special therapeutic features that are of greater importance than in other phe- nomena of S3q3hilis. In ordinary syphilitic phenomena a moderately-active course of treatment usually suffices, and a few days' delay in getting the disease well in hand is of no consequence. When nerve-involvement exists, however, the treatment must be very energetic, indeed, if we would avoid irreparable damage to delicate and important nerve and brain structures. The problem in such cases is how to get the patient under the full physio- logic effects of mercury most speedily. As a rule, internal medication alone cannot be relied upon; some patients, and especially those Avith nerve phe- nomena, cannot tolerate the internal use of the drug at all. The hypodermic method is much quicker and more reliable, but not all patients will submit to it. A point of practical value is the fact that the drug acts best when applied as nearly as possible to the location of the nerve-implication. Mer- curial inunctions of the neck and scalp are most efficacious in cerebral dis- turbance, while inunctions of the region of the spine are quite effective in cord symptoms. It is necessary to use ordinary inunctions in addition, in order that a sufficient quantity of mercury may be absorbed. Cases are met with in which mercury seems to be ineffectual and we are compelled to rely upon the iodids. Such cases are rare, so rare that some of them, perhapvS, are instances in Avhich the fault lies, not with the mercury, but with the manner of its use. While the mainstay of treatment is mer- cmy, certain drugs are of great value as adjuvants, and, aside from drugs, other therapeutic resources may be resorted to with advantage. Stubborn cases that resist ordinary treatment often yield readily to some one or more of the adjuvant methods. As regards the general treatment of early syph- ilitic nerve disorder, hot baths, free water-drinking, and laxatives are of especial value. These points will be expatiated upon later. Counter-irritation and derivation are often of value in early nerve syphilis. Local or general depletion may be justifiable. The author be- lieves that in some cases of severe head-symptoms it is wise to apply leeches to the mastoid regions or even perform venesection. The same rules govern here as in toxemias of other kinds. Electricity, massage, and counter-irri- tation are often serviceable in subduing obstinate symptoms tending to chronicity. It has occurred to the author that there is too much specializing GENEKAL. MANAGEMENT OF SYPHILIS.' 507 in the management of some cases of syphilis. Mercury and potassic iodid are, i.t is true, the only specifics for the disease; but this does not warrant neglect of certain remedies that are of great value for the relief of certain special conditions. Gold is especially valuable in nerve symptoms as ,a tonic and alterative. Barclay's and Clark's formulas have already been mentioned as the only reliable preparations of gold. G-old seems to have a special effect in preventing, and, to a certain extent, removing, sclerotic changes in the tissues affected by the syphilitic neoplasm. The bromid in the Barclay com- binations may be of service in correcting the vasomotor perturbations that probably exist in early nerve syphilis. In addition to the specific and eliminant treatment for early nerve syphilis, nervine tonics and remedies to correct anemia may come into play. Of the preparations of iron, ferratin, subcarbonate of iron, reduced iron, and the new preparation known as peptomangan are best. Cases occasionally arise in which a tonic stimulant becomes necessary. Under such circumstances, the wine and fluid extract of coca are of special service. The question now arises: How long shall the treatment of nerve-lesions be continued? As a matter of principle, the author believes that any course of treatment of syphilis of less than three years' duration is open to criti- cism, and is especially inclined to be dogmatic in regard to cases presenting early nerve or brain symptoms. The author has been much impressed by some of Hutchinson's cases of nerve syphilis. It would appear that some of them might have been avoided by proper treatment. Hutchinson's treat- ment is largely symptomatic; if at the end of a six months' course the symptoms have disappeared, treatment is stoj)ped, to be resumed only on the occurrence of symptoms. Steady systematic treatment by mercury, iodids, and gold is the sole assurance of safety for the syphilitic. After many years of experience with this plan in syphilis the author has rarely seen visceral, bone, nerve, or brain involvement in cases in which instruc- tions have been carried out to the letter. Geneeal Management of Syphilis. — In his attempt to cure an un- questionably specific disease by specific medication the practitioner is very apt to overlook certain essentials in the general management of syphilis that are fully as important as the use of remedies which are considered anti- syphilitic per se. Indeed, it is questionable whether philosophic general management does not often accomplish more in the long run than our mer- curials and iodids. This much may, at least, be said, viz.: that, while specific medication alone may cure syphilis, good general management, plus specific medication, is almost certain to do so. If the surgeon were com- pelled to rely upon one plan alone in the treatment of the average case, judicious general management would be most likely to achieve success. Ckire of the Moufli and Teeth. — As a matter of clinical observation, it is safe to assert that the patient who takes the best care of his mouth and 508 TEEATMEXT OF SYPHILIS. teeth is least dangerous to those about him. The question of tobacco-using is very pertinent in this connection, for it is the patient who smokes or chews tliat is most likely to have outcroppings of the disease in the mouth and throat. In addition to its local irritating action, tobacco unquestion- ably has a detrimental constitutional eifect that impairs the efficacy of medicines. Patients with bad teeth and gums should have their mouths put in order by a first-class dentist at the outset of treatment. The importance of preventing or lessening the severity and duration of lesions of the lips, mucous as]Dect of the cheeks, and tongue is not only important as bearing on the prevention of infection of innocent persons, but also with reference to the proplwlaxis of the post-syphilitic mucous lesions described in the jDreceding chapter. Dietetic Management. — The regulation of the diet of syphilitic patients is a very simple matter so far as foodstuffs are concerned. The author's advice to patients is usually to eat the best they can get and all they want of it, with this qualification, viz.: that they abstain from sweets and acids during the administration of mercury, and whenever the mouth, tongue, or throat is affected by ulcers, mucous patches, or inflammation. In the event of these lesions' appearing, spices should also be interdicted, and it may be- come necessary to prescribe a fluid diet. In case of mercurial stomatitis the latter is absolutely essential, and milk should usually be relied on as the most nourishing and acceptable form of aliment. The question of alcoholics is the most important point of all. There should be no compromise in this matter. Liquors, both vinous and malt, should be absolutely forbidden, excepting when ordered by the physician to combat some emergency or to counteract extreme debility. Patients often say: "T\"ell, but there's Tom A., who had syphilis; Dr. X. treated him and allowed him to drink and smoke all the time, and he got along finely." We might say to this patient: "The procession of veterans on Decoration Day would indicate to the superficial observer that war is not invariably fatal; yet the little white head-stones on the sunny slopes of the southern hills show that war cannot be recommended as a safe and pleasant occupation" — or words to that effect. That Tom A. has been shot at and missed is no criterion for the management of the case in hand. Again, there is always the possibility that Dr. X. was just as ignorant or as mercenary in Tom A.'s case as some physicians are in those six-month "cures" of so-called syphilis with which the conscientious surgeon is only too familiar. Eeverting again to AVillard Parker's aphorism, liquor is one of the "devils" of which the syphilitic patient must rid himself if he dfesires to give his physician a fair chance to cure him. Exposure to Cold and Wet. — This is a point of practical import. The syphilitic is necessarily more sensitive to changes of weather and exposure to the elements than a healthy person. There is no doubt that treatment, embracing, as it does, mercurials, the iodids, and hot baths, tends to increase GENERAL MANAGEMENT OF SYPHILIS. 509 this predisposition to cold-taking, rlienmatoid pains, etc. Patients of a rheumatic or gouty diathesis are not always easy to treat when syphilitic. When the patient is debilitated from any cause, whether connected with the syphilis per se or not, great caution is necessary. The skin must be kept warm, and exposure to wet weather avoided so far as possible. The adminis- tration of codliver-oil in combination with iron, quinin, or the hypophos- phites, is often of great service in warding off hypersensitiveness to baro- metric changes and in correcting debility. Such remedies are a sine qua non where the patient is strumous. The Correction of Pernicious Ideas of the Duration and Treatment of Syphilis. — It may be necessary to disabuse the patient^s mind of one or more of several fallacies, viz.: 1. That syphilis can be antidoted in a short time by specific medication or a sojourn at the Hot Springs. 2. That the disease is incurable. 3. That mercury is necessarily injurious. The nature and natural course of infectious diseases should be ex- plained, and the patient impressed with the similarity of syphilis to the commoner eruptive diseases, such as small-pox, measles, etc. He should be made to plainly understand that syphilis may be successfully conducted through its natural course to a cure; that there is no royal road to health; that attempts to "stamp out" the disease may stamp out the patient, but never the syphilis; that, while syphilis can be cured in the large majority of cases, it can only be cured by careful systematic treatment, usually for three years, and in severe cases a still longer time. The patient usually requires enlightenment on the mercury question. He should be assured that the attempt to cure syphilis without mercury is equivalent to an attempt to play Hamlet without Hamlet. He should also be informed that mercurj^, properly used, is rarely, if ever, injurious. Its abuse may injure; its proper use, almost never. Mercury is less likely to play us false than almost any drug of recognized therapeutic potency, yet nobody condemns the proper use of other drugs as remedies. Those who condemn mercury have never learned to use it properly. Patients should also understand that the cases of alleged mercurial poisoning that are harped upon by an ignorant laity and still more culpably ignorant physicians are, as a rule, either due to a misapplication of the drug or, what is more likely, are really neglected cases of syphilis that are suffering for want of mercury. So-called "mercurial lesions" are frequently cured by tonic doses of the bichlorid. It has already been admitted that mercury may do damage if injudiciously used, but its evil effects can be early detected and readily controlled. Hydrotherapy in Syphilis. — The free use of water, internally and exter- nally, is nowhere productive of more benefit than in the general manage- ment of syphilis. As an adjuvant to internal treatment, hot baths especially are invaluable. The Turkish or Eussian bath once or twice weekly has an excellent general as well as local effect, and where possible should be pre- 510 TEEATMEXT OF SYPHILIS. scribed in all cases of syphilis. Hot baths — and especially Turkish baths — have several important effects in syphilis. These are, briefly: — 1. Stimulation of the nutrition of the skin, thus rendering eruptions less likely to occur. 2. Elimination of peccant materials, and of mercury itself, thus pre- venting saturation of the system with the drug, and assisting the system in throwing off the products of retrograde metamorphosis of syphilitic neoplasia. 3. Increase of retrograde tissue-metamorphosis, thus hastening resolu- tion of syphilitic deposits. 4. A general tonic effect. 5. Followed by the cold shower, they have a marked tonic effect upon the skin, lessening the danger of cold-taking. A careful survey of the results and methods of Hot Springs treatment has convinced the majority of syphilographers that it is the hot baths, per se, and not some mysterious property which the waters contain, that is efficacious in assisting the cure of syphilis at this famous resort. Anything that favors rapid tissue-metamorphosis and hastens elimination of waste- products benefits syphilis. In this respect the hot baths at the springs may be imitated by baths that can be obtained at home — at least in our large cities. It is the author's custom to advise Turkish baths throughout the entire course of treatment for syphilis. These baths should be crowded to the point of tolerance. This varies with the resistancy of the patient. There are few patients, indeed, who cannot stand two baths per week. Special courses of rubbing with mercury and daily Turkish baths for three or more weeks are often very useful. By the exercise of a little care patients may be made to bear the frequent baths very Avell. A useful practical point is that patients do best who drink freely of very hot water while in the bath. The question of the advisability of a sojourn at Hot Springs often arises during the course of treatment of syphilis. The laity entertains a very fallacious notion of the merits of the waters of this resort. There is a belief on the part of many patients that syphilis cannot be ciired save by a trip to the springs. There seems to be complete ignorance on the part of most laymen of the fact that the usual course of treatment at the springs comprises large doses of mercury and potassic iodid, the baths being a secondary consideration. The author has had occasion to send a very small proportion of syphilitics to Hot Springs, and these were not sent because of faith in any specifically curative property of the wateres. The cases in which the author advises a sojourn at the springs are: — 1. Patients who can well afford the time and expense and who accept the trip as a therapeutic luxury. 2. Patients who wish to be away from home while undergoing vigorous treatment for palpably disfiguring lesions. 3. Patients who are run down in health and upon whom remedies no longer THE HOT SPRINGS FOR SYPHILIS. 511 act energetically. To such as these the reinvigoration incidental to a trip to the springs, with its freedom from care and worry, the rejuvenating effects of the hot baths, and the change of climate are often of great value. 4. Patients who cannot tolerate either mercurials or iodids save in a Avarm climate and with freedom from business cares. It will thus be seen that the eases in which a sojourn at the springs is really necessary are relatively few; the necessity being essentially the same in most' eases as in other debili- tating diseases. When a sojourn at the springs has been decided on, there are several points that should be impressed upon the patient's mind, viz.: 1. The fact that a sojourn at the springs does not cure syphilis nor lessen the duration of treatment. 2. That the springs are of little value unless careful treat- ment at the hands of some capable physician at that resort is also under- taken. In the selection of a physician the patient should be guided by his medical attendant at home. It must be confessed, however, that this is a matter that is difficult of control. No matter how carefully the patient may be directed to a reputable physician at the springs, he is quite likely to give ear to the wily drummer of the still wilier quack. Of the patients referred directly to skillful physicians at the springs, about one in ten arrive at the designated office. But we cannot cure our patients of foolishness and mental vacillation. The one great objection to be urged against the springs is that the patient may be led to believe that he is cured by a few weeks' sojourn thereat, and consequently neglect himself on his return. If, however, he has consulted a reputable physician at the springs, he will be informed of the necessity of returning to his regular medical attendant for a continu- ation of treatment. The charlatan, on the other hand, simply advises the patient to return to the springs and be ''cured" when he has "another at- tack of syphilis." Such dishonesty — or, perchance, ignorance — has been responsible for a large number of uncured and incurable cases of syphilis. One of the fairest dissertations upon the therapeutic value of the Hot Springs is an article by Dr. J. M. Keller,'- whose experience at that resort has certainly been extensive enough to give authority to his opinion. He says as follows: — . . . If asked — "Does the water of itself cure syphilis?"' — I answer, posi- tively, "iSTo!" If asked how it acts, the answer is simply that, by its powerful eliminative and diaphoretic power, the patient is enabled to take, if necessary, ten- fold more mercury and potash than he could possibly take without its aid; more than he could with the help of any artificially-heated bath I have ever had experi- ence with. Of the naturally-heated water patients can drink ad liMUim, for it has never been known to produce nausea. A bath at a temperature of 98° F., with ^ J. M. Keller : "Hot Springs as a Health Resort," St. Louis Medical and Sur- gical Journal, August, 1879. 512 TREATMENT OF SYPHILIS. copious draughts of the water, -will produce more profuse diaphoresis than tlie arti- ficially-heated bath will at 110°. The daily assertions, and many circular statements, that syphilis, under any plan of treatment here, can be cured in four or six weeks are all false, and have done much to ruin the reputation which the springs actually deserve. It is useless for anyone to come here under any such assurances expecting to be cured. They will surely be disappointed. They may, and generally do, find all outward or visible manifestations gone after six- weeks' active medication and bathing, and may be per- suaded that the disease has been eradicated, never to return; but the delusion seldom lasts very long, if they end their visit after that length of time. As a rule, it is useless for syphilitics to come here unless they come detennined to stay at least ten weeks. Then, if they have been properly treated, 1 am satisfied they can go home with a pretty strong assurance of the disease's being cured by continual treatment for a year or two. Dr. Keller's remark, that syphilitics treating at the springs "may, and generally do, find all outward or visible manifestations gone after six iveehs' active medication and lathing," is very suggestive in view of the fact that the same result may be attained, upon the average, by the proper use of mercury alone. The cases of secondary symptoms that do not yield within six weeks are relatively rare. Taken all in all, the claims of the springs to a specific influence in syphilis do not seem to be worth serious consideration. Laying aside ,the alleged specific action of the Hot Springs in syphilis, however, the author believes that the water has properties that are not possessed by ordinary hot water. Wherein the naturally-heated hot water difEers from that which is artificially heated does not seem to have been satisfactorily demonstrated. That the former is "charged with electricity" has been claimed, but the proofs of this electric property seem rather vague, judging from the statements of jshysicians at the springs. This much is certain, however, — and the author has verified this point by experiment upon his own person — one's experience with ordinary hot baths is not a safe criterion for guidance in taking the baths at Hot Springs. An ordi- nary hot bath at 110° F. may be taken daily for some time without dele- terious effects; not so the baths at the springs. They will be found very depressing when taken frequently at more than a moderate temperature — say 96° to 98° F. How much the climatic and atmospheric conditions at the springs have to do with the peculiar effects of the baths the author is not prepared to state. It is safe to say, however, that they should never be taken save under competent medical supervision. In studying the various classes of cases that go to the springs for treat- ment the author has been struck by the large number of unsuitable cases that wend their way to this resort for treatment. Hot Springs appears to be the Mecca of incurables. It is high time the public was given to under- stand that the springs is not a cure-all. Much harm results from the pre- vailing ignorance upon this point, and no little damage is done to the rep- utable members of the profession at the springs by improperly selected aBISTEEAL CONCLirSIONS. 513 cases, especially when such cases happen to fall in the hands of the qnacks at that resort, as is so often the case. SypJiilo phobia. — There is an nnfortunate and illogical tendency on the part of both patients and physicians to regard one who is once syphilitic as always syphilitic, and to pronounce every ailment during his after-life syphi- litic. It must be remembered that the syphilitic patient is in nowise in- sured against other ailments. Eheumatoid pains, sore throat, acne, etc., may mean no more in him than in any other individual. The physician should assure his patient that every little pimple or transitory pain does not necessarily mean that his syphilis is not cured. One of the most frequent trailers in the wake of syphilis is herpes pro- genitalis. This is a trophoneurotic effect of syphilis oftentimes, but does not mean syphilis any more than it does any other debilitating disease. But the little ulcers may annoy the patient greatly, and deceive the phy- sician; hence they must be explained. Similar herpetic ulcers often appear in the mouth and may be mistaken for mucous patches. Sometimes these ulcers are due to mercury or the iodids; sometimes they are a pure neurosis. A sore throat is very often experienced by syphilitics long after the disease proper has passed away. This is also in many cases a purely nervous derangement — or at least nervous perturbation is at the bottom of it. Often, too, it is gouty or rheumatic. GENEEAL CONCLUSIONS. 1. The cure of syphilis should not be attempted by specific medication alone, but certain general principles of management should be applied. 2. IsTo attempt should be made to destroy the chancre. Irritants should be avoided, and the patient should be assured that there is little or no danger of serious local destruction. The time-element and the necessity for caution in diagnosis should be remembered. 3. Treatment should not be begun until a positive diagnosis has been made, excepting in the rare cases where internal treatment may be neces- sary to clear up the doubt. 4. There should be little restriction in diet. All forms of liquor and tobacco should be forbidden. 5. The patient should understand that the natural course of syphilis is from eighteen months to three years. The disease cannot be cured in less time, and on the average it requires three years' treatment. 6. He should be informed that mercury, properly used, is absolutely necessary in the majority of cases of syphilis, and that no case is safe with- out it. Mercury is neither pernicious nor dangerous when properly used. 7. Most of the so-called bad effects of mercury are really cases of syph- ilis that have not had enough mercury. 8. Hot baths are necessary throughout the entire course of treatment; Turkish baths, if they can be had; plain hot baths if the former cannot. 514 TEEATMENT OF SYPHILIS. 9. The Hot Springs are not necessary in the management of syphilis. They may be of assistance in rare cases, but do not shorten the duration of syphilis a single day, nor can they be depended on for a cure. They never lessen the necessity for medical treatment. 10. Lesions in syphilitic patients or those who have once had syphilis should be diagnosed and treated upon their merits. "Once syphilitic, every- thing syphilitic" is fallacious reasoning. Patients formerly syphilitic may have non-specific- lesions, as may anyone else. 11. The laity should be given to understand that syphilis, properly treated, is not only not incurable, but is one of the most curable of all dis- eases, providing it be given the same chance for a cure as is given other chronic diseases of equal importance. This means steady and uninterrupted treatment for many months. The treatment should comprise, in the main, mercury and the iodids. 12. Careful consideration should be given to complicating conditions and to certain symptoms in the period of sequels that can in no sense be regarded as syphilitic. In short, due regard should be given the patient as well as his syphilis. 13. Matrimony should be interdicted until at least three years after infection. It may then be permitted, providing the patient has had no symptoms of syphilis for at least eighteen months. In women the period of probation should be longer. In any event, matrimony should not be sanctioned unless the case has been carefully treated for the proper length of time. As there is always a certain element of danger that cannot be esti- mated, even approximately, the patient should assume all responsibility save that of a reasonable probability of safety. This, and nothing further, should be assumed by tbe physician. PART VL DISEASES AFFECTING SEXUAL PHYSIOLOGY. CHAPTER XXL Abeeeant and Impeefect Diffeeentiation of Sex. The' relation of physical deformities of congenital origin involving the sexual organs to abnormalities and imperfections of the sexual function is a most important one. The subjects of physically aberrant sexual differ- entiation are more numerous than is generally believed; fortunately, how- ever, the majority of cases are either slightly marked or of but little prac- tical importance as regards their physiologic and social status. Certain marked cases of physical aberration of sexual structure have always been of vital importance to medical jurists. Hermaphroditism, so- called, has received considerable attention from authorities on medical jurisprudence. In England, where the law of primogeniture prevails, the male is relatively so important a factor in the body social that the legal traditions upon the subject of hermaphroditism have been much more en- during and important than elsewhere. As our knowledge of physiology and morphology has advanced, how- ever, the so-called hermaphrodite has not only decreased in frequency in all social systems, but is a much less important factor in jurisprudence. The most important features of such cases at the present time are the questions of: 1. Impotency and sterility in both sexes. 2. Sexual perversion and inversion or other psychopathies of a sexual type. That the evils resulting from aberrations of structure of the sexual organs produce mechanic and functional obstacles to procreation is in no- wise remarkable and is sufficiently well understood. The psychosexual aspect of the question is not, however, so fully and intelligently comprehended as it should be. The term hermaphroditism has been applied in a loose and unscientific fashion, the physical conformation of the subjects being accepted as the chief factor in diagnosis. Hermaphro- ditism literally implies a mingling of the physical and functional qualities of both sexes. The crucial test as now accepted is the existence of a more or less perfectly formed testicle and ovary in the same individual. Even from this stand-point the existence of true hermaphroditism is open to seri- ous question. If hermaphroditism be accepted as implying the performance of the male or female function at will, such a condition cannot possibly exist (515) 516 ABEEEANT AND IMPEEFECT DIFFEEENTIATION OF SEX. in view of the fact that the sexual function does not begin and end with the act of sexual congress, procreation being necessary to its complete ful- fillment. The so-called hermaphrodite is sterile — fortunately for society — and, so far as procreation is concerned, cannot functionate as either male or female. The author is of opinion that, while pseudohermaphroditism Fig. 120. — Aberrant psychosexual differentiation Avith imperfect physical dif- ferentiation. Sexual organs of normal form, but undeveloped. (Author's is by no means rare, true hermaphroditism does not, and from biologic reasoning, cannot, exist. Although in most cases of pseudohermaphroditism it is possible to classify the subject as either male or female with greater or less ease, it DIFFICULTIES IN DIAGNOSIS. 517 must, nevertheless, be acknowledged that cases occasionally occur in which the differential diagnosis demands the highest degree of diagnostic skill. A case coming under 'the observation successively of Guyon and Fournier pointedly illustrates this. These distinguished gentlemen rendered lengthy and diametrically-opposed opinions as to the sex of the subject. Cases occasionally occur in which a differential diagnosis is impossible until the age of puberty, when certain sexual attributes — menstruation, the growth of beard, changing voice, etc., as the case may be — decide the ques- tion of sex. In very rare instances the sex cannot be decided during life. In some of the eases of alleged hermaphroditism the subject not only does not present what can justly be termed an admixture of male and female organs, but is practically a neuter, being without either desire or capacity to perform the functions of either sex. When, however, the subject of general and local malformation is also the subject of sexual perversion, observation of the ease may indicate an apparent commingling of the func- tional capacity. A case coming under the author's observation aptly illus- trates this. The case was that of a mulatto cook to whose case attention was called by some of the lads of the neighborhood, who came for relief from typic gonorrhea, which they claimed they had contracted from him. Investigation proved the proof of the boys' story. This hypospadiac male had contracted the disease from a female in the normal manner, and. sub- sequently, performing the passive role in the sexual act, had given the disease to the lads. A case illustrating the difficulties of diagnosis in so-called hermaphrodi- tism is reported by Dr. G. E. Glreen^: — Case. — A housemaid, aged 24, had symptoms Avhich seemed to point to retained menses. She was five feet seven inches in height, of dark complexion, and anemic in appearance. For several years she had been in domestic service, and was well known to the doctor personally. On examination, the external genitals appeared to be those of a woman; in keeping with this was the arrangement of the pubic hair, while there was in addition considerable mammary development. There was an oval body, freely movable, in the right labium and a similar one in the left. On separating the labia a clitoris was found, rather larger than usual. Below this was a small opening, which apparently led to a narrow and contracted vagina. Subsequent examination, however, under ether, revealed a very different state of things. The "swellings" in the labia proved to be testes; the labia were formed by a splitting of the scrotum into two halves. At the bottom of the "split" the "clitoris" was clearly the penis, with its glans only developed, and Avithout the corpus spongiosum. Upon its under surface there was a groove which led backward to a urethral orifice, into which a silver female catheter easily passed into the bladder. The sex of this "housemaid" was evidently, therefore, male, and the question arose what was to be done under the circumstances. The patient was anxious to continue being a woman, but the law does not allow a man to masquerade in woman's clothes. Dr. Green determined that the difficulty would be met if he were to remove the testicles from the "labia." This was aecord- ^ Quarterly Medical Journal. 518 ABEERAXT AXD IMPEEFECT DIFFEEENTIATION OP SEX. ingly successfully done, and no\y, in his unsexed condition, the man has resumed his ordinary occupation of that of a "housemaid." Cases of pronounced type of physical sexnal aberration with normal psychosexual development are not infrequent. An illustration of this coming under the observation of C. A. AVheaton, of St. Paul, is shown in connection with the subject of hyposj^adia (Fig. 22). Aberrant sexual differentiation may not involve any physical defects of the sexual organs; it may be purely psychic, and dependent upon im- perfection differentiation of sexual affinity. That there is an essential de- fect in the psychosexual centers of the cerebral cortex is probable; but, if Fig. 121. — Pseudohermaphroditism (aberrant genitosexual differentiation), showing testes, which were retained within the pelvis. Subject was a male. such defect exists, it is too occult for detection by any known method of research. Cases of psychicall3'-defective sexual differentiation present them- selves under three forms: 1. Cases Avith normal development of physical sexual tj-pe, both general and local. These constitute the class of cases in which sexual perversion is least likely to be suspected. 2. Cases of normal general physique, but defective or aberrant development of the genitals. 3. Cases in the male in which the genitals are imperfectly developed and the general physique effeminate. The same classification applies to both male and female. The author has, however, observed homosexuality oftener among neuropathic females CLASSIFICATIOIS^ OF IMPEEFECT SEXUAL DIFFEEENTIATIOX. 519 of an iiltrafeminine type than in those of masculine attributes. It is ad- mitted that this is probably an exceptional experience. Sexual affinity has been held to be a form of hunger which, traced to its source, is merely chemic affinity. If this be true, as the author believes it to be, imperfect differentiation of sexuality should be expected to lead to reversional peculiarities manifested by sexual perversions of vari- ous forms. This point will be more fully discussed in the next chapter. The point that the author desires to make here is that pederasts, urnings, — a term applied by Caspar to individuals having "the body of a man and the soul of a Avoman," — and some other sexual perverts (inverts especially) are closely akin to hypospadiacs and epispadiacs — so-called hermaphrodites. Psychic hermaphroditism or pseudohermaphroditism may be quite as read- ily accepted as a possibility as the physical type. The subjects of imperfect or aberrant sexual differentiation may be specially classified as follows: — , -|- .f . j|-^ x- C Pederasts, urnings, subjects of bestiality and inverts; ,. ,, 1 , /affiTi I ^■^■! individuals with a sexual affinity for their ity^ JithoTphysk^ri defect, ^ °^™ sex-homosexuality. The latter is called in the female gynandry, and, in the male, an- drogyny. This class is not numerous. either general or local. («) The simplest variety. Genital defects partaking of more or less of the attributes of the opposite sex, with normal sexual appetite. (&) Genital defects of similarly atypic conformation, 2. Defective — i.e., imper- 1 associated with perverted sexual appetite, feet or aberrant — differentia- ^^ (c) Aberrations of general physique only — i.e., a pJiy- tion of structure. "l sique approximating that of the opposite sex — associated with perversion of sexual appetite. Most cases of homosexuality belong to this class. [d) Aberrations of general physique with associated genital defects and perverted sexual appetite. In class 2 — a, l, d — are embraced epispadias and hypospadias and rudimentary development or absence of uterus, ovary, testicle, and penis. Much of the rubbish that has been popularly accepted on the question of hermaphroditism, has been promulgated by men about town and phy- sicians who are ignorant of sexual morphology. On several occasions the author has been invited by physicians to inspect a wonderful hermaphrodite, which, on examination, proved to be a male of by no means extraordinarily- defective type. These cases on investigation proved to be attaches of dis- reputable houses in which the alleged femininity of the subject was being devoted to profitable mercantile designs. In one case — which was claimed to be a male pervert — the subject afterward confessed that his perversion was for revenue only, his sexual appetite being only gratified in the normal manner. This was borne out by the testimony of some of his disreputable associates. 520 ABEEEAXT AXD IMPEEFECT DIFFEEENTIATION OF SEX. GiTv/ one of tlie older writers on medical jurisprudence, classified cases of genital malformation as follows: — 1. Male . individuals with such unusual formations of the generative organs as in many respects to re- semble the female. 2. Female individuals with such unusual formations of the same organs as to resemble the male. 3. "Where a mixture of the sex- ual organs of both sexes is exhibited without either being entire. It is obvious that there are certain acquired condi- tions which would fall under the above classification, yet would not be true cases of aberrant sexual differentia- tions: e.g., a prolapsed and hypertrophied uterus has been mistaken for a rudimentary penis, and females thus af- flicted have been known to copulate with other females. An hypertrophied clitoris may be mistaken for a rudimentary penis and may perform the male part in copulation. The importance of caution in de- ciding the sex in cases of gen- ital malformation is aptly il- lustrated by a comparatively recent case occurring in Chi- cago. In this case society was electrified by the discovery that a supposed young lady who had been visiting about and sleeping with lona fide young lady friends was a boy. The first intimation of the truth was the development of a pronounced beard with a bass vocal accom- paniment. Fig. 122. — Aberrant genitosexual differentiation (hypospadiac). Male type, psychosexually; general physique of female type. ^ Guy, op. cit. ABEEEANT PSYCHOSEXUALITY. 521 There was considerable anxiety for a time lest tlie supposed girl had discovered his masculine qualities prior to their detection by others. He naively confessed that "it always did make him feel funny to sleep with the girls." The assertion that certain cases of sexual perversion are akin to epi- spadias and hypospadias and the result of imperfect differentiation, may seem a trifle far-fetched, but the author nevertheless holds the opinion that, even when the differentiation of sex is complete from a gross physical stand-point it is still possible that the receptive and generative centers of sexual, sensibility may fail to become perfectly differentiated. The result, under such circumstances, might be, on the one hand, sexual apathy, and, M'l >/ ^ '■ /I J ; > i 1 1 Fig. 123. — Pseudohermaphroditism (aberrant genitosexual differentiation), show- ing vulva, pseudovagina, and absence of uterus. Subject was a male. upon the other, an approximation to the male or female type according to the circumstances of the case. Such a failure of development and imper- fect differentiation of structu.re would necessarily be too occult for detection from a physical stand-point by any means of investigation at our command. It is, however, only too well recognized by its results and is often re- sponsible for disgusting cases of sexual perversion that society is prone to attribute to moral depravity. This point, and the relation of reversion of type to sexual perversion, will be more fully discussed in the next chap- ter. That a failure of differentiation and development is equally responsible for certain cases of sexual perversion and instances of hypospadias and epi- spadias is the principal point to be remembered at this juncture. 522 ABEEEAXT AXD IISIPEEFECT DirFEEEXTIATIOX OF SEX. Cases of gross physical aberration of genital structure are not difficult to account for, so far as the modus opera.ndi of their formation is concerned; but their cause is not so readily explicable. How far maternal impressions enter into the causation of genital deformity is a question upon which it is to be hoped much light may some day be shed. There is eyidently an exhaustion of formatiye energy before the oc- currence of complete fusion of the two lateral segments, of which the em- bryo is practicalh' composed. Defective genital formation bears the same relation to this exhaustion of formative energy as do crania lifida, spina bifida, etc. It is obvious that the degree of deformity depends entirely upon the period at which developmental progression ceases. So far as ap- pearances go, one would naturally conclude that differentiation does not cease at a very early period in the life-history of the fetus, else what is ordi- narily accepted as true hermaphroditism would not only occur in reality, but would be frequent. G-eoffroy St. Hiliare, one of the older writers, mapped out a very elabo- rate plan in explanation of hermaphroditism in a work especially devoted to that subject. He divided the generative apparatus into a series of por- tions or segments, three in each lateral division. The upper set comprised the testes and ovaries; the middle the womb, prostate, and seminal vesi- cles; the lower the penis, scrotum, clitoris, and vulva. According to him, therefore, there might occur any number of varieties of hermaphroditism, according to the combination of faulty structures. This scheme was de- fective because of the fact that, in spite of all appearances to the contrary, differentiation never falls quite short of determining one or the other sex. The simplest plan for the explanation of genital deformities and anom- alies is to remember that the fetus practically develops in two lateral seg- ments and that any failure of union at the genital furrow will result in a greater or less degree of aberration of genital conformation. The view that hypospadia and epispadia are the result of atresia and rupture of the fetal urethra^ is apparently untenable in view of the generally-defective physique found in most cases of the kind. The relation of aberrations of genital formation to sterility and im- potence is very important. Impotence does not exist in the female unless there be atresia or complete absence of the vagina. Almost any aberration of the structure of the ovary or uterus ma}', however, produce sterility. In the male impotency is more apt to result than sterility, as serious deformity may prevent either erection or sufficient development of the organ to per- mit intromission. Xo matter how great the deformity, however, the in- dividual may be fruitful if circumstances be favorable, so long as the tes- ticles are functionally perfect. ^ Thiersch and Tilden Brown : "ISIorrow'.? System of Genito-Urinaiy and Skin Diseases." DIAGNOSIS OF SEX. 523 In determining the sex of alleged hermaphrodites the following points require consideration: — 1. The character of the voice. 2. The development of the mammse. 3. The growth or absence of beard. 4. The form of the shoulders, hips, and waist. 5. The presence or otherwise of the menses or vicarious discharges. 6. The character of sexual desire. In respect to this point the occa- sional co-existence of sexual perversion with genital deformity should be given its due meed of consideration. Thus, in a case in which difficulty of diagnosis existed a perverted sexual affinity for the same sex might mislead the physician. 7. The presence or absence of rudimentary (or perfect) testes or ovaries. 8. The form of the supposed clitoris or penis, the method of attach- ment of its prepuce, and the absence or presence of perforation in its glans. 9. The presence or absence of the hymen (rudimentary), nymphse, labia majora, or bifid scrotum, as the case may be. In cases of doubt it is safest to regard the individual as a female until time and pubescence have settled the question. The cases of imperfect or aberrant sexual diff'erentiation included un- der the head of sexual perversion are obviously more difficult to study than those in which the aberration is of a purely physical character. This is especially true regarding sapphic love, or sexual af&nity of female for female. That such cases are frequent is certain, but they are extremely dif- ficult to trace. The confessional of the family physician doubtless might offer evidence of a clinical character, but he is very chary of airing the short- comings of his patients in this particular direction. The existence of this aberrant sexuality can only be explained by aber- rant psychosexual differentiation. In the ease of the male, instances are so common that the subject is decidedly trite. It is not only charity, but a sense of justice and a desire to lessen the stigma upon human nature, that impels the author to include typic cases of sexual perversion under the head of aberrant sexual differentiation, and to attribute the condition to perverted or imperfect evolutionary development, on the one hand, and a reversal of t3^pe, on the other. CHAPTEE XXII. Diseases of the Sexual Function and Instinct. Geneeal Considerations. — The sexual function is animated by the most vital of all animal instincts. When made to subserve its real purpose — procreation — sexual desire is fundamentally the most disinterested of the purely animal appetites. G-ranting that it is a mere difEerentiation of its ancestral instinct^ hunger, its ultimate object is higher than that of the parent appetite. The ultimate object of hunger is the preservation of the life of the individual, while that of the sexual passion is the preservation of the species. The fact that the individual derives pleasure from the sex- ual act detracts not at all from the unselfishness of its object, so far as its relation to the grand scheme of jSTature is concerned. The sexual passion is no more open to impeachment on the ground of selfishness than is the fundamental instinct of hunger. Both are alike productive of pleasure in their gratification; both are alike subject to abuse by those who pursue the pleasure of gratification of the animal appetites with a total disregard of their natural objects. There are relatively few who "eat to live'^; those who live to eat are legion. The proportion of human beings who copulate for procreative purposes is very small as compared with those for whom the sexual act is the axis upon which the world revolves. As regards his sexual ethics, man has probably retrograded from the primal stock from which he has descended — or ascended, according to the point of view. Those of the lower animals that modern human society pre- tends to imitate — the monogamous types — are vastly superior to man from the sexual stand-point. The pairing of animals, even though it be for a limited period only, means something. The unwritten law is unbroken. With human beings, the contract involved in the pairing system legiti- matized in monogamous social organizations, means much or little, accord- ing to the moral bent and sexual capacity of the individual. The sexual immorality and perverted sexual physiology of the human race is generally discussed from the stand-point of morals, with a total dis- regard for common sense, to say nothing of natural law. It does not seem to occur to the moralist and would-be social reformer that there is an or- ganic basis for sexual infractions of moral and physiologic law — still less is it understood that the moral code is a relative matter, devised to subserve some selfish motive or other, with a total disregard for natural law. The question of the relative social value and safety of monogamy and polygamy is too broad for discussion here. That monogamy, from a socio- logic stand-point, irrespective of arbitrary moral codes, is best adapted to our own social necessities, is admitted. That it is in conformity with nat- ural law so far as the human race is concerned, the author does not believe. (524) GENERAL CONSIDEEATIONS. 525 Man, by nature, instinct, and physiologic demand, is a polygamous animal. Monogamy, like many other social customs, is a sacrifice of natural law to personal and social selfishness and expediency. The sexual immorality and perverted sexual physiology of man — taking our own moral code as the standard — are the result of the battle of social with natural man. If man is basically a monogamous animal, nature builds poorly and is an unreliable physiologic conservator. It is evident that, inasmuch as the object of the sexual function is the preservation of the species, the act of copulation should be performed only at such times and under such circum- stances as subserve that object. In the lower monogamous animals copula- tion and desire both cease with impregnation. This does not hold good with the human species. Even with polygamous animals the beginning of breeding heralds the cessation of copulation. The domestic fowl — ^whose polygamy, by the wa}', was originally acquired through forced adaptation to the commercial demands of its human proprietors — presents a shining example of the relative decency of polygamy so far as the female is con- cerned. To even hint that the female of the human species was originally designed for a monogamous animal is perhaps dangerous, after expressing the opinion that the male is polygamous by nature, yet the author unhesi- tatingly affirms that view. A certain proportion of females experience sex- ual desire even during gestation, but the fact remains that desire is rela- tively feeble in women, as a rule, and normally coitus should be repugnant to the female during gestation. Where it is not, there is simply hereditarily- perverted sexual physiology due to the unphysiologic approaches of the male practiced from time immemorial, or local irritation from disease. Socially it is not well that there should be "one law for the man and another for the woman," but such, apparently, was Nature's original intention, however much it has been subverted to social demands and individual selfishness. While in no sense desiring to apologize for the sexual immorality and perverted sexual physiology of the human race, the author firmly believes that much of it is explicable upon the foregoing grounds. This view is especially pertinent with respect to the etiology of sexual excess. Man and woman alike have suffered from abrogation of natural law. It is, of course, admitted that polygamy as practiced in the harems of the Orient is like- wise productive of perverted sexual physiology; but the basic sexual in- stinct of the human male is in nowise responsible for his abuse of the sex- ual function. Ignorance of sexual physiology is one of the fundamental causes of diseases of the sexual function, and especially of those produced by mas- turbation. Society imposes certain sexual restrictions upon the human race, while at the same time discountenancing the acquirement of knowledge of the sexual function and its object. Society also furnishes the worst pos- sible environment for its own moral ends. The natural desires, especially 526 DISEASES OF THE SEXUAL FUXCTIOX AXD IXSTIX'CT. of the male, are excited by yarions impressions to wMch lie is exposed until sexnal irritability inevitably results. The indiyidual is then asked to be chaste and virtuous, notwithstanding the fact that society furnishes him with an environment that would lead one to infer that virtue is an unknown quantity. Society has not changed its moral law — written or unwritten — pari passu with its advancing wickedness. It is not so many years since such books, pictures, and plays as are tolerated to-day were tabooed. Latter- day art, literature, and stage furnish an atmosphere of sexual immorality to which, sooner or later, every youth — male or female — is inevitably exposed. Tabooed books and pictures are not very dangerous; the person who in- dulges in them knows full well that such things are evil. Trilby, the fad, did more damage to the sexual morale of society than all the tabooed ob- scene books ever written. Clandestine vice, known to be under the ban, is honest enough, to say the least. Yiee thinly veiled, or gilded over by the mawkish sentiment engendered by Trilby pink teas and yellow breakfasts and apologized for by social faddists, is insidious and deadly. A Magdalen repentant has ever been a lesson in morality, but the naive admission of Trilby that she had had a certain limited number of lovers can hardly be admitted to Magdalenic literature. The example often set by stage people in their private (sic) lives, toler- ated as it is by society, is a very dangerous factor in the promulgation of sexual immorality. Society proclaims from the house-tops: "Thou shalt not^^; and then whispers softly in the ear of the favored ones: "Of course, I don't mean geniuses like you." And the favored and talented few go on and on, even exploiting their sexual derelictions for advertising purposes. The public press must come in for its share of blame in the promulga- tion of pernicious sexual impulses among the young. Sexual immorality is either condoned or discussed in a tone of flippancy that amounts to con- donation. To the minds of the young and inexperienced, sexual license would seem to be the unwritten code of modern society. Is it fair that society should demand that the young should remain in ignorance of the physiologic side of sexual matters, while its vicious aspects are paraded in all their nakedness? How difficult the task of the mother who endeavors to inculcate purity in the minds of her daughters! And how much more difficult the task of the father who endeavors to keep his son off the rocks and shoals, not by teaching — often not by example — but by discipline! The sum-total of results is that the growing lad comes to regard sexual purity as something to be ashamed of, and female virtue as extremely out of fashion. Young girls, too, are likely to regard with tolerant eyes those moral lapses which are common to social, literary, and stage lions. The resultant evils are sufficiently obvious. Inasmuch as society has practically thrown down all but the traditional theoretic barriers between sexual purity and impurity, it would seem that GENEEAL COXSIDEEATIOXS. 527 abuses of sexual physiology can only be combated upon purely physical grounds. In a certain sense, too, the selfishness of the individual must be appealed to. Young lads should be taught that masturbation is dangerous to their physical well-being — that they can never become as perfect men, morally, physically, or intellectually, if they indulge prematurely in any sort of exercise of the sexual function as they will if they remain continent. The young lad's instinct of self-preservation will accomplish much more than lessons in morality that are momentarily being contradicted by scenes, persons, and incidents about him. A most profound impression may often be made by stating that early indulgence blunts sexual sensibility, and thus to a certain degree deprives the individual of the legitimate pleasures of his later matrimonial life. And this statement is by no means exaggerated. It is probable that no man who has indulged in sexual congress or masturba- tion to any degree prior to full maturity is ever possessed of normal sexual sensibility in later life. The psychic effect of early sexual indulgence and masturbation is even more deleterious than the purely physical. Youth is imaginative, as well as hyperesthetic, and its pleasures are consequently relatively keen. The sexual experiences of youth so mold the psychosexual centers that a stand- ard is set for all future sexual experiences. The adult life of the individual is often devoted to the pursuit of a sexual ideal that exists only in his brain — an ideal that is but a memory of his younger and more impressionable days. This ideal is the will-o'-the-wisp that leads many men into sexual immorality and excess. Wise counsel and intelligent instruction of young lads in sexual matters might do more for the morals of society than any amount of preaching. Much has been said of the evils of quack literature in polluting the minds of the young, still more has been said of the harpy-like proclivities of the quack. There is, however, something to be said upon the other side of the question. There is a "soul of good in things evil." Many lads would go on in their evil ways indefinitely did they not stumble upon quack literature, which, while exaggerating the evils of masturbation and sexual excess, none the less sounds the first note of warning they have ever re- ceived. The profession is largely responsible for this, by crying down any attempt on the part of scientific men to impart knowledge of sexual matters to the laity. Why the profession should join the ignorant public in tabooing sexual knowledge is a mystery, quite as much so as a great deal of other cant and hypocrisy that has pervaded the medical profession from time im- memorial. So-called ethics has done more to foster quackery than to pre- vent it. And the public smiles derisively at a profession which, after years of travail, will tolerate "practice limited to diseases of women" on profes- sional cards; yet would roll up its eyes like a dying rabbit should it per- chance run across a card inscribed: "diseases of men only." Precisely what phase of sentiment elevates a woman with a leucorrhea to a higher plane 538 DISEASES OE THE SEXUAL FUXCTIOX AXD IXSTIXCT. than that which a man with spermatorrhea occupies is one of the things which, as Dundreary says, "no fellow can find out." Irrespective of cause, it is a deplorable fact that the regular profession is woefully ignorant and culpably negligent regarding the sexual ailments of its clientele. The respectable physician is still laughing at the complaints of men who consider themselves impotent, on the one hand, and prescribing vir- gins for broken-down roues and sexual wrecks, on the other. The fact that the virgins are to be sacrificed on Hymen's altar satisfies the medical im- becile who, like the ostrich, has his head in the sand, and the sacrifice at the same time conforms with social demand. The impotent man should receive intelligent advice from the general practitioner. The man who is unable to copulate is face to face with a grim reality. Whether psychic or not, his impotence is a material fact of which he is only too keenly con- scious. As for the virgins who are daily prescribed as placebos or panaceas, it is high time they were represented at court. The remedy lies with the profession. The sexual organs and function are the noblest attributes of man, and their diseases are quite as worthy of intelligent study and con- siderate treatment as affections of other organs. False modesty and mawk- ish sentiment have no place in scientific medicine. At present, the igno- rance and mock prudery of a large proportion of the profession is absolutely sickening. CHAPTER XXIII. ABERRATIONS OF THE SEXUAL INSTINCT. Sexual Perveesion and Ixveesion. The subject of sexual perversion, — Contrare Sexualempfindung, — al- though a disagreeable one for discussion, demands the attention of the scientific physician, and is of great importance in its social, medical, and legal relations. J. G-. Kiernan, in discussing the hypothetic dependence of the Whitechapel murders upon sexual perversion, says: — The subject may seem to trench on the "prurient," which in medicine does not exist, since "science, like fire, purifies everything," and what Macalilay caUs "the mightiest of human instincts" is too intimately related to the physical basis of human weal and woe for any physician prudishly to ignore any of its phases.^ The subject has been until a recent date studied solely from the stand- point of the moralist, and, from the indisposition of the scientific physician to study them, the unfortunate class of individuals who are characterized by perverted sexuality have been viewed in the light of their moral respon- sibility rather than as victims of a physical, and incidentally of a mental, defect. It is certainly much less humiliating to us as atoms of the social fabric to be able to attribute the degradation of these poor unfortunates to a physical cause than to a willful viciousness over which they have, or ought to have, volitional control. Even to the moralist there should be much sat- isfaction in the thought that a large class of sexual perverts are physically abnormal rather than morally leprous. It is often difficult to draw the line of demarkation between physical and moral perversion. Indeed, the one is so often dependent upon the other that it is doubtful whether it were wise to attempt the distinction in many instances. But this does not affect the cogency of the argument that the sexual pervert is generally a physical aberration — a lusus naturce. Krafft-Ebing^ expresses himself upon this point as follows: — In former years I considered contrare Sexualempfindung as a result of neuro- psychic degeneration, and I believe that this view is warranted by more recent investi- gations. As we study into the abnormal and diseased conditions from which this malady results, the ideas of horror and criminality connected with it disappear, and there arises in our minds the sense of duty to investigate what at first sight seems so repulsive, and to distinguish, if may be, between a perversion of natural instincts ^Medical Standard, November, 1888. - Journal of Psychiatry and Neurology, vol. ix, No. 4, p. 565. ^* (529) 530 SEXUAL PEJRYERSIOX AXD IXYEESIOX. which is the result of disease and the criminal offences of a pei-verted mind against the laws of morality and social decency. By so doing the investigations of science will become the means of rescuing the honor and re-establishing the social position (sic) of many an unfortunate whom unthinking prejudice and ignorance would class among depraved criminals. It would not be the first time that science has rendered a service to justice and to society by teaching that what seem to be immoral con- ditions and actions are but the results of disease. There is in every community of any size a colony of male sexual per- verts; tlie}^ are usually known to each other, and are likely to congregate together. At times they operate in accordance with some definite and con- certed plan in quest of suhjects wherewith to gratify their abnormal sexual impulses. Often they are characterized by effeminacy of voice, dress, and manner. In a general way, their physique is apt to be inferior — a defective physical make-up being quite general among them, although exceptions to this rule are numerous. Sexual perversion is more frequent in the male; women usually fall into perverted sexual habits for the purpose of pandering to the depraved tastes of their patrons rather than from instinctive impulse. Exceptions to this rule are occasionally seen. For example, the instance of a woman of perfect physique, who is not a professional prostitute, but moves in good societ}', who has a fondness for women, being never attracted to men for the purpose of ordinary sexual indulgence, but for perverted methods. The physician rarely has his attention called to these things, and, when evidence of their existence is placed before him, he is apt to receive it with skep- ticism. He regards tlie subject as something verging on Mlinchausenism, or, if the matter seem at all credible, he sets it aside as something unholy with which he is not or should not be concerned. It is, indeed, not to be wondered at that the physician, who sees so much to disgust him with the human animal, should be reluctant to add to his store of contempt. The nian about town is very often au fait in these matters and can give very valuable information. Indeed, witnesses enough can be found to convince the most skeptic. Sexual perversion ma}' be best defined, in a general way, as the pos- session of impulses to sexual gratification in an abnormal manner, with a partial or complete apathy toward the normal method. The affection presents itself in several forms, which may be tabulated as follows: — (a) Sexual perversion without defect of struct- ure of sexual organs. ° ] (b) Sexual perversion with defect of genital haps hereditary sex- ( , , , -u j-^- ^ . -^ ^ structure: e.g., hermaphroditism. •P ■ /(f) Sexual perversion with obvious defect of cerebral development: e.g., idiocy. VARIETIES OF SEXUAL PERVEESIOX. 531 (a) Sexual perversion from pregnancy, the menopause, ovarian disease, hysteria, etc. (b) Sexual perversion from acquired cerebral disease, with or without recognized in- II. Acquired sexual per- j sanity. version. '^ (c) Sexual perversion (?) from vice. (d) Sexual perversion from overstimulation of the nerves of sexual sensibility and the receptive sexual centers incidental to sex- ual excesses and masturbation. When the author's classification as above presented first appeared, it was by no means cordially received, its practicality being overlooked. Its recent adoption by Havelock Ellis, who asserts its superiority to Krafft- Ebing's classification, is extremely gratifying.^ As regards the clinical manifestations of the disease, sexual perverts may be classified as: (a) those having a predilection (affinity) for their own sex; (6) those having a predilection for abnormal methods of gratification with the opposite sex; (c) those affected with bestiality. Instances of all these different varieties have been observed. It is hardly necessary to say that the sexual pervert is by no means a modern institution. Sexually-perverted conduct evidently characterized some of the ancient orgies. It is certain that sexual perversion was prev- alent in the time of Nero. The author is not aware that attention has hitherto been called to the Scriptural evidence of its ancient existence. If, however, Scriptural chronology be correct, it was recognized at least as early as a.d. 60. Positive proof of this is seen in the Epistle of Paul to the Eomans: Chapter I; 24, 26, 27, and 28 verses. The text reads: — / Wherefore God also gave them up to uncleanness through the lusts of their own hearts, to dishonor their own bodies between themselves. Who changed the truth of God into a lie, and worshipped and served the creature more than the Creator, who is blessed forever. Amen. For this cause God gave them up unto vile affections; for even their women did change the natural use into that which is against nature; and likewise also the men leaving the natural use of the women, burned in their lust one toward another; men with men working that which is unseemly, and receiving in themselves that recompense of their error which Avas meet. And even as they did not like to retain God in their knowledge, God gave them over to a reprobate mind, to do those things which are not convenient. The Scriptural authority thus quoted may not add any particular dig- nity to the subject of sexual perversion, but it is certainly of interest as showing the early recognition of this peculiar morbid state. 2 Havelock Ellis, "Psychology of Sex. 532 SEXUAL PEETEESIOX AXD IXVEESIOX. The precise causes of sexual perversion are obscure. The explanation of the phenomenon is, in a general way, much more definite. Just as we may have variations of phj^sical form and of mental attributes in general, so we may have variations and perversions of that intangible entity: sexual affinity. In some cases, perhaps, sexual differentiation has been psychically imperfect, and there is a reversion of type; as Kiernan remarks: — The original bisexuality of the ancestors of the race, shown in the rudimentary female organs of the male, could not fail to occasion functional, if not organic, rever- sions ^Yhen mental or physical manifestations were interfered with by disease or con- genital defect. The inhibitions on excessive action to accomplish a given purpose, which the race has acquired through centuries of evolution, being removed, the animal in man springs to the surface. Removal of these inhibitions produces, among other results, sexual perversion. Eeasoning back to cell-life, we see many variations in sexual af&nity and the function of reproduction between the primal segmentation of the cell — the lowest tj'pe of procreative action — and that complete and perfect differentiation of the sexes which requires a definite act of sexual congress as a manifestation of the acme of sexual affinity, and for the purpose of reproduction. The variations in the methods of sexual gratification — or, to attribute it to instinct, of perpetuating the species — which are presented to the student of natural history are numerous and striking. It is not the author's intention, however, to give this matter more than passing notice. The method of sexual gratification — i.e., procreation — of fishes is a curious phenomenon. It is difficult to appreciate the sexual gratification involved in the deposition of the milt of the male fish upon the spawn of the female, yet that the so-called instinctive act of the male is unattended by gratifica- tion is improbable. Indeed, it is an argument as applicable to the lower animals as to man, that, were the act of procreation divested of its pleas- urable features, the species would speedily become extinct: for the act of procreation pe?' se is possessed of no features of attractiveness, but of many that, are repulsive, and in themselves productive of discomfort. It is puzzling to the healthy man and woman to understand how the practices of the sexual pervert can afford gratification. If considered in the light of reversion of type, however, the subject is much less perplexing. That maklevelopment, or arrested development, of the sexual organs should be associated with sexual perversion is not at all surprising; and the more nearly the individual ai^proximates the type of fetal development which exists prior to the commencement of sexual differentiation, the more marked is the aberrance of sexuality, of which more anon. There is one element in the study of sexual perversion that deserves especial attention. It is probable that few bodily attributes are more readily transmitted to posterity than peculiarities of sexual ph3'-siology. The off- spring of the abnormally-carnal individual is likely to be possessed of the same inordinate sexual appetite that characterizes the parent. The child of ETIOLOGY OF SEXUAL PERVEESIOX AXD INVEESIOX. 533 vice has within it, in many instances, the germ of vicious impulse, and no purifying influence can save it from following its own inherent inclinations. Men and women who seek, from mere satiety, variations of the normal method of sexual gratification, stamp their nervous systems with a malign influence which in the next generation may present itself as true sexual perversion. Acquired sexual perversion in one generation maji' be a true constitutional and irradicable vice in the next, and this independently of grosa physical aberrations. Carelessness on the part of parents is responsible for some cases of acquired sexual perversion. Boys who are allowed to as- sociate intimately are apt to turn their inventive genius to account by in- venting novel means of sexual stimulation, with the result of ever after diminishing the natural sexual appetite. Any powerful impression made upon the sexual system at or near puberty, when the sexual apparatus is just maturing and very active, although as yet weak and impressionable, is apt to leave an imprint in the form of sexual peculiarities that will haunt the patient throughout his after-life. Sexual congress at an early period often leaves its impression in a similar manner. Many an individual has . had reason to regret the indulgences of his youth because of its moral effect upon his after-life. The impression made upon him in the height of his youthful sensibility is never eradicated, but remains in his memory as his ideal of sexual matters, for there is a physical as well as a psychic memory. As he grows older and less impressionable, he seeks vainly for an experience similar to that of his youth, and so joins the ranks of the sexual mono- maniacs who vainly chase the will-o'-the-wisp, sexual gratification, all their lives. Variations of early impressions may determine sexual perversion rather than abnormally-powerful desire. Let the physician who has the confidence of his patients inquire into this matter, and he will be surprised at the result. Only a short time since, one of the author's patients, a man of exceptional intellect, volunteered a similar explanation for his own ex- cesses. Satiety also brings in its train a deterioration of normal sexual sen- sibility, with an increase, if anything, in the sexual appetite. As a result, the deluded and unfortunate being seeks for new and varied means of grati- fication, often degrading in the extreme. Add to this condition intem- perance or disease, and the individual may become the lowest type of sexual pervert. As Hammond^ concisely puts it, regarding one of the most disgust- ing forms of sexual perversion: — Pederasty is generally a vice resorted to by debauchees who exhaust the re- sources of the normal stimulus of the sexual act, and who for awhile find in this new- procedure the pleasure which they can no longer obtain from intercourse with women. As shown in the preceding chapter, even when the differentiation of sex is complete from a gross physical stand-point, the receptive and gener- ative centers of sexual sensibility may fail to become perfectly differen- ^Op. cit. 534: SEXUAL PEEYEESIOX AXD IX'YEESIOX. tiated. The result under such circumstances might be, upon the one hand, sexual apathy, and, upon the other, an approximation to the female or male type, as the case may be. Such a failure of development and imperfect differentiation of structure would necessarily be too occult for discovery by any physical means at our command. It is, however, only too readily recognizable by its results. There exists in every great city so large a number of sexual perverts that seemingly their depraved tastes have been commercially appreciated by the demi-monde. This has resulted in the formation of establishments whose principal business it is to cater to the perverted sexual tastes of a numerous class of patrons. Were the names and social positions of these patrons made public in the case of most of our large cities, society would be regaled with something fully as disgusting, and coming much nearer home, than the Pall Mall Gazette exposures. The individuals alluded to would undoubtedly resent the appellation of "sexual pervert"; but, nevertheless, in many instances they present the disease in its most inexcusable form: tbat from viciou? impulse. Person- ally, the author cannot appreciate any difference, from a moral stand-point, between the individual who is gratified sexually only by oral masturbation performed by the opposite sex and those unfortunate mortals whose passions can be gratified only by performing the active role in the same disgusting performance. One is to be pitied for his constitutional fault; the other to be despised for -his deliberately-acquired debasement. The professional jDrostitute who panders to the depraved sexual tastes of certain male speci- mens of the genus homo has, at least, the questionable excuse of commercial instinct, and in some cases the more valid one of essential sexual perver- sion. These excuses the majority of her patrons certainly dp not have. An interesting theory, bearing upon the question of sexual perversion in its relations to evolutionary reversion, is advanced by Clevenger^: — A paper on "Eesearches into the Life-history of the Monads," by W. H. Dallinger, F.R.M.S., and J. Drysdale, M.D., was read before the Eoyal Microscopical Society, on December 3, 1873, wherein fission of the monad was described as being preceded by the absorption of one form by another. One monad would fix on the sarcode of another, and the substance of the lesser or under one would pass into the upper one. In about two hours the merest trace of the lower one was left, and in four hours fission and multiplication of the larger monad beg-an." Professor Leidy has asserted that the ameba is a cannibal, whereupon Michels^ calls attention to Dallinger and Drysdale's contribution, and draws therefrom the inference that each cannibalistic act of the ameba is a reproductive or copulative one, if the term is admissible. At first glance such a suggestion seems ludicrous enough; but a little consider- ation will show that, in thus fusing two desires, we have still to g-et at the meaning ^ "Physiology and Psychology," 1885. - A full description of this interesting phenomenon may be found in the Monthly Microscopical Journal (London), for October, 1877. ^ American Journal of Microscopy, July, 1877. EELATIOX OF SEXUAL DESIEE TO HUXGEE. 535 and derivation of tlie primary one — desire for food. The cannibalistic ameba may, as Dallinger's monad certainly does, impregnate itself by eating one of its own kind, and we have innumerable instances, among algae and protozoa, of this sexual fusion's ap- pearing vei-y much like ingestion. Crabs have been seen to confuse the two desires by actually eating portions of each other while copulating; and, in a recent number of the Scientific American, a writer details the Mantis 7-eligiosa female eating off the head of the male mantis during conjugation. Some of the female aracJmidce find it neces- sary to finish the marital repast by devouring the male, who tries to scamper away from his fate. The bitings and even the embrace of the higher animals appears to have reference to this derivation. It is a physiologic fact that association often transfers an instinct in an apparently outrageous manner. With quadrupeds it is most clearly olfaction that is most related to sexual desire and its refiexes; but not so in man. Ferrier diligently and vainly searched the region of the temporal lobe near its connection with the olfactory neiwe for the seat of sexuality; but, with the diminished importance of the smelling sense in man, the faculty of sight has grown to vicariate olfaction; certainly the "lust of the eyes' is greater than that of other special sense-organs among bimana. In all animal life multiplication proceeds from growth, and until a certain stage of growth, puberty, is reached, reproduction does not occur. The complementary nature of growth and reproduction is observable in the large size attained by some animals after castration. Could we stop the division of an ameba, a comparable in- crease in size would be effected. The grotesqueness of these views is due to their novelty, not to their being unjustifiable. While it must thus seem apparent that a primeval origin for both ingestive and sexual desire existed, and that each is a true hunger, the one being repressible and in higher animal life being subjected to more control than the other, the question then presents itself: Wliat is hunger? It re- quires but little reflection to convince us of its potency in determining the destiny of nations and individuals and what a stimulus it is in animated creation. It seems likely that it has its origin in the atomic affinities of inanimate nature, a view mon- istic enough to please Haeckel and Tyndall. Spitzka,^ in commenting on the foregoing, says: — There are some observations made by alienists which strongly tend to confirm Clevenger's theory. It is well known that, under pathologic circumstances, rela- tions, obliterated in higher development and absent in health, return and simulate conditions found in lower, and even in primitive, forms. An instance of thi^ is the pica, or morbid appetite of pregnant women and hysteric girls for chalk, slate- pencils, and other articles of an earthy nature. To some extent this has been claimed to constitute a sort of reversion to the oviparous ancestry, which, like the birds of our day, sought the calcareous material required for the shell-structure in their food. There are forms of mental perversion properly classed under the head of the degener- ative mental states in which a close relation between the hunger appetite and sexual appetite becomes manifest. Under the heading "Wollust, Mordlust, AntliropopJiagie," Kraf!t-Ebing describes a form of sexual perversion where the snfEerer fails to find grati- fication unless he or she can bite, eat, murder, or mutilate the mate. He refers to the old Hindoo myth, Civa and Durga, as showing that such ob- servations in the sexual sphere were not unknown to the ancient races. He gives an instance where, after the act, the ravisher butchered his victim and ^ Science, June 25, 1881. 536 SEXUAL PERVEESION AND INVERSION. would have eaten a piece of the viscera; another where the criminal drank the blood and ate the heart; still another, where certain parts of the body were cooked and eaten. ^ Nature (London), commenting on Kiernan's article, quotes Ovid: '^Mulieres in coitu nonnemque genas cervicemque maris mordunt." Illustrations of the varying types of sexual perversion are, of late years, finding their way into literature. A very interesting series of cases of inverted sexuality is reported by Krafft-Ebing,^ which vividly demon- strate the psychic peculiarities of their class. The following is a fair type, save in the fact that the condition was in nowise betrayed by femininity of 'physique. This is not usual, but by no means rare: — - Case 1.- — Mr. X., merchant, residing at the time in America, 38 years old, said to be of a family sound in mind and body, affected since youth with neuras- thenic complaints, otherwise sound, wrote me in the fall of 1882 a long letter, the most important parts of which are here transcribed: — "I have read your article in the Zeitschrift fiir Psychiatrie. By it I and thousands of others are rehabilitated in the eyes of every thinking and half-way-fair- minded man, and I give you my heartiest thanks therefor. You well know how cases like mine are derided, execrated, and persecuted. I well understand that science has taken hold of this matter so recently that, in the eyes of one whose mind is sound and who is unversed in the nature of this disease, it appears as a horrible and unnatural crime. Ulrich has not overestimated the prevalence of this disease. In my own city (13,000 inhabitants) I personally know of fourteen cases, and in a city of 60,000 people I know of eighty. "I will take the liberty of encroaching on your time by giving a short sketch of my life, and shall do so with all frankness. It will perhaps furnish you with data for your critical studies of this malady. You may make such use of these statements as you see fit so long as my name is suppressed. "Music and literature were always my hobbies. My whole disposition is femi- nine. I hate all noise, disturbance, and obscenity. As a child, I associated constantly with girls and played with their dolls and toy-kitchens. I liked to dress in girl's clothes and so earned the nickname of 'girl-lover' ('maedchen-scMiecker') . Aftenvard, when I, became a student and took part in turning and gymnastics, it was still my delight to help my mother in her household duties. At the age of thirteen I arrived at puberty, — that is, I acquired a fondness for another being; but it was for one of my own sex. At school I always had my lover and was horribly jealous of any young girl or school-mate toward whom he showed any preference. My delight was to kiss him, while my sense of propriety overcame my sexual desires, though to gratify them was the very goal of my wishes. You will be surprised to learn that until I was twenty-eight years of age I never had a seminal emission, either through involuntary emissions, onanism, or by performing the sexual act with a man. "While still a young man I had a serious love-affair with a sophomore. He returned my love in a way, but only with the enthusiastic friendship of a boy. Once, ^ "Ueber gewisse Anomalien des Geschlechtstriebes," von Krafft-Ebing, Archiv fiir Psychiatrie, vii. It is unnecessary to call attention to the logic of Kiernan's deductions from the above as applied to the Whitechapel horrors. ("Sexual Perver- sion and the Whitechapel Murders." J. G. Kiernan, Medical Standard, November, 1888.) - "Psychopathia Sexualis." PECULIARITIES OF SEXUAL PERVERTS AND INVERTS. 537 when we happened to be sleeping together and my member became sexually excited, he naively asked me if I took him for a girl. I ventured only to kiss him and he returned my kisses. In the manner of youths we raved over poetry and literature. Our parting was for me almost heart-breaking. The young ladies in the house of my master where I lived had no effect upon me. I associated Avith them in a friendly, but entirely dispassionate, manner. "Xew, but entirely Platonic, love-affairs with young men followed; but although the outward appearances were most agreeable, there often came over me the de- pressing thought- — you are not like other men — and this troubled me most when I was in a circle of laughing, joking comrades who were full of animal spirits and sometimes indulged in licentious pleasures. I did not know whether I should laugh or cry. It was an almost unbearable condition, and I was forced constantly to throw sand in the eyes of others and to act contrary to my inclinations. I was out of this dilemma only when in the society of those like myself; it was therefore necessary for me to seek the society of those whom it would have been more ad- visable for me to have avoided. I never found in the society of beautiful women that invigoration of the mental powers which is commonly the case, but did find it among fascinating young men. I prefer to associate with married women or entirely innocent and ingenuous young ladies. Every attempt to draw me into the matri- monial net disgusts me, and on the question of marriage I am sensitive to a ridiculous degree. "Until I was twenty-eight years old I had no suspicion that there were others constituted like myself. One evening in the castle-garden at X , where, as I subsequently found, those constituted like myself were accustomed to seek and find each other, I met a man who powerfully excited my sexual feelings, so much so that I had a seminal emission. With that I lost my better manhood and came often to the park and sought similar places in other cities. "You will readily conceive that Avith the knowledge thus acquired there came a sort of comfort — the satisfaction of association and the sense of no longer being alone and singular. The oppressive thought, that I was not as others were, left me. The love-affairs which now followed gave my life a certain zest which I had never known before. But I was only hurrying to my fate. I had formed an intimate acquaintance with a young man. He was eccentric, romantic, and frivolous in the extreme and without means. He obtained complete control over me and held me as if I were his legal wife. I was obliged to take him into business. Scenes of jealousy which are scarcely conceivable took place in my house. He repeatedly made attempts at suicide with poison and it was with difficulty that I saved his life. I suffered terribly by reason of his jealousy, tyranny, obstinacy, and brutality. When jealous he would beat me and threaten to betray my secret to the authorities. I was kept in constant suspense lest he should do so. Again and again I was obliged to rid my house of this openly insane lover by making large pecuniary sacrifices. His passion for me and his shameless avarice drove him back to me. I was often in utter despair and yet could confide my troubles to no one. After he had cost me 10,000 francs, and a new attempt at extortion had failed, he denounced me to the police. I was arrested and charged with having sexual relations with my accuser, who was as guilty as myself. I was condemned to imprisonment. My social position was totally destroyed, my family brought to sorrow and shame, and the friends who had heretofore held me in high esteem now abandoned me with horror and disgust. That was a terrible time! And yet I had to say to myself: 'You have sinned — yes, grievously sinned — against the common ideas of morality, but not against Nature.' A thousand times no! A part of the blame at least should fall upon the antiquated law which would confound with depraved criminals those who are forced by nature to follow the inclinations of a diseased and perverted instinct. 538 SEXUAL PEEVEESIOX AND INVERSION, "You may get an idea of how natural and spontaneous our actions are from the following incident: — "About two years ago I was with a friend in a company of jovial acquaint- ances. A bright^ fun-loving young lady whom I might well have a passion for, but who, as a woman, made no impression whatever upon me, dressed herself in the uniform of an officer with moustache, etc. From the minute when she entered the room in this metamorphosis! felt a sexual passion toward her. "A friend once advised me to marry and dress my wife in male attire. I know of a case in Geneva where an admirable attachment between two men like myself has existed for seven years. If it were possible to have a pledge of such a love they might well make pretensions to marriage, but in the absence of that the proposal of Ulrich seems laughable indeed. One thing is true. Our loves bear as fair and noble flowers, incite to as praiseworthy efforts as does the love of any man for the woman of his affections. There are the same sacrifices, the same joy in abnegation even to the laying down of life, the same pain, the same joy, sorrow, happiness, as with men of ordinary natures. "I will add that, so far as I can judge, I am of perfect physical build, and that there is nothing remarkable as regards my sexual organs. My walk and voice are masculine, and one would never suspect me to be what I have described, while many of my class betray themselves by their expression, downcast eyes, gait, posture, bending of the body, manner of sitting, or dress. "In consequence of the disgrace that came upon me in my fatherland I am obliged to reside in America. Even now I am in constant anxiety lest what befel me at home should be discovered here and thus deprive me of the respect of my fellow-men. "May the time soon come when science shall educate the people so that they shall rightly judge our unfortunate class; but before that time can come there will be many victims." The following case of Krafft-Ebing's is an excellent illustration of in- verted sexuality in the female. It is a t}q3e that is quite familiar to all students of the ^Dsycholog}^ of sex: — Case 2. — Miss X, 38 years old, consulted me in the fall of 1881 regarding severe spinal irritation and chronic insomnia, for which she had extensively used chloral and morphine. Her mother was of a nervous organization; the rest of the family apparently healthy. Her sufferings dated from a fall upon the back received in 1872, which caused the patient a severe shock. In connection therewith there developed neuras- thenic and hysteric symptoms with severe spinal irritation and insomnia. Episodically there was hysteric paraplegia of eight months' duration and instances of hysteric hallucinatory delirium with convulsions. In addition there were symptoms of mor- phinism. A stay of several months in the clinic removed these and also materially alleviated the neurasthenic condition. These gratifying results were in great part accomplished by general faradism. At her first appearance the patient attracted attention by her clothing, features, man's hat, short hair, spectacles, gentleman's cravat and a sort of coat of male cut covering her woman's dress. She had coarse male features, a rough and rather deep voice, and, with the exception of the bosom and female contour of the pelvis, looked more like a man in woman's clothing than like a woman. During all the time I had her under observation there were no signs of eroticism. When I spoke about her clothing she said she wore it because it was convenient. I PECULIAEITIES OF SEXUAL PEKYEETS AND INVEKTS. 539 I incidentally discovered that as a child she had a fondness for horses and masculine pastimes, but never took any interest in feminine occupations. She later developed a taste for literature and sought to fit herself for a teacher. She never enjoyed dancing, and the ballet had no interest for her. Her highest enjoyment was to go to the circus. Up to the time of her sickness in 1872 she had no particular fondness for persons of either sex. After this there developed in her an attachment toward women, especially young women. She was never passionately aroused in her intimacy with them, but her friendship and self-sacrifices toward those she loved was boundless, while from that time on she had abhorrence for men and male society. Her relatives informed me that the patient had an offer of marriage in 1872, but refused it. She took a trip to a Avatering-place and returned entirely changed sexually, and made use of expressions which implied that she did not consider herself to be a woman. Since then she would only associate with women, had love-affairs with them, and let fall insinuations that she was a man. Her passion for women showed itself in tears, fits, jealousy, etc. While she was at the baths in 1874 a young woman fell in love with her, thinking she was a man in woman's clothing. When this young lady afterward married, Miss X became very melancholy and complained of faithlessness. Her friends noticed that after her sickness she evinced a decided prefer- ence for male clothing and a masculine appearance, while before her illness she had been in nowise other than a womanly character, at least as regard her sexual feelings. Further investigations showed that the patient was carrying on a purely Platonic love-affair with a young woman and Avrote her tender love-letters. The foregoing case is a type that is very frequently met with in women. It is by no means necessary that tlie female should be masculine in phy- sique, however. In such relatively-mild cases she often is not. TsTor is it necessary that physical indulgence of a perverted character should occur; it often does not go beyond the psychic phase. Favoring circumstances will inevitably produce the extreme result, however. Parents, sociologic stu- dents, physicians, and educators should understand this. The medico-legal importance of a recognition of such cases was shown by the Mitchell- Ward murder at Memphis some years since. Tardieu^ chronicles the following interesting points with regard to one form of sexual perversion: — I do not pretend to explain that which is incomprehensible, and thus to penetrate into the causes of pederasty. We can nevertheless ask if there is not something else in this vice than a moral perversion, than one of the forms of psyclwpatMa sexualis, of which Kaan has traced the history. Unbridled debauchery, exhausted sensuality, can alone account for pederastic habits as they exist in married men and fathers of families, and reconcile with the desire for women the existence of these impulses to unnatural acts. We can form some idea on the subject from a perusal of the writings of pederasts containing the expression of their depraved passions. Casper had in his possession a journal in Avhieh a man, member of an old family, had recorded, day by day, and for several years, his adventures, his passions, and his feelings. In this diary he had, with unexampled cynicism, avowed his shameful habits, which had extended through more than thirty years, and which had succeeded to an ardent love for the other sex. He had been initiated into these new pleasures by a procuress, and the description which he gives of his feelings is startling in its 'Sur les attentats aux mceurs," Paris, 1858, p. 125. 540 SEXUAL PEEVEESION AND INVEESION. intensity. The pen refuses to write of the orgies depicted in this journal, or to repeat the names which he gave to the objects of his love. I have had frequent occasion to read the correspondence of known pederasts and have found them applying to each other under the forms of the most passionate lan- guage, idealistic names which legitimately belong to the diction of the truest and most ardent love. But it is difficult not to admit the existence in some cases of a real patho- logic alteration of the' moral faculties. When we witness the profound degradation, the revolting salacity of the individuals who seek for and admit to their disgusting favors men who are gifted both with education and fortune, we might well be tempted to think that their sensations and reason are altered; but we can entertain no doubt on the subject when we call to mind facts such as those I have had related to me by a magistrate, who has displayed both ability and energy in the pursuit of pederasts. One of these men, who had fallen from a high position to one of the lowest depravity, gathered about him the dirty children of the streets, knelt before them and kissed their feet with passionate submission before asking them to yield themselves to his infamous propositions. Another experienced singularly voluptuous sensations by having a vile wretch inflict violent kicks on his gluteal region. What other idea can we entertain of such hoiTors than that those guilty of them are actuated by the most pitiable and shameful insanity? Some of the manifestations of sexual perversion^ quoted by various au- thorities, are very extraordinarj^, and it is difficult to associate them with titillations of sexual sensibility. Perhaps the most familiar of these cases is that of Sprague, who was committed in Brooklyn many years ago for highway robbery.^ It is unnecessary to present this case in detail, but an outline of it may prove interesting. Sprague was arrested immediately after having assaulted a young lady by throwing her down, violently re- moving one of her shoes and running away with it. He made no attempt to steal anything else, although she had on valuable jewelry. When the trial came on, insanity was alleged as a defence. Numerous witnesses, the principal of whom was the father of the defendant, a clergyman of the highest respectability, testified to the erratic conduct of the prisoner. A family history was elicited which bore most pertinently upon Sprague's case, his grandfather, grandmother, great-granduncle, three great-aunts, and a cousin having been insane. He had himself in his youth received numerous blows and falls upon the head, and within a year from the last head-injury he had developed severe headaches, associated with which his friends noted a bulging of the eyes. About this time the prisoner developed a fondness for stealing and hiding the shoes of females about the house, and it was found necessary by his relatives and the female domestics to carefully conceal or lock up their shoes to prevent his abstracting them. Upon in- vestigation it was discovered that the act of stealing or handling the shoes produced in him sexual gratification. Wharton- some years ago chronicled a most peculiar case of sexual per- version. In this instance the morbid sexual desire impelled the individual 1 Beck, "Medical Jurisprudence," vol. i, 1860, p. 732. 2 «^ Treatise on Mental Unsoundness," etc., Philadelphia, 1873. UNIQUE CASES OF SEXUAL PEEVEKSION" AND INVEESION. 541 to assault young girls upon the streets of Leipzig by grasping them and plunging a small lancet into their arms above the elbow. The fact was de- veloped after his arrest that these peculiar acts of assault were accompanied by seminal emissions. This authentic case gives a vivid coloring to the rational hypothesis that the notorious Whitechapel assassin was a sexual pervert. Many cases of sexual perversion manifest themselves only under the influence of disease or drunkenness. Ovarian irritation and those obscure cases of hysteria in women which we are unable to trace to a definite physical cause are frequently associated with sexual perversion. The physiologic (?) disturbance incidental to pregnancy is, in certain neurotic patients, productive of similar aberration. "Whether the influence of liquor obtunds the moral faculties or develops an inherent defect of sexual physi- ology in any given case is, of course, difficult to determine. The author knows of an individual who co-nducts himself with perfect propriety when sober, and who is a man of exceptional intellect, but who, when tinder the influence of alcohol, is too low for consort with the human species. Some of the cases of sexual perversion that have come under the au- thor's observation have been quite as unique as that of Sprague's or the case related by Wharton. In one instance a man who frequented houses of ill fame found it impossible to qualify sexually until a chicken had been de- capitated. The sight of the struggling, bleeding fowl was eminently aphro- disiac in his case. Under no other circumstances was it possible for him to secure an erection. In another case the pervert was in the habit of renting a full set of regal robes, crown and all. These he would put upon the object of his attention. Having seated the woman upon an improvised throne, he would besiege (?) his ready-made queen until his object was attained. Ego- mania was evidently a dominant phase of the sexual psychopathy of this particular case. Heredity, on the one hand, and acquired disease or injury, on the other, sometimes bear a very important relation to sexual psychopathy. A very interesting case bearing on both these etiologic factors was reported by Urquhart^ : — Case. — Young man, 26 years of age, of medium height and weight and fairly- robust development, was sentenced to one year's imprisonment at hard labor as a punishment for immoral practices. The judge in passing sentence remarked that while it might not be the logical course of treatment, it was the only thing to do, for he was not legally insane, and if set at liberty would only go on with his vicious prac- tices. The heredity in this case was exceptionally bad. The father was a drunkard and roue. He was syphilitic and died young. The mother was also syphilitic — in- fected by the father during her pregnancy. Subject's only sister was a prostitute, but his only brother was decent and respectable. When a small boy, subject fell over a staircase, striking on his head and injuring his skull. He became unconscious, with ^ Journal of Mental Science, January, 1891. 542 SEXUAL PERVERSION AND INVERSION. bleeding at the ears. His mother noticed thereafter a great change in his conduct. At school he soon became a confirmed masturbator, and showed a marked amorous preference for male children. It Avas finally discovered that it was unsafe to permit other boys to be in his company. His sexuality toward the opposite sex was per- verted, and women in general disgusted him. His habits toward his own sex finally attracted the attention of the police, because of which he attempted to kill himself. He Avas finally apprehended, tried, and sentenced to prison. A peculiar ease was reported by A. E. Eeynokls/ of a man who liacl a love-affair with a woman whose right lower extremity had been amputated at the thigh, and became so much attached to her that he was afterM^ard im- potent with perfectly-formed women, it being necessary for him to secure females who had undergone mutilation similar to that of his former attach- ment in order that he might be sexually gratified. A peculiar phase of sexual perversion is occasionally seen among mas- turbators, male and female. The individuals suffering from this have a peculiar predilection for titillating the sexual organs in various outlandish fashions. Such patients are, in many instances, particularly fond of intro- ducing foreign bodies of various kinds into the urethra and thus gratifying their sexual desires. Such cases occur even among persons who have op- portimities for normal gratification. Thus, an interesting case is reported by Poulet of a married woman, the mother of three children, who failed to receive gratification from ordinary intercourse, and practiced masturbation with a blunt piece of wood fastened to a wire. Her unfortunate failing was exposed through the slipping of the foreign body from her grasp into the bladder. Kiernan reports a somewhat similar case of an insane girl who was admitted into his service at the Cook County Insane Asylum. In this instance the physical appearance of the sexual organs and anus led to a suspicion of pederasty, which was confirmed upon investigation. The association of sexual perversion with malformations of the sexual organs with or without associated close approximation to the general phy- sique of the opposite sex, male or female, as the case may be, is certainly not surprising. The author has met with some most peculiar illustrations of this form of sexual perversion. The relation of both physical and psychic defects of sexual differentiation to sexual perversion has been expatiated upon in the preceding chapter. Treatment. — The treatment of sexual perversion is highly unsatis- factory, largely from the fact that the abnormality of sexual instinct is due to defective sexual differentiation — psychic or organic, or both. To the average pervert, his or her condition seems normal. The victim recognizes the fact that he differs from the usual standard of sexual normality, but he is absolutely incapable of reasoning out his defect from any other stand-point. He often desires to be cured of his abnormal sexuality — only, ^ Transactions of the Chicago Medical Society. TEEATMENT OF SEXUAL PEKVEESION AND INVEESIOIsr. 543 however, by the substitution of the instinct which seems common to those about him. There is no innate repugnance to his own condition, which is as normal to his own mind as is a confusion of colors to the color- blind. He knows his abnormal sexuality only from study and comparison of normal individuals. He regrets his social ostracism, while really seeing nothing wrong in the condition that has brought it about. Taking into consideration the congenital character of most cases, the difficulty of cure is self-evident. Where there is physically imperfect differentiation of sex, the case is absolutely hopeless. Perversion from impressions of an abnormal psychosexual character made while the sexual function is, so to speak, in its plastic, formative stage, perversions due to functional neuropathic dis- turbances, and perversions from vice, are often susceptible of cure. Thera- peutic suggestion is of paramount importance in most cases. Psycho- therapy is the key-note of treatment. As, Kiernan so tersely says: — Insistence on the morbidity of the pervert ideas^ and prohibition of sexual literature as in the sexual neurasthenic, together with allied psychic therapy and anaphrodisiac methods cannot but benefit. These patients, like the hysteric, will not "will" to be cured while they axe subjects of sympathy. It has long been the author's belief that a large proportion of both boys and girls may be easily converted into sexual perverts by unnatural sexual impressions at or about the age of pubert}^, when the centers of sex- ual receptivity and impulse are in a plastic state. It is strange that phy- sicians did not discover this earlier. The sexual dangers of boarding-schools were long ago pointed out by a French novelist, x\dolphe Belot.^ A word of warning, therefore, may not be out of place. For the insane pervert the asylum is the only recourse. In rare in- stances of perversion, castration, oophorectomy, and clitoridectomy are worth consideration. 'Mdlle. Giraud, Ma Femme.' CHAPTEK XXIV. Satyriasis, XYiiPHOMAxiA, Mastuebatiox, Sexual Excess, AND UnPHTSIOLOGIC CoITUS. SATYEIASIS. Satyriasis is a disease that occurs in the male, with or without insanity, the principal manifestation of which is an abnormally excessive and un- reasonable sexual desire. It is not a frequent disease as brought to the at- tention of the physician, probably because the opportunities for gratification of the male are relatively numerous. The disease consists of constant desire, attended with vigorous, often painful, erections, which in some instances no amount of sexual intercourse will relieve. It has been termed "erotic delirium,'^ and it may or may not be due to coarse disease of the brain. In the worst cases the unfortunate individual may be the subject of mania and delirium of a violent form. William Acton^ relates the case of an old man, suffering from satyriasis, whose desire was so extreme that he would mas- turbate whenever he was brought into the presence of women. After his death a small tumor was found in the pons Varolii. Shocks and injuries in- volving the cerebellum are peculiarly apt to be followed by persistent erec- tions. This phenomenon has been noticed in subjects executed by hanging. Injuries of the spinal cord, although in the majority of instances inhibiting the sexual function by producing complete paralysis of that portion of the cord which seems to bear an intimate relation to sexual sensibility — the genito-spinal center — produce in some instances, from irritation of the same nervous structure, persistent erection. Cases of this kind are related by Lallemand.- The following case is one that has been very frequently quoted: — Case. — ^The subject was a soldier, who, in climbing over the walls of the garri- son, fell upon his sacrum. Following this injury he became paraplegic and suffered with persistent priapism. This lasted for some time, and could not be relieved by intercourse. All pleasurable sensations and the power of ejaculation were destroyed, although sexual desire was very ardent. During sleep, however, the unfortunate subject had lascivious dreams, accompanied by slight sensation and ejaculation. The causes of satyriasis, as enumerated by different authorities, are: masturbation; disease of the brain, particularly those affecting the cere- bellum; injuries and diseases of the spinal cord, sexual excesses, and the administration of poisonous doses of cantharides. Prolonged continence is ^ "On the Eeproductive Organs." ^ "On Spermatorrhea." (544) SATYRIASIS AND NYMPHOMANIA. 5i5 another rare and dubious cause to which satyriasis has been ascribed. J. W. Howe/ quoting from Blandet, describes a case of this kind: — Case. — The patient was an earnest, hard-working, and zealous missionary. He was unfortunate in the possession of an intensely passionate nature, although he had not gratified himself in a vicious manner. So intense was his excitement in the pres- ence of women that it became necessary to seclude himself from them so far as pos- sible. This plan proved a failure, for he became so much worse that he suffered from satyriasis in an extreme degree. A cure was finally accomplished by the normal in- dulgence of his passion. The mild form of excessive sexual desire called priapism may be due to local irritation. In some instances such irritation will produce severe priapism without sexual desire. The author has at present under treatment a gentleman who is suffering in this manner: — Case. — The patient is 50 years of age, has been somewhat dissipated and a high liver, as a consequence of which he has gout in an extreme degree. He has suffered for several years from vesical irritation, attributed by him to stricture of long standing. The urethra on examination presents no abnormality; the urine is highly concentrated and strongly acid. As soon as the patient retires for the night he begins to be troubled with severe erections that are so vigorous as to be quite painful and which persist during the entire night. Sexual intercourse gives no relief. This case can only be attributed to sexual hyperesthesia incidental to long-continued gout and irritation of the genito-urinary tract. This does not manifest itself during the day-time, but during the night, when, as is well known, the spinal cord is relatively hyperemic and in a condition of in- creased functional activity. The same explanation hold goods here as in nocturnal emissions, which will be discussed later. NYMPHOMANIA. Nymphomania (erotomania, furor uterinus) is a disease, analogous to satyriasis, occurring in the female. It is characterized by excessive and inordinate sexual desire, and very often by the most pronounced lewdness and vulgarity of speech and action. In the most severe forms it is apt to be associated with, and dependent upon, other forms of insanity, with or without gross brain disease. In some instances the disease is a reflex mani- festation of irritative affections of the sexual apparatus. Thus, ovarian and uterine diseases are apt to be associated with it. Any irritation of the ex- ternal genital organs in females of hysteric temperament may produce the affection, all that is necessary being a nervous and excitable state of the nervous system, a passionate temperament, and local irritation of the sen- sitive sexual apparatus. Some of the recorded cases of nymphomania are very pitiful. It has been known to be associated with the cerebral disturb- ance incidental to pulmonary consumption. Thus, a case has been recorded ^ "Excessive Venery." 546 ETIOLOGY OF NYMPHOMANIA. of a woman in the last stages of this disease who exhibited the most inor- dinate sexual desire, and a short time before her death importuned her husband to have intercourse with her. The association of hysteria with this unfortunate psychosexual condition is one with which nearly every gynecologist of experience is perfectly familiar. Nymphomania is also known to occur as a result of masturbation and sexual excess. In women of a highly erethistic temperament it has de- veloped as a consequence of sudden cessation of the normal method of sexual indulgence. Knowledge or experience in sexual matters is by no means necessary to the development of nymphomania, for it has been known to occur in individuals who had neither masturbated nor indulged in sexual inter- course. Some of the most painful cases of the disease have occurred during pregnancy. The principal astonishing feature of such unfortunate cases is the acquirement of lewd actions and expressions on the part of women pre- viously and naturally pure-minded and refined. Such women may use ex- pressions and indulge in actions that lead the physician to wonder where they could possibly have acquired a knowledge of them. The gynecologist is compelled to be on his guard with reference to a not-infrequent form of nymphomania, but one which is little suspected by those surrounding the patient, in which the woman develops a fondness for gynecologic manipulations. The subterfuges and devices of such patients to induce handling of the sexual organs by the physician are often remark- able. One of the most frequent forms of this malingering is the pretense of retention of urine, although every disease that they ever heard of may be complained of by such patients in their insane endeavors to obtain manipulations at the hands of the physician. Howe relates an interesting case of this kind occurring under his ob- servation at Bellevue Hospital: — Case. — A girl, aged 18, was admitted, supposed to be suffering from retention of urine. She was thin; her eyes were deep-set, but bright and staring, and were found filled with tears. Her statement was that she had passed no water for three days; that she was subject to these attacks and was treated by having her water drawn off. I in- troduced the catheter, and found only a few ounces of urine in her bladder, not enough, indeed, to corroborate her history. The next morning, as she had not urinated during the night, I drew off the urine again. While doing so I noticed by a series of peculiar convulsive movements that she was under the influence of strong excitement. Further examination showed that the labia minora, clitoris, and adjacent parts were red and swelled and bathed in a profuse mucous secretion. I then remembered that on the pre- vious evening she had shown a somewhat similar state of excitement, and gave the nurse orders to watch her closely all day. In the evening the nurse informed me that the patient kept up a constant friction of the genitals when she supposed no one was watching, and even when eyes were on her she endeavored by uneasy movements in the bed to continue the titillation. Knowing then what I had to deal with, the patient was given a sedative and told that she must empty her bladder without assistance. For thirty-six hours subsequently she obstinately insisted on her inability MASTURBATIOISr. 547 to urinate. When she was told no catheter would be employed again there was no further retention. Soon after she left the hospital I learned that a physician friend of mine was treating her for uterine disorder, but he, too, soon found out the true nature of the case, and advised her to get married. . A number of cases of a similar nature have come nnder the author's observation, both in hospital experience and private practice. The treatment of satyriasis and nymphomania consists chiefly in the removal of irritation of the sexual apparatus, the administration of anaphro- disiac remedies, to be hereafter considered, and attempts to restrain sexual excesses, or to break the habit of masturbation, as the case may be. Where there is actual organic disease the case is lOvely-to be found to be incurable in the majority of instances, particularly if the structural disease involves the nervous centers. In women, extirpation of the ovaries or the procedure of Mr. Baker Brown — clitoridectomy — may be performed. Howe recom- mends the application of the actual cautery to the back of the neck. Basing this treatment upon the theory that the disease takes its origin in overex- citation of the nerve-fibers of the cerebellum or some of the ganglia in the neighborhood, he also suggests blisters and setons as answering the same purpose. Dry cupping to the nucha is also serviceable. Means to restore the general health are always indicated. In the severe cases of the maniacal form of excessive sexual desire the asylum is usually our only recourse, though castration is occasionally effective. Castration, however, is a remedy to be suggested with the greatest caution. There has latterly been a tend- ency to recommend this operation in various conditions without duly weighing the responsibility involved. MASTUEBATION. Masturbation — often erroneously styled onanism — consists in the pro- duction of the venereal orgasm by some mechanic means other than normal sexual congress — usually by manual friction. Perverted methods of sexual contact properly come under a different head. The habit of masturbation is very common, especially in the male. The larger proportion of young lads become addicted to it, sooner or later, to a greater or less degree, and it is far more common in adult life than is generally believed. The habit sometimes persists after marriage, even where the individual is potent. Cases of this kind have come under the author's observation. Eegarding the prevalence of the practice, it is probable that few boys escape it; indeed, competent authorities have asserted that the man who can truthfully say that he has never masturbated is a rara avis. Fortunately for the comparative reputation of the human species for intelligence and decency, masturbation is met with in the lower animals. Bulls, dogs, cats, monkeys, and domestic fowls have been known to practice it. Howe claims that in such instances the animals have received pernicious 548 MASTUEBATIOX IN INFANTS. training from degraded human beings, but students of natural histor}' are not likel}' to agree with this view.^ Masturbation is peculiarly a vice of civilized humanity. Precocious jjassions, incidental to an immoral and sexually-exciting environment, asso- ciated with a defective will-jDower and degenerate nerve-constitution follow in the wake of civilization. The restrictions put upon sexual indulgence in civilized social systems are such that the fear of consequences deter both the male and female from sexual indulgence. There is no restriction of op- portunities for masturbation and no social penalties; hence the individual deems himself privileged to indulge as he sees fit. The influences to which boys especially are subjected are of the worst sort. Erotic books, pictures, newsj)aper nastiness, vile plays, and the counsel and example of depraved associates — often of adult age — tend to keep the sexual organs in a per- jjetual condition of excitement. Curiosity is often a factor in the etiology of masturbation. Accidental friction of the genitals develops the interest- ing fact that pleasurable sensations are thereby elicited. The result is ob- vious. Many boys are led into the habit by the teachings of depraved adults who convey the impression to the easily influenced mind of the susceptible and curious boy that the seminal discharge, however produced, is necessary to the preservation of manl}' health. It is claimed that ver}^ joimg children — even infants at the breast — have been known to masturbate. In such cases the term masturbation is hardly applicable. Very young children do not experience the venereal orgasm and emission, and mere titillation of the genitalia cannot fairly be pronounced masturbation. Irritation of the genitalia often impels children to rub the parts in the endeavor to obtain relief. In some instances the hands are used and in others the thighs are spasmodically rubbed together. The sensation thereby elicited is probably pleasurable to a degree, corre- sponding, perhaps, to that experienced by scratching or rubbing areas af- fected by pruritus in any location. That pleasurable sensations may be elicited by genital friction when the parts are presumably in a normal con- dition is shown by the fact that nurses not infrequently deliberately handle the genitals for the purpose of quieting the crying child. The influence of genital irritation in impelling children to handle the genitals is well shown in vesical calculus. The elongated prepuce resulting from boys with vesical calculus tugging at the penis in a vain effort to ob- tain relief from reflex penile pain is sufficiently familiar. The great danger of genital irritation in children is that the friction induced for its relief may continue until a precocious sexual sensibility is developed, which prolongs the habit of genital titillation until puberty ar- rives and true masturbation supervenes. A fact not generally recognized ^ "Excessive Venery," etc., Joseph W. Howe. What would have been Howe's opinion of the case of a young heifer who allowed the approach of the bull at any and all times, in season and out of season? MASTUEBATION IN INFANTS. 549 is the precocious development of puberty as a consequence of the frequent and long-continued stimulation of the parts. The sources of irritation that serve to direct the child's attention to its genitals may be direct or reflex. Among the direct causes are such condi- tions as intertrigo, eczema, phimosis, balanitis, and the contact of highly- acid urine. Phimosis, and the consequent retention of irritating secretions, is the most potent and frequent direct source of irritation. A long prepuce, even when not phimosed, is also a fertile source of trouble. The principal reflex causes of genital irritation in children are vesical calculus and AscU' rides recti. Pseudo-emissions finally characterize infantile attempts at masturba- tion as the subject approaches puberty. The discharge is at first composed only of urethral and prostatic mucus combined with the secretion of the glands of Cowper. This discharge is attended by a more or less typic orgasm. After puberty is established — whether precociously or not — the discharge gradually assumes the properties of seminal fluid — imperfectly elaborated, it is true, yet containing the characteristic spermatozoa. If the habit be persisted in, the semen is never perfectly elaborated, but is thin watery, and contains relatively few spermatozoa. The prevalent custom of alloAving children to sleep together is often responsible for the inculcation of vicious habits; this is especially true when great disparity of ages exists, for a precocious or vicious boy or girl ap- proaching puberty is sure to contaminate the morals of every child with AA'hom he or she is brought in intimate contact. Parents should be taught to regard every intimate attachment of their offspring for other children as worthy of distrust, and this warning is especially justifiable in cities. Country children, with their excellent jjhysique and many opportunities for the diversion of their superfluous animal spirits, are proportionatel}^ less likely to become vicious; then, too, they are not so apt to be taught vice by lewd persons of more advanced years. Primary sexual precocity constitutes a foundation for many cases of masturbation. This sexual precocity may be due (1) to heredity and (2) to the causes of local irritation already mentioned. Persons of an extraordi- narily amative disposition, who indulge excessively in sexual intercourse, are apt to procreate children who are not only feeble in physique and in- tellect, but possessed of premature sexual desire. It has been claimed, and apparently with justice, that children of illegitimate parentage are particu- larly apt to develop sexual precocity. Premature sexual desire is sometimes associated with a precocious development of the sexual organs. Mr. South, an English surgeon, some years ago reported a case of a child, 20 months old, in whom the penis was larger than the average adult organ, the pubes being covered with hair. This extraordinary freak was addicted to mas- turbation. Female children may, through uncleanliness, become confirmed mas- 550 MASTUKBATION IX WOMEIST. turbators. This should be imjiressed upon the minds of mothers whenever compatible with delicacy. Filth is quite apt to accumulate about the female genitals, and with the addition of highly acid, or, perhaps, decomposed, nrine may produce great irritation. Eubbing the genitals is natural under such circumstances, with the usual lamentable results. The amount of titillation necessary to produce an orgasm in some highly erethistic females is often surprisingly slight. The author has met with several cases that demon- strate this. One, a single Avoman of 23, had only to will that an orgasm occur, in order to perform masturbation, and the slightest touch upon the genitals when she was sexually excited produced the desired result. An- other subject, a girl of IT, masturbated several times a da}' by simply rub- bing the thighs together. Still another young woman has an orgasm when- ever she attempts to run a sewing machine. The use of this appliance is especially apt to produce uterine congestion and irritation, with coincident sexual excitement, as every competent gynecologist knows. In many cases of masturbation among women pelvic disease is directly responsible for the vice; hence some cases must be regarded in a more than charitable light. It is unfortunate that we have so few opportunities for determining the frequency of masturbation among women and female children, for, although the female sex is much less vicious than the male, the vice is probably often responsible for nervous and local gynic disease. Women resent any allusion to their sexual functions, and mothers will usually hate the physician most cordially if he so much as suggests the possibility of their children's mas- turbating. They will usually believe what is said of other children, but as to their own, that is quite a different matter. A short time since a lady brought a young relative to the author regarding some painful trouble with the sexual organs. The child was only eight years of age, yet it was pre- cociously developed, and hair had already appeared upon the pubes and labia majora. The ostium vaginte was dilated, the hymen pouched inward; the nymphfe enlarged, reddened, and bathed with mucus; and the clitoris larger than in most women. The slightest touch upon the parts caused the clitoris to become erect, and the involuntary movements of the child's limbs showed plainly the nature of the trouble. To say that the mother resented the diagnosis would be putting it mildly. Xeither false modesty nor the fear of resentment on the part of parents should deter the phy- sician from his plain duty in these delicate matters. It is a discouraging fact that it is difficult to impress these jjoints upon parents. Whether this be due to their cerebral density or oversentitive recollection of their own evil ways is a question difficult to answer. Young girls — and, upon the average, women — are naturally much purer minded than the male sex, and their associations are not apt to be such as tend to lower the moral tone. "When the female becomes corrupted it is usually through the efEorts of the opposite sex, and not through the in- fluence of members of their own, although the corrujDt woman is especially MASTURBATION IN WOMEN AND BOYS. 551 dangerous to her chaster sisters. There are, of course, many exceptions to the rule, especially in boarding-schools, which are sources of especial dan- ger to both sexes. The female sexual organs are less exposed than the male, and in the performance of the natural function of urination are not handled, as is necessary with the male. Females are consequently less likely to dis- cover accidentally that pleasurable sensations may be excited by manipula- tion of these organs, and thus be led into masturbation. After the age of puberty the female is protected from sexual desire to a certain extent by the periodic relief afforded to the generative apparatus through the physio- logic function of menstruation. The sexual excitement attendant upon the beginning of menstruation is usually speedily relieved by the normal flow; even if it is not, it is obvious that manipulation of the organs is not apt to be practiced at that time. When the flow ceases, spontaneous sexual excite- ment has usually disappeared, and does not again recur until the next men- strual epoch. This point should be taken into special consideration.^ In the case of the male the organs are not only handled during micturition, but they are apt to obtrude themselves at times when the mind is entirely free from sexual thoughts. The distension of the bladder with the urine accumulated during the night is, for example, likely to produce vigorous erections in the morning. Such erections, although not primarily depend- ent upon sexual excitement, are very apt to divert the mind in the direction of sexual matters, and so tempt to manipulation. Certain kinds of gymnastic exercise are productive of voluptuous sen- sations that may lead to masturbation. Howe says-: — These exercises are common in gymnasiums and school-grounds. My attention was first called to this subject by the history of a masturbator. He entered school at the age of seven. The next day he visited the school-gymnasium. Noticing the swinging pole, he took hold with the rest of the boys, swinging himself around the circle for some time. In a few minutes he had such peculiar sensations about the genitals that he had to stop and rest. Again and again he swung himself around, with the same effect, the sensations becoming more positive and intense. The tingling sensations finally terminated in an orgasm. This led him to a closer exami- nation of his organs and new methods of excitement, until he became a confirmed masturbator. Exercises involving climbing, swinging, and sliding are especially per- nicious; yet healthy boys may indulge moderately in them without evil results. A robust boy is not apt to thus injure himself, as might a lad of less animal vigor and muscular strength. A ca'rdinal point in training boys should be to avoid perineal strain and friction, and swinging exercises that produce vertigo and heighten cerebellar sensibility, until the muscles gen- ^ In a general way it may be asserted that girls who masturbate are degenerates, bearing the same relation to normally constituted girls that nyphomaniacs do to normal adults. ' Op. cit. 552 MASTUEBATION AND SEXUAL EXCESS. erally have been well trained, and then to indulge in sucli exercises with great moderation at tirst. Many boys experience vohiptnous sensations while climbing, but they are usually delicate lads. The author has known a boy to fall from a tree and experience a broken arm because of an orgasm while climbing. Both young and old subjects Avith prostatic irritation are apt to have an orgasm while riding horseback. One of the author's patients cannot ride a trotting horse on this accoimt. This man has been a masturbator^ and latterly experienced gonorrheal prostatitis that left the seat of sexual sensibility very hyperesthetic. Boys of studious and retiring habits are most apt to be masturbators and to suffer severely from its effects. Sedentary and intellectual pursuits foster an hyperesthetic condition of general, as well as sexual, sensibility. The active, robust, manly boy who indulges in out-of-door athletic sports, hunting and so on, has an outlet for what has been aptly termed the "ef- fusive cussedness" of boy-nature, and is not apt to study his sexual appa- ratus. Again, if he acquires the habit, he breaks it off sooner by virtue of his greater will-power, and it is less likely to do him permanent injury than his more delicate and intellectual brother. The "mother's boy," of all others, requires watching. Obviously, the damage produced by masturbation is more marked in the male than in the female. Much vitality is consumed in the frequently recurring calls for a restoration of a highl3^-elaborated and complex secre- tion like the semen. In the female the act produces merely a succession of nervous shocks, the injury produced being modified by the nervous resist- ance of the individual. As the function of the female in the sexual act is comparatively passive, we are not apt to be consulted regarding its effects in after-life. The author recalls a case, however, of a married woman who had been a masturbator, who claimed that she had never had a natural orgasm, the excitement stopping just short of culmination. The sexual orgasm has been likened to an epileptic attack, which, in truth, it greatly resembles, both in its phenomena and effects. The mental hebetude and physical prostration folloAving the discharge of nerve-force characteristic of an epileptic attack are well recognized. The sexual orgasm is analogous to epilepsy in that it aj)pears to be attended by an expenditure of nerve-force, followed temporarily by a certain degree of nervous prostra- tion with disinclination to mental exertion, and physical lassitude. Lalle- mand^ states the self-evident fact that in children and women the effects that in the adult male are termed spermatorrhea are not due to a loss of semen, but to the impression made by the orgasm upon the nervous system. This he terms ehranlement nerveux epiJeptiforme. This is similar to the nervous exhaustion produced by mental excitement or convulsions, the latter being ^ Op. cit. NATUEE OF THE SEXUAL OEGASM. 553 especially marked in yonng susceptible cliildren. Tickling produces a sim- ilar effect. He relates a case in which a fatal result was produced by the effect of repeated convulsive shocks upon the brain, similar to those re- ceived b}^ sensitive subjects from tickling the soles of the feet. The venereal orgasm, therefore, is not merely local, involving pleas- urable sensations and the evacuation of the seminal vesicles, but profoundly affects the whole nervous system. So important is the relation of the sexual act to the general nervous system that it is only mature individuals who can bear even infrequent acts of copulation without more or less injury. In young persons all the vital powers should be conserved for growth and development. In some animals the epileptiform character of the sexual orgasm is very prominent. Writers have called especial attention to the conduct of the male rabbit, who, after each act of copulation, falls over upon his side, the whites of the eyes being turned up, and the limbs in a condition of clonic spasm. Similar phenomena occur in some other animals, and are due to the effect on the spinal cord of the discharge of nerve-force. The severity of the impression or shock upon the nervous system in the case of the human subject has been aptly illustrated in those occasional instances of sudden death during or after copulation. Apoplexy and paralysis and fatal cardiac syncope have been known to result in individuals predisposed to these conditions, as a consequence of the sexual orgasm. The seat of sexual sensibility has been a matter of some dispute. Some writers claim that it resides principally in the glans penis. Acton, how- ever, questions the accuracy of this theory, relatLug a case that apparently contradicts it, as follows: — Some time ago I attended an oflBcer on his return from India who had lost the whole of the glans penis. This patient completely recovered his health, the parts healed, and a considerable portion of the body of the penis was left. He found, to his surprise, that the sexual act was not only possible, but that the same amount of pleasure as formerly was still experienced. He assured me, indeed, that the sexual act differed in no respect — so far as he could detect — from what it had been before the mutilation.^ That sexual sensibility is not limited to the glans penis is proved by certain masturbators who, failing to find gratification from ordinary manip- ulation, cause the orgasm by titillating the urethra. In Acton's ease it is possible that the patient was not perfectly normal sexually before the mutilation. It is probable that through external impressions transmitted by the eye, ear, and touch, the sympathetic system assumes a special sexual func- tion. It is incredible that sexual impressions are transmitted altogether ^ It would be interesting to know the final result in this case of Acton's. Is it not analogous to those cases in which, after amputation of the arm or leg, the patient is haunted by the "ghost-hand" or foot for a time? 554 MASTUKBATION Ais'D SEXUAL EXCESS. through the ordinal)^ sensitory nerve-filaments. It is Avell known that emo- tional excitement produces a profound impression upon the sympathetic nervous system. The nervous filaments of the sympathetic supplied to the generative apparatus, and particularly to the prostatic sinus, are, in all prob- ability, the principal seat of sexual sensibility. It is possible that through their infiuence reflex impressions heighten the ordinary sensibility of the part, the secretory function of the testes, and the sensibility of the prostatic sinus, but this is effected also through the sensitive nerves distributed to the delicate mucous membrane of the glans penis. Accumulation of blood always causes a gradual augmentation of sensibility; but in this case the glans penis, in passing from a non-erect state to complete turgescence, becomes the seat of a completely new and specific sensibility, up to this moment dormant. All the attendant phenomena react on the nervous centers. From this it appears that, in addition to the nerves of general sensibility, which fulfill their functions in a state of repose, and also during erection, although in a different manner, there must be, in the glans penis, special nerves of pleasure the particular action of which does not take place except under the indispensable condition of a state of erethism of the glans. When this is over, the nerves return to their inaction and remain unaffected under all ulterior excitement. They are, then, in the same con- dition as the remainder of the generative apparatus; their irritability ceases with the consummation of the act, and, together with this irritability, the venereal appe- tite ceases, only to be repeated, with the same resultant phenomena, at each new excitation. Symptoms of Masturhation. — The alleged characteristic appearance of the masturbator has been overestimated by the reputable physician, as well as the quack. In extreme cases, associated with other causes of debility, the masturbator may have an unmistakable appearance, but in the majority of cases in boys, and nearly always in girls, there is nothing to be learned from the physiognomy. Of the exceptional cases that seem to present certain peculiarities, the author recognizes two classes, viz.: (1) the overgrown, clownish, but robust lad, with sheepish expression, but heavy, almost stupid intellect; and (2) the slender, delicate, and intellectual lad of refined ways and sensitive nervous temperament. The first has inevitably a greasy skin, with plentiful acne, but excellent color; the second, a sallow or pale com- plexion and sunken eyes, with heavy circles about them. The clownish lad rarely acknowledges his fault, but the more refined lad is quite apt to hint at it involuntarily in a round-about fashion, especially if he already feels the bad effects of the vicious practice. Unfortunately, many youths will consult the doctor on some trivial pretext, and become discouraged because he does not intuitively detect the real difficulty. Young lads often so ex- press themselves when finally confronted with a direct accusation. Acton expresses himself on the effects of masturbation as follows^: — The habit causes the worst physical consequences. At first there is little urethral irritation. Pain may occur in making water, with a frequent desire to mictu- ^ "The Reproductive Organs," etc., William Acton. EFFECTS OF MASTUEBATIOISr. 555 rate; the meatus is frequently red; and ejaculation previously excited only by much friction, now takes place immediately; the secretion is watery, even slightly sanguino- lent, and emission is spasmodic. A sense of weight is felt in the prostate, perineum, or rectum, and often anomalous pains in the testes. Nocturnal emissions become frequent, and easily excited by erotic dreams. These at first are pleasurable, but later the patient is only made aware of ejaculation by the condition of his linen. In other instances the semen does not pass away in jets, but flows away imperceptibly. In some cases it makes its way back into the bladder. Other patients will tell you that emissions have ceased, but on going to stool, with the last drops of urine, a quantity of viscid fluid, varying from a drop to a teaspoonful, dribbles from the end of the penis, perhaps containing spermatozoa in greater or less number. The vicious habit — having impaired the growth, health, and intellect of the patient — ceases often to be voluntarily indulged in, because no longer pleasurable. The drain on the system during defecation or micturition, however, continues, and what depended at first on artificial excitement, is kept up by irritation or inflamma- tion of the urethra, vesiculse seminales, and spermatic ducts. Too frequent irritation of the testes causes badly-formed semen to be secreted, which is at once emitted. The mucous membrane is more sensitive than usual, acquiring an irritability like that often seen in the bladder, and which irritability appears more or less general. Pleasurable sensations seldom attend the expulsion of ill-conditioned semen, overuse of the sensations probably causing them to become blunted. The patient is now frequently reduced to complete bodily and mental impotence. The majority of scientific surgeons will hardly accept this description of the effects of masturbation as applying to any but exceptional cases. Obviously it is often difficult to determine the precise relation of certain symptoms to masturbation. While the quack has overdrawn the evils of the habit from purely mercenary motives, respectable medical men have been too much inclined to go to the other extreme, and either ignore the subject entirely or pass it by as a matter of trivial importance. Mr. Acton is a notable exception to the rule, but has, perhaps, presented the subject more forcibly than it deserves. Admitting that serious effects of masturbation are relatively rare, its results are none the less worthy of attention: — - The first effect in confirmed cases is a general lack of tone in the gen- erative apparatus. The penis and testes are relaxed and flabby, and the scrotum pendulous; varicocele often exists. Great sensitiveness of the urethra, and especially of the prostatic sinus are usual, and this is a source of pseudo-impotence in many cases by producing premature ejaculation. According to Lallemand, thickening, degeneration, and often atrophy of the ejaculatory ducts, seminal vesicles, and seminal tubules are sometimes seen. Such conditions are rare, but are occasionally to be observed in some cases of "masturbatory insanity." Prostatic sensibility is generally in- creased, and confirmed masturbators are likely to develop prostatitis, semi- nal vesiculitis, cystitis, or epididymitis, during an attack of gonorrhea. The symptoms of masturbation in children and youths are by no means so clear as some authors would have us believe. Thus Lallemand remarks as follow^s: — 556 MASTUEBATION AND SEXUAL EXCESS. However young children may be, they get thin, pale, and irritable, and their features become haggard. We notice the sunken eye, the long, cadaverous-looking countenance, the downcast look which seems to arise from a consciousness in the boy that his habits are suspected, and, at a later period, from the ascertained fact that his virility is lost. Habitual masturbators have a damp, moist, cold hand, very charac- teristic of great vital exhaustion; their sleep is short, and most complete marasmus comes on; they may gradually waste away if the evil passion is not got the better of; nervous symptoms set in, such as spasmodic contraction, or partial or entire con- vulsive movements, together with epilepsy, eclampsia, and a species of paralysis accompanied with contractions of the limbs. When a child, who has once shown signs of a great memory and of considerable intelligence, is found to evince difficulty in retaining or comprehending what he is taught, we may be sure then it does not depend upon indisposition, as he states, or idleness, as is generally supposed. Moreover, the progi^essive derangement in his health and falling off in his activity and application depend upon the same cause, the intellectual functions becoming enfeebled in the most marked manner. While there is some consistency in Lallemand's overdrawn account of the appearance and physical condition of the masturbator, the cases that it will fit are few and far between. As a matter of fact, in a great majority of instances of masturbation the objective effects are not sufficiently marked to attract attention. Even in these cases, however, a permanent impression may be made upon the constitution of the individual by virtue of which he is less strongly organized, more susceptible to disease, and less capable of entering upon the battle for existence than boys who have masturbated but little, if at all. Sexual capacity and enjoyment in after-life may be considerably impaired as a consequence of masturbation in youth, although the habit may have made no physical impression sufficiently pronounced to attract attention. Hyperesthesia of the nerves of sexual sensibility, with relaxation of the mouths of the ejaculatory ducts, and dilation and hypersecretion of the urethral and prostatic follicles are frequent results of masturbation. It would seem that the overstimulation and frequent emptying of the seminal vesicles incidental to the vicious habit causes them to acquire in- tolerance of their contents; this results in nocturnal emissions and pre- mature ejaculation, during normal intercourse. These effects, however, will, in the majority of instances, disappear as the individual grows older, if the habit be discontinued, although it is probable that sexual pleasure is permanently impaired in most instances. In a number of cases, far larger than has been supposed, chronic, persistent inflammation of the seminal vesicles results, with incidental sexual derangements and neurasthenia. As regards the prognosis in children, Lallemand remarks as follows: — In respect to the evil habit in children, it is easy to re-establish the health, if we can prevent the little patient's masturbating himself, for at this period the resources of Nature are great. It is not so easy, however, to repair the injury inflicted on nutrition during the development of the body; nevertheless the consequences dis- appear readily, and all the functions become re-established; not so, however, when masturbation occurs after puberty. EESULTS OF MASTURBATION. 557 In the female enlargement and hypersensitiveness of the clitoris and labia minora, with a reddened, lijqDersecreting condition of the mucous mem- brane, are usual. So sensitive may the parts become that the most careful examination may ^Jroduce orgasm. The mind is usually disturbed in both sexes, but more from a sense of shame and a fear of jjossible results than from physical cerebral disturb- ance. Naturally the frequent discharge of nervous force produces more or less debility and nervous irritability: i.e., neurasthenia. The assertion may be safely made that every man who has ever mas- turbated to any extent has forever lost, to a greater or less degree, his capacity for sexual enjoyment, and the same is true of women. Much, of matrimonial happiness is due to this fact, and the divorce-court speaks volumes in evidence of it. Failing to secure the anticipated pleasure, and not recognizing the source of the fault, the individual is apt to stray into forbidden paths in quest of that which, like the ignis fatuus, ever eludes the grasp. Persistent local irritation is a factor in this. The importance of insanity and imbecility in their relations to mas- turbation has been greatly exaggerated, and authorities are divided as to the causal relation of the vice to mental disease. Very often the physician confounds the propter with the post; indeed, it is probable that no healthy boy was ever made insane by masturbation alone. Given, however, a feeble frame, unstable cerebral equilibrium, structural disease of the brain, faulty environment, or hereditary predisposition, and masturbation may prove a powerful element in the determination of insanity and imbecility. Mas- turbation produced by actual brain disease, as in senile dementia, or asso- ciated with sexual perversion does not concern us here. Phthisis, epilepsy, cardiac disease, neurasthenia, hypochondria, nymphomania, satyriasis, etc., are the principal remaining disturbances alleged to be produced by mas- turbation. The author holds very much the same position regarding them as in relation to insanity, with the exception of functional cardiac disturb- ance, neurasthenia, and h3q3ochondria. These conditions may result from -any cause that produces a morbid impression upon the mind and nervous system, and are, therefore, frequent results of masturbation. With the premise that some peculiarity of physical structure, hereditary or acquired, exists as a predisposing factor, it must be admitted that mas- turbation is an occasional cause of insanity. The intimate relation between the functions of the central nervous system and the sexual organs is suffi- cient to suggest the possibility of insanity's arising from abuse of the sexual powers, under physical circumstances favoring mental derangement. From a priori considerations, involving the immediate effects of sexual excitement and indulgence upon the brain and spinal cord, we might nat- urally expect insanity to be a frequent result of masturbation and excessive venery. It is to be remembered, however, that there is a special provision of nature for the restoration of nerve-force after sexual indulgence. This 558 ilASTUEBATIOX AXD SEXUAL EXCESS. protects the majority of indiTidnals "who abuse their sexual apparatus from immediate and serious results inyolTing the cerebro-spinal func- tions. Even in the young and growing child, and in the youth at the period of puberty, the vital powers are so active, and the circumstances promoting tissue-building and repair of nerve-waste are so favorable, that the nervous structures are protected for a long time. Between the sexual acts there is a rapid building up, which prevents immediately serious results. ^^Tien sexual abuse is discontinued, whether such abuse consists in masturbation or overindulgence in sexual intercourse, recuperation is ex- traordinary rapid. No matter how seriously disturbed the functions of the cerebro-sjoinal axis may appear to be primarily, the restoration of function and power usually speedily occurs when the cause of excitation and irri- tability has been removed, actual structural change in the nervous system being very rare in these cases. When, on the other hand, there exists a condition of unstable nervous equilibrium incidental to faulty and imperfect nervous structure, whether due to heredity, congenital defect, or acquired disease, the conditions are entirely different. Under these circumstances, actual structural alteration of nerve-fibers and cells and the vessels of the brain, with coincidental psychopathic phenomena, are naturally to be ex- pected as occasional results of the severe and repeated shocks to the suscep- tible nervous system produced by the sexual orgasm. The immediate effect of sexual desire upon the brain — even in individuals considered perfectly sound from both a physical and mental stand-point — is sometimes very marked. In certain individuals, in whom the amorous propensity is very pronounced, the reason, will, and, indeed, all of the higher faculties of the mind are inhibited for the time being under the influence of sexual passion, leaving the individual to be swayed entirely by his animal impulses. While in this condition of furor sexualis the most extravagant and unreasonable acts of sexual immorality and crime are often committed by individuals who, in their sober senses, would abhor such viciousness. It is safe to assume that very few individuals of a passionate disposition can be said to be perfectly balanced mentally when under the influence of powerful sexual desire. If, then, the sexual passion is capable of obtunding the moral sensibility, reason, and judgment of individuals who are structurally sound, what is to be expected of persons of a primarily feeble intellect and faulty nervous structure? There seems to exist in some cases, in which the intellect is comparatively feeble, a surprising degree of sexuality. As expressed by Deslandes, "the generative sensibility is often augmented in proportion as the intellect becomes enfeebled." It is unfortunate that those who have had most opportunities for the study of masturbatory lunatics have not made a more careful analj'^sis, not only of the relation of masturbation to the deplorable mental condition of their patients, but of the relation of hereditary and acquired predisposing causes, both to the acquirement of the habit and its resitlts upon the brain. EELATION OF MASTUEBATION TO INSANITY. 559 Some very eminent writers tend to exaggerate the importance of the relation of masturbation to insanity. Esquirol has made much of the habit as the primary cause of mental maladies. Eitchie says:— As might be expected, these cases chiefly occur in members of families of strict religious education. Experience supports this expectation; and facts also show that those who from this cause become insane have generally been of strictly moral life, and recognized as persons who have paid much attention to the forms of religion. It is also frequently observed, especially in the acute attack resulting from this cause, that religion forms a noted subject of conversation or delusion.^ This opinion, so far as it goes, is really a substantiation of what has already been said regarding the necessity of some primary predisposing condition in the majority of cases of so-called masturbatory insanity. It is hardly conceivable that religion per se is ever a cause of mental disease. That prolonged fasting and other religious exercises, in combination with the various emotions to which religious ceremonies are apt to give rise, may produce mental disturbance in certain individuals of primarily feeble nerv- ous structure and unstable nervous equilibrium is unquestionable. It can hardly be said that the masturbatory lunatic presents a char- acteristic form of psychopathia. Such patients, however, are liable in some instances to transitory maniacal excitement, alternating with periods of depression and melancholic delusion. In many cases there is a tendency to monomania of a religious cast. In occasional cases the melancholia termi- nates in attempts at suicide or self-mutilation. It is probable that epilepsy bears about the same relation to masturba- tion as does insanity, in that a primary predisposition is necessary in order that the cause may be operative in its production. That individuals sub- ject to epilepsy are apt to have an attack when under the influence of sex- ual excitement is well known. It is related of the first Napoleon — who, as is well known, was subject to epilepsy- — that he experienced a paroxysm every time he attempted copulation. Phthisis, as a result of masturbation and sexual excess, has been dwelt upon mainly by quacks, but to a certain extent the subject has received at- tention from reputable and scientific physicians. The causal relation of sexual abuse and excess to consumption has been overrated. Instead of consumption's being a frequent result of masturbation, it is probable that the peculiar nervous organization of the phthisically-disposed is very often a predisposing cause of sexual excess and masturbation. Satyriasis and nymphomania are occasionally observed as phenomena in the clinical his- tory of phthisis. A case has already been mentioned of a woman in the last stages of consumption who continually importuned her husband to have intercourse with her, the sexual impulse being particularly strong a short time before death. In a general way, it may be accepted that the relation ^ Quoted by Aeton. 560 MASTUEBATION AND SEXUAL EXCESS. of masturbation and sexual excess to pulmonary consumption is precisely the same as that of any other condition involving nervous waste and vital depression. Anything that will lower resisting power predisposes to phthisis. The fact that quite a proportion of consumptive males are mas- turbators is a very weak argument, for the reason that the majority of males masturbate .more or less at some period of their lives. ^ The effects of masturbation and sexual excess upon the heart are very similar to those produced by mental excitement, overstudy, nervous shock, liquor, and the excessive use of tobacco. Palpitation and breathlessness are the most frequent manifestations of sexual errors. It has been alleged that cardiac hypertrophy and dilation may result from overuse of the sexual apparatus. This, however, is open to question; the capacity for experi- encing orgasm probably becomes exhausted long before such results can occur. Some writers, following Lallemand, have dwelt much upon a cold, clammy feel of the palms as characteristic of the masturbator, but this sign is fallacious. Its only claim to accuracy probably lies in the fact that, inasmuch as most boys masturbate, it is safe to assume that the boy with the moist and clammy hand-clasp is addicted to the practice like his fellows. That the assumption is apt to prove correct in the majority of cases is no proof of the accuracy of the sign. It would be as logical to as- sume that a boy masturbates because, forsooth, he is a boy; a very safe rule, by the way. The peculiar mentality of some adult masturbators is aptly illustrated by the confessions of Eosseau. This unfortunate individual, although one of the most renowned literati and philosophers of his day, not only tacitly confesses in his writings that he habitually practiced masturbation, but de- lineates in a most impressive and striking manner the influences that con- tributed to the excitation of his sexual passions, and shows in an all-too- vivid manner the attractiveness that the imagination of youth finds in the disgusting habit. In the words of an eminent writer upon the subject: — Rousseau seemed to be utterly unaware that, the miserable mental and bodily condition, which he goes on to describe and to deplore, was in any way the natural consequence of the habit. This, perhaps, is not to be wondered at, since the very medical men he consulted did not attribute his maladies to the real cause. Modern ex- perience, however, and the confessions of recent patients who have sinned and suffered — as Rousseau did — give only too clear an explanation of his ailments.- In the case of Rousseau the habit of masturbation was undoubtedly due primarily to sexual precocity. His description of his mental condition is most masterly. ^ That sexual excess is often due to consumption is questionable. As a rule, phthisis, like aS debilitating diseases, lessens both sexual desire and power. ^ Acton, op. cit. MASTURBATION AND SEXUAL EXCESS. 561 The intellectual brilliancy displayed by this celebrated victim of mas- turbation is certainly paradoxic, if the elaborate descriptions given by some writers of the mental hebetude and stupidity resulting from the vice are to be believed. The explanation, however, probably lies in the fact that Eousseau, being a man of extraordinary intellectual power, was not afEected as the average individual would be. The mental vagaries, inaptitude for mental concentration, sluggishness of thought, shrinking from society, hy- jDersensitiveness, disturbed emotional equilibrium, and morbid introspection described by him are matters of every-day experience to individuals who have indulged in masturbation to any great extent. These are, moreover, phenomena which, if the truth were known, have been experienced even by those who have succeeded in breaking off the habit, and have apparently suffered no permanent evil results from it. SEXUAL EXCESS. In a general way, sexual excess bears the same relation to physical and mental disturbances as masturbation. The results differ chiefly in degree, and physical- impairment from sexual excess is more frequent than is gen- erally supposed. Earely, indeed, is our attention called to such serious con- sequences as may result from masturbation, but there are numerous reasons that satisfactorily explain this. The general belief is that the extent of sexual indulgence is to be limited only by physical capacity, as it is unlike masturbation in being harmless under all circumstances. The author vent- ures to assert, however, that sexual excess is the most prolific cause of that most civilized and fashionable of all hydraheaded diseases, neurasthenia. Excessive sexual indulgence is, of course, relatively infrequent; oppor- tunities are not so favorable and frequent as for masturbation. The habit of sexual excess is, to a certain extent, self-regulating, because of the fact that exhaustion of desire, and perhaps power, sometimes occurs before serious physical injury has been done, and the individual must stop for the time being. The age at which sexual excess is apt to occur is generally far enough advanced to escape the marked depression produced by masturba- tion upon the susceptible youth. Continued excess will, however, produce effects similar to those of masturbation. The reciprocal "magnetism" experienced during normal intercourse un- doubtedly protects the individual to a certain extent, and several patients have stated that intercourse with some females is extremely exhausting to them, while Avith others they are not debilitated by much more liberal indulgence. That this magnetism, however, protects the reckless roue in pursuit of variety is questionable. The extent to which cohabitation may be indulged in with impunity necessarily varies with the individual, but, on the average, it may be said that there are few who are not injured by indulgence oftener than twice or thrice weekly. One of the author^s patients expressed a view that was hardly 562 ilASTUKBATIOX AXD SEXUAL EXCESS. in accordance with this, in the statement that he was "'now very moderate'^ and conld "get along yery well with a single nightly indulgence." Another subject claims to have achieved a record of thirty-two separate and perfect acts of copulation, with orgasm, within thirty-six hours, and does not con- sider the exploit remarkable — which cannot be said of his story. Much of the nervous derangement met with in both men and women is probably due to excessive sexual indulgence, and it is certain that many local diseases of women are either produced or enhanced by sexual excess. Very little consideration is shown by the average man toward his wife; in- deed, her welfare is usually a secondary consideration in sexual matters. Voluntary sexual excess on the part of women is rare, and, where they are especially importunate, there is usually some physical defect to account for it. With men sexual excess is voluntary, in and out of matrimony. It is the misfortune of many men to believe that their existence revolves around the penis and testicles; indeed, a large proportion of masculine humanity is imbued with the fatuous idea that man's principal mission in life is pan- dering to his own animal appetites. In thus worshiping, so to speak, his virile members, man reverts back to a period of the world's history so ancient as to make the situation as ludicrous as it is humiliating. It is the author's belief that if the sexual monomaniacs were removed from society its ranks would be sadly depleted. The importance of the relation of sexual excess and masturbation to the welfare of the human race is obvious. We have but to review our ancient history a little to observe the deterioration of races resulting from unbridled licentiousness. It would be well for both men and women to understand that if they desire to perpetuate their families with good healthy stock they must be moderate in sexual indulgence. Every stock-breeder understands this principle, and we may as well learn to apply it to the human species. Marriage at a premature age bears the same relation to the quality of the progeny as does sexual excess in more mature life. It has been found that breeding very young animals is unprofitable, for the reason that the progeny are poorly developed and weak. In a general way it may be said that in the case of the human subject the progeny of individuals who marry very young are almost invariably unfit for the struggle for existence. The result is, in many instances, very similar to that of consanguinity. Experiments by Goddard years ago showed that in animals frequent copulation impairs the quality and quantity of the semen. Examination of the sperm ejaculated by stallions at different acts of copulation during the same day showed that the spermatic fluid, although dense, opalescent, and of a yellowish or amber color at the first cover, became thinner and clearer; so that after about the fourth act of copulation it was almost like water, the spermatozoids being very few in number. The experimenter concluded that the spermatic fluid ejaculated at the flrst act of copulation in the morning would be quite certain to fecundate, while that of later acts would fre- TEEATMENT OF MASTUKBATION AND SEXUAL EXCESS. 563 quently fail. It is therefore better for a stallion to be allowed to cover only one mare per day, the result being much better than where the animal is obliged to cover four or five.^ Individuals who indulge excessively in coitus notice that the orgasm after numerous acts of intercourse is attended by the expulsion of little or no semen. The fluid that attends ejaculation after repeated orgasm is com- posed mainly of secretion from the prostate, Cowper's glands, and urethral follicles. This shows conclusively that the individual who copulates most is apt to create the least, and vice versa. The most frequent results of sexual excess met with in practice are premature failure of sexual power, impairment of vigor, premature ejacula- tion, partial and complete impotence. These conditions will receive atten- tion later on. Sexual perversion in its various forms is one of the rarer re- sults of masturbation and sexual excess. UNPHYSIOLOGIC COITUS. Any method of producing the orgasm by contact of the sexes save the normal one is unphysiologic, and therefore injurious. Onanism, or prema- ture withdrawal for the purpose of avoiding pregnancy, is a common prac- tice, and one against which the laity should be warned. Its injurious ef- fects are, in general, similar to those of masturbation and sexual excess. Coitus interruptus is often injurious. TREATMENT. The management of masturbation and sexual excess is largely of a moral character, and chiefly prophylactic rather than curative. The first step in the cure or prevention of the vice of masturbation and, incidentally, of sexual excess, is to improve the moral tone and strengthen the intellectual power of the patient. The more perfect the mental discipline, the easier it will be to improve the morale of the indi- vidual. One of the first steps should be the interdiction of all literatu.re, classic or otherwise, that tends to foster sexual impulses. Any work that treats of sexual matters in a manner suggestive of condonation of indul- gence is injurious, no matter how gilded the phraseology may be. Strange as it may seem, there is a certain amount of innate depravity in the human mind which impels growing lads, and sometimes girls, to seek for pruriency in everything they read. Even the Bible is not unimpeachable regarding its effects upon the young; indeed, there are few books from which a child can obtain more pernicious ideas of sexual matters than from the Old Testa- ment. Oftentimes a natural and pardonable curiosity impels a child to seek for information upon a subject toward which he instinctively turns, but in regard to which he has always been kept in ignorance. There is one point in sexual physiology that should always be impressed ^ "Traite de Physiologie," par Longet. 564 MASXrEBATIOX AXD SEXUAL EXCESS. iipon our patients. The impression prevails among young men that ex- ercise of the sexual function is an absolute physical necessity, irrespective of the method of its accomplishment. Indeed, it is probable that some phy- sicians, Tvho certainly ought to know better, foster this idea by ill-weighed and injudicious counsel. This idea is most ijernicious in its effects and it becomes our duty to correct it. Although no adult man or woman under existing social conditions is physiologically well-balanced in a state of celibacy, one may be perfectly healthy and physically vigorous while lead- ing a life of absolute continence, if the mind be properly disciplined and the body made completely subservient to the will. The excuse of physical necessity is too often a subterfuge to justify fornication and even masturba- tion. That such an excuse should ever be offered is striking testimony re- garding the prevalent ignorance of sexual physiology. A better education in the ethic and physiologic aspects of the sexual function is a crying neces- sity. The patient should be impressed with the idea that the sexual appa- ratus is less than a secondary consideration in the physical life of the in- dividual; indeed, the average man would be better off' without it so far as his mere physical welfare is concerned. It is unnecessary to existence, and its functions may be held in abeyance for very long periods, even for life, with- out necessarily producing physical injury. "When thus held in abeyance the generative function may be called into action at any time and present no evidences of deterioration from the compulsory rest — assuming that the physical has been held under the control of the moral nature. If the mind be disturbed Ijv sexuahty, as it is apt to be in our present state of society, enforced sexual rest is often productive of evil effects. AYlien. in the strug- gle between the moral and physical natures, the will is triumphant, the re- sult is never detrimental. The old maxim that ''idleness is the mother of mischief^' is especially applicable to the sexually depraved, which naturally leads to the corollary that proper mental and physical training and exercise are a potent antidote to sexuality of both thought and action. The individual who exercises both mind and body to the extent of reasonable fatigue has little desire for sex- ual indulgence. There is no better anaphrodisiac than an hour in the gym- nasium, followed by a cold shower and a vigorous rub. The lad who takes pride in his physique and is attracted to athletic sports is seldom addicted to masturbation a? compared with his fellows. The practice of athletics necessitates sexual abstinence or moderation, as is well known to trainers; indeed, every athlete knows that after a few weeks' training the desire for sexual indulgence is, in a measure, lost. Physical exercise, in addition to diverting the superfluous nervous energy from the sexual organs, is also beneficial by lessening the activity of secretion of semen, and, inasmuch as distension of the tubuli seminiferi and seminal vesicles by semen acts reflexly in producing sexual desire, anything TKEATMENT OP lIASTURBATIOjSr AXD SEXUAL EXCESS. 565 that inhibits the secretion is necessarily beneficial. Muscular exercise that involves a certain amount of attention and mental application, such as box- ing, fencing, cricket, hand-ball, etc., are particularly beneficial, as tending to divert the mind from sexual matters. The effect of the mind upon se- cretion is illustrated not only by the effect of mental emotion upon the sexual organs, but upon the lacteal, gastric, and salivary secretions. It is possible for an individual to indulge immoderately in physical exercise and yet have the mind constantly occupied by sexual affairs. The exercises men- tioned are therefore more apt to secure the desired result than those that merely involve physical labor. With reference to continence in youth, Acton says: — The argument in favor of the great mental, moral, and physical advantage of early continence does not want for high secular authority and countenance, as the recollection of the least-learned reader will suggest in a moment. Let us be content here with the wise Greek, who, to the question when men should love, answered: "A young man, not yet; an old man, not at all"; and with the still- wiser English- man, who thus writes: "You may observe that among all the great and worthy persons (whereof the memory remaineth, either ancient or recent) there is not one that hath been transported to the mad degree of love — which shows that great spirits and great business do keep out this weak passion. . . . By how much the more ought men to beware of this passion, which loseth not only other things, but itself. As for the other losses, the poet's relation doth well figure amorous affection, for he quitteth both riches and wisdom. . . . They do rest, who, if they cannot but admit love, yet make it keep quarter." The social habits of the young require close supervision. Evil asso- ciates are easily found in any community, however respectable. It is not unusual to observe a cluster of boys admiringly listening to the lewd tales of some stable-boy or man-of-all-work, and the instruction in vice received at the hands of his elders is most pernicious in its effects upon a lad whose highest ambition is to be mannish — and he is quite apt to confound the depravity of his teacher with manliness. Late hours, the dance, liquor, tobacco, high living, and the society of females of questionable virtue and free manners foster sexual excitability and must be avoided. Suggestive and immoral plays have much to do with the vitiated sexual tone of our social system and should be interdicted. When the general health is impaired tonic treatment should be instituted. It is often the case that the morale of the patient does not appreciably improve until his general physical condition has changed for the better. The importance of careful attention to dietetic regimen in controlling the tendency to masturbation and sexual excess can scarcely be overrated. The relation of a stimulating and highly nutritious diet to sexual desire and capacity was well understood by the ancients. The old maxim — '^Sine Bacclio et Cerere friget Venus'' — is as pertinent as it is classic. In the lives of many individuals Bacchus and Venus go hand in hand as dominating powers. With some persons excessive sexual desire is directly dependent 566 MASTURBATION AND SEXUAL EXCESS. upon high living. G-outy conditions of the blood incidental to the latter are especially apt to be associated with irritation of the genito-urinary tract, and particularly of the nerves of the sexual sensibility. If one would re- main continent he must not only abjure all mental sources of sexual excite- ment, but he must also abstain from stimulants, tobacco, highly-seasoned food — in short, all articles of diet that tend to induce nervous irritability. It is probable that a strictly vegetarian regimen is the best that can be advised for an individual who desires to remain continent both in mind and body. With our present pernicious social customs the unaided efforts of the will are not always successful in conquering the lusts of the flesh. When local diseases exist, whether the subject be male or female, their cure is essential, for, so long as there exists any source of sexual irritation, moral persuasion will be of little avail. Circumcision is a valuable measure, as it relieves existing phimosis and, by uncovering the gians finally results in a loss of sensibility of that structure to a certain degree, and makes the act of masturbation less attractive. In extreme cases in the female amputa- tion of the clitoris has been known to cure; this, hoAvever, is an operation to be very cautiously advised. Baker Brown, of London, the originator of the operation, performed it for all sorts of nervous troubles and received severe censure for his pains; indeed, he was well-nigh ostracized by his pro- fessional brethren — with more sentiment than justice upon their part. The bromids, gelsemium, camphor, hyoscyamus, and other drugs of the anaphrodisiac class are useful in some cases. They will serve to lessen sex- ual desire and thus prove beneficial where the patient really wishes to break off the habit. Cold bathing is an excellent adjuvant, cold sitz-baths being especially beneficial. The passage of the cold steel sound has often an ex- cellent tonic as well as moral effect. The psychrophor sometimes acts well. Deep instillations of silver nitrate are often very useful. Children who are mentally defective should be carefully watched, for once the habit is commenced a cure is almost impossible. The masturbatory lunatic is rarely cured of his masturbation. The penis has been blistered from glans to root, in such cases, without interfering with the habit. The straight-jacket might perhaps be of service temporarily, but immediately he is liberated the poor unfortunate invariably begins his vicious practices again. In obstinate cases, which means the majority, the author unhesi- tatingly advocates castration. Vasectomy or ligation of the vasa deferen- tia may, however, be tried first. The prognosis in the majority of victims of masturbation is good, but occasionally all means fail and the patient becomes a mental and physical wreck. The average boy or girl discovers the perniciousness of the practice — thanks to quack literature, as a rule — ^before arriving at adult age, and stops it, with little apparent physical disturbance resulting from the habit later on. Marrias:e as a remedv for masturbation is not to be thought of unless TREATMENT OF MASTURBATION AND SEXUAL EXCESS. 567 the subject is perfectly sound, mentally and physically — or at least prac- tically so — and of suitable age. Under any circumstances the physician should give the matter most serious consideration before assuming the re- sponsibility of advising matrimony. There is a wider latitude in the case ■of women than men in this respect, as a woman is seldom impotent. In a general way the vices of sexual excess and unphysiologic coitus require the same management as masturbation. Fortunately the patients who indulge in venery to excess are older and possessed of more powerful wills than the subjects of masturbation and are more easily influenced by argument, especially if their selfishness be appealed to. CHAPTEK XXV. Impotence and Stekility. Geneeal Considerations. — Through certain organic or functional disturbances of the sexual organs the procreative function may fail of its object. To the sexual perturbations that are responsible for inability to propagate the species the terms impotence and sterility are applied. These conditions may be found in both male and female. Impotence implies inability to consummate the sexual act. This in- ability may be due to organic or psychic causes, or, as it is usually ex- pressed, may be real or imaginary in either sex. Irrespective of the under- lying cause, the material result so far as copulation is concerned is of a purely mechanic nature. The male fails to penetrate the vagina of the female because of failure, imperfection, or transitory nature of erection, or penile deformities — congenital or acquired — that make intromission impos- sible. The condition is rare in the female, for the reason that, so long as she presents a more or less suitable receptacle for the male organ, she does not usually consider herself impotent. Impotency in the female usually implies either some deformity or disease that produces atresia of the vagina or some local inflammatory affection — acute or chronic — that gives rise tO' vaginismus: i.e., pain and spasm during attempts at copulation. In neu- rotic or hysteric subjects this condition may occur independently of local inflammation or atresia. Sterility practically implies incapacity for fecundation; copulation and even orgasm may be perfect, yet fecundation cannot occur because of or- ganic defect in one or both parties to the sexual act. These defects are several, and, broadly speaking, are of two kinds: (a) mechanic and (&) nutritive. In the first category are (1) conditions in which, although copu- lation is normal, and both ovule and sperm-cell are healthy, certain local conditions prevent them from meeting at the proper time; (2) the germ- cell and sperm-cell having met, their blending is mechanically prevented; or (3) the ovule having been fecundated, certain local conditions prevent the development of the ovum. In the second category are various more or less obscure conditions that affect the vitality of the ovule and the vitality, number, and activity of the spermatozoa. Independently of constitutional weakness of either ovule or spermatozoon, or both, there is probably a mysterious lack of affinity be- tween them in some cases that either prevents them from blending or, if blending occurs, makes the union unproductive. Whether certain viti- . (568) IMPOTENCE AND STEEILITT. 569 ated conditions of ovule or spermatozoa may make the one deadly to the ,other is at least open to speculation. A moment's reflection will show that both male and female may be theoretically fertile, although practically sterile. It may also be seen that, although sterile with one person of the opposite sex, either male or female may be fertile with others. Sterility and impotence may or may not be combined. Thus, as a con- sequence of removal of the testes the male may be entirely shorn of sexual desire, and is necessarily at the same time made incapable of producing the germinal material necessary for fecundating the ovule. On the other hand, the testes may be removed in some cases, and yet for a greater or less length of time the potency of the individual remains impaired. Stallions that are gelded late are apt to retain their sexual desire and power; if, however, castration be performed when they are young, they are rendered both im- potent and sterile. It is nothing unusual for owners of stock to keep on hand a horse that has been gelded late in life, for the purpose of gratifying the mares during the period of horsing. In horses of this kind emissions occur of a character somewhat resembling normal semen, although sperma- tozoa are necessarily absent. The secretion emitted under such circum- stances is furnished by the mucous glands of the urethra, the prostatic follicles, and Cowpers glands. The possibility of retention of the power of copulation after castration is so well recognized in the harems of the East that eunuchs from whom both testes and penis have been removed bring a much higher price in the market than those who have been merely cas- trated. Individuals who are absolutely incapable of emitting true semen may be perfectly potent. Such cases are an illustration of potency com- bined with sterility. Individuals in whom the testes are intact, the penis having been re- moved, are necessarily impotent, although under favorable circumstances they could hardly be said to be sterile. If it were practicable to bring the semen of such individuals in contact with the healthy ovule, fecundation would be as likely to occur as in individuals possessing perfect virile power. The same holds true of men whose epididymes, vasa deferentia, or ejacula- tory ducts have been occluded by injury or disease. In time the testes may fail to elaborate fertile semen, but at first it certainly is formed. In- dividuals who from various causes are unable to secure or maintain an erection, may nevertheless be capable of impregnating the female, for such persons are likely to have emissions, and the ejaculated fluid may be capable of fecundating the ovule. It is not even necessary that the semen thus ejaculated should be thrown into the vagina, as has been shown in instances in which contact and emissions without penetration have been permitted by the female, with resulting pregnancy. It appears to be possible for preg- nancy to occur when the semen is deposited only upon the external female genitals, although the recorded evidence is somewhat dubious. 570 • steeility in the male. Sterility in the Male. Sterility in the male has been sadly neglected by the profession. When • consulted with reference to nnfruitfulness in married life, the medical man, as a matter of routine, usually attributes the difficulty to some inherent incapacity or acquired morbid condition of the female. It is probable that much of the effort that is directed to the cure of sterility in women is mis- applied, the husband and not the wife being at fault. If the direct and remote results of gonorrheal infection in both male and female be given due consideration, the responsibility of the sterner sex in the matter of sterility will at once be seen to be considerable. It has been stated by eminent gynecologists — and with reason — that at least one-sixth of the cases of sterility that are brought to the attention of the physician, are due, not to difficulties in the female, but to morbid conditions in the male. Etiology. — Sterility in the male is due to : 1. Some morbid condition that perverts the vitality of the seminal fluid and renders it incapable of fecundating the ovum. 2. Conditions obstructing the escape of the semen from the ejaculatory ducts. 3. Conditions preventing the proper deposition of the semen in the vagina. 4. Defective development of the testes is apt to give rise to sterility on account of the functional inactivity of the im- perfect organs. 5. Cryptorchidism. According to Kehrer, the cause of childless marriages is to be sought much oftener on the side of the man than has heretofore been the custom. This statement is based upon investigations of the semen. Kehrer inves- tigated ninety-six cases: — In 3.12 per cent, there existed inability to copulate; in all such cases there had been preceding masturbation.^ The men suffered from frequent pollutions, or the ejaculations were premature and the penis could not be inserted into the vagina. In these cases Kehrer claims, impregnation may result, if before the attempt at coitus a speculum be introduced into the vagina. In several cases conception was obtained by this maneuver. In 31.21 per cent, azoospermia — absence of spermatozoa — existed. In most of these cases gonorrhea, with unilateral or bilateral orchitis, had preceded. The author lays particular stress upon occlusion of the ejaculatory ducts through gonorrheal prostatitis. But azoospermia was also found where no disease of the sexual organs had occurred, and where nothing abnormal in the genital organs could be demonstrated. Oligospermia- — deficient quantity of semen — was demonstrated in 11.45 per cent. Several times masturbation was confessed, or else gonorrhea with orchitis, or syphilis, had preceded. But, in addition, Kehrer thinks that the diseases of the female sexual apparatus that may cause sterility are considered too lightly. Utero-vaginal catarrh under certain circumstances leads to sterility, and Kehrer also thinks that bacteria may exert a destructive influence upon the ovules. It is a question whether these bacteria produce inflammation of the ^ Considering the prevalence of masturbation, this observation is of no special value. ETIOLOGY OF STEEILITT IN THE MALE. 571 mucous membrane or only find in the latter suitable conditions for further develojDment. Noeggerath found eight sterile marriages in a series of four- teen to be the fault of the male. Gross, in a table comprising one hundred and ninetj^-two cases, shows that the male was deficient in one out of every six. Sterility in the male may be due to any of the following conditions: — (a) Non-secretion of semen — aspermia. (b) The semen may not contain spermatozoa — azoospermia. (c) The spermatozoa may be few in number, motionless, or their move- ments ephemeral- — oligospermia. (d) Obstruction to the passage of active semen to the deep urethra and seminal vesicles. (e) Obstruction to its escape from the meatus — as in stricture. (/) Escape of the semen at some point between the deep urethra and meatus, thus preventing its proper deposition in the vagina — as seen in hypospadias and extensive urethral fistula. Cryptorchids, in whom the testes are not only retained, but are also in an embryonal and imperfectly-developed condition, are usually, if not in- variabl}^, sterile; this does not apply to monorchids. Cryptorchids are often potent to a high degree. A cryptorchid gonorrheic under the author's care is extremely vigorous sexually. Individuals from whom both testicles have been removed are necessarily sterile. When both organs have sustained serious injuries, sterility may result, either from destruction of the secreting structure of the organs or from traumatic occlusion of the efferent ducts. The semen may be secreted in proper quantity and of a healthy quality, yet it may be prevented in some manner from reaching the mouths of the ejaculatory ducts. This condition is more frequent than is generally sup- posed, it being difficult of detection on account of the fact that impotency is 'not necessarily associated with it, and the sexual orgasm is attended by the ejaculation of secretions from various portions of the sexual tract that collectivel}^ resemble semen, and which under normal circumstances form an important component part of the bulk of that fluid. As already stated, the relation of gonorrhea or urethritis to sterility is a very important one. Epididymitis is attended by the exudation of inflam- matory lymph in and about the epididymis. This may be speedily absorbed, or may become organized into connective tissue that subsequently contracts and completely obliterates the tubes of the epididymis — a. condition that most effectually prevents the escape of semen from the testes into the vas deferens. AVhen consulted regarding matrimonial imfruitfulness, the phy- sician should carefully inquire of the husband as to the existence at some previous time of double epididymitis. The explanation of the apparent sterility of the wife may not be satisfactorily determined until after a micro- scopic examination of the semen of the husband has been made. Injuries to the prostatic urethra incident to operations upon stricture 572 STEEILITT IN THE MALE. or stone in the bladder may produce occhision of the months of the ejacu- latory ducts and consequent sterility. Cauterization of the prostatic sinus may result in a similar condition. A well-known French writer observed, regarding the use of the porte-caustique by Lallemand, that by its use many men had been unsexed. It is- to be remembered that sterility in the male may be attended by absolutely no s)'^mptoms that will lead to a satisfactory diagnosis without resort to the microscope. Both seminal ducts may be oc- cluded, so that the semen cannot by any possibility pass through the ejacu- latory ducts, yet, if the testes are Avell developed and firm and in a perfectly normal condition, sexual desire, power of creation, and pleasurable sensa- tions are normal. When these phenomena are natural, yet spermatozoa are not emitted, it is usually safe to infer that there is mechanic obstruc- tion to the escape of semen from the testes, rather than a secretory per- turbation, even though these organs and their ducts present no evidences of disease. The gross appearance of the fluid ejaculated during the sexual orgasm in azoospermia may be almost precisely similar in appearance to normal semen, the absence of spermatozoa alone constituting its principal clinical feature. As a rule, hoAvever, the fluid is thin and Avatery. Men who are suffering from pronounced stricture of the urethra are apt to be sterile, as a consequence of interference AAdth ejaculation of the semen. In eases of stricture of long duration, sterility may persist for some time after the urethral obstruction has been removed. This is due to the fact that the obstruction to ejaculation has resulted in the semen's being habitually forced backward into the bladder past the veru montanum, the function of which is to prevent such backward passage under ordinary press- ure and to facilitate the extrusion of the spermatic fluid from the urethra. It is said that there exists in Paris a certain class of prostitutes Avho pre- A'ent conception by passing the index finger into the rectum of the male during intercourse, and pressing upon the membranous urethra just in front of the prostate at the moment of ejaculation. This ingenious and disgust- ing practice causes the semen to be forced back into the male bladder by overcoming the resistance of the veru montanum. If this performance be indulged in frequently, the function of this erectile structure may be per- manently destroyed, and the indiAadual ever after ejaculate his semen into his own bladder. In most cases of pronounced stricture the semen is re- tained in the urethra until erection subsides, Avhen it sloAvly dribbles away. In hypospadias and epispadias the deformity of the urethra may be such as to prevent the extrusion of the semen far enough into the vagina to accom- plish impregnation. Individuals thus affected are practically sterile. A further and excellent illustration of potency conjoined AAdth sterility is a ease that the author has elseAAdiere described as illustrative of the effects of pathologic changes in the epidid5'-mis. A tuberculous testicle was removed from this patient, and in a feAV months chronic inflammation and indura- ETIOLOGY OF STEKILITY IN THE MALE. 573 tion occurred in the remaining organ. As a consequence, while the patient found that his sexual desire and power were very much stronger than prior to the operation, he stated that after the appearance of disease in the re- maining organ he no longer had emissions, the orgasm being apparently perfectly normal with the exception of the absence of seminal discharge. It is sometimes very difficult to determine accurately the causes of a lack of fecundating power in the semen. Thus, the spermatozoa may be absent from the seminal fluid in cases in which there is no history of in- flammatory trouble with the testicle or other causes that would prevent its formation or discharge. In some instances, probably from constitutional depression or cachexia, the elaborated semen is perverted in quality and deficient in quantity, the vitalizing element being either absent entirely or of such degenerate con- stitution that it is incapable of impregnating the ovule. Spermatozoa may be present at one time, and absent at another in certain instances, accord- ing to the constitutional condition of the patient at the time. In one case of a professional man of the author's acquaintance, sterility had existed for a number of years;, the semen, being examined at various times, was found to contain no spermatozoa, yet they finally appeared in the seminal dis- charge, and the patient succeeded in impregnating his wife. In connection with the subject of sterility the varying vitality of both ovule and spermatozoa must be taken into consideration. As is well known, there is no constant relation between the performance of the sexual act and the discharge of the ovule. It is, therefore, necessary, in order that im- pregnation may be facilitated, that both the male and female elements be capable of retaining their vitality for a certain length of time. Obviously, if this were not the case, it would be necessary for copulation and ovula- tion to occur simultaneously. By a wise provision of Xature, however, both ovule and spermatozoa retain their vitality for a considerable time. It has been claimed by some physiologists that their vitality is preserved for a week or ten days, or even longer. If during the persistence of this vitality the male and female elements are brought in contact, impregnation is likely to occur. Anything that lessens the period during Avhich the elements neces- sary to conception retain their vitality tends to produce sterility. In some females it is necessary for copulation to take place either Just before or shortly after menstruation, in order that conception may occur. The mid- period is necessarily the least favorable to conception, for at this time the ovule has reached its minimum degree of vitality, if, indeed, it has not al- ready become disintegrated. Between this period and the next ovulation a sufficient time will have elapsed to impair, or perhaps destroy, the vitality of the spermatozoa. The sources of fallacy in taking this fact as a basis for precautions against pregnancy are the varying vitality of the ovule and spermatozoa and the fact that ovulation is probably not necessarily coin- cident with menstruation; indeed, ovulation mav occur at the time of the 574 STERILITY IX THE MALE. sexual act as a result of extreme sexual excitement. These physiologic facts are worth}^ of consideration in the management of some cases of steril- ity. For example, if copulation be permitted only just before and after menstruation, the sexual energies of both parties to the act are conserved and made more actiye. The sexual passion is stronger in the female at this time, and, if the male is abstinent at other times, he too is apt to be more passionate and vigorous. By taking this precaution the ovum and sperma- tozoa will be brought in contact at the time when the vitality of both is at its maximum. Leaving the question of impotence out of consideration, it is a well- known fact that sterile marriages are occasionally observed where both hus- band and wife are perfectl}^ capable of procreation, yet for some peculiar reason the elements necessary for conception have apparently no affinity for each other, and this independently of the question of sexual passion. The truth of this assertion is shown by the fact that in many instances indi- viduals who have been childless in a first marriage have married again, and have reared large families. The physiologic question involved under these circumstances is well recognized by stock-breeders, who find, for example, that certain mares cannot be fecundated by a stallion that is perhaps dis- tinguished by the multiplicity of his progeny, but are readily impregnated when covered by another and perhaps inferior stallion. It is conceivable that varying states of vitality of the spermatozoa may result from morbid condition affecting the general health. Perfection of elaboration of the various secretions of the body depends greatly on the con- dition of the individual. It is well known that the secretions of the salivary, mammary, and gastro-intestinal glands are greatly modified by mental emo- tions, and by various pathologic conditions affecting the system at large, and why may not this be equally true as regards the semen? It is probable that the condition of the emotional faculties at the time of copulation have much to do with fertility in the human subject. This is one of the pos- sible explanations of the infrequency of conception in prostitutes. Abuse of the sexual apparatus, either through masturbation or sexual excess, next to inflammatory troubles of the testicle is probably the most frequent cause of sterility. Prolonged overstimulation of the secreting structures of the testes finally results in exhaustion and relaxation of the organs, the semen being imperfectly elaborated, even though its quantity and consistency may be apparently the same. Again, the frequent shocks to the nervous system involved in the oft-recurring orgasm, in combination with the drain afforded by the excessive loss of seminal secretion, results in constitutional debility; and this again, reacting upon the semen, devitalizes it. The important relation that the bodily condition bears to the number and constitution of the spermatozoids can hardly be overestimated. Other things being equal, the activity and potency of the spermatic cells is in direct proportion to the strength and vigor of the general system. IMPOTENCE IN THE MALE. 7o Diagnosis. — The diagnosis of sterility in the male can be made only by examination of the ejaculated discharge. When the spermatozoids are found to be absent, feeble, imperfectly formed, or few in number, the source of the infecundity of the individual is at once apparent. Careful physical examination of the testicles and spermatic cords, with exploration of the urethra, may demonstrate the fact that the trouble is not defective elaboration of semen, but obstructive, the semen being prevented from escaping into or from the urethra. This is the only logical inference if the testes are firm and hard and of the proper size, the spermatic cords being also apparently healthy. Treatment. — The treatment of sterility in the male is unfortunately unsuccessful in a large proportion of cases. Chronic inflammatory con- ditions of the epididymis may sometimes be removed hj measures that will be suggested later in the consideration of diseases of the testicle. Electricity is perhaps the most reliable remedy at our command for these conditions. Tonics, proper food, and attention to sexual hygiene may occa- sionally accomplish the desired result. It must be confessed that there are many cases in which, however faithfully we may seek for the cause of sterility, it escapes observation, and the case is consequently absolutely in- curable. Some of the conditions that obstruct the passage of the semen from the urethra may be removed, stricture being the morbid state that is especially amenable to treatment. Certain cases of deformity of the penis may be cured by operation, and sterility thus corrected. impotence in THE MALE. In the majority of cases of impotence there is apparently a normal, or, at most, merely a debilitated and flaccid condition of the generative ap- paratus, but the patient is unable to obtain an erection. The lack of power varies in degree from a condition in which there is absolutely no manifesta- tion of the ph3''siologic function of erection to cases in which the erection is partial, but insufficient for copulation. In some instances erection is perfect, but of a transitory character, ejaculation occurring prematurely. Care should be taken to differentiate the cases, else treatment is not apt to be successful. Clinically it will be found that cases of impotency may be divided into: — 1. Those in which virility is impaired by general constitutional de- bility or exhaustion of nervous force, the lack of sexual vigor being func- tional and secondary to the general disturbance. These cases may depend upon sexual excess or masturbation, which produce both local and general debility. They may or may not be associated with spermatorrhea, nocturnal emissions, etc. 2. Those in which the patient is strong and vigorous, his testes secret- ing actively, and his vesiculce seminahs being overdistended as a conse- 576 IMPOTENCE IN THE MALE. quence of infrequent indulgence. In these cases premature ejaculation and a transitory character of erection are the principal features. 3. Those in whicli^ as a consequence of masturbation or sexual excess, there exists hyperesthesia of the floor of the prostatic urethra. Imperfect secretion and premature ejaculation characterize these cases. 4. Cases in which there exists some pathologic condition of the sexual apparatus that acts by disturbing innervation and producing mental de- pression, chiefly from the moral efllect of the condition. 5. Those in Avhich deformity or acquired disease interferes with erec- tion, completely or partially preventing it. 6. Those in which congenital malformations, injury, disease, or sur- gical operation have impaired or destroyed the structure of the sexual ap- jDaratus to an extent sufficient to prevent copulation. Some of these conditions are amenable to treatment, while others are unfortunately beyond the reach of medical art. Impotence is divided for description into the false and true varieties. PsEUDO-iMPOTEXCE. — False impotence is the form that is most fre- quently seen, and is usually dependent upon causes of a purely mental or moral character, the sexual organs, so far as can be determined by exam- ination, being perfectly healthy. Individuals sufl'ering from this form of impotence are usually of a highly impressionable nervous temperament primarily, or have become so as a consequence of masturbation or sexual excesses. Some men who are apparently perfectly healthy flnd themselves unable to perform the act of copulation as a consequence of a lack of con- fidence due to a recollection of early indiscretions and an exaggerated esti- mate of their effects. Ignorance of sexual physiology is often the founda- tion for this form of impotence. Failure to accomplish the act of sexual intercourse is sometimes due — paradoxic as it may seem — to extraordinary vigor and secretory activity of the sexual apparatus. Individuals who have masturbated but little, or perhaps none at all, and who have never attempted sexual intercourse until they have attained their majorit}^ are frequently troubled in this manner. The author recalls several cases of this kind: — Case 1.- — A young professional man 30 years of age, a fine, healthy-appearing subject as could be imagined. He had masturbated but little as a boy, and after attaining adult age became very fond of the society of women and acquired the reputation of being something of a roue, yet he assured the author that he had never been able to accomplish the act of copulation, premature ejaculation having attended every attempt — such attempts having been made at very infrequent inter- vals. He seemed to think that there Avas some organic disease, either of the sexual organs or "of the blood," that inhibited his sexual powers. Examination showed that the sexual organs were perfectly healthy. On careful interrogation he said that he had never attempted intercourse twice consecutively, but had become thoroughly disgusted by his first failure on each occasion. It seemed that intercourse had always been attempted under circumstances involving not only extreme sexual excitement, but more or less uneasiness as regards the possibility of detection. All possible means were tried to convince this patient that he was perfectly sound, and sexually potent, ETIOLOGY OF PSEUDO-IMPOTEXCE IN THE MALE. 5?? but without result. He still entertains the opinion that he is impotent, and nothing but success in copulation, which will certainly be achieved if the act is ever attempted under proper circumstances, will ever convince him to the contrary. Overdistension of the seminal vesicles, in combination with overexcitement and consequent hyperes- thesia of the prostatic sinus existing at the time of attempted copulation, is the explanation of the pseudo-impotency of this individual. Case 2.- — A similar case that recently came under observation is much more tractable. This patient states that he has never masturbated and had never attempted intercourse until past the age of 25. He is of an exceedingly passionate temperament, and has found that he has never been able to accomplish the act at a first or even a second attempt, but that if he attempted the act repeatedly with a person with whom he had the opportunity of associating for several days at a time, he finally succeeded, and was thereafter in a perfectly normal condition. The persistency of this individual is all that has saved him from the same despairing frame of mind as that Avhich exists in the previous case. The form of impotency born of excessive and uncontrolled desire has been familiar from time immemorial. Three centuries ago Montaigne dilated upon it in his philosophic essays as follow's: — Xeither is it in the height and greatest fury of the fit that we are in a con- dition ... to sally into courtship, the soul being at that time overburthened and laboring with profound thoughts, and the body dejected and languishing with •desire; and hence it is that sometimes proceed those accidental impotencies that so unreasonably surprise the willing lover, and that frigidity which by the force of an immoderate ardor so unhappily seizes him in the very lap of fruition; for all passions that suffer themselves to be relished, and digested are but moderate. The surgeon is not infrequently called upon for relief for just such impotencies as Montaigne so clearly describes. That the remedy is better psychic control goes without saying. Continence as a cause of true impotence has been admitted by some writers. Howe relates two interesting cases that were apparently due to this cause^: — Case 1. — In the winter of 1876 an undertaker of this city was admitted to St. Francis Hospital, suffering from prolapse of the rectum. He was 45 years old and his general health was good. After recovering from the prolapse he informed me that he Avas impotent, and likewise was subject to nocturnal emissions. During the whole course of his life he had refrained from any gratification of his passions, and had never attempted sexual intercourse until within the past year. Twelve months previous to his admission he had married, and without expecting anything of the kind found himself impotent and unable to consummate the marriage. Every attempt at intromission failed, through weak erections and rapid emissions. He denied mastur- bation, and the condition of the genitals seemed to confirm his statement. From the age of 25 he had emissions once a fortnight and frequent erections, but the erections were feeble, and lasted only for a few moments. Since his marriage the emissions had increased in frequency, and there seemed to be much relaxation and apparent elonga- tion of the penis. The patient did not seem to be depressed by the fact of his impotence. ^ "Excessive Venerv," etc. 578 IMPOTENCE IN THE MALE. He attributed it all to total abstinence, and hoped that, in the course of time, Xature would effect a cure. The author does not believe that continence per se ever causes true impotence. The cases in which it apparently does so are usually either masturbators or congenitally weak, or both. A few cases are recorded by Lallemand and others where rectal disease caused temporary impotence, but the patients were not continent, and they recovered from the spermatorrhea and impotence when the prolapse was cured. In the patient whose history has just been given the prolapse of the rectum may have added to the genital weakness, but it was probably not the cause of it. Howe records a second interesting case of impotence from continence, unaccompanied by spermatorrhea: — Case 2. — The patient was 38 years old, and a broker by occupation. His general health was excellent, and he was constantly and actively employed in a flourishing business. He commenced to masturbate a little when a boy of 12, and occasionally was guilty of the habit until he reached the age of 16, at which time he discontinued it altogether. At twenty he had intercourse in a natural way, and without any difficulty whatever. For six months subsequently he cohabited at intervals of two weeks, and never at any time indulged to excess. A period of eight years then elapsed without any opportunity for sexual congress. At the termination of that period he again attempted to renew his sexual relations with his former partner, but, to his great annoyance, failed. Though he subsequently made frequent trials, the result was the same. He finally gave up all hope, firmly believing that his impotence was beyond the reach of therapeutic agents. He attributed his loss of virility to continence, and not to any dissipation or bad habits in early life. A period of ten years elapsed, during which interval he tried sexual congress but once, and was unsuc- cessful. He had few emissions, and few erections. For twelve months previous to calling at my office he had had only three emissions, and no erections of any degree of permanence. He thought his desire for sexual pleasures had not diminished, but, the knowledge of his impotence being ever present, would prevent him from attempting it again. This mental state necessarily complicated his case, and added to the difficulty of a cure. On making an examination of his genital organs I found the penis and testicles somewhat smaller than natural. The left testicle was smaller than the right, and more than ordinarily sensitive to pressure. Otherwise the parts were unchanged. Knowing that the patient's habits were excellent, and that his general health was good, I made a favorable prognosis, and put him under treatment. He continued under treatment for three months, improving sloAvly. His erections were more frequent and natural, and his hopes of final recovery revived. He suddenly, without any notifica- tion, ceased his visits at the office. The summer following he consulted me for gonor- rhea, and informed me that a few days after he had ceased calling he renewed his attempt at intercourse, and succeeded, and had kept well in that respect ever since. The author has seen so many cases similar to those reported by Howe that he feels warranted in the belief that prolonged continence in excep- tional cases bears a definite etiologic relation to impotence. As already stated, however, he does not believe that continence alone ever causes true impotence. In some cases the patient's statements regarding masturbation should be discounted. It is nothing unusual for patients to assert that they ETIOLOGY OF PSEUDO-IMPOTENCE IN THE MALE. 579 have practiced the vice "but a few times," etc., when, as a matter of fact, they have not only practiced it very frequently, but are not yet rid of the habit. In a general way, however, men who abstain from sexual intercourse up to thirty years of age are often impaired in their sexual power — pseudo- impotence — whether they have masturbated or not; where they have mas- turbated, especially if the habit^has not been broken, impotence is common. It should be remembered, in considering the subject of pseudo-im- potency, that the sexual passion varies in intensity in different individuals. Many persons are of frigid temperament and are apt to exhibit more or less sexual indifference. This is usually associated with a relative sluggishness of the sexual apparatus, which, however, is perfectly natural to the particu- lar individual. A'ery slight mental disturbances at the time of attempted intercourse may result in temporary impotence. Anxiety or mental worry of any kind is apt to give rise to it. Individuals who have labored mentally or phys- ically to the extent of producing exhaustion are apt to experience temporary inhibition of sexual activity and desire. This physiologic phenomenon may be, as has already been suggested, taken advantage of in the treatment of sexual disorders. Emotional influences that are capable of making a pow- erful impression upon the nervous system are especially apt to inhibit sex- ual desire, the more particularly as they tend to check the secretion of semen. The influences that tend to produce activity of secretion of the testes are chiefly emotional, and, conversely, diverse mental influences may check the secretion. An eminent writer ujDon hysteria outlined this fact as follows^ : — The glands liable to emotional congestion are those which, by forming their products in larger quantity, subserve to the gratification of the excited feeling. Thus, blood is directed to the mammae by the maternal emotions, to the testes by the sexual, and to the salivary glands by the influence of appetizing odors; while in either case the sudden demand may produce an exsanguine condition of other organs, and may check some function which was being actively performed, as, for instance, the digestive. The emotion of fright or the condition of mind produced by the fear of detection or of the results of copulation will invariably inhibit the sexual power. Disgust, indifference, or antipathy for the party of the second part has often a similar effect. The practical physician does not usually put much faith in the theory of affinity as existing between the sexes, but the author is of opinion that in many instances failure to consummate the marital act is due to a lack of harmony between the contracting parties. An apparent instance of this is the following: — ^ Carter, on "Hysteria." 580 lilPOTEXCE IX THE MALE. Case. — A man, 31 years of age, perfectly healthy, the sexual organs being perfectly formed and apparently in a normal condition, came to the author for relief of impotence. He was a man of very highly-wrought nervous organization, and had never been anything of a roue. The only possible exception that could be taken to his physical condition was the fact that he was somewhat inclined to corpulence. He stated that he had not experienced an erection for some months. During this time, however, he had been working very hard, and had not allowed his mind to dwell on sexual matters, and he himself was inclined to attribute the absence of erections to this fact. As he contemplated matrimony, however, he desired a course of treat- ment. On inquiry he stated that he had on several occasions failed in accomplishing intercourse, but that he had found that with certain females he was perfectly potent, while with others he was absolutely impotent. He ^^as assured that there was no physical impediment to matrimony, and a course of local faradization was advised. He improved very rapidly, and in a few months the sexual function became so active that the bougie electrode could not be passed because the slightest contact with the urethra produced vigorous erection. He stated that when he took a Turkish bath, as per advice, he was considerably embarrassed by the occurrence of erections so soon as the attendant attempted to rub him. Under these circumstances the author felt perfectly justified in advising matrimony. The result was unfortunately not what had been expected, for a year after marriage he had not yet succeeded in accomplishing intercourse. There was evidently in this case some inhibitory cause of a mental character, as shown by the fact that after marriage he still had vigorous erections and nocturnal emissions with dreams. As soon as the idea of attempting intercourse entered his mind he found it absolutely impossible to secure an erection. The author finally succeeded in curing this case by the exercise of a little ingenuity. The Mife was sent away for three months, the husband being meanwhile treated with electricity. On the day of the wife's home-coming the patient was provided with a rectal suppository containing a little belladonna, opium, and camphor. He was in- structed to insert this on going to bed and was assured that the wonderful suppository never failed. The treatment was a brilliant success and there was no future trouble, the wife becoming pregnant within a few weeks. The fact that certain individuals of highly-sensitiye nervous organiza- tion are impotent respeetiug some women, while with others they are per- fectly potent, is a well-known fact. Individuals of this sort are rery often convinced that they are impotent. Ijy failure in experimenting with prosti- tutes for the purpose of determining whether or not they are justified in assuming the matrimonial state. The fact that they are impotent under such circumstances is highly complimentary to their moral tone. The en- vironment that surrounds the average prostitute, in conjunction with the purely mercantile character of the transaction, is not likely to inspire w^ith sexual passion an individual possessed of the average amount of decency and self-respect. It is not unusual for individuals to state that, excepting when under the influence of liquor, they are ahsolutely impotent with prostitutes. Considerahle and forcible argument may be necessary to convince patients who have applied what they consider the crucial test of attempting inter- course with jirostitutes. and have failed, that they are not impotent. Boubaud records a case which, although it has become so extensively Cjuoted bv writers upon the subject that it has been worn almost thread- ETIOLOGY OF PSEUDO-IMPOTENCE IN THE MALE. 581 bare, is nevertheless very pertinent as applied to patients who are psychically impotent with some women, while perfectly potent with others: — Case. — M. X., son of a general of the First Empire, was brought up at his father's country-seat, which he did not leave until he was eighteen years of age, Avhen he went to the military school. During his long period of isolation in the country he had been initiated, at the age of fourteen, into an experience of the pleasures of love, by a young lady, a friend of the family. This lady, then twenty-one years old, was a blonde; wore her hair in the English style, that is to say, in corkscrew curls: and in order to lessen the liability of detection in her amorous intrigue, she never had intercourse with her young lover except when clothed in her day attire, — that is to say, wearing gaiter-boots, corsets, and a silk gown. All these details I mention purposely, for they had great influence, not only over the degree of excitability of the genital function, but over its very existence, in the case of M. X. The young lady was of strong passions, and, as it appeared, exhausted the strength of the young neophyte, and the severe regimen of the military school was no more than sufficient to restore to the genital organs the energy which had been seriously affected by too early and too frequent indulgence. But w-hen, the period of his study having passed, he A^as sent to a garrison, and was disposed to enjoy the rights w^hich Nature had restored, he perceived that sexual desire was only provoked by certain women and with the concurrence of certain circumstances. Thus, a brunette did not produce in him the slightest emo- tion, and a woman in her night-dress was sufficient to extinguish and freeze every amorous transport. In order that he might experience the venereal desire, it was necessary that the woman should be blonde, should wear gaiter-boots, should be laced in a corset, wear a silk gown, and, in a word, fulfill all the requirements of the lady who had first caused M. X. to experience the sexual orgasm. And this was not by reason of any sentimental love, the magic power of which lasts through a life-time. In his early sexual relations M. X. had only been actuated by animal desire. His heart had never been touched, and after twenty-five years, in consulting me for his singular infirmity, he declared that he had loved with his heart but one \\'oman, and to her he had never been able to render homage, for, by a perverse coincidence, she was a brunette. His fortune, his name, his social position, made it the duty of M. X. to marry, but he had always resisted the solicitations of his family and friends, knowing that he would be incapable of availing himself of his marital rights, with a wife arrayed in the costume of the nuptial bed. Yet he was in good health, Avas of the sanguino- choleric temperament, was above the medium height, and was of so strong a consti- tution that for fifteen years he had been an officer in a regiment of heavy cavalry. Evidently his impotence was relative only, for, w'hen the woman was blonde and when the other conditions specified existed, he accomplished the sexual act with all the ardor of a healthy man of amorous disposition. Eoiibaucl finally cured this patient by suggestion, in conjunction with the use of alcoholic stimulants to the point of mild intoxication. The spell once broken, there was no further trouble. Such psychosexual inhibitions as the case related by Eoubaud are more frequent than is generally supposed. Prolonged sexual relations with an individual of a certain type not infrequently makes such a profound psychic 582 IMPOTENCE IN THE MALE. impression that other types of women are unattractive. Especially is this true of men of tine nervous organization who happen to consort with women of decided blonde or brunette type. Prolonged association with one type by no means rarely makes the other unattractive, sometimes even repellant. This is, of course, not always a mere matter of physique. Certain intel- lectual attributes in the woman may have much to do with the psycho- sexual impression she produces. Cases have been noted in which pseudo-impotence was relieved by the affected individual's picturing in his imagination the person of some woman other than the one with whom he was attempting to cohabit. In certain im- pressionable individuals impotence may result from a lack of affinity between the parties to the act, actual antipathy on the part of either being unneces- sary to its causation. Goethe took advantage of this physiologic fact in his "Elective Affinities.'' In this tale is described the mutual enjoyment ob- tained by an estranged couple through the medium of their imaginations, each party to the act imagining the other to be the individual for whom an affinity was felt. Goethe carries the theory of affinity still further, and describes the child that was born as the fruit of this particular conjugal act as in nowise resembling its parents, but presenting a strong resemblance to both individuals for whom the parents felt an affinity, and who were pres- ent in imagination at the time of conception. Hammond relates a case that is aptly illustrative of the manner in which certain mental conditions will produce temporary impotence: — Case.^A married gentleman, who before entering into the matrimonial state, had been excessively given to sexual intercourse, but who had no reason to think that his powers were exhausted, or even materially weakened, found himself on his wedding-night and for some days thereafter absolutely incapable of consummating the marriage. His wife was a highly-educated, intelligent, refined, and beautiful woman; he w^as devotedly attached to her, and on marrying at once and for all gave up the evil associations of his younger days. His passions were strong, but as soon as he attempted intercourse the desire he had previously entertained vanished at the thought that it was a profanation for a man like him to subject so beautiful and pure a woman to such an animal relation as sexual intercourse. "She is too good for me," he would say to himself; "I ought to have married a woman used to this sort of thing, or, better still, have remained single and gone on in the old way." This happened several times, and then, in disgust with himself, he paid a visit to one of his former female associates, and soon satisfied himself that his powers were as good as ever. Again he essayed the act with his wdfe, and again he met with disappointment. He had now been married a week, and the marriage was still unconsummated. A case like this presented very little difficulty: I reminded him of the fact that in all probability, however pure and noble his wife might be, there was no profanation in sexual intercourse, chastely undertaken; that she had sexual organs which were intended for the performance of certain functions; that these functions were all connected with the propagation of the human species; that there was but one way that I knew of by which the species could be propagated; that she had selected him as the man who Avas to put her in the Avay of fulfilling her office in ETIOLOGY OF TEUE IMPOTENCE. 583 the grand scheme of Nature, and that my advice to him was to lower his estimate of her angelic character, and to look upon her in the not less worthy light of a woman to be treated as other women are treated under like circumstances. He left, promis- ing to be less exalted in appreciation, but the next morning returned with the in- formation that it was no use; he had tried his best, his erections were strong and repeated, but as soon as he went further toward the object he had in view his desire become utterly extinguished. She was "too good, too delicate, for a mere animal like him; he could not desecrate her beautiful body by any such vile act," etc. With the sensible co-operation of the wife Hammond had no difficulty in curing this case by suggestion. Sexual perversion may cause impotence. It is obvious that individuals for whom the natural method of performance of the sexual act has no at- tractions are apt to fail should they attempt it. Impotence of a transitory character may be due to the psychic effect of satiety as well as to the de- bilitating influence of sexual excess. This is the form of impotence most frequently seen in married men. Through resulting psychic perturbation, a lack of responsiveness on the part of the female is an occasional cause of pseudo-impotence in the male. This is particularly apt to arise in mar- ried men and is probably in the majority of instances primarily their own fault. Teue Impotence. — True impotence is rare in both male and female; extremely so in the latter. The function of the male in the act of copula- tion is an active one, and erection of the sexual member is necessary; whereas in the case of the female no preparation is necessary for the sexual act, her function being comparatively passive. The necessary element in the case of the male is a sufficient degree of firmness of erection to permit the introduction of the penis into the vagina, and any individual who is possessed of this amount of capacity cannot justly be said to be affected with true impotence. It is unnecessary to potency that the individual should experience either desire for, or pleasure in the performance of, the act of copulation. In certain conditions perfect erection and even ejacula- tion are possible, although the individual does not experience either desire or pleasure. Some of the diseases affecting the spinal medulla produce this phenomenon. In certain cases of aspermatism a similar state of affairs is noted. Severe priapism due to cantharidal poisoning is not usually attended by sexual desire, and intercourse under such circumstances may be abso- lutely devoid of pleasure. The term impotence in the case of the male should be restricted to those cases in which there exists some actual physical impediment to the performance of the act of copulation. Such impediment may, however, be temporary or permanent. Etiology. — The causes of true impotence may be classified as (a) con- genital; (b) acquired. (a) Congenital Causes. — 1. Marked h3rpospadias or epispadias. In some cases of the former the penis is curved or otherwise deformed. In the 584 IMPOTENCE IN" THE MALE. latter condition exstrophy of the bladder ma}^ co-exist. The author has met "vrith one ease of impotence due to a congenital lateral curvature of the penis. 2. Imperfect development of the penis and testes, the former being too small and too flaccid for copulation. Oftentimes the penis seems overlarge, yet the erectile tissiie is not well developed, and erection is consequently imperfect. 3. Congeriitally-excessive development of the joenis (?). This form of impotence may be only a relative affair, the real cause being a dispropor- tionate smallness of the vagina of the individual with whom intercourse is attemj^ted. In the absence of tumors it is probable that the cases in which the penis is too large to permit of copulation are extremel}'' rare, if, indeed, they ever occur. 4. CrA'ptorchidism or monorchidism, with imperfect development of the penis. 5. Excessive redundancy of the prepuce, with phimosis. 6. Congenital tumors of the organ. (b) Acquired Causes. — 1. Tumors of the penis, ^Drepuce, or glans. 2. Inflammatory thickening of the prepuce, with phimosis, incidental to balanitis, gonorrhea, or chancroid. 3. Large venereal vegetations. 4. Excessive obesity. This cause is frequent, but is sometimes over- come by the ingenuity of the patient in reversing the relative positions of the male and female during copulation: an expedient as old as the De- cameron. Obesit}^ also lessens desire. 5. Ankylosis of both hips may prevent copulation in the normal man- ner, although by appropriate posturing the act may be accomplished, at least by the male. 6. Tumors of the scrotum or testes, such as hydrocele, sarcocele, he- matocele, cancer, and elephantiasis. The two latter conditions may involve the penis. 7. Chancre or chancroid of the penis of sufficient size and irritability to interfere with copulation by the pain the act produces. 8. Gonorrheal or simple urethritis. 9. Acute or chronic chordee. The former condition occurs in gonor- rhea; the latter may result from frequent and severe attacks of urethritis, or from stricture, and may occasionally arise as a consequence of ure- throtomy. 10. Inflammation of the deep urethra, prostate, and seminal vesicles. 11. Circumscribed inflammation of the corpora cavernosa. In these cases calcareous plates sometimes form. 12. Cicatrices from wounds of the penis or urethra, interfering with erection. 13. Eemoval of the penis and testes. If the operation be performed early in life removal of the latter only is necessary. ETIOLOGY OF TEUE IMPOTENCE. 585 14. The habit of masturbation, spermatorrhea from whatever cause, nervous shock, and in some instances organic disease of the brain and spinal cord may produce a complete and permanent loss of power of erection by exhaustion or inhibition of the nervous stimulus to the parts. 15. Temporar}'- and symptomatic impotence is sometimes the result of existing constitutional diseases, su.ch as fevers. Debilitating and prostrat- ing acute or chronic disease, and neurasthenia from overwork or worry, may produce it.^ Certain local conditions are occasionally attended by symptomatic im- potence. Thus, inflammation of the testicles, varicocele, and tumors of the testes or scrotum other than those that are capable of interfering mechanic- ally with the act of copulation may produce complete impotence. In some instances this is due to reflex inhibition of the sexual power, while in others the condition is a purely mental one, resulting from the moral effect of the knowledge of the existence of pathologic conditions of the sexual apparatus. In varicocele, particularly, both elements in the causation of impotence de- serve consideration. There is a lack of tone — in fact, a marked debility of the generative apparatus in many instances — and associated with this ener- vation there is profound mental disturbance, resulting from the conscious- ness that the sexual organs are not healthy. Syphilitic orchitis may in a similar manner produce impotence, and, as already seen, sterility. If this condition be not speedily relieved, permanent impotence and sterility may result as a consequeilce of changes in the secretory structure of the. testes incidental to the pressure of the syphilitic neoplasm. Various drugs have been said to produce impotence; but a certain amount of skepticism is pardonable in this connection. It certainly must require large doses of the various sedative and alterative drugs to bring about this condition. Arsenic, antimony, lead, iodin, camphor, and hash- eesh are among the drugs that are said to produce impotence. Iodin has been accredited with the power of producing atrophy of the testes. The author does not believe, however, that a single authentic case can be pro- duced in which such atrophy is justly attributable to the use of this drug. One explanation for the popular idea that the potassium iodid is capable of producing atrophy of the testes is that certain cases of syphilitic orchitis have been insufficiently treated with the drug, or treated too late. Atrophy of the testicle has resulted, not from the drug, but from pressure-innutri- tion produced by syphilitic neoplasm that large, and long-continued doses of iodid might have removed in time to save the testis. The carbonated waters taken in excess are said to produce impotence. The author regards this as a pleasing delusion on the part of "men about town." ^ Vecki ("Sexual Impotence") claims that a severe cold produces impotence by inhibiting olfaction. The author admits the clinical fact, but believes the temporary impotence to be due to the constitutional effect of the cold. 586 IMPOTENCE IN THE MALE. Ill some cases of impotence it is impossible to attribute the condition to any particular cause. Teeatment. — The treatment of impotence may be divided into (a) morale (b) medicinal and surgical. The latter may be subdivided into: (1) general; (2) local. The mainstay of treatment in false or nervous impotence consists of psychotherapy. The principal requirement is the restoration of the pa- tient's self-confidence. The greatest delicacy and judgment are necessary in the management of these cases. The patient should feel that his ph};-- sician S3^mpathizes with him in his apparent afHictioii. It will not do to laugh at his ailment, or to treat it lightly, even though assured that his impotence is imaginary rather than real. The patient is usually compara- tively strong and healthy, but has masturbated to a certain extent and has experienced nocturnal emissions with greater or less frequency. Morning erections are strong and vigorous, and apparenth^ perfectly normal. Sexual desire is felt and may be present in an exaggerated form. When such a patient attempts intercourse, erection either does not occur at all or takes place in a spiritless way that is not at all encouraging to his mind. When he reflects that he has masturbated, and that he has experienced an occa- sional nocturnal emission, with perhaps other little symptoms that coincide with the description of spermatorrhea outlined in some quack treatise or other, he becomes completely demoralized. So careful do these patients study. quack literature, and so firmly convinced of their impotency do they become, that it is often absolutely impossible to gain their confidence or to benefit them in any way whatever. A symptom that greatly depresses the patient's mind is the escape of prostatic fluid and urethral mucus during prolonged and vigorous erection. An effort should be made to obtain the fullest confidence of such indi- viduals, and they should be given instruction in the rudiments of sexual physiology. In the majority of cases they may be reasoned out of their per- verted and pernicious notions regarding their physical condition. Many times we are compelled to be somewhat disingenuous in our management of the case, for, the patient's confidence once gained, some comparatively trivial local or general measure may cure the case, providing the individual believes in the potency of the treatment. Above all, the patient should be assured that his sexual apparatus is in an exceptionally strong and healthy condition. Marriage should be recommended where practicable. Eegard- ing this point, however, marriage should never be advised unless the occur- rence of strong and vigorous erections proves copulation to be possible. Even under these circumstances, an occasional unfavorable result will ensue, because of persistent psychic inhibition of erectile power at the time copula- tion is essayed. In cases dependent upon moral or mental causes prevailing when copulation is attempted, removal of the circumstances that produce mental depression is, of course, necessary. The elements of sexual indifEer- TREATMENT OF IMPOTENCE. 587 ence due to mental worry, nervous shock, fear, excessive passion, or disgust for the individual with whom intercourse is attempted may be amenable to correction. In those cases of married men in which lack of affinity is the principal cause of impotence, medical measures are apt to be unsuccessful, although some form of local stimulation of the sexual organs may possibly be effi- cacious. The divorce-court is, however, a better and more logical remedy if the circumstances imperatively demand a cure. In many instances of purely nervous impotence irritability of the pro- static urethra exists. This may be removed in the majority of instances by the occasional passage of a cold steel sound. If the case be obstinate, astringent applications may be made by means of the cupped sound or deep urethral syringe. The prostate or seminal vesicles are sometimes congested or chronically inflamed. Massage of these parts relieves this condition. The psychrophor or cooling sound is sometimes serviceable. In cases of premature ejaculation success may often be attained by a second attempt at copulation. The patient should be advised to avoid ex- citement during intercourse. He may very often succeed in delaying or- gasm by thinking of something else beside sexual intercourse at the time of its performance. Patients who are apprehensive of failure should be advised to refrain from intercourse during the night, and to attempt it only in the early hours of the morning. In some instances the glans penis is excessively sensitive as a conse- quence of a redundant or phimosed prepuce. Under such circumstances circumcision will usually effect a cure. Bathing of the glans in a solution of alcohol and tannin is an excellent plan to remove hyperesthesia. It is well for newly-married men affected with nervous impotence to confide in their wives and explain their temporary debility. The patient should be informed that soonor or later he will have a vigorous erection — as soon, at least, as the novelty of the situation has worn off and his timidity has been allayed. He should be instructed to immediately take advantage of the situation, when an erection does occur, and perform the marital act. Measures of a general and hygienic character are requisite, especially in the management of cases in which actual structural disease does not exist. These general measures involve proper exercise, diet, baths, proper hours of sleep, temperance, or, better, total abstinence in the matter of alcoholics and tobacco, and freedom from care and worry so far as possible. Such measures apply also to the treatment of spermatorrhea, a condition with which impotence is very often associated. Cases in which impotence is due to an exhausted condition of the sex- ual apparatus and incidentally of the general nervous system, with in some instances impairment of nutrition, primarily require complete sexual rest. Occasional or so-called moderate indulgence is not to be thought of in these cases. Perfect continence must be insisted upon for the time being, the 588 lilPOTEXCE IX THE MALE. length of time varying with the grayity of the case. It is unfortunate that the majority of patients^ and particularly voluptuaries, are loath to accept such advice, believing, as they do, that by means of aphrodisiacs their virile powers should be restored without interfering with the indulgences that are responsible for their condition. Hammond's remarks upon this point are certainly judicious. He says: — I have generally found that in those cases in which an erection sufficient for intromission does not take place, sexual repose for about a year is necessary. Again, the age of the patient and the length of time during Avhich the condition has existed are factors to be considered in determining the question. In persons over forty, and in whom the condition has lasted six months, no attempt should be made for even a longer period than a year. With every unsuccessful effort, even though no emission occurs, the nervous excitability is still further lessened, and the morale materially lowered. Generally in these extreme cases there is no difficulty in securing the requisite quiescence. The patient is fully aware of his inability, and is in no mood to undertake what he knows will result in failure. It sometimes happens, however, that masturbation, with the erection almost nil and the orgasm imperfect, is practiced, when the individual finds that intercourse is impossible. It is in this respect that the requirement of rest must be strictly enjoined. Cases in which the principal trouble consists of premature ejaculation and feeble erection unquestionabh^ require rest for a time; but the patient is apt to disregard the instructions of his medical adviser because still re- taining a certain degree of potency and able to copulate after a fashion — sufficiently well, at least, to make the indulgence pleasurable. In cases of this kind the patient should be informed that it is absolutely impossible to benefit his condition unless he will consent to at least six months' con- tinence. The moral tone and mental condition of the patient deserve special consideration. The remarks that have been made in connection with the subject of masturbation and sexual excess are pertinent in these cases. Ex- ercise, intellectual occupation, and avoidance of all sources of sexual stimu- lation must be insisted upon. Where practicable, the patient should be advised to take a change of scene; in short, to cease associations that tend to excite his sexual passions. Traveling — and particularly a sea-vo3^age — is excellent for these cases. Cold shower-baths or plunge-baths are excellent adjuvants to the gen- eral treatment. Delicate patients should begin by a course of sponge-bath- ing. Cold sitz-baths or hot and cold water in alternation is useful. Whatever form of bath be selected, it should be followed by brisk rubbing with a towel or flesh-brush. Local douches with hot and cold water alternately are very stimulating to the parts. The Turkish bath taken in moderation and fol- lowed by the cold plunge constitutes one of the best of general tonics. The diet requires some attention. It should consist of an abundance of easity-digestible and nutritious food, a preponderance of nitrogenous ele- TEEATMEXT OF IMPOTEXCE IX THE MALE. 589 ments being essential. The yarious preparations of malt and codliver-oil are excellent means of improving nutrition. An abundance of good rich, milk and cream is demanded. Meats should be eaten rare and should con- tain considerable fat. A moderate amount of stimulants is often useful. Claret, port, sherry of good quality, or Dublin stout may be taken with the meals. The patient should be advised to sleep upon a hard mattress with light covering, this measure being particularly essential if nocturnal emis- sions are a feature of the case. Certain internal remedies are useful. Contrary to the general belief, however, there are no specifics for impotence — i.e., there are no drugs that can be depended upon to so stimulate the sexual apparatus as to immediately render copulation possible. Nearly if not quite all of the aphrodisiac reme- dies that are apt to be useful in impotency, with the possible exception of cantharides, act rather as general restorers of nervous energy than by a special predilection for, and stimulation of, the sexual apparatus. Much of the reputation of various drugs depends upon the moral effect of their administration in cases of pseudo-impotence. Nearly all the celebrated nostrums and quack remedies recommended as specifics for impotence have become celebrated through their influence upon the minds of the patients. An individual who is impotent because of lack of confidence in his virility is likely to be relieved by a trituration of milk-sugar, providing he has con- fidence in the efficacy of the placebo. If some alleged aphrodisiac be given, it is apt to acquire an undeserved reputation for efficacy. The best remedy for a lack of tone in the generative apparatus is probably iron. The tincture of the chlorid may be given in doses of from 15 to 20 drops in water, three times daily, after meals. The pyrophosphate of iron is perhaps a more eligible preparation and equally efficacious. It should be administered in doses of from 5 to 10 grains thrice daily. It may be advantageously com- bined with strychnia. The following is a favorite prescription of the author's: — I^ Ferri pyrophos 3ii S ij. Strychnise sulph gi"- j- Syr. glycyrr giv. M. Sig. : 3j three times a day, after meals. Ferratin and peptomangan are both excellent ferruginous preparations. Nux vomica, or its alkaloid, strychnia, has an excellent reputation in the condition under consideration. Phosphid of zinc and nux vomica may be given in combination. The following is an excellent formula: — IJ Zinci phcsphidi gr. v. Ext. nucis vomicae gr. xx. M. Ft. pil. Xo. xl. Sig. : One three times a day, after meals. 590 IMPOTEXCE IX THE MALE. Opium, the bromids, ergot, digitalis, gelsemium, and alcoholics all have their uses in nervous impotence. Phosphorus is the most reliable remedy in these cases. It may be giren in solution, as a tincture, in combination with zinc as in the formula just given, or in its pure state. A pill composed of V30 grain of phosphorus and ^/^ grain of nux vomica is an excellent combination. The principal objection to the use of phosphorus is the offensive eructations and gastric disturbance it sometimes produces. The mineral acids — such as dilute phosphoric, muriatic, and nitric — are all of service. Hypodermic injections of strychnia are often useful, a single daily injection of ^/g^ grain of the sulphate of strychnia being more elticacious than much larger and more frequent doses taken i^er orem. Cantharides exhibits a more marked and direct immediate action upon the generative apparatus than any other aphrodisiac. It should be given cautiously, however, for in large doses it may produce inflammation of the bladder and, coincidently, severe strangury. So severe are its effects in some cases that obstinate priapism and insatiable sexual desire may occur, perhaps with inflammation and sloughing of the penis and vesical mucosa. Deaths from the drug have been frequently observed. In impotence the tonic effect of the drug should be aimed at. It may be given in from 10 to 15 drops three times daily. In occasional cases a gradual and cautious increase of the dose is warrantable. Thus, 10 to 15 drops three times a day may be given to commence with, the dose being increased 1 drop each day until slight strangury is produced, when it should be discontinued. If there has been no beneflt to the impotence by this time, further administration of the drug is useless. Damiana is a much-vaunted remedy for impotence that is useful to a certain degree. The dose is 1 or 2 drams of the fluid extract three or four times daily. Both damiana and cantharides will be reverted to in a subsequent chapter. Ergot is often a valuable remedy in impotence, particularly in those cases in which there seems to be a lack of tone in the vascular supply of the penis. It may be given in doses of 10 to 20 drops, three or four times daily. Certain cases of impotence have been attributed to a lack of tone in the dorsal vein of the penis, this condition resulting in too rapid removal of the blood from the part during erection. Injections of ergotin in the course of the vein and ligation of the vessel have been recommended for this hypothetic condition, but, inasmuch as it is probable that the dorsal vein of the penis plays only a small part in the phenomena of erection, the logic of this treatment is open to question. The author has performed the operation of ligation a number of times, and has observed some apparent benefit, but is not prepared to say that the improvement was not due to the psychic effect of the operation. It is well worth trial, however, in other- wise intractable cases. According to Bartholow, jaborandi, or its alkaloid. TEEATMENT OF IMPOTENCE IN THE MALE. 591 pilocarpin, is an active aphrodisiac, being indicated in cases characterized by debilit}^ He claims that it is more efficacious than any other agent. The dose should be 30 minims of the fluid extract, night and morning, or from ^/g to ^/s grain of the muriate of pilocarpin thrice daily. Cimicifuga is also recommended by the same authority, particularly in those cases of impotence accompanied by spermatorrhea of long-standing, with excessive nervousness and anxiety and diminished sexual desire. In cases in whjch premature ejaculation from sexual hyperesthesia and active secretion of semen are noted, regular intercourse with moderate fre- quency, and the administration of such remedies as potassiimi bromid, chloral-hydrate, gelsemium, and ergot will usually relieve the condition. Potassium bromid is the most popular sedative for sexual hyperesthesia or excessive desire, so often attended by partial impotency. Its efficacy has, however, been disputed by some authors. In explaining the sources of fallacy of those who dispute the anaphrodisiac effects of the bromids Bar- tholow speaks as follows^: — 1. The physiologic effects of potassium bromid are not very decided, and are readily modified by any local disturbance. 2. Its therapeutic action is still more decidedly influenced by local morbid processes. 3. It is indicated where a sedative to the nervous system is required: e.g., in insomnia, too great reflex excitability, nervous and spasmodic affections of the larynx and bronchi, sexual excitement, and irritable states of the sexual organs. 4. It will be effectual in the foregoing conditions, in proportion to the degree in which structural lesions are absent, or, in other words, in proportion to the de- gree in which these morbid states are functional rather than organic. 5. These conclusions, the result of observation and experiment, afford us a satisfactory solution of the cause of failure in the use of the bromid of potassium. Sexual excitement in mania is due, as shown by Schroeder von der Kolk, to structural alteration in the medulla oblongata, the center, according to this author, of the sexual impulse. The bromid of potassium can have no influence over these structural alterations, and hence cannot control manifestations of sexual excitement depending upon them.- The local and general application of electricit}^ in its various forms is very useful in impotency. It is especially useful in the form of the general faradic bath, the current being applied while the patient is in a tub of hot water. Its application should be followed by a cold shower- or sponge- bath, and the application of static electricity to the spine, particularly over the lumbo-sacral region. It is sometimes beneficial to apply the latter form of electricity to the perineum, penis, and testes. Hammond claims that he has succeeded by means of the static apparatus in restoring sensibility to the glans penis and adjacent tissues when galvanism and faradism had failed. While inclined to take some of this gentleman's clinical observa- "Treatment of Spermatorrhea," p. 101. A deduction that by no means folloAvs Schroeder von der Kolk's observations. 592 IMPOTEKCE IN THE MALE. tions cum grano sails, the application of the static current in this manner seems rational enough. The stimulating effect of static electricity upon the nervous system is something remarkahle; some patients say that it acts like a glass of champagne. The faradic current in moderate strength is a powerful stimulant to the sexual organs. The ordinary sponge electrodes may be used, the posi- tive pole being applied to the lower part of the spine and the negative to the penis and testes. More benefit, however, is sometimes to be derived by applying the negative electrode to the genitals and the positive to the inner aspect of the thighs. A wire brush electrode may be used instead of a sponge, this being attached to the negative pole and passed up and down the spinal column. The positive pole may be placed first upon the nucha and afterward upon the lower portion of the spine, the wire brush being passed over the genitals. More or less pain is caused if the current be at all strong, but considerable benefit will be derived from its use. The cir- culation and nutrition of the spinal medulla is greatly improved, and the vigor of the sexual nerves is necessarily increased. The application of the Fig. 124. — Author's insulated prostatic electrode. wire brush to the genitalia is especially serviceable in cases of impotence that appear to depend chiefly upon anesthesia of the nervous supply of the glans penis. The galvanic current is often useful, either alone or in com- bination with the faradic current on alternate days. One of the best stimulants for the sexual organs is the faradic current applied directly to the prostate. An insulated sound or bougie is attached to the negative pole of the faradic battery and passed down to the prostatic urethra. The positive electrode may be applied to the spine, thighs, hypo- gastrium, or genitals. It is best applied by means of a large flat sponge electrode to the lumbar region. The prostate may be faradized by a rectal electrode attached to the negative pole. The galvanic current may be used in a similar manner. In cases in which the trouble appears to depend chiefly upon hyperesthesia of the prostatic sinus much benefit may often be derived from the application of the positive pole of the galvanic battery to the pro- static urethra. A local electric bath may be given by suspending the penis and testicles in a receptacle of warm water, the negative electrode being placed therein, and the positive held in the patient's hand. In applying TEEATMENT OF IMPOTENCE IN THE MALE. 593 electricity directl}' to the prostate care should be taken to avoid too pow- erfirl currents and too long continuance of their application. Inflamma- tion of the neck of the bladder, and even prostatitis, are possible sequences of carelessness in this regard. In the milder types of impotence the local application of electricity by the insulated sound in combination with the general measures that have been suggested will rarely fail to restore the vigor of the sexual apparatus, providing the patient is faithful in his treatment and devotes sufficient time to it. It is not well to make promises regarding the length of time neces- sary, and the patient should be told that the period necessar}^ for treatment can only be determined by the progress of the case, some cases yielding in a short time, while others require a protracted course of treatment. It should be remembered that to achieve permanency of result it is necessary for the patient to continue treatment, and to abstain from sexual indulgence for some little time after his capacity has apparently been re- stored. In cases of premature ejaculation and failure of erection due to ex- treme sensitiveness of the glans penis, circumcision is usually necessary, as most of these cases are affected Avith redundancy and phimosis. The daily application of cold water to the glans is an excellent adjuvant to circum- cision. The application of electricity by the galvanic brush is a very valu- able method of treatment. The application of stimulating embrocations to the penis has been rec- ommended for impotence. As a general rule, they are worse than useless. Sinapisms, however, as recommended by Eoubaud, may be of temporary service in some instances. The irritation produced by mustard is sufficient to reflexly excite an erection in the majority of instances. Care should be taken not to prolong the application, lest serious inflammation result. Cases of impotence secondary to cerebral or spinal disease should not be subjected to much special treatment. All therapeutic efforts should be directed to the cure or improvement of the primary condition. As improve- ment of the condition of the brain and cord occurs, a corresponding im- provement in sexual vigor is noted. Some remedies for impotence are in- jurious in cases dependent upon spinal disease. For example, spinal ex- citants, such as phosphorus and strychnia, should not be given in locomotor ataxia, as they are liable to aggravate the organic disease, and will in nowise benefit the impotence. In some extreme cases of sexual hyperesthesia, the application of silver nitrate to the deep urethra by means of the deep ure- thral syringe is of benefit. Most of the deformities of the sexual apparatus that produce impo- tence are not amenable to treatment. Diagonal section of the roof of the contracted urethra may benefit some cases of curvature of the penis. Epi- spadias, hypospadias, and certain tumors of the penis, scrotum, and testicles are amenable to treatment by the knife. 594 IMPOTEJs'CE IN THE MALE. As a temporary expedient and in psychic impotence^, the application of very hot water to the penis and testes just prior to copulation is often efficacious. The cases of impotency that are most trying to the physician are those met with in individuals at ahout middle age who have for many years in- dulged ezcessively in sexual intercourse. Patients of this sort consult the physician in the hope of receiving a remedy that will enahle them to go on with their excesses, and, as a rule, they do not attribute their condition to its true cause. It is hard to convince such patients that they are paying for their early indulgence, and that they ought not to expect to perform the sexual act so often and so indiscriminately as when they were young. Such an opinion seldom satisfies them. The physician is consulted by many middle-aged roues who complain of real or imaginary sexual exhaustion, spermatorrhea, premature old age, etc., and these cases are certainly difficult to manage. If the patient cannot be made to understand the physiologic conditions involved in his case, and the importance of resting sexually in order that the organs involved may recuperate their exhausted vitality, very little success can be obtained by treatment. There is a vulgar notion among the laity to the effect that a man is capable of just so many acts of sexual indulgence during his life-time, and that he may either distribute these acts at proper intervals throughout a great number of years or may perform them within a few years early in life. There is much of truth in this, for it is a cardinal rule that overexcitement of any function will cause loss of power. The man that copulates with moderation is the one best fitted for procrea- tion, because he is, from a sexual point of view, the most energetic. It is a well-known fact that the male population of the Orient become impotent at a very early age, earlier than any other race of men, on account of free in- dulgence of their sexual appetites. For that matter, among all nations men and women alike suffer from premature old age when excessive sexual in- dulgence is conjoined with a life of indolence and ease. The man who in- dulges in sexual intercourse most frequently in his youth is the one who is most likely to become impotent or sterile when he reaches middle age. It is said that quite a proportion of Oriental males become impotent at the age of from 30 to 40 years. Moderation in sexual intercourse is not only conducive to prolonged virility, but to longevity. It is certain that many cases of neurasthenia in both male and female are due to sexual excess. The treatment of the class of cases under consideration depends for its success mainly upon careful instruction of the patient in sexual phys- iology. The cause of his disability should be explained to him, and he should be assured that the only hope of restoration of virility and of its perpetuation lies in complete rest of the sexual function for a prolonged period, with moderate indulgence for the rest of his life, after his capacity has returned. In conjunction with these moral means for restoration, the STERILITY AND IMPOTENCE IN THE FEMALE. 595 remedies and local measures already recommended may be employed as the case demands. Where imjDotence depends upon one or more of the organic conditions enumerated in connection with etiology, the cause should be dealt with upon its surgical merits. AsPEEMiA. — The term "aspermism/' or aspermia, has been applied to some cases in which, although erections are normal and copulation is per- formed with facility, there is no ejaculation of semen. There may or may not be sexual desire. A peculiar feature of these cases is that the patient, although unable to have an emission during normal intercourse, invariably acknowledges the occurrence of voluptuous dreams attended by pleasur- able sensations and emission of semen. On examination the urethra will be found to possess the usual amount of sensitiveness in all parts, excepting the prostatic sinus, where there is apparently complete anesthesia. The author has observed several cases in which aspermism was the foundation of impotence and sterility. One of these is of particular in- terest: — Case. — A healthy man, 35 years of age, who had never had any ailment or in- jury, sought advice regarding failure of emission. The patient stated that he had been sexually normal until within a year, since which time he had found it impossible to have either orgasm or emission. Sexual desire was normal, and erections perfect, but no amount of duration of effort in copulation was sufficient to bring about an orgasm. Sexual intercourse had never been indulged in to any great extent, even be- lore any abnormality was noticeable. Erotic dreams and nocturnal emissions were quite troublesome. This case finally yielded to faradism of the prostatic urethra. The treatment was directed to the relief of the evident anesthesia of this part that was apparently at the bottom of the difficulty. Eoubaud advanced the theory that aspermia depends upon spasmodic contraction of the muscular fibers about the mouths of the ejaculatory ducts, preventing the escape of the semen into the prostatic sinus. This view is hardly in accordance with the physiology of the part. Keyes says, anent this point: — Were there desire and pleasure, prostatic mucus would be secreted in excess and would be thrown out by ejaculation, while the semen proper would collect and distend the seminal vesicles and ducts below th6 ejaculatory orifices, and would escape and fiow away from the meatus with the relaxation of spasm brought about by the fatigue following prolonged sexual intercourse, but this is not the case; the fault is evidently in the neiwes. There is no pleasurable sensation, no call for secretion of prostatic mucus, nor for a supply of spermatic fluid. There is anesthesia of the prostatic sinus, and, although the power of having an orgasm and ejaculation remains, as proved by dreams, yet there is some connecting-link missing in the chain which transforms friction of the glans into pleasure at the prostate, and finally into secretion in the testicle. There is probably not only anesthesia of the floor of the prostatic ure- thra, but a lack of the special sensibility of the nerves of the glans penis 596 STEEILITT AND IMPOTENCE IN" THE FEMALE. that is normally acquired during erection. It is possible, too, that, although the nerves of the prostatic sinus are normally sensitive, the nerves of the glans fail to appreciate and transmit pleasurable sensations. The function of the latter nerves is perhaps inhibited by the consciousness of the patient of the lack of sensibility in the glans. During sleep inhibition does not occur, and the subconscious memory of normal copulation, of which the patient was once capable, is sufficient to impart a pleasurable sensation and reflexly produce an orgasm. The treatment of this condition is generally very unsatisfactory. Kou- baud reports a case in which blistering the perineum, with subsequent ap- plication of powdered morphin, produced a cure. He recommends anti- spasmodics, in accordance with his theory of the pathology of the disease. Electricity in the form of the static and faradic currents applied to the spine and genitalia would appear to be the most rational form of treatment, and has been moderately successful in the author's hands. STEEILITY AND IMPOTENCE IN THE FEMALE. An exhaustive discussion of sterility and impotence in women would be out of place in this work. It belongs more properly to treatises upon gynecology. A few general remarks, however, may be of especial service when coming in juxtaposition with the discussion of sterility in the male. Statistics show that about one in eight marriages are unproductive. As already seen, a portion of the responsibility for sterility must be borne by the male. Most of it, however. Justly falls upon the female. Etiology. — The causes of sterility in the female are very numerous, but only the principal ones will be given here. These are as follow: — 1. Inability to receive the semen. (Impotence from various causes.) 2. Inherent or acquired resistancy to impregnation. 3. Failure to ovulate. 4. Inability to develop the ovum after fecundation. The female most often fails to receive the semen from default upon her own part. Various local conditions may prevent her from having coitus. These conditions comprise such congenital or acquired malformations Dr imperfections of development as prevent penile intromission. In these rare cases the female is impotent as well as sterile. Impotence in the female may be due to incapacity for the conlplete performance of the sexual act. She may, however, be none the less capable both of insemination and impregna- tion. Frigidity — i.e., absence of sexual desire or aversion to its performance — and absence of orgasm constitute one variety of female impotence. Many women never experience the slightest degree of voluptuous excitement dur- ing cohabitation, yet they are fruitful and bear children. It has been held that the erectile structures of the genital organs become turgid even in this class of cases, Just as it occurs in the male, without orgasm; but this is doubtful. Orgasm is necessary to the normal performance of the sexual ETIOLOGY OF STERILITY AND IMPOTENCE IN THE FEMALE. 597 act in the female as well as in the male, and, while conception may occur without it,, it is the exception rather than the rule, be the orgasm ever so slight. The orgasm in the female must subserve some physiologic purpose, which purpose must be the correlative of the orgasm in the male. The male orgasm being of an expulsive character, it follows that the female orgasm must be for the purpose of furthering the reception of the semen. Competent observers have described the peculiar behavior of the uterus during orgasm. The organ appears to assume a more perpendicular posi- tion, and sinks lower in the pelvis; the os uteri becomes softer; the labia of the uterus project and retract alternately in such a manner as to produce a "suction" effect. These phenomena are accompanied by the emission of a clear, sticky mucus. Granting the occurrence of these phenomena in the cases observed, they probably occur in all cases where there is a normal orgasm. They probably also occur to a greater or less degree in all females to whom sexual congress is in any degree pleasurable. Acton^ states that it is his belief that the majority of women do not experience sexual desire. He expresses his opinion as follows: — I should say that the majority of women (happily for society) are not very much troubled with sexual feeling of any kind. What men are habitually, women are only exceptionally. It is too true, I admit, as the divorce-courts show, that there are some few women who have sexual desires so strong that they surpass those of men^ and shock public feeling by their consequences. I admit, of course, the existence of sexual excitement terminating even in nymphomania, a form of insanity that those accustomed to visit lunatic asylums are fully conversant with; but, with these sad exceptions, there can be no doubt that sexual feeling in the female is, in the majority of cases, in abeyance, and that it requires positive and considerable excitement to arouse it at all; and even if aroused (which in many instances it can never be) it is very moderate compared with that of the male. Many persons, and particularly young men, form their ideas of women's sensuous feelings from what they notice early in life among loose, or, at least, low and vulgar women. There is always a certain number of females who, though not ostensibly in the ranks of prosti- tutes, make a kind of trade of a pretty face. They are fond of admiration, they like to attract the attention of those immediately above them. Any susceptible boy is easily lead to believe, whether he is altogether overcome by the siren or not, that she, and therefore all women, must have at least as strong passions as himself. Such women, however, give a very false idea of the condition of female sexual feeling in general. Association with the loose women of the London streets in casinos and other immoral haunts (who, if they have not sexual feeling, counterfeit it so well that the novice does not suspect but that it is genuine) seems to corroborate such an im- pression, and, as I have stated, it is from these erroneous notions that so many un- manned men think that the marital duties they will have to undertake are beyond their exhausted strength, and for this reason dread and avoid marriage. Married men, medical men, or married women themselves would, if appealed to, tell a very different tale, and vindicate female nature from the vile aspersions cast on it by the abandoned conduct and ungoverned lusts of a few of its worst examples. "The Reproductive Organs." 598 STEEILITT AND IMPOTENCE IN THE FEMALE. One would infer from Acton's opinion that frigidit}^ is the normal and physiologic condition of the average woman. While ready to ac- cept the statement that a large proportion of married women do not ex- perience sexual desire, the author does not believe that their frigidity is natviral, but holds that it is usually due to mistreatment on the part of the husband. The average man when entering upon the matrimonial state gives very little consideration to the question of reciprocal pleasure. A virtuous woman necessarily entertains primarily an aversion' for sexual intercourse, which is both unesthetic and j)ainful in the beginning, and shrinks from it with becoming modesty and physical fear. This condition of mind is by no means improved by the conduct of the husband, whose sole idea is to obtain gratification, irrespective of the feelings of his wife. For a time he is perfectly satisfied with his matrimonial relations because of their novelty. As soon as this wears off, however, he begins to recall past experiences, and finds fault with his wife for her lack of reciprocity. By this time, unfortunately, the disgust and dread of the marital act that have been inspired by the brutality of the husband have become a part of the woman's very existence, and she usually is ever afterward absolutely frigid. Having become satiated and disgusted with the marriage-relation the hus- band is apt to seek elscAvhere for that of which he has been deprived through his own mismanagement. It is the authors opinion that in most instances of frigidity in married women the difficulty would have been obviated and the woman would have become, after a time, perfectly natural in respect to the sexual function if the husband had been more intelligent and con- siderate. It is by no means the ex-roue alone who is open to impeachment. The inexperienced man is often more at fault, through ignorance, than the man of the world who, perhaps, has done more than his share in educating women in sexual love. The old adage that "familiarity breeds contempt" is an excellent one as applied to matrimonial infelicity. The divorce-courts speak volumes with respect to inharmonious sexual relations of married persons. Ignorance on the part of the woman, brutality or ignorance on the part of the husband, and perhaps in some instances excessive indulgence on the part of both— this latter bringing satiety and physical ills in its train — are responsible for many of the cases that are brought all too prominently before the gaze of a patient and long-suffering public. The prevalent custom of married people occupying the same bed is the cause of more instances of lack of harmony in sexual matters, and incident- ally of more cases of sexual excess, than anything that could be mentioned. It certainly tends in many instances to lessen the mutual respect of married couples, and to pall the attractiveness of the matrimonial state. If married persons occupied separate apartments the novelty of matrimony would not be likely to wear away, and our divorce-courts would be shorn of a large proportion of their cases. ETIOLOGY OF STEKILITY AND IMPOTENCE IN THE EEMALE. 599 Certain mental conditions modify the sexual passion in women. It would certainly be too much to expect a refined woman to be possessed of sufficient animal propensities to be able to display a genuine passion with one for whom she has an aversion. Once let a woman — -however passionate naturally — experience a feeling of disgust or hatred for her husband, and it is probable that she could not exhibit genuine sexual passion if she would. It is certainly true that some women are extraordinarily passionate with certain individuals, while absolutely frigid with others. This is well illustrated in the case of the average prostitute, whose passion in her strictly-business relations is more often assumed than real, but who nevertheless has usually a favorite lover who certainly has no cause for complaint. Apropos of in- harmonious conjugal relations there is another circumstance that often ex- plains the frigidity exhibited by married women. Many women are allowed to become mere household drudges, and become so exhausted physically that it is hardly fair for their husbands to expect any reciprocity upon their part. The tendency of hard labor to divert the nervous energies from the sexual apparatus has already been expatiated upon, and is as true of the female as the male. Many women are restrained from the exhibition of sex- ual passion by the fear of conception, their apprehensions being augmented by the popular and to a certain extent justifiable notion that the danger of impregnation is proportionate to the amount of passion exhibited by the woman. In order that impregnation may occur, it is necessary that living spermatozoa should come in contact with a mature healthy ovule at some jjoint above the uterine cervico-corporeal junction. There are many local conditions that prevent this meeting, even though the sexual act be nor- mal. Uterine displacements and flexions, stenosis of the cervix or either os, uterine or intra-uterine growths, especially those located in or about the cervix; and stenosis of the Fallopian tubes, ojDposing both the doAvnward passage of the ovule and the upward passage of the spermatozoids, are all serious obstacles to fecundation. Conditions resulting in painful or diffi- cult intercourse necessarily tend to prevent the ovule and spermatozoids meeting under physiologic conditions. Hypertrophy of the cervix with contracted os, pathologic processes wholly or partially occluding the vagina, vaginismus from urethral caruncle or other cause, tumors of the vulva or vagina, and imperforate hymen are illustrations of such conditions. It must be understood that, while women under such circumstances are prac- tically sterile, they are not literally so. The author recalls a very peculiar case occurring in the New York Charity Hospital showing that sexual congress may sometimes be carried on by the female under extreme difficulties: — ■ Case. — A woman, 20 years of age, with complete atresia vaginae, who, strange to say, nevertheless led the life of a public prostitute. The external parts were per- fectly developed, but there was no opening whatever corresponding to the normal situ- 600 STERILITY AND IMPOTENCE IN THE FEMALE. ation of the vagina. The case diflferedj too^ from ordinary atresia, inasmuch as there was no thickened fibrous cord between the bladder and rectum such as is ordinarily met with in occlusion of the vagina, and which represents the walls of the canal that have become fused together. AVhen the index finger of each hand was intro- duced into the bladder and rectum respectively nothing could be felt between them but the walls of these viscera. Neither uterus nor ovaries could be detected. How this woman copulated is a mystery. There was no evidence of pederasty. Whatever the circumstances may have been, the woman certainly was not aware of her con- dition, but supposed that she had been performing the act of copulation like other women. The urethra was very commodious, and it is possible that it had been utilized as a sexual way. Such cases have been reported. The conditions that interfere with the normal development of the ovule are a terra incognita to science. It is jorobable that many immature ovules escape prematurely from healthy Graafian follicles from one cause- or an- other. On the other hand, they may be devitalized by disease. In either event they are incapable of impregnation. It is not necessary that the ovaries should be healthy, however, in order that conception may occur. ■ Women with extensively diseased ovaries sometimes conceive and bear healthy children. If a single Graafian follicle be healthy and there is noth- ing to prevent the ovule and spermatozoa coming together, conception may occur. On the other hand, a healthy mature ovule may be formed, and many healthy ovules be discharged from the ovary from time to time, but fail to reach the uterine cavity. Infla^lmatory affections of the ovary in- volving thickening of the walls of the Graafian follicles may prevent healthy ovules from leaving. A healthy ovary may be so bound down by surround- ing inflammation that the ovules cannot escape. Other conditions that are fatal to the physiologic purpose of the ovule are diseases of the Fallopian tubes, adhesions of the fimbriae to the ovary, and uterine disease producing closure of the uterine extremities of the tubes. Granting that conception has occurred, the uterus may not furnish a suitable nidus for the reception, attachment, and subsequent development of the ovum. The corporeal endometrium is a highly-organized structure and often the seat of pathologic conditions. Gestation demands that it be healthy. Intra-uterine disease is so frequent, however, that good authorities consider it to be the cause of sterility. Women thus diseased are perfectly capable of conception; but, the uterine mucous membrane being unfitted for the at- tachment and development of the ovum, they are practically sterile. Endometritis, the most common of intra-uterine diseases, bears a very important relation to sterility. It not only interferes with gestation, but the dense, glairy discharge it produces may, by plugging the cervical canal, not only obstruct the entrance of spermatozoa, but by its toxicity destroy or inhibit their vitality. Catarrhal states of the Fallopian tube often result from endometritis. The mucus it produces may so coat the ovule in its downward passage that the spermatozoa either cannot penetrate it or else they are killed by its toxic properties. ETIOLOGY OP STEEILITY AND IMPOTENCE IN THE FEMALE. 601 There are numerous other etiologic conditions, some of which are symp- tomatica'lly associated with those already mentioned. In 408 cases of steril- ity studied by Kammerer dysmenorrhea was observed in 69; menorrhagia and metrorrhagia in 57, scanty menstruation in 41, amenorrhea in 2, de- layed menstruation in 8, hysteria in 16, nervous headache in 3, intercostal neuralgia in 1. Some of these derangements probably had no causal rela- tion to the sterility, but depended on the same conditions as the latter. A profuse uterine discharge, of whatever kind, may wash away the ovule before or after impregnation. Dysmenorrhea is undoubtedly a fre- quent cause of sterility. In the membranous form sterility is a matter of course. Dysmenorrhea is due to uterine or ovarian disease or to some ob- struction to the free escape of the menses. It is attended, moreover, by spasmodic uterine contractions that ma}^ persist as a matter of habit, and cause the expulsion of the fecundated ovum. The same conditions that produce dysmenorrhea also prevent the spermatozoa from entering the uterus or destroy them after they have entered. Teeatment. — The treatment of sterility and impotence in the female belongs to the domain of gynecology. CHAPTER XXVI. Spermatokkhea. Few subjects in medical literature have been treated in so confusing a manner as spermatorrhea has by the few authors who have deigned to give it attention. The special treatises upon the subject by American writers have been limited in number, and authors in general have well-nigh ignored it. So obnoxious has the subject become because of the treatises of quacks and impostors that reputable physicians have shown a somewhat excusable, but illogical, tendency to ignore it altogether. It is a remarkable fact that nearly all of our knowledge of the subject has been handed down from the classic, yet overdrawn, treatise of Lallemand: a work that has been ex- tensively quoted — both the original and the English translation.^ Excel- lent monographs have, however, been written by Milton, Acton, Howe, Hammond, and Bartholow, the latter being the only work devoted to sper- matorrhea alone. It is unfortunate that the reputable general practitioner knows so little of the pathology and treatment of the various phases of aberration of the sexual function included under the term spermatorrhea. As a rule, the physician takes little interest in the subject, probably because of the dis- repute into which it has been brought by imposters and quacks; and, as a consequence, cases of this kind either consult the charlatan primarily or are driven to him by the indifference and repugnance exhibited by most reputable physicians. This course is not only unjust to the patient, but imworthy of the physician. ISTo function of the body is more intimately associated with the welfare and happiness of the human race than that of the sexual organs, and the physician is no more justified in ignoring its disturbances or refusing to treat patients suffering from them than in the case of aberrations of structure and function of the stomach, liver, or kid- nej^s. It is not at all remarkable that spermatopathic quacks flourish and wax fat, when the reputable physician by his neglect of a plain duty to humanity actually drives patients into their toils. It is unfortunately true, moreover, that a course of quackery usually produces a psychopathic con- dition that makes the patient insusceptible to either moral persuasion or medical treatment, should he finally fall into the hands of a scientific phy- sician who is competent and willing to advise him. The definition of spermatorrhea has given rise to considerable dis- cussion. The majority of scientific authorities are not inclined to accept as spermatorrhea any case in which the loss of semen is attended by erec- tion and ejaculation. Spermatorrhea as a steady flow of semen does not ^ "Des Pertes Seminales Involuntaires." (602) DEFIXITIOJsT OF SPEEMATOEEHEA. 603 occur, as was formerly supposed. The seminal loss occurs only at intervals and under special conditions, largely mechanic in character. It is evident that spermatorrhea was recognized by the ancients. Thus, under the name of tabes dorsalis Hippocrates describes a condition that is evidently spermatorrhea, as follows: — This disease proceeds from the spinal cord. It is frequently met with among newly-married people and libertines. There is no fever, the appetite is preserved, but the body falls away. If you interrogate the patients, they will tell you that they feel as if ants were crawling down along the spine. In making water or going to stool they pass semen. If they have connection the congress is fruitless. They lose semen in bed, whether they are troubled with lascivious dreams or not — they lose it on horseback or in walking. To epitomize, they find their breathing difficult; they fall into a state of feebleness, and suffer from weight in the head and a singing in the ears. If, in this condition, they become attacked with a strong fever, they die, with cold extremities. Acton defines the disease as follows: — The condition or ailment which we characterize as spermatorrhea is a state of innervation produced, at least primarily, by the loss of semen. This term, I admit, has many objections, but its general acceptance would render it inconvenient to alter it or to employ any other.^ According to Bartholow, the term spermatorrhea should be restricted to that condition in which involuntary seminal losses occur with sufficient frequency to produce a definite morbid state. - Many surgeons regard spermatorrhea as a loss of semen independently of intercourse or masturbation: i.e., involuntary losses of all kinds. This interpretation of the term is objectionable because of its comprehensiveness. It necessarily embraces certain conditions in which involuntary emission of semen occurs as a perfectly physiologic phenomenon. Some authorities will not accept as spermatorrhea any case in which the discharge from the ure- thra does not contain spermatozoa, as demonstrated by microscopic exam- ination. This is too sweeping, for in severe cases the formation of the semi- nal elements may finally cease, the other ingredients of the seminal secretion being normal or nearly so. According to. the author's views, the term sper- matorrhea should be applied to all involuntary seminal discharges that occur without orgasm. Seminal losses with orgasm are most conveniently styled pseudosper- matorrhea. The frequency of involuntary losses is no diagnostic criterion, for, while robust individuals might not be injured by two or three dis- charges weekly, delicate patients might be powerfully affected by a single weekly emission. In estimating the importance of involuntary emissions due consideration should be given to their effect upon the mind of the patient. For example, a patient who is ignorant of sexual physiology and ^ Acton, op. cit. ^ "Spermatorrhea," Roberts Bartholow. 604 spePl:iIatoekhea. has read quack literature extensiyel}' may be great!}' depressed and worried by an emission occurring once in three or four weeks, while another less impressionable individual, who knows something of sexual physiology and has not had his mind poisoned by fallacious treatises, will bear several emissions weekly without apparent ill effects. The assertion has been made that nocturnal emissions are no more injurious in their effects upon the nervous system than similarly frequent acts of normal intercourse. The author does not believe this to be true. ^Tiether or not the depression re- sulting in many patients from an occasional emission is altogether due to the moral impression produced by it is open to question, but certain it is that intelligent individuals with a knowledge of sexual physiology claim that such emissions are much more enervating than normal intercourse. They confessedly lack the physiologic stimulation of normal coitus. Etiology. — Lallemand^s theory of the pathology of spermatorrhea im- plies the existence of irritation of the prostatic urethra and seminal ducts produced by various influences. He admits as causes of the disease gouty and rheumatic conditions of the sexual apparatus, gonorrhea and stricture, phimosis and accumulation of smegma preputii, masturbation and sexual ex- cess, the excessive use of such drugs as cantharides, ergot and various diu- retics, intemperance, excessive drinking of coffee and tea, constipation, irri- tation of the rectum from ascarides, hemorrhoids, fistula, prolapsus ani, etc. He claimed that in severe cases he had demonstrated upon autopsy inflamma- tion and thickening, with sometimes ulceration of the vesiculse seminales, ejaculatory ducts, and prostatic urethra. Eecent investigations in the pathology of the seminal vesicles vindicate Lallemand to a certain degree, but such conditions probably exist only in rare and extreme cases, in which the spermatorrhea is not causal, but secondary and symptomatic or even merely coincidental. The author regards the essential condition in spermatorrhea as hyper- esthesia and exhaustion of the general nervous supply of the genitalia, the special areas of sexual sensibility in the genitalia, the afferent nerves of sexual sensibility, the genito-spinal center, and the psychosexual centers in the brain. Hyperesthesia of the caput galUnaginis is a most important ele- ment, both in true and false spermatorrhea. There certainly is exhaustion and irritability of the nervous system, probably occurring in the following order: 1. Of the nerve-supply of the area of special sexual sensibility on the floor of the prostatic urethra. 2. Of the afferent nerves of sexual sensibility. 3. Of the transmitting fibers of the spinal cord. 4. Of the receiving centers of the brain. The final result is a greater or less loss of general nerve-tone; i.e., neurasthenia. The author does not wish to imply that these effects are not more or less simultaneous, but that the serious results are likely to be manifested in the order named. Inasmuch as spermatorrhea in the majority of instances is the result of sexual excess or masturbation, and, moreover, the effects of the venereal orgasm being expended upon the nervous system, it ETIOLOGY OF SPEEMATOKKHEA. 605 is rational to infer that the disease when fully developed is essentially a neurosis. Bartholow expresses a similar view, which is in direct opposition to Lallemand. According to Bartholow, spermatorrhea is always a neurosis, and any structural alterations that may be found are coincidental, not causative. He asserts, moreover, that Lallemand's cases in which organic changes in the sexual organs were claimed as the essence of the disease, were selected for the purpose of justifying his theory and practice. Sir Henry Thompson claims that sexual indulgence cannot have the effect of producing prostatitis — considered to be so important in the etiology of spermatorrhea by Lallemand— unless gonorrhea already exists. This dictum, however, the author cannot accept. Peyer^ says: — Spermatorrhea in itself is not a disease, as little as fluor albus in the female sex, but is only a symptom of various pathologico-anatomic conditions, affecting either locally the seminal vesicles, their duets, their muscles, and surrounding mucous membrane, or else resulting from general disturbances of the body, especially in the nervous system. The several nervous disorders that accompany spermatorrhea are mostly not its consequences, but co-ordinate symptoms of a pathologico-anatomic con- dition: the original cause of this loss of semen. Granted that spermatorrhea is symptomatic in many cases, it is not necessarily symptomatic of the existing perceptible organic local conditions of the sexual organs. These conditions may exist coincidentally, often sec- ondarily, and are sometimes produced by the same causes as are responsible for the spermatorrhea, the essential condition underlying the spermatorrhea being in the nervous system.^ The most important local condition associated with spermatorrhea and pseudospermatorrhea is dilation and relaxation of the orifices of the ejacu- latory ducts as a consequence of frequent overdistension. The vesiculge seminales in the first instance become so hyperesthetic that they are intol- erant of their contents. This intolerance, in combination with hyperesthe- sia and irritability of the veru montanum, results in frequent reflex ex- pulsion of the semen. Finally the orifices of the ejaculatory ducts become so dilated that the semen dribbles away at will. Such cases, however, are extremely rare. It is not the loss of fluid that produces debility at first, but the frequency of the discharge of nervous force, which, as already in- dicated in connection with the subject of masturbation, is quite similar to that produced by an epileptic attack. As a consequence of frequently- recurring orgasm produced in sexual intercourse or by masturbation, the organs become so weak that the jolting produced by horseback-riding, or the strain incidental to gymnastic exercise, causes an emission. So hyper- ^ Clinical Microscopy. - It is a striking fact that spermatorrhea is verv rare among the host of patients who consult the surgeon for prostatic and deep-urethral disease. 606 SPEEMATOKEHEA. esthetic are the sexual centers in many instances that the mere thought of sexual indulgence produces an emission, often without erection or sen- sation. Prolonged sexual excitement without gratification is one of the fre- quent causes of the simpler forms of spermatorrhea. Familiarity with women, in combination with the fostering influences of immoral literature and associations, keeps up a constant irritation of the sexual organs that increases their sensibility and stimulates the secretion of semen. If the patient does not masturbate in his ignorance or viciousness, Nature is quite likely to relieve the condition of turgescence of the sexual organs by an emission during sleep. If the cause be not removed, the seat of sexual sen- sibility becomes very irritable, the organs meanwhile growing weaker until finally involuntary losses become extremely frequent. It will be observed that pseudospermatorrhea may merge into the true variety. Lallemand divided seminal losses into nocturnal and diurnal, the noc- turnal losses being frequent, physiologic, and due to sexual excitement, but becoming pathologic after a time in some instances because of their abnor- mal frequency. Some patients, he claimed, were subject to both diurnal and nocturnal escape of semen. Diurnal emissions, according to this au- thority, are much less frequent than those occurring at night, although they are more serious and more rebellious to treatment. They occur mostly Avithout erection or ejaculation, during or just following the acts of def- ecation and micturition. The results, after the disease is well established, were described by Lallemand, as follows: — The penis becomes relaxed, the erections feeble. The corpora cavernosa either atrophy or their vessels lose tonicity; the corpus spongiosum and the glans penis also shrink. The testes undergo a certain degree of atrophy; the superficial veins of the penis become dilated and tortuous. The nervous system very often manifests sympa- thetic disturbances in the form of vertigo, pains along the course of the principal nerves, etc. The subjective symptoms, after a variable longer or shorter period, be- come very marked; there are pains in the lumbar region, aching in the arms and testes; capricious appetite and feeble digestion; the bowels become deranged, con- stipation alternating with diarrhea. Spermatorrhea is sometimes a symptom of nervous disease, particularly of the spinal cord. Thus, it is occasionally seen in locomotor ataxia. In conditions of this kind spermatorrhea is a secondary consideration and should be regarded as such with respect to treatment. In the majority of instances the disease is associated with complete or partial impotence. The milder types of pseudospermatorrhea are quite apt to be associated with pseudo-impotence because of the effect of the nocturnal emissions upon the mind rather than upon the virility of the patient per se. Numerous local diseases have been mistaken for spermatorrhea, afford- ing abundant material upon which the patient's mental distemper is fed by the quacks. VARIETIES OF SPERMATOEEHEA. 607 Besides nocturnal emissions, the organic affections and functional per- turbations that are most often erroneously termed spermatorrhea are: chronic urethral catarrh, stricture with accompanying gleet, prostatorrhea, prema- ture ejaculation of semen, vesical catarrh, and phosphaturia. Yaeieties of Teue Speematoeehea.— 1. Diurnal emissions without erections or sexual stimulation of any kind. 2. Frequent nocturnal emissions without sensation or power: i.e., escape of semen with neither pleasurable sensations, dreams, nor erections. 3. Escape of semen on slight provocation without erection, or, at most, with imperfect erection. These varieties may be associated, in a measure. Usually where there Fig. 125. — Microscopic appearance of normal human semen, a, Spermatozoids. 6, Columnar epithelium, c, Bodies inclosing lecithin-granules, d, Squa- mous epithelium from the uretlira. d', Testicle-cells, e, Amyloid cor- puscles, f, Spermatic crystals, g, Hyaline globules. are diurnal losses there are also unconscious losses at night. All varieties are usually associated with complete or partial impotence. Prostatorrhea may co-exist. Bartholow divides the disease into (1) the genital form and (2) the cerebral form: a classification that appears somewhat impractical. Vaeieties of Pseudospeematoeehea. — 1. Occasional nocturnal emis- sions, with orgasm, usually with dreams, and almost always accompanied by erections. There are usually no injurious effects except perhaps those of a 608 SPEKMATOEEHEA. mental character. In. some cases^ however, the various disturbances out- lined in the symptomatology of true and false spermatorrhea result. 2. Premature ejaculation in coitus, associated with pseudo-impotence ("spermatospasm os") . (a) From prostatic hyperemia and hypersecretion. (&) From follicular prostatitis. 4. Hypersecretion of the urethral and prostatic glands during erection. 5. The appearance of spermatozoids in the urine after erections, etc. 6. Discharge of semen during a very difficult stool. 7. Discharsfe from chronic urethral catarrh. 3. Prostatorrhea TABULATED ETIOLOGY OF SPEEIIATOEEHEA AND PSEUDOSPEEMATOEEHEA. " (a) Defective will-power and unstable nervous equilibrium. (5) Effeminate and defective physique. (c) Hereditary inordinate sexual desire. (d) Mental influences, exciting sexual desire; e.g., erotic novels, pictures, and stories. (e) Evil associations and example. (/) Freedom from restraint in associating with the opposite sex. (g) Excesses in eating and drinking. General J Predisposing causes Local <; Exciting causes (a) Precocious development of the sexual organs and function. (&) Maldevelopment of sexual organs, such as hy- pospadias and phimosis. Imperfectly de- veloped and weak testes. (c) Acquired conditions of disease, such as phi- mosis, stricture, urethritis, prostatic conges- tion and inflammation, cystitis, stone in the bladder, seminal vesiculitis, balanitis, her- pes, and constipation. (d) Eeflex irritation from hemorrhoids, ascarides, fistula, etc. (e) Varicocele. (a) Masturbation. (&) Sexual excesses. (c) Cerebro-spinal disease and injuries. Symptoms of Speematoeehea and Psetjdospeematoekhea. — The line of demarkation between true and false spermatorrhea is determined by the occurrence or absence of erection and orgasm at the time the emissions of SYMPTOMS OF SPEEMATOEEHEA. 609 semen occur. Aside from this difference the symptoms of the true and false varieties are the same, differing in degree only. It is, of course, un- derstood that an exception is made of those rare cases in which seminal losses are the result of cerebro-spinal disease — as sometimes seen in locomotor ataxia. Local Symptoms. — -A sense of weight and dragging in the testes and spermatic cords; sensitiveness and perhaps neuralgia of the testes, urethra, and cords; relative smallness and softness of the testes, pendulous scrotum, congestion of the pampiniform plexus, — often amounting to varicocele, — dilation of the superficial veins of the penis and relative diminution in size of the organ, the veins of which are distinctly enlarged, coldness and loss of sensibility of the penis, and, most important of all, the escape of semen at stool or with the urine, or as a result of erotic dreams or sexual excitement. On examination the entire urethra, prostate, and, especially, the prostatic urethra are almost uniformly very sensitive. Partial or complete impotence is usual. It is to be remembered that none of the foregoing symptoms are characteristic; neither are they of importance, so far as spermatorrhea is concerned, unless involuntary seminal discharges without orgasm co-exist. The semen is abnormally constituted, being thin, and more or less watery. It is often scanty in amount. The spermatozoa are relatively few in num- ber, inactive, and poorly developed. In extreme cases spermatozoa may be absent: azoospermia. General Symptoms. — There is more or less disturbance of the sym- pathetic nervous system, as evidenced by capricious appetite, impaired digestion, constipation, or diarrhea. Pain in the back, headache, and neu- ralgias in various situations, gastralgia, and abdominal pain are not unusual. The headache is usually occipito-frontal, and sometimes associated with more or less marked vertigo or a sense of cerebral fullness. The skin is usually sallow and pale, or muddy. Acne is plentiful in young subjects. The facial expression is one of care and anxiety, or of deep melancholy. The subject is morbidly self-conscious and inclined to shun companionship. Profound mental depression with failure of memory and loss of the power of concentration are usually prominent symptoms. The patient acquires the habit of introspection and becomes extremely hypochondriac. His genius for the invention of symptoms, fostered as it usually is by reading quack literature, becomes phenomenal. Insanity is perhaps rare, but suicidal mania is occasionally seen. Thoughts of suicide are a choice in- tellectual morsel with a large proportion of these patients, but the real suicidal intent is generally lacking. Many such patients come to regard thoughts of suicide as a mild sort of dissipation which perhaps makes their melancholy more tolerable. The knowledge that there is a final way out of their troubles — although they are not in the least inclined to take advan- tage of it — is in the highest degree comforting to some spermatorrheic or spermatophobiac patients. 610 SPEEJIATOEEHEA. The circulation is generally feeble in spermatorrhea. Coldness of the feet and hands is often complained of, and the pulse is apt to be irritable and either quick and feeble or irregular. Lithemia is a frequent concomi- tant of the disease. Bartholow says that the urine is "pale, of low specific gravity, and loaded with urates." Pale urine of low specific gravit}^ and loaded with urates is something of an anomaly. Phosphaturia and oxaluria are very frequently met with in spermatorrhea, oxaluria being especially fre- quent. The lumbar pain so often met with is not uncommonly due to oxaluria rather than to the sexual derangement per se. Many spermatorrheics complain of disturbed or failing vision. Blur- ring or spots before the eyes — muscce volitantes — are the most frequent sources of complaint. The most important varieties of pseudospermatorrhea, so far as their liability to be mistaken for true spermatorrhea is concerned, are charac- terized b}^ the escape of semen-like fluid from the urethra (a) at stool, (&) with the last straining effort of micturition, or (c) during or after sexual excitement, either with or without erection. Bartholow remarks upon this point as follows: — After every erection without ejaculation there is a mucous flow from the urethra. A mixture of this with the semen produces the 'so-called watery semen. The same discharge is often observed after urination and defecation. It alarms the patient because he believes that it is seminal. These are the cases to Avhich M. Lallemand applies the term "diurnal pollution." If a proper examination of this fluid be made, it will be found not to contain spermatozoa. It is a thick, transparent albuminous fluid, alkaline in reaction. The presence of spermatozoa is essential to prove the exist- ence of semen. No other test is applicable than the microscopic. It cannot be denied that spennatozoa may be found in the urine or mucous secretion from the urethra, if a nocturnal emission, or an emission produced by natural or unnatural means, has recently occurred; but these fluids should be examined, when this source of error may be eliminated. This accords with the views of Flint, who long ago said^: — In most of these eases the fluid is either the liquor prostaticus or a secretion from the vesiculse seminales. The microscope affords the only mode of determining that the fluid is seminal. Were this mode of examination generally adopted, cases of spermatorrhea would be extremely rare. Hassell, in one of the early editions of his work on the urine, says^: — Care must be taken not to confound the discharge of urethral gleet with seminal fluid; the distinction is easy, since the former is distinguished by the presence of infusoria, by the presence of scaly epithelium, and by the escape's being, in general, continuous. Sometimes the gleety discharge occurs only after sexual excitement and lasts but for a short time, Avhen, of course, its character is more apt to be mistaken. The prostatic fluid might also be mistaken for semen: in this the spermatozoa would also be absent, and, in addition, the microscope would reveal in it the presence of the ^ "Practice of Medicine." - "The Urine in Health and Disease.' SYMPTOMS OF SPERMATOKRHEA. 611 Drostatic cylinders, and perhaps, also, of the peculiar lamellated concretions of phos- 3hate of lime, which are found in the prostate in such numbers. Like the mucus :rom ordinary gleet, that from the prostate may also be continuous, but more fre- quently it appears only after A'iolent efforts of defecation, when a small quantity of natter may be expressed, forming only a drop or two, of a thick, stringy, and trans- jarent fluid, which appears at the orifice of the urethra. It is easy to mistake the discharge of chronic urethral catarrh for ;emeii. This mistake does not often occur;, however, for the experienced nan with past gonorrheal troubles does not usually attribute his discharge :o any but the real cause. A moment's reflection is sufficient to show that :here is abundant room for mistakes in the microscopic diagnosis of urethral iischarges. The prostatic, urethral, and Cowper's glands are prodigal in Fig. 126. — Spermuria. Last drop of urine expelled in a case of spermatorrhea. iecretion, and slight stimuli or mechanic pressure are often sufficient to ;ause the secretion to appear at the meatus. Bladder-mucus or muco-pus, md phosphatic deposit in the urine, are also sources of error. It must be ■emembered, however, that in genuine spermatorrhea sexual excitement md mechanic pressure may cause true seminal discharge, which may at mce appear at the meatus, or pass backward to appear later in the urine. iiVhenever true semen appears at the meatus without orgasm, the author relieves that the function of the muscular urethra is temporarily inhibited, )r overcome by prostatic pressure, or else orgasm occurs, but is too feeble to )e perceptible to the patient's weakened sensorium. Symptomatic spermatorrhea in central nervous disease requires brief 612 SPEEMATOEKHEA. special consideration. As niight be inferred from the fact that sexual ex- cesses and masturbation bear an important etiologic relation to locomotor ataxia, spermatorrhea is more often associated with that form of nervous disease than with any other. In passing, the author desires to express the opinion that, notwithstanding the fact that sexual abuses are often a very important factor in tabetic etiology, it is very doubtful if such influences alone ever cause tabes. Primary predisposition, — often involving heredit}'-, — syphilis, alcoholism, and nervous overstrain, one or all, are likely to co- operate with faulty sexual hygiene, which becomes, therefore, merely a con- tributory cause, albeit an important one. Sexual phenomena in tabes usually develop in the early stage of the disease. Meryon, Trousseau, Duchenne, Topinard, and, later, Bartholow are a few of the prominent writers who have called attention to these symp- toms. Topinard speaks as follows^: — Four symptoms present themselves: spermatorrhea, satyriasis, anaphrodisia, and impotence. The first occurs among the most remote antecedents of the first period of tabes, throughout which it continues. The nocturnal pollutions, at first accompanied by erections and a sensation of pleasure, at last become passive. After the sper- matorrhea, or without having been preceded by it, there occur, after some months or years, progressive diminution of desire, difficulty in procuring satisfaction, and at last absolute imjDotence. Topinard mentions a case of ataxia in which the patient was tortured for thirty years by priapism so obstinate as to yield only to large and in- creasing doses of opium. Among other neuropathic disorders in which spermatorrhea often oc- curs as a symptom may be mentioned neurasthenia from various causes; tumors and other diseases of the pons, medulla, and especially of the cere- bellum; inflammation, tumors, and syphilis of the spinal cord: epilepsy, cer- tain phases of insanity, and diabetes mellitus. AVith reference to the diagnosis and relative importance of symptomatic spermatorrhea, Bartholow says-: — • In all cases in which the involuntaiy loss is a symptom it is of little conse- quence from the therapeutic point of view: the centric lesion, of which it is a sign, is the point of importance to which our attention should be directed. That the spermatorrhea is a . symptom merely should be easily determined by reference to the accompanying lesions. There will be present evidences of degenerative changes in the great vessels, in the fundus oculi, in the organs of special sense, and in cerebro- spinal centers. As a rule, spermatorrhea as a substantive affection occurs in the young, in men at the most vigorous period of life, and is a result of the abuse of the sexual organs. On the other hand, spermatorrhea as a symptom appears after the middle period of life, during the decline of sexual activity, and coincidently with symptoms indicating lesions of the cerebro-spinal apparatus. When spermatorrhea is a symptom, the important centric lesions on which it depends soon manifest them- "De I'Ataxie Locomotrice,'" etc. Op. cit. SYMPTOMS OF SPEEMATOEEHEA. 613 selves by other and more characteristic signs, whereas when spermatorrhea is a disease the case remains in very much the same state for months or even years. Attention to these points can hardly fail to conduct the examination to a correct conclusion. Pseudospermatorrliea, Avhile really of slight pathologic importance, is, because of its relative frequency, of greater clinical moment than the genu- ine form. The psychic effects of spermatophobia are so numerous and varied, and so magnified by the imagination of its victims, that the in- genuity and breadth of mind of the physician are often sorely taxed in the management of such cases. While inexcusable, it is, in a way, hardly re- markable that most physicians are content with a laissez-faire policy in deal- ing with spermatophobiaes. Conscious that the patient is suffering with ailments which, from an organic stand-point, are maladies imaginaires, the medical man feels justified in "pooh-poohing" his patient's tale of woe which, baseless though it is, is yet sufficiently unutterable to the sufferer. The lack of an organic foundation renders the symptoms none the less prominent. Pseudo-impotency is often regarded as a fitting subject for jest on the physician's part, but, to the sufferer, the absence of erection, or the presence of other conditions that render successful copulation impos- sible, is terribly real. Each and every symptom, therefore, merits consid- eration — as a beginning of suggestive therapy, if nothing more. The spermatophobiae invariably becomes extremely hypochondriac and practices introspection with a zeal that is worthy of a better cause. The slightest sensation of a subjective character, which, by persons of a normal psychic condition; would either be ignored or attributed to some rational cause, is attributed by the sufferer from pseudospermatorrhea to seminal losses. Should he perchance discover in addition to an occasional emission a little cloudiness of the urine, or a slight discharge at the meatus after micturition or during a difficult stool, his worst fears are confirmed and he believes himself a victim of the worst imaginable type of spermatorrhea. Should he have any remaining doubts as to the diagnosis they are dispelled by the first chance bit of quack literature that he peruses. And peruse quack literature he will, as the only possible source of enlightment upon sexual matters. Eeliable information — indeed, the simplest physiologic truth — is denied him because of the hide-bound condition of an ultra- ethical and, if the truth were known, often essentially hypocritic profession. The author is aware that the foregoing statement has a decidedly radical flavor, but he has, nevertheless, no hesitancy in expressing the view that some phases of so-called medical ethics are positively sickening. The symptomatology constructed by spermatophobiaes is best appre- ciated by perusal of their correspondence. It is as historians of their own cases that these patients especially distinguish themselves. All experi- enced neurologists and andrologists will at once recognize the t^^De shown in the following letter received by the author: — 614 SPEK^IATOEEHEA. My dear Doctor: You will doubtless be surprised to receive a letter from me so soon after the consultation of yesterday; but^ on reflection, I fear that I gave you a very meager account of a case which seems to me much more serious than you realize, judging from the advice you gave me to "stop studying my symptoms and cultivate a spirit of indifference toward my numerous sensations." I therefore take the liberty of writing my symptoms more in detail: — The state of my mind is, jjerhaps, more important than anything else. As I told you, I dread getting among people, no matter how congenial they may bej but I did not tell you the chief reason for my aversion to society. I am sure that my appearance betrays my condition, and many times I know from the queer way in Avhich people look at me while talking with each other that they are discussing my ailment. Imagine my feelings, if you can. Of course, my confusion settles all possible doubt in their minds as to the correctness of their conclusions. I am positive, also, that the horrible odor of which I spoke to you really does come from the affected parts, and is so plain that he who runs may read. At the times when I detect the odor, the parts seem bathed, in a cold, clammy sweat, though the skin does not feel \vet. I have fre- quent spells of ringing in the ears, and sometimes snapping sounds with some pain that must be in my ear-drums. Just before meals I am dizzy, and this comes on just from hearing dinner ahnounced. I notice that the spots before my eyes come only in daylight and are plainer on cloudy days. I am sure my hair is getting very thin and it seems very oily at times, and at such times the scalp is hot and tingling. Almost always, after meals, there is a full feeling in my stomach and bowels, and my breath seems like the odor of tobacco, though I do not use it. I get very much depressed at times and' feel like suicide. I did not tell you this, but it is a fact. If I did not hope that medical science has some cure for my terrible disease I doubtless would make away with myself ere long. I wish that at my next visit to you you Avould examine my rectum. I am sure there is something wrong there, for just before and after my bowels move I feel a peculiar crawling sensation that starts just at the opening of the bowel and passes along the stride into the testicles. I notice, too,* that these organs — the testicles — are sometimes drawn up tightly and at other times hang quite low, the left one actually dragging at times. I have frequent palpitations, as I told you, but perhaps I did not tell you that at such times there is a strange tickling and fluttering feeling at my heart which has a tendency to cause a sense of suffocation. I think that I have given you the. most important symptoms that have occurred to me as being necessary to give you besides those I told you of yesterday, but, if you do not mind, I will bring a full written list of all of them the next time I come, which will assist you a great deal in the treatment of the case. Yery truly yours. Treatment. — General Considerations. — In considering the therapeutics of spermatorrhea a knowledge of the relations of the involuntary seminal discharges to various organic and functional disturbances of the sexual organs or nervous system^— or both — is of paramount importance. A knowledge of the pathologic conditions underhdng seminal losses is especially valu- able in assigning to spermatorrhea its proper role — that of a symptom. Understanding the symptomatic character of involuntary seminal losses, the physician is not likely to overrate the importance of certain very common cases in which the involuntary discharges constitute but little, if an}^, de- parture from the strictly physiologic. If, however, he labors under the TREATMENT OF SPEEMATOEEHEA. 615 erroneous impression that the disease-entity consists merely in involuntary discharges of semen, he is likely to be unnecessarily alarmed, and, what is worse, he is likely to seriously alarm his patient. In true spermatorrhea it is to be remembered that, while the disease is essentially a neurosis — according to the author's view — there are often associated with the neu- rosis pathologic conditions of the genito-urinary system that demand at- . tention. These pathologic changes may have arisen coineidently with the neurosis — being produced by the same causes — or they may either precede or follow the neurosis — being due to causes absolutely independent of those producing the latter. No matter what relation pathologic changes in the genito-urinary system may bear to spermatorrhea, no form of treatment is likely to be successful that does not aim not only at the correction of the essential neuropathic condition, but also at the removal of co-existing local derangements. Thus, while, in the author's opinion, deep-seated gonorrheal infection does not cause spermatorrhea, it may co-exist with, and constitute a very important and obstinate factor in the perpetuation of that disease. An intelligent therapy of . spermatorrhea must necessarily comprehend proper treatment for the conditions produced by the deep infection, what- ever such conditions may be. The majority of cases of pseudospermatorrhea are due to conditions that are essentially, if not absolutely, physiologic. This has come to be generally accepted by reputable physicians. Unfortunately, however, it has too often been taken for granted that the patient is quite as well balanced mentally, and should be quite as well versed in the principles of physiology, as his medical adviser. When a youth, perhaps barely past puberty, im- mature of mental development, and unstable of nervous system — to say nothing of the melancholy and hypochondriasis produced by ungratified sexual desire and brooding over an imaginary spermatorrhea — presents him- self to the average reputable practitioner, he is either laughed at for his ignorance or informed that his case is not worthy of serious consideration. He is rarely convinced, however, that his case is deserving of ridicule, still less that his symptoms are "trifles light as air." On the contrary, he be- comes convinced that his case is either more serious or offensive than his physician cares to undertake, or else that the derision aroused by his tale of woe is merely a subterfuge to conceal medical ignorance. Should he chance to consult with a lay friend, more experienced than himself, he is informed that, from esthetic motives, ordinary physicians object to treat- ing, or even studjdng, such important and serious cases as his own. The quack, that court of last resort for the ignorant and incurable, is suggested and finally appealed to. The author has no hesitancy in asserting that the reputable profession is itself largely responsible for the opulence and indisputable power of the quack. Would it not be better to employ the same psychic instability that is utilized by the quack for the purpose of alarming the patient and preying 616 SPEEMATOEEHEA. upon his fears, in an honest endeavor to correct his psychopathic state? Therapeutic suggestion, honestly — which means scientifically — used will re- lieve most cases of pseudospermatorrhea, both psychically and physically, and keep them out of the hands of the harpies that find in such patients their most lucrative victims. The patient should be given to understand primarily that, while his case demands attention, it is by no means so serious as he supposes and will yield readily to treatment. He should be instructed in sexual physiology, but not expected to become an adept in one lesson. Such organic or functional disturbances as may have a bearing upon his symptoms demand careful attention. Oftentimes regulation of the diet, attention to the bowels, and the passage of the cold sound a few times will lessen the frequency of emissions which the practitioner pronoimces off- hand, physiologic. If, in the meantime, the patient's confidence has been gained and proper psychic control attained, the result is likely to be all that could be desired. There are very few spermatophobiacs who do not demand careful attention, for, no matter how trivial the sexual derange- ment per se, the patient's psychic state is such as to make his ailments terribly real to him. The author takes this opportunity of saying that in his opinion the neglect of the profession to do its full dut}^ in such cases is responsible for much suffering — -both mental and physical. It is, of course, understood that there are occasional cases in which a perfectly- healthy subject consults the physician regarding infrequent emissions the significance of which the patient does not understand and whom_it is per- fectly safe to dismiss with a few words of instruction in sexual physiology. It is to be remembered, however, that the practitioner is not often consulted until the patient has developed a psychopathic state that demands the most judicious management. Prophylaxis. — Subservience to the rules of sexual hygiene is pre- ventive of both pseudospermatorrhea and real spermatorrhea, save in ex- ceptional instances where the seminal losses are symptomatic of, or sec- ondary to, debilitating general diseases or lesions of the nervous system. Even in the case of locomotor ataxia, however, it is to be remarked that proper sexual habits ma}' be prophylactic, for it is probable that sexual excesses bear a very important etiologic relation to that disease. The vari- ous features of genito-urinary and sexual hygiene have been discussed in the special chapter devoted to that subject, and have received especial at- tention in the chapters upon impotence, sterilit}'', and masturbation. The cure of local organic disturbances of the sexual organs is obviously prophy- lactic of spermatorrhea. Special Treatment. — In considering the treatment of pseudosperma- torrhea it is well to remember that in the form characterized by more or less frequent involuntary emissions the frequency of their occurrence is not the sole criterion of their importance. The important point is the degree of tolerance of the emissions. Just as some individuals may copulate very TKEATMENT OF SPERMATORRHEA. 617 frequently without apparent harm, certain plethoric subjects may appar- ently tolerate involuntary emissions that would produce most disastrous results in feebler subjects. It is to be remarked, however, that frequent emissions are in themselves usually a sign of disturbed innervation both of the sexual organs and general nervous system, or of some local source of reflex irritation. Before deciding the question of the necessity of treat- ment, even in apparently slight cases, it is wise to ascertain the condition of the sexual organs. The emissions may be a symptom of local disturbance of a congestive or inflammatory character that may later on cause serious trouble, but which may be readily relieved by proper early attention. By far the most important measure of general treatment in the class of subjects seeking advice in pseudospermatorrhea is physical training. With careful development of the muscular system will come improvement in nervous tone, both general and local. Exercise should, so far as pos- sible, be taken in the open air, although field-sports should be aided by proper gymnastic training to secure general and symmetric muscular de- velopment. Exercises involving pressure or strain upon the perineum should be avoided, as a rule. Climbing, bicycling, and horseback-riding are especially perniciolis. The cold bath or cold shower — very cautiously used at first — constitute an auxiliary measure of great value. The baths should not be prolonged — stimulation, not sedation or refrigeration, is desired — and should be followed by brisk toweling, or rubbing, either with the hands of an attendant or by means of a flesh-brush wielded by the patient him- self. The functions of the kidney and bowel, and especially of the stom- ach, demand attention in all cases of sexual disturbance. Constipation and excesses or indiscretions in eating and drinking are particularly to be avoided. Sexual rest — both psychic and physical — is a sine qua non, save in certain cases where matrimony is advisable, either primarily, or after a suitable course of treatment. It is not, as a rule, difficult to elicit a history of the usual cause of spermatorrhea — masturbation — in most cases. The patient's frankness, however, often has a limit. He alludes to the habit of masturbation in the past tense, and forgets to inform the physician that he has not yet discon- tinued the practice. If the inquiry be pressed closely, he usually lies out- right. It has been the author's experience, however, that a large proportion of such patients can eventually be induced to betray themselves. A popular method of deceiving the physician is to inform him that masturbation is performed unconsciously during sleep. This is a possible, but unquestion- ably rare, occurrence. A very valuable method of diminishing the frequency of seminal emis- sions is sleeping upon a hard and uncomfortable bed. Patients occasionally discover this for themselves. Several patients of the author's have derived excellent results from sleeping upon the floor. A hard mattress is often effective. Physical discomfort and erotism are somewhat incompatible, and 618 SPEEMATOEKHEA. the patient whose bones and muscles are aching from a vain effort to find comfortable and luxurious repose is not very likely to be disturbed by lascivious dreams. A few weeks of this practice will often break up the emission-habit. Light and relatively cool covering is advantageous. In a general way, the tendency to nocturnal emissions is directly proportionate to the liLKuriousness and warmth of the bed. Certain mechanic appliances have been used to break up the emission- habit. The most effective of these is the so-called "spermatorrhea-ring." Although originally a quack device, this appliance is often successful. It consists of a double ring adapted to the circumference of the penis when flaccid. The inner or elastic ring holds the appliance in situ after it has been slipped upon the penis, while the outer ring, which is provided with moderately sharp metallic serrations, inflicts punishment upon the mem- ber Avhenever it chances to become erect. The ring is to be applied at night and, as a rule, if an erection occurs the patient is immediately awak- ened — before an emission can take place. In some cases erection and emis- sion occur despite the appliance. In true spermatorrhea such devices are ineffective. A very ingenious device is a similar appliance connected with a small battery placed beneath the patient's pillow. An erection completes the circuit and causes a small alarm bell to ring, awakening the patient and thus forestalling emission. Any plan that will serve to interrupt the emission-habit is likely to be successful. It has been noted that the dorsal decubitus favors emissions, theoretically because in this position there is a determination of blood to the genito-spinal center — relative hyperemia — -with consequent heightening of reflex sensibility. In many cases the patient rarely, if ever, has an emission while lying upon his side. Under such circumstances a towel tied about the body in such a manner that the knot rests in the middle of the back, often serves to awaken the patient, or make him so uncomfortable that he instinctively and unconsciously avoids the dorsal decubitus.^ In some cases the patient has emissions only while lying upon one or the other side. Changing to the opposite side is often effectual under such circumstances. In cases in which the patient fosters emissions by handling the genitals during sleep, the author has advised the patient to wear a pair of ordinary boxing-gloves at night. This simple device renders manual manipulation of the genitalia quite difficult. In all forms of spermatorrhea complicated by chronic congestion or inflammation of the prostate or — as is frequently the case — by chronic in- flammation of the vesiculse seminales, the most important measure of treat- ment is massage, performed by the flnger of the surgeon via the rectum. Instruments have been devised for the performance of prostatic and ve- "The Reproductive Organs," William Acton. TEEATMENT OF SPEEMATOEEHEA. 619 sicular massage, but digital massage is the only safe, intelligent, and reliable method. Considerable experience is, moreover, necessary to the proper per- formance of the massage. The surgeon with short stubby fingers merely wastes his time in attempting to perform this manipulation, which is in itself sufficiently simple. Aphrodisiac remedies, like those of an opposite character, are used far too recklessly in spermatorrhea. This is natural enough, considering (1) that the profession in general overrates the potency of this class of reme- dies, and (2) the imperative demand of the patient to be relieved of the sexual incapacity that often exists in pseudospermatorrhea and almost al- ways in true spermatorrhea. In the author's opinion there is no class of remedies so fallacious as the aphrodisiacs. Erections produced to meet emergencies by large doses of aphrodisiac drugs are pathologic, and inevitably followed by a reactionary depression which makes the patient's sexual powers more unreliable than ever, to say nothing of the local irritation produced by the action of such drugs upon the genito-urinary mucosa. In moderate doses, however, with a clear understanding of their tonic rather than their aphrodisiac proper- ties, there are a number of drugs that have a markedly beneficial effect in all forms of sexual debility, whether characterized by spermatorrhea or not. Of these drugs, phosphorus is the most reliable, where tolerated by the stomach. It is best given in the pure state in pill form, but the dilute phos- phoric acid, the phosphid of zinc, and the hypophosphites are quite serv- iceable. Nux vomica or strychnia and its preparations come next in order, and may advantageously be combined with phosphorus. Ergot is also useful as tending to restore muscular and vascular tone in the genital apparatus. It also tends to the correction of nervous hyperactivity of all kiiids, and is too seldom employed with this object in view. The most overrated remedy for diseases of the sexual apparatus is damiana. That this drug has a tonic effect in spermatorrhea and sexual debility in general is true, but as an aphrodisiac it is an arrant fraud. In general, it is inferior to strychnia. The drug should be given in liberal doses — 2 to 5 grains of its solid or 1 to 2 drams of the fiuid extract three or four times daily. Cantharides is the most popular of all remedies of the aphrodisiac class. It has been the basis of "love-philters" from time immemorial. Its true worth, however, can be summed up in very few words. As an aphrodisiac it is not only unreliable, but such results as may be obtained by large doses are pathologic, and therefore dangerous. Given in rational doses as a tonic, it is serviceable to a moderate degree. It seemingly has a general tonic effect, and in addition a somewhat stimulating action upon the nerves of sexual sensibility and the genito-spinal center. A marked degree of sexual stimulation is never to be obtained save by dangerously large doses. Nor is the drug always reliable in producing in rational doses even a mild degree 620 SPEEMATOEEHEA. of stimulation of the sexual apparatus. It has been claimed — and it must be confessed with some reason — that cantharides acts locally only by yirtue of its irritant action upon the genito-urinary mucosa via the urine. If this be true, any stimulating effect upon the genito-spinal center and nerves or sexual sensibility must be produced reflexly. The possibility of the drug^s acting by virtue of an irritant effect upon the mucous surfaces of the genito-urinary tract should impose additional caution in its adminis- tration where inflammatory or congestive conditions of the sexual organs exist. A dose of more than 20 minims of the tincture should rarely be exceeded, although by increasing one minim daily, as suggested in the pre- ceding chapter, this dose may sometimes be exceeded. When malformations of the sexual organs exist tliey should be cor- rected by surgical measures so far as possible. Phimosis and meatal stenosis demand attention with especial frequency. The various other conditions already enumerated under the head of predisposing causes should be sought for, and if found should receive appropriate surgical treatment. Disturb- ances located in the rectum and anus are quite frequently overlooked. These conditions are important sources of exaggeration of the genital re- flexes, and require most careful consideration. Varicocele, if large, always demands operation. Even in the milder forms the patient's psychopathic state is such that an operation is often not only justifiable, but positively indicated. Such conditions as prostatorrhea from prostatic hyperemia or follicular prostatitis have received attention elsewhere in this volume. Seminal dis- charges during a dithcult stool should be explained to the patient, and his constipation relieved. In many such cases the prostate is the seat of hjqDer- emia or inflammation demanding especial attention. Hypersecretion dur- ing erection and the appearance of spermatozoids in the urine after sexual intercourse or excitement should be explained to the patient upon a physio- logic basis. Anaphrodisiac measures constitute the most popular routine treatment for spermatorrhea. In the author's opinion, however, remedies of this class are much abused. In cases of what may be termed the sthenic type, charac- terized by a greater or less degree of constitutional vigor associated with marked sexual irritabilit}^, anaphrodisiac measures are a distinct advantage. The bromids in free doses, gelsemium, camphor, and lupulin are types of this class of remedies. In many cases remedies directed to the alleviation of irritation of the mucous membrane are distinctly anaphrodisiac. Alka- lies — the salts of lithia especially, if the subject be lithemic — and such remedies as pichi, buchu, ustilago maydis, triticum repens, and the balsams are of service under such circumstances. In a large proportion of cases of pseudospermatorrhea, and in a ma- jority of, if not all, cases of true spermatorrhea, a tonic rather than, a seda- tive line of therapy is demanded. The use of remedies of the aphrodisiac TREATMENT OF SPEEilATOERHEA. 621 class as tonics has already been dwelt upon. Proper exercise and bathing for improving nervous tone have also received attention. Quinin, arsenic, manganese, and iron — the latter two especially if anemia exists — are often of distinct service. The fluid extract of salix nigra has seemed serviceable as a sexual tonic. It is well to remember that in the class of affections under consideration tonics should generally be combined with suitable mild laxa- tives. Constipation is nowhere more pernicious in its effects than in diseases involving the sexual functions. One of the best ferruginous preparations is ferratin in tablet form. Peptomangan is an excellent combination of man- ganese and iron. One of the most valuable tonics at our command is static electricity. The general tonic effect of the static current is not so generally appreciated by the profession as it deserves. That the moral effect of the spark is valuable in pseudospermatorrhea is obvious. A simple yet often effective tonic treatment is the free ingestion of raw eggs. The popular notion of the efficacy of eggs as an aphrodisiac is, of course, a fallacy, yet their effects as a tonic must be admitted and, more- over, they seem to have a special tonic effect upon the sexual apparatus. In several cases of very frequent nocturnal emissions in sickly, delicate lads the author has obtained excellent results from the free use of raw eggs. Whether the beneficial effect of egg is to a certain extent due to the small amount of contained phosphorus is open to question; its efficacy may well be attributed simply to its highly nutritive properties. Psychotherapy has a wide and important field of usefulness in the various forms of spermatorrhea. Suggestion necessarily enters into all methods of treatment to a certain degree. Cases occur, however, in which positive efforts in this special direction are warrantable. The services of the specialist in psychotherapy — or suggestion-therapy — may sometimes be enlisted to good advantage. The treatment of spermatorrhea secondary to organic cerebro-spinal disease necessarily resolves itself into the treatment of the primary nervous disorder. In many cases, however, appropriate local treatment is of dis- tinct service in diminishing what is obviously not only a serious drain upon the patient's vitality, but also a source of most profound psychic de- pression. Cold sitz-baths and the prolonged local application of cold water to the genitalia — especially the testes — are of great value as a sexual sedative primarily, and more remotely in improving the tone of the sexual organs. Galvanism applied to the external surface of the genitals or, in selected cases, directly to the prostate via the rectal or deep urethral electrode, is often very serviceable. The faradic current, however, often acts better when the condition is largely psychopathic, because of the moral effect of the sound of the rheotome. Cold-water enemata are often of service, especially where congestive or inflammatory conditions of the seminal vesicles exist. The psychrophor of Winternitz — which consists essentiallv of a double-cur- 622 SPEEMATOEEHEA. rent metallic catheter — is a valuable adjunct to the treatment of cases char- acterized by urethro-prostatic hyperesthesia. The psychrophor is intro- duced into the bladder and a current of cold water — -ice-water if necessary — made to pass through it for some minutes — the time varying with the degree of tolerance. This is to be repeated daily or every second day. In general^ the urethral sound is the most useful instrument for the local treatment of all forms of spermatorrhea. If introduced cold and allowed to remain in the urethra for from five to ten minutes it combines the effects of mild refrigeration with the blunting of nervous sensibility by its mechanic action. There is also an improvement in the circulation of the prostate produced by the pressure of the instrument and the reactionary hyperemia incidental to its withdrawal. The milder forms of pseudosper- matorrhea usually yield readily to the occasional use of the sound. In some cases the sound is painful, though the psychrophor is well tolerated. Sound- ing should usually be performed twice or thrice weekly. Direct medication of the prostatic urethra — and incidentally of the mouths of the ejaculator}^ ducts — is a very popular method of treatment of spermatorrhea. When judiciously and aseptically applied, various astrin- gents act well in these cases. The most useful astringents are silver nitrate, copper sulphate, t-annin, thallin, protargol, and ichthyol. These may be used in the form of suppository, ointment, or solution. The most useful astringent is silver-nitrate solution in a strength of 2 ^/^ to 30 grains to the ounce. In the authors experience a relatively mild solution in considerable quantity is usually best. Where strong solutions are used, only a few drops should be injected. The author's deep urethral syringe (Fig. 4?) will be found serviceable, especially in using the milder solutions. With this syringe the prostatic urethra can be thoroughly flooded with the solution. In using the stronger solutions the Keyes-Ultzmann syringe is better for the general practitioner. If the instillations are followed by prostatic massage, their beneficial effects are enhanced. The recent introduction of animal extracts into medicine has been seized upon with avidity as a possible solution of all problems in the therapy of diseases involving the sexual function. The vaporings of Brown-Sequard were used as a justification of all sorts of quackery, "regular" and other- wise. The "fake" solutions of spermin and its congeners, fathered by a noted highly-ethic (?) neurologic specialist of this country, will be remem- bered in this connection. In view of the nitroglycerin upon which such action as these preparations possessed depended, it is not surprising that their false pretensions have been exploded. Legitimate solutions of spermin have been indorsed as of limited value by competent authority,^ but, from a sexual stand-point, nothing so far discovered has greatly impeded the on- ' Vecki, Poehl. and Hirscli. Tide V. G. Veeki on "Sexual Impotence," 1899. TKEATMENT OF SPEEMATOERHEA. 623 TvarcT progression of remorseless old Father Time, nor cancelled the debt the roue must sooner or later pay to Nature. One of the most popular methods of treatment of spermatorrhea among surgeons of a past generation was cauterization of the prostatic urethra with pure silver nitrate, via the porte-caustique of Lallemand: an instrument which, as the late M. Eicord Justly said, " has been responsible for more eunuchs than all the harems of the East." Cauterization of the prostate is occasionally justifiable, but only in the hands of the expert, and rarely by any other method than via the endoscope under direct illumination and ocular control. The caustic application should generally be limited to the caput gallinaginis, being made with the view of lessening hyperesthesia and curing chronic inflammation of that structure. As formerly used, complete obliteration of the mouths of the ejaculatory and prostatic ducts was a fre- quent result of the method. Sterility is a necessary consequence of such rough treatment. Marriage is often advised in spermatorrhea and its congeners. This "prescription" involves very serious responsibility. In some cases of pseudo- spermatorrhea the physician may safely advise matrimony, but he should use great care in determining the patient's potency. Even psychic impo- tence may be a bar to marriage. In true spermatorrhea marriage is rarely justifiable. The author has commented elsewhere on the heinous practice of prescribing healthy and presumably innocent women in the treatment of masculine degenerates who cannot be other than wrecks of humanity. Oftentimes the game is not worth the candle, even though an apparent success be obtained. There is rarely an instance in which the woman pre- scribed does not get the worst of it. Such offerings upon the altar of hymen — to say nothing of the still-broader question of infection — are responsible for quite a proportion of the sum-total of human misery, both psychic and physical. Both the profession and the public may one day awaken to a sense of their duties in this matter, and the time may come when proposals of marriage, or, at least, applications for a license to marry, will be unorthodox unless accompanied by a clean bill of health from a reputable physician. PART VIL DISEASES OF THE PEOSTATE AXD SEMIKAL VESICLES. CHAPTEE XXYII. DISEASES OF THE PROSTATE. AxATOMY, Physiology, Anomalies, and Ixjueies of the Pkostate. Anatomy and Physiology. — An exhaustive anatomic description of the prostate would not comport with the purpose of this work; but it is almost impossible to give a practical outline of the various diseases affect- ing this organ -nithout a preliminary discussion of some of the main points in its anatomy and physiology. Especially is this necessary in view of the fact that our text-books upon anatomy are notably defective in their de- scriptions of the part. Slight attention is usually given to the prostate in the dissecting-room, comparatively few students acquiring even a super- ficial knowledge of its structure and functions. Without entering into an elaborate discussion of the views of those who beKeve the prostate to be essentially a muscle, or their opponents who claim that it is essentially a gland, it will suffice to say that the prostate is a mus- culo-glandular organ surrounding the neck of the bladder. It lies behind the triangular ligament, or deep perineal fascia, and impinges upon the rec- tum, through the thin walls of which it may readily be palpated by the finger. The relation of the organ to the rectum is one of the most important of its gross anatomic relations, having an important bearing on both the symp- tomatology and diagnosis of prostatic disease. The close anatomic associa- tion of the prostate and rectum very often results in coincidental disturbance in both organs through the medium of the associated nerve-supply as a con- sequence of disease in one or the other. In a general way. the old description of the prostate as resembling a horse-chestnut is fairly accurate as regards its form and size. The organ measures, on the average, about an inch and a half in breadth, an inch antero-posteriorly, and somewhat less than an inch in thickness. It is supported by the pubo-prostatic ligaments derived from the anterior vesi- cal ligaments, posterior layer of the triangular ligament, and the levator- ani muscle. The organ presents the appearance of two moderately-distinct lateral halves or lobes. The so-called median lobe is a misnomer, this structure being a pathologic formation. It is not surprising that such a mistake should be' quite general when authorities state, as does one ex- cellent anatomist, that "the median lobe is a cause of obstruction in fully (624) ANATOMY AND PHYSIOLOGY OF THE PEOSTATE. 625 20 per cent, of jDrostates after the age of sixty." The prostate is tun- neled by the urethra and the prostatic and ejaculatory ducts. On its floor is a longitudinal, highly-sensitive, erectile structure, the veru montanum. This is probably the principal seat of sexual sensibility. Upon either side of the veru montanum is a longitudinal depression, the prostatic sinus, into Avhicli open the prostatic ducts, some fifteen or twenty in number. At the anterior extremity of the veru montanum are situated the mouths of the ejaculatory ducts upon either side. Just in front of the veru montanum- is a depression known as the uterus mascuUnus, or prostatic utricle, from \YJXI Fig. 127. — Conventional illustration of the anatomic relations of the parts about the base of the bladder. U, U, Ureters. YD, TD, Vasa deferentia. S, Y, Seminal vesicles. P, Prostate. C, G, Cowper's glands. B, Bulb of the urethra. its supposed homology to the uterus. The prostatic urethra does not trav- erse the prostate in the same manner in all individuals, the roof of the canal being barely covered in by prostatic tissue in some cases. It does not always begin anteriorly in the center of the prostatic apex, being occasion- ally deflected to one or the other side. The length of the prostatic urethra and the direction of its curve vary greatly. In the average adult it meas- ures about an inch and a quarter in length. Its curve is quite sharp and 626 DISEASES OE THE PEOSTATE. short in the child, longer and more gradual in the adult. A knowledge of the normal curve of the prostatic nrethra is of great importance in diag- nostic explorations of the canal, inasmuch as pathologic conditions of the organ or the tissues about the vesical neck produce alteration in its con- formation and length. The structure of the prostate differs somewhat in children and adults. The assertion has been made, and accepted in certain Fig. 128. — Showing the internal anatomic relations of the bladder, urethra, and prostate. A, A, Ureteral orifices. B, Trigonum vesicse. C, Veru montanum. D, Orifices of the ejaculatory ducts. E, E, Cowper's glands. F, Membranous urethra. G, Bulbous urethra. quarters, that children have no prostate. This, however, is incorrect. The difference between the child and the adult is mainly in the relative propor- tion of glandular and fibro-muscular elements. Even in very young chil- dren the muscular elements are sufficiently abundant to give a sharply- ANATOMY AND PHYSIOLOGY OF THE PKOSTATE. 627 defined and prominent character to the organ. The glandular and fibro- connective-tissue elements, however, are not so abundant and well marked as in the adult. The veru montanum, ejaculatory ducts, mouths of the prostatic follicles, and seminal vesicles — which are so closely associated with the prostate and its functions — are capable of definite demonstration even in young infants. The argument has been advanced that children really have no prostate, because, its function being purely sexual, there is no oc- casion for its development until sexual power manifests itself. This argu- ment is not particularly logical, in view of the fact that the seminal vesi- cles and veru montanum, which are perhaps of more importance from a sexual stand-point than the glandulo-muscular elements of the prostate, are disproportionately well developed in infants. Even a superficial dissection shows that very young children have well-developed prostates, sparsity of the prostatic glandular tissue to the contrary notwithstanding. In a general wa}', however, it may be asserted that the prostate is of no great functional importance until puberty arrives. Whether or not the muscular tissue of the prostate is of importance in micturition, thus rendering the organ to a certain extent a urinary one, is a question that has awakened much controversy. In the authors estima- tion, Avhile urination might be carried on in the absence of the muscular tissue of the prostate, the organ nevertheless appears to play a distinct sec- ondary or auxiliary role in micturition. While admitting, therefore, that the prostate is to all intents and purposes a procreative organ, it would seem that it is a participant in the function of micturition, and should therefore receive consideration as a urinary organ as well. In infants the author has demonstrated that the muscular structure of the prostate is practically continuous with the muscular structures of the vesical walls. As the subject grows older a certain amount of circumscrip- tion and reinforcement of the prostatic muscular tissue seems to occur, so that there is a more distinct line of demarkation between the prostatic and vesical muscular tissue, although the circular fibers of the prostate are still continuous at the outlet of the bladder with the false vesical sphincter. On section the prostate is of a pale-reddish color, rather dense and firm, and quite friable, the fibro-muscular elements being contained in a proper fibrous capsule. The impression derived from the usual descriptions of the prostate is that its glandular, and consequently its most important, elements from a functional stand-point are contained within the proper fibrous capsule. This is an error. The principal glandular elements of the organ are outside the circumscribed structure that we know as the pros- tate body proper, in the tissues surrounding the prostate, seminal vesicles, and vesical neck. The glands and ducts are numerous, forming the tissue- mass of which the seminal vesicles constitute the most important part. This tissue is richly supplied with nerves and blood-vessels. A consideration of this particular feature of the anatomy of the prostate serves to explain the 628 DISEASES OF THE PKCSTATE. obstinacy of infectious diseases involving the organ, and lays peculiar em- phasis upon the oft-repeated assertion of the intrinsic incurability of gon- orrheal infections of this part. A careful dissection of the prostate and its associated glandular structures about the vesical neck should be very in- teresting to those who believe that deep gonorrheal infection in the male may be speedily cured by instilling a few drops of silver-nitrate solution into the prostatic urethra. The muscular elements are arranged in a circular fashion, forming pos- teriorly a rather distinct muscular ring, constituting the dividing-line be- tween the vesical cavity and the true vesical neck: i.e., the prostatic urethra. This ring of circular fibers constitutes the internal or false sphincter vesicae. Anteriorly the muscular fibers of the prostate are continuous with the ac- celerator-uringe muscle surrounding the membranous urethra. It is difficult to say whether the false sphincter vesicae is a part of the muscular structure of the vesical wall or of the prostate. This point is of no great moment inas- much as there is practically a structural and functional continuity between the prostate and bladder-muscle even in the adult. The tendency has been in the direction of a too-arbitrary differentiation of the two organs: a dif- ferentiation hardly warrantable from a physiologic stand-point, save in so far as the sexual function of the prostate is concerned. The circulatory supply of the prostate is very rich. The arteries are derived from the internal pudic, hemorrhoidal, and vesical. The veins form an elaborate and intricate plexus about the organ, inosculating with those supplying the rectum and anus in a very intimate manner. This peculiar relationship of the vascular supply of the rectum, anus, and prostate ex- plains, to a certain degree, their close pathologic relationship. Thus, hemor- rhoids, constipation, and hepatic obstruction are liable to lead to passive congestion of the prostate, and even predispose to active inflammation. Conversel}^, inflammatory and congestive prostatic disturbances may pro- duce rectal tenesmus, hemorrhoids, or even proctitis. The veins of the pro- static plexus are prone to become tortuous and varicose in elderly subjects: a condition that is often associated with hemorrhoidal disease. The nerve-supply of the prostate is derived mainly from the hypogas- tric plexus. The organ is liberally supplied with filaments from the sym- pathetic. This sympathetic supply is closely associated with that of the rectum and anus: a relationship that in some cases forms another strong pathologic link between the two organs. The consideration of the nerve- anatomy of these parts enables us to understand the strangury, spasmodic stricture, and retention of urine that often occur as a result of operations about the rectum and anus. The elaborate sympathetic and sensory nerve- supply of the prostate, particularly of the prostatic urethra, is explanatory of the more or less remote reflex disturbances, both mental and physical, that so frequently occur as a result of prostatic disease. By means of the sympa- thetic nerve-supply the prostate is brought into most intimate relation with ■ AiSTATOMY AND PHYSIOLOGY OF THE PKOSTATE. 629 all the organs in the function of wliich the s}anpathetic ganglia play an im- portant role. The sexual function of the prostate is rather complex^ comprising sev- eral elements, viz.: special sensory, secretory, and mechanic. While its urinary role should not be ignored, it is of no great moment; the urine may be physiologically retained or expelled independently of the pros- tate. The prostatic urethra, and especially its floor in and about the veru montanum, is the seat of the pleasurable sensation experienced in the per- formance of the sexual function. The prostatic follicles secrete a milky, slightly-acid fluid, the function of which is to dilute and increase the bulk of the semen. The muscular fibers of the prostate are involved in the con- vulsive, spasmodic perineal contraction that expels the semen during ejacu- lation. This is due to a distinct reflex contraction excited by overdistension of the prostatic urethra with seminal fluid at a time when the nerves of sexual sensibilit}^ are relatively hyperesthetic. Standard anatomic authorities assert that the follicular prostatic glands in some old subjects contain small calculi, composed of calcium carbonate and animal matter. This assertion is based upon the fact that it is prac- D Fig. 129. — Midsection of prostatic urethra. D,- Ejaculatory ducts. Sp, Sinus pocularis, or utricle. (After Cruveilhier.) tically only in old subjects that these calculi are of sufficient size or so lo- cated as to produce mechanic disturbance. The author has become con- vinced from the dissection of a large number of prostates in subjects under middle age that prostatic calculi — corpora amylacea— are frequently found in young subjects. They are even found in children. If the examination of the prostate be restricted to the tissue immediately surrounding the pro- static urethra, these peculiar bodies will not often be found. If, however, the tissue outside of the capsule proper — i.e., the glandular tissue surround- ing the base of the prostate and vesical neck — ^be carefully examined they Avill frequently be met with. The author has found them in the tissues sur- rounding the vesical neck fully an inch above the base of the prostate proper. Attention has frequently been called to certain striking points of sim- ilarity between the prostate and uterus, both anatomic and physiologic. It is unnecessary to enter upon an exhaustive discussion of this subject. It is well to remember, however, the general resemblance between them in the clinical study of prostatic disease, especially with reference to surgical treatment of circumscribed neoplasms and the medical treatment of con- 630 DISEASES OF THE PEOSTATE. gestive and inflammatory affections of the organ. The prostate is neces- sarily a more obscure field for research than the nterns; hence analogic reasoning is sometimes of great clinical and therapeutic value. Anomalies of Development. — Congenital anomalies of the prostate are clinically rare. They are probably more frequent than is generally sup- posed; but, as they are not likely per se to prove of pathologic importance, they are not often brought to our attention. Defective development in- cidental to extreme hypospadias and epispadias are occasionally seen. In these cases the prostate is usually absent. This anomaly requires no con- sideration excepting as incidental to the deformity of which it is a part. Defective development of the prostate is associated, as a rule, with de- fective development of the sexual apparatus as a whole. The prostate is likely to be wanting in cryptorchids. In certain cases of sexual per- verts, and in individuals who are sexually imperfectly developed and differentiated, the prostate remains undeveloped in both muscular and glandular structure, as might be expected from the rudimentary condi- tion of the rest of the sexual apparatus. The inhibition of prostatic g-rowth is due, not to failure of the individual to normally perform his sexual functions, but to inhibition of development that may be more or less general, and which always involves all the component parts of the sexual apparatus. That imperfect or exaggerated development of the prostate occurs alone is possible, but this is a question which, for obvious reasons, is extremely difficult of solution. Aberrations of development of the most important structure of the prostate — viz.: the veru montanum — have been described. Independently of infectious or inflammatory disease, cases of imperfect or exaggerated development of this structure probably occur. It would be difficult, however, to eliminate in such cases the effects of masturbation and sexual excess. Stricture of the prostatic urethra is asserted by so excellent an authority as Thompson to be unknown. The author had, however, at one time several specimens in his possession in which distinct bridles, apparently congenital, were present in the anterior portion of the prostatic urethra. Several other specimens showed an ab- normal narrowing of the prostatic urethra, with a distinct lateral deviation of the canal at its junction with the pars membranosa. In certain specimens the prostatic urethra, instead of tunneling the center of the apex of the prostate, diverged so far from the median line that obstruction to instru- ments must almost necessarily have been experienced during the life of the patient, had instrumentation become necessary. It will be readily un- derstood that such abnormal narrowing and deviation in all probability pro- duce no disturbance so long as there is no disease of the mucous membrane. Should gonorrheal infection occur, however, a far different state of affairs might supervene, and the congenital condition produce considerable trouble. The author believes that such congenital aberrations of the prostatic ure- thra may occasionally be responsible for difficult urethral instrumentation. WOUNDS OF THE PKOSTATE. 631 INJUEIES OF THE PKOSTATE. Traumatism of the prostate, save 'from surgical operations and manip- ulations, is exceptional. Contusions and lacerations due to direct force from falls or blows are especially rare on account of the situation of the organ, protected as it is by the pubic and ischial rami and ischial tuberosities. The force of falls and blows upon the buttocks is usually broken by the latter osseous parts. Blows upon the perineum are not likely to injure the prostate because of the distance of the organ and the elasticity of the musculo-cellular cushion constituted by the tissues of the ano-perineal region and ischio-reetal fossa. Accidents have been known where the membranous urethra has been torn completely across at the apex of the prostate, yet that organ has escaped injury. Crushing injuries involving the prostate are almost necessarily fatal, excepting where the prostate is injured indirectly through the medium of fractured pelvic bones that are driven into the organ. In extensive crushing injuries the traumatism of the prostate is comparatively a minor consideration. In- cised, punctured, and lacerated wounds of the prostate from accidental in- jury are occasionally seen. Sharp bodies may be driven into the perineum, the patient perhaps falling astride them. Most of the accidental injuries are due to a fall upon some pointed object. Dugas cites a case in which the branch of a tree was driven into the perineum and the prostate wounded. A^elpeau reported a similar case in which a wooden stake was driven into the perineum. Brittle substances introduced into the rectum have been known to penetrate the prostate. Obviously such penetration can occur with great facility. Injury to the prostate by fire-arms is necessarily very rare. Eicord, however, reported a case in which a musket-ball penetrated the false pelvis, passed downward along the iliac fossa, entered the true pelvis, and penetrated the prostate. It v/as detected by digital examination of the rec- tum and extracted by perineal section. Wounds of the prostate inflicted in surgical operations are frequent. It is necessarily wounded in all perineal lithotomies with the exception of the simple median operation. It is often wounded in perineal urethrotomy, and invariably wounded in the proper performance of perineal puncture for vesical drainage. Operative wounds are not dangerous per se, unless the incision or laceration, as in the case of extraction of too large a stone, extends beyond the bounds of the fascial investments of the prostate, thus involving the pelvic cellular tissue or peri- toneum. The prostate is often injured from its urethral aspect in the pas- sage of the catheter or sound, or in the performance of that extremely haz- ardous operation, internal prostatotomy. These forms of prostatic trauma are exceedingly dangerous because of the exposure of the injured tissue to sepsis and the necessarily-imperfect drainage. An additional element of danger is uncontrollable hemorrhage. These factors are done away with in perineal or suprapubic operative wounds of the prostate. Another danger 632 DISEASES OF THE PROSTATE. is the formation of a false urinary passage. False passages traversing the prostate and beginning in the prostatic nrethra or at some point in the nrethral walls at a greater or less distance anterior to the apex of the organ are frequently seen. Instances have been known in which a catheter or soimd has been passed through the urethral walls at some point in front of the bulbo-m'embranons region, traversing the tissues outside of the ure- thra and penetrating one or the other lobe of the prostate, thus finally reaching the bladder by a roundaboitt and most dangerous route. The revival of the Bottini operation affords another variety of trauma of the prostate. TThether the advantages of the operation compensate for its dangers the future will tell. Dangers of Prostatic AYounds. — As already suggested, wounds from the interior are not likely to be followed by serious results, providing the in- jury be limited to the prostate itself. Lacerations and contusions are more dangerous than smooth incisions, save with respect to hemorrhage, which is obviously greater in clean incised wounds, unless such wounds be ex- ternal and open. In considering the question of hemorrhage from operative or accidental wounds of the prostate, it is well to remember that the region of the prostate is very vascular and rather difficult of access for the applica- tion of methods of hemostasis. Eetention of urine from congestive or in- flammatory occlusion of the urethra, or from complete or partial obliteration as a result of the traumatism, is likely to be an important consideration in prostatic injuries. Pyogenic infection and abscess, possibly followed by urinary fistula, and septic cellulitis are serious results that are likely to occur in extensive injuries, especially where drainage is imperfect. The septic cellulitis may be limited to the ano-perineal region and ischio-rectal fossa, or may extend over a large area of the subcutaneous and intermuscular planes of cellular tissue. If the wound extends beyond the bounds of the prostate, septic pelvic cellulitis or general peritonitis may develop, these being intrinsically fatal. Constitutional manifestations of septic or pathog- enic intoxication may supervene. It will be observed that, in a general way, the conditions produced by and dangers of prostatic injuries are essentially the same as in traumatism of the urethra and bladder. Symptoms. — There is nothing characteristic in the symptomatology of prostatic wounds; in general they are similar to those of deep-urethral trau- matisms. The principal symptom is urethrorrhagia, providing the wound communicates with the urethra, and hematuria. If an open wound of the prostate exists and the urethra be injitred, the hemorrhage occurs at the site of the injury and also at the meatus. Eetention of urine has already been alluded to, and is an important factor in the symptomatology of pro- static traumatism. If extravasation of blood into the surrounding tissues be extensive, a hematoma may result that may be felt by way of the rectum, around which viscns it may burrow for a considerable distance. The local and constitutional symptoms that speedily follow serious injuries of the NEUROSES OF THE PROSTATE. 633 prostate are similar to those following urethral injuries producing urinary infiltration, cellulitis, or abscess. Treatment. — External operative wounds do not demand special con- sideration. In both internal and external wounds that are not extensive, and in which a catheter can readily be passed, a full-sized soft instrument should be introduced into the bladder and retained from three days to a week or more. Great care is necessary to maintain urethral asepsis. If hemorrhage be excessive or urinary extravasation exists, or there is reason to believe that the wound of the prostate is serious, and in any case in which the catheter does not pass readily, a free perineal section should be made and the bladder drained by a large tube. Where the perineum is extensively disorganized by injury and it is difficult to find the proximal end of the urethra, suprapubic cystotomy, retrograde exploration, and perineal incision should be combined. Suprapubo-perineal drainage should be instituted in such cases. This is much safer than prolonged and necessarily hap-hazard search for the normal channel via the perineum. Infiltration of urine de- mands free incision in any and all situations in which intumescence of the tissues is suggestive of extravasated urine. The incisions can hardly be too free or too numerous, with due regard to anatomic dangers. The same principles should govern the management of urinary abscess and cellulitis. The early and free use of the knife in septic cases is the only hope of sav- ing life. The tendency to asthenia, incidental to the profoundly depressing influence upon the sympathetic nervous system produced by injuries of this region, and the great danger of toxemia, constitute a direct and positive in- dication for free and liberal supportive measures, dietetic and stimulant. neuroses of the prostate. Xeueoses of the Prostate and Eeflex jSTeuroses of Prostatic Origin. — Considering the abundant nervous supply of the prostate and its environs, especially its liberal endowment with sympathetic nerve-filaments and resultant intimate association with the rectum, bladder, and other viscera, the occurrence of nervous phenomena of various kinds referable directly or indirectly to disturbance of the prostate is not surprising. It is true that many neurotic disturbances which the author believes should come properly under the head of neuroses of the prostate originate primarily in demonstrable organic disease, but the clinical fact remains that pronounced nervous disturbance, such as direct or reflex neuralgia, and sometimes con- siderable psychic disturbance, may persist, constituting the principal source of disquiet long after the primary organic causes have wholly or partially dis- appeared. The primary condition may be of so little moment that there would be little or nothing to attract the attention of the physician were it not for the disproportionate nervous disturbance that results. In using the term prostatic neurosis the author is well aware that a cer- 634 DISEASES OF THE PEOSTATE. tain degree of ambiguity must necessarily enter into the consideration of the subject; but in the present state of our knowledge of disease, from prac- tical clinical experience, and more especially to subserve the purpose of an intelligent therapy, the term seems sufficiently clear and comprehensive. In considering prostatic neuroses there are several points to be borne in mind, viz.: the physiologic and anatomic analogy between the prostate taken as a whole and the uterus, the relation of the prostate to urination, its sexual function, and, finally, its intimate association with the rectum, anus, seminal vesicles, urethra, and bladder. Peostatic Keuealgia and Hypeeesthesia. — ^N'euralgia of prostatic origin, unattended by evidence of organic disease or at most associated with very slight organic changes, is by no means rare. It is probable that a certain degree of hyperemia exists in the majority of cases of prostatic neuralgia; yet disturbance of the circulation does not seem absolutely essential. Hy- peresthesia of the prostate is usually limited to its urethral portion and is very frequently met with. Hyperesthesia and neuralgia are often asso- ciated, the former being the more likely to exist alone. Etiology." — The causes of prostatic neuralgia and hyperesthesia are (1) sexual excesses and masturbation; (2) the gouty or rheumatic diathesis; (3) traumatism of the prostate, surgical and accidental; (4) acute or chronic congestion; (5) acute or chronic infectious inflammation; (6) urethral dis- ease, notably stricture; (7) foreign bodies or tumors in the bladder; (8) psychic disturbance with attendant mental suggestion incidental to (a) ig- norance of sexual physiology and the influence of quack literature, (b) in- judicious and perhaps unnecessary treatment of the prostate, or (c) the prolonged duration of mental disturbance produced by actual organic dis- ease. The latter cases are especially liable to be associated with hyperemia. Prostatic 'catarrh is also a frequent concomitant. It would be difficult to dissociate the local irritation produced by highly-acid urine in gouty and rheumatic patients from the exaggerated general nervous sensibility produced by lithemia. Many cases are found, however, in which neuralgic pain — referable to the perineum, anus, neck of the bladder, and urethra^ — is experienced by lithemic patients in whom the correction of the irritating acid properties of the urine is not followed by appreciable benefit until alkaline and antilithic remedies have modified the diathesis. The author has under observation at the present time a gen- tleman, 45 years of age, who has been for some years annoyed by neuralgic pain of the kind described, associated with intense hyperesthesia of the prostatic urethra. He is particularly annoyed by persistent erections at night, and, irrespective of the reaction of the urine, the act of urination gives him considerable pain. Careful examination of the bladder and the urethra via the endoscope, cystoscope, and mechanic exploration fail to re- veal any organic condition that will explain his symptoms. There is ap- parently no disturbance of the kidneys that might cause the condition by XEUKOSES OF THE PEOSTATE. 635 reflex irritation. The origin of the difficulty was probably a gouty consti- tution associated with strictures of large caliber. The latter were operated upon some years ago with perfect success save the failure to ameliorate the annoying symptoms described. Similar symptoms are often produced by rectal or anal irritation: a condition that was absent in this case. Neu- ralgic pain referable to the perineum and vesical neck, perhaps radiating into the testes, is by no means unusual in disease of the lower bowel. This is worthy of remembrance. Neuralgia of the prostate following operations upon the organ, or op- erations upon the bladder involving it, is occasionally met with. The au- thor has under observation a young man operated through the perineum for vesical drainage for the cure of obstinate cystitis in whom the result was perfect so far as the cystitis was concerned, but the patient has been tor- mented ever since by ano-perineal, crural, and testicular neuralgia. There is no condition of the prostate, bladder, or rectum that explains the difS.- culty. In another case, a man operated for large-calibered penile stricture, persistent, deep-seated, intermittent perineal pain, frequent urination, and marked hyperesthesia of the prostatic urethra have existed for some years. Careful exploration fails to detect any condition that- would explain the trouble. The urine is normal. Urethrotomy, while effective in curing the stricture, completely failed to relieve the prostatic neuralgia. Acute and chronic hyperemia of the prostate are sometimes responsible for hyperesthesia and neuralgia of the organ, and in such cases the per- turbation of blood-supply is really the essential condition. Unfortunately, however, the pain is not only the most prominent feature in the mind of the patient, but it often persists in spite of all measures tending to correct the circulatory disturbance. That a strong psychic element enters into these cases, as, indeed, it does in the majority of cases of genito-urinary dis- ease, is admitted. Psychic disturbance may be the starting-point, not only of vascular disturbance attended with neuralgia and hyperesthesia, but may produce neurotic phenomena independently of perturbation of the circula- tion. Prolonged and unnecessary treatment of the prostatic urethra is not only likely to produce hyperesthesia of the organ, but also persistent psychic disturbance, possibly hypochondriasis or even melancholia, with or without local pain. Hysteria in the male from this cause is not infrequent. Psychoses from prostatic irritation are very frequent, but care must be taken to carefully discriminate between cases that are psychic ab initio and those in which the psychic element is simply an ingraft upon the symp- toms produced by organic disturbance. Acute or chronic inflammation is usually the essential condition, but many cases occur in which, after the inflammation has disappeared, neuralgic pain — referable to the vesical neck and radiating into the perineum, testes, thighs, and rectum — persists in spite of all treatment — often perhaps because of it. Eeflex prostatic irrita- tion produced either by vesical or urethral disease is frequent. Urethral and Ij DISEASES OF TJIE PROSTATE. rineal pain associated with stricture or stone in the bladder is a familiar imple. Stricture occasionall}' produces neuralgia referable not only to J prostate, but apparently involving the entire bladder. A case at pres- t under observation clearly demonstrates this clinical fact. A gentleman, years of age, suffered from pain in the region of the bladder and frequent cturition for six or seven years. He had been operated for stricture some le prior to the beginning of the neuralgic pain, and was inclined to at- bute his trouble to the urethrotomy. Examination revealed several icture-bands of large caliber that had evidently escaped the original op- ition. A second urethrotomy was performed with perfect relief of the nptoms. A peculiar feature in this case was severe hypogastric pain enever the urine was held for several hours. This has completely disap- jred since the operation. The term prostatic hyperesthesia should comprehend the condition of called vesical irritability that has been described by some authors as euralgia of the vesical neck." The more important and highly-sensitive ;-ts involved in the sexual and urinary functions are integral parts of the )state. The prostatic urethra derives most of its importance (save that ;idental to its function as an outlet for the bladder) from certain ana- nic and physiologic peculiarities of the prostate proper. The elaborate i highly-sensitive nervous supply of the prostate is the seat of urinary iire; its nervous supply, by virtue of special nervous filaments supplied efly to the caput gallinaginis, is responsible for the voluptuous sensations lidental to coitus. Hyperesthesia of the prostate manifests itself in two ways: 1. Exag- 'ated sensibility of the prostatic urethra to the pressure of urine with re- tant frequent micturition. This may be associated with inhibition of the iction of the false vesical sphincter, as a consequence of which the urine ters the highly-sensitive prostatic urethra at more frequent intervals, le capacity of the bladder itself is probably diminished by reflex irrita- n of the vesical muscle. A careful consideration of the physiology <»f cturition readily explains the so-called vesical irritability resulting from :)static hyperesthesia. 2. The sexual function of the prostate is likely to profoundly disturbed by hyperesthesia of the organ, particularly if the :)ut gallinaginis be involved. Xocturnal pollutions, imperfect erection, d premature orgasm, or perhaps complete impoteniia cccundi may residt, 5se conditions being not alwaj's amenable to treatment. Treatment. — Xeuroses of prostatic origin constitute a most emphatic iication for attention to genito-urinary hygiene. Careful regulation of it, attention to the various emunctories, and careful supervision of sexual bits are the key-note of treatment. Remedies for lithemia are often essen- 1. Eegulation of the diet, however, is more important in such cases. To- sco and liquor especially are to be interdicted. Certain sedative remedies ; often of groat value. The hmmids. camphor, — or their combination, cam- I HYPEKEMIA Or THE PROSTATE AND PEOSTATORRHEA. plior monobromid. — aucl gelsemium are of especial valiie^ the latter rem being perhaps most reliable. Ergot is often of great service. Cold sitz-b< and enemata are useful. Careful attention should be paid to the condh of the bowels; strong cathartics should be avoided and mild laxatives gi^ The local measures of treatment are numerous and often unsatisfactory, some cases in which there is a strong psychic element a cold sound or psyehrophor is serviceable. Should actual organic disease of the prost urethra exist, however, such measures may do harm. In some cases nervous organization of the patient is such that local treatment merely rects his attention to the part and exaggerates his symptoms. In cases wl there is disease of the mucous membrane of the prostatic urethra, the j cious application of silver nitrate with the deep-urethral syringe or endosc is of value. Deep-urethral injections, however, have probably been prod ive of more damage in this class of cases than in any other that could be n tioned. Many eases of neuralgia and hyperesthesia of the prostate, in wl there primarily existed no pathologic change whatever in the deep uret' mucous membrane, are treated so assiduously by deep urethral inject that the erroneous diagnosis of disease of the prostatic urethra is made g by the development of genuine pathologic conditions. It appears very il ical, in cases in which careful local examination and conscientious urinal fail to show organic disease, to treat the prostatic urethra by frequent jections of the silver nitrate to cure a posterior urethritis existing onl the mind of the practitioner. The readiness with which the diagnosi posterior urethritis, which happens to be the prevailing fad, may be m and the ease with which one may supply himself with the necessary ins ments for deep urethral injection, constitute a constant menace to m patients who have genito-urinary disease, real or imaginary. In cases in which actual organic disease exists the first duty of surgeon is to institute appropriate measures for its removal. "While ] best from a psychic stand-point to impress the patient with the radical suit expected from the treatment, the surgeon should remember that e after the primary organic difficulty has been cured the neurosis may rem The experience derived from the removal of the original cause in r( neuralgias in other situations has been that the neuralgia frequently sists in spite of a radical operation for the removal of the offending co tion. The same clinical observation applies to neuralgia and hyperesth of the prostate. HYPEREMIA OF THE PROSTATE AXD PROSTATOREHEA. Hyperemia.— -The line of demarkation between prostatic hypere and inflammation is often rather indefinite. From a pathologic, and n especially from a clinical, stand-point, there are, nevertheless, many c of prostatic disease that are essentially active or passive hyperemia ra 638 DISEASES OF THE PROSTATE. than inflammation. Tliat hyperemia predisposes to, and is likely to termi- nate in, true inflammation is well understood. Especially is this true of prostatic diseases involving local circulatory disturbance. This proposition is therefore taken for granted as a preliminary to the discussion of pro- static hyperemia. In perhaps the majority of cases of prostatic disease the diagnosis of prostatitis, acute or chronic, is made and passes without ques- tion. That no harm thereby results in the majority of cases is simply be- cause the principles of treatment are essentially the same in both conditions. In some cases, however, a true appreciation of the conditions present would be of direct benefit to the patient, as in certain cases of passive congestion from venous obstruction. Measures that relieve passive hyperemia are likely to prevent the development of true inflammation. Etiology. — Active prostatic hyperemia has its point of departure, as a rule, in perturbation either of the sexual function or of the physiologic act of micturition. The prostate is, from time to time, the seat of physiologic hy- peremia, as is true of all glandular organs. This attends sexual excitement, hoRvever such excitement may be produced. Under normal conditions the circulation resumes its usual status as soon as the excitement ceases. Its return to a normal circulatory state is still more rapid when the sexual func- tion has been naturally performed. Prolonged sexual excitement without gratification is the most prolific source of prostatic hyperemia. Frequent masturbation and sexual excess will also produce it. The periods of rest be- tween the acts of ejaculation are so short that the circulation cannot regain its normal equilibrium. Sexual excess and masturbation are even more potent in the production of pathologic hyperemia when associated with erotic mentality, alcohol, high living, and a gouty or rheumatic diathesis. If hyperemia be long continued, subacute or chronic inflammation will probably supervene. The relation of sexual excitement to prostatic disease demands great consideration. It should be understood that physical continence may be associated, so to speak, with mental incontinence, with a resulting pro- static hyperemia that may produce both functional and organic disturbance. The importance of avoiding sexual stimuli, psychic and physical, cannot be too strongly presented in the management of all prostatic and vesical dis- eases. More or less prostatic hyperemia is probably almost always present in urethral and bladder disease, acute or chronic, being due not only to in- flammation of the vesico-urethral mucous membrane per se, but also to fre- quent micturition produced by irritation of the vesical neck. The termina- tion of the act of micturition is characterized by reflex spasm of the cut-off muscle, which is greatly exaggerated by hyperesthesia of the posterior urethra incidental to inflammation or reflex irritation of the part. So ex- aggerated is the spasmodic contraction of the physiologic cut-off that actual traumatism of the prostate results. There is marked disturbance of the cir- HYPEEEMIA OF THE PEOSTATE AND PEOSTATOEEHEA. 639 culation and not only active hyperemia, but lessened power of resistance of both glandular and muscular structure to infection. Irritative and inflammatory affections of the lower bowel produce re- flex irritation of the vesical neck with associated prostatic hyperemia. The hyperemia and associated spasm may be so severe as to produce retention. This is observed after operations about this part and in inflamed hemor- rhoids. Eectal tenesmus, as seen in certain cases of dysentery and acute proctitis, is apt to produce similar conditions affecting the prostate and vesical neck. In chronic disease of the lower bowel, such as polypi, stricture, tumors, and particularly hemorrhoids, passive congestion of the prostate re- sults from venous obstruction. The author has observed well-marked pro- static enlargement associated with stricture of the rectum and hemorrhoids that has disappeared after an operation upon the lower bowel. Constipa- tion, excessive horseback-riding, and cycling are sometimes efficient causes of prostatic hyperemia. Hyperemia of the prostate is a feature of all cases of strangury pro- duced by drugs. Cantharides, turpentine, and, it is said, the various bal- samic preparations may produce this condition. Prostatic hyperemia rarely, if ever, goes on to acute inflammation idiopathically. Instrumental inter- ference with associated trauma and sepsis, or mixed infection from posterior urethritis, is usually necessary to precipitate acute inflammation. Obstruct- ive urethral disease is likely to produce more or less marked prostatic hy- peremia. Urethral strictures of small caliber are usually associated with more or less prostatic engorgement. Large-calibered penile strictures may produce prostatic hyperemia reflexly, even where there is no appreciable obstruction to urination. The slightest contraction in the bulbo-mem- branous region, from the close association of its nervous and vascular sup- ply with that of the prostate, is likely to produce circulatory disturbance of the latter structure. Hyperemia of the prostate may become chronic. The chronic form is usually passive, and most frequently associated with constipation and un- gratifled sexual desire. Sexual excitement is the most important factor in its production, and is especially likely to exist in masturbators, in whom it is characterized by the escape of prostatic fluid at various times. The affection is usually supposed by the patient to be spermatorrhea, while by the profession at large most eases are classified as prostatorrhea. The prostatic congestion causes hypersecretion, and probably relaxation of the mouths of the prostatic ducts. The condition might be classified as pro- static catarrh were it not for the quite general association of this term with true inflammation. Follicular prostatitis as described by most writers im- plies this result of hypersecretion, and to the author appears to be a mis- nomer. The principal disturbances from this form of prostatic disease are of a psychic rather than physical character. Whether or not chronic hyperemia of the prostate from sexual causes 640 DISEASES OF THE PROSTATE. may be the foimdation of hypertrophy of the organ in after-life has been the subject of much contention. The author inclines to the afhrmative, as will hereafter appear. Symptoms. — One of the most characteristic symptoms of prostatic hy- peremia is a sense of fullness in the perineum and a Yoluptuous sensation as of impending orgasm. There is likely to be a sensation of fullness in the rectum with possibly erotic sensations and more or less tenderness during evacuation of the bowel. An urgent desire to urinate is almost invariably excited by defecation. There may be considerable prostatic en- gorgement without much, if any, increase in the frequency of micturition. If, however, the point of departure be direct or reflex irritation or inflam- mation of the posterior urethra, frequent and painful micturition is an inevitable result. Even in cases in which micturition is not increased in frequenc}', the patient will very likely complain of some pain and a bruised sensation in the perineum following the act. If the hyperemia be long con- tinued, "'jDrostatorrhea'' is likely to supervene as a consequence of hyper- secretor}' activity of the prostatic glands. In some cases the floor of the prostatic urethra becomes so hypersensitive that frequent seminal emissions occur. Eusty or bloody semen is occasionally observed; but, as a rule, this symptom is indicative of seminal vesiculitis. Pain during the paroxj-smal spasm of seminal ejaculation is a frequent symptom. On the other hand, many patients state that coitus is beneficial. In such cases it is very safe to conclude that the condition of the prostate is one of simple hyperemia. Even in such cases, however, it is not unusual for the patient to experience only temporary relief from coitus. Often-repeated indulgence results in aggravation of the symptoms. Eectal examination may elicit some fullness and tenderness of the prostate. This is not always present, as there may be quite a degree of passive hyperemia without much increase in the size of the 'prostate. This sj^mptom is Cjuite apt to be unreliable because of the variability of the size of the prostate as felt per rectum and the varying de- gree of digital expertness in rectal examination. Passive hyperemia of the prostate associated with circulator}' disturbance in the lower bowel, or de- pendent upon a gout}'' or rheumatic diathesis, is occasionally associated with hematuria. The author has observed a number of cases of hematuria with the expulsion of the characteristic fusiform clot found in prostatic hemor- rhage in which no cause could be determined other than passive prostatic congestion which attention to the assumed etiologic factors speedily relieved, measures to relieve portal congestion having been especially efficacious. This is worthy of consideration in cases of hematuria of obscure origin. Peostatorehea. — A frequent symptom of chronic hyperemia of the prostate is a discharge of its characteristic secretion from the urethra. This is favored by sexual excitement, erotic ideas being often sufficient to produce it. Under such circumstances it is associated with more or less urethral se- cretion, which escapes during the excitement, while the prostatic secretion HTPEEEMIA OF THE PEOSTATE AND PEOSTATOEEHEA. 641 afterward comes away with, the urine. It is most frequently observed during straining at stool, and sufficient secretion may escape with the urine to pro- duce an appreciable deposit in this fluid on standing. Very often no prostatic discharge is noticeable excepting at the termination of micturition, when, according to the patient's story, the urine appears to be decidedly milky. These patients are the most likely of all to become victims of the quack; they constitute by far the larger proportion of cases of alleged spermator- rhea. Associated with the local difficulty is more or less hyponchondria, perhaps verging upon melancholia. The patient occupies himself very in- dustriously in magnifying every symptom, real or imaginary, of which he may chance to be the victim. His unstable psychic condition explains the profound influence that quacks and quack literature are likely to have upon him. Associated with the so-called prostatorrhea may be more or less ves- ical irritation, largely neurotic in character, and perhaps neuralgic pains in the urethra, perineum, groins, and thighs. The majority of patients com- plain of pain in the back as the most prominent symptom aside from the urethral discharge. Whenever fluid escapes from the meatus during the intervals of mic- turition, excepting in the act of defecation, some morbid condition of the anterior urethra is superadded to the prostatic hyperemia. The pro- static fluid cannot escape unless the true sphincter vesicae — i.e., the mem- branous urethra and its muscular investments — is relaxed physiologically, or the prostate is mechanically squeezed by the perineal muscles and the passage of hardened feces. The fluid that escapes during sexual excitement usually consists of urethral secretion. In cases of simple chronic hyperemia of the prostate the prostatic discharge does not contain inflammatory ele- ments, being made up almost entirely of prostatic secretion, mucus, and some effete epithelial cells. There may be present, especially after sexual excite- ment, a certain number of seminal elements that have escaped from the over- distended vesiculas seminales. The escape of semen into the prostatic urethra is favored by relaxation or patulousness of the mouths of the ejaculatory ducts, and is often immediately induced by straining at stool. The seminal elements are scanty and by no means a constant or necessary symptom. Rarely, indeed, are they sufficiently abundant to justify a diagnosis of sper- matorrhea. No matter how few in number they may be, however, they are hailed with delight by the quack and are often assigned undue importance even by honest practitioners. Treatment. — The first principles of treatment of prostatic hyperemia involve all of the rules of genito-urinary hygiene, a subject already ex- haustively discussed. Briefly, the urine should be rendered unirritating by the administration of bland fluids, of which distilled water or the various saline mineral waters may be taken as the type. Alkaline remedies may be administered where simpler measures are not sufficient to neutralize urinary acidity. The diet should be unstimulating. All sources of sexual exeita- 643 DISEASES OF THE PEOSTATE. tion, both psychic and physical, should be removed. Exercise should be re- stricted and, if necessary, prohibited altogether. Athletic feats, cycling, horseback-riding, and climbing are particularly to be enjoined. The author would especially call attention to climbing exercises as practiced by young lads and some athletes as especially injurious. The danger of the condi- tion's becoming chronic should be impressed upon the patient. Instru- mentation of the urethra is, in general, to be avoided in acute hyperemia. Numerous internal remedies are more or less serviceable in prostatic congestion. Mercurial and saline cathartics and laxatives are especially beneficial b}' relieving hepatic obstruction, thus indirectly removing ob- struction to the pelvic circulation. Ergot and gossypium are of undoubted value, directly tending to correct the circulatory disturbance. Sexual ex- citement is best combated by the bromids in combination with gelsemium. Monobromid of camphor, hyoscyamus, and other anaphrodisiacs are likely to be of service. Suppositories of ice and enemata of cold water are often valuable, cold sitz-baths being an excellent adjuvant. In prostatic hy- peremia dependent upon ano-rectal or vesical disease, attention should, of cotiTse, be given to the primary condition. In cases of chronic prostatic hyperemia associated with so-called pros- tatorrhea special attention should be paid to the psychic disturbances pres- ent. Earely, indeed, are such cases presented to the reputable practitioner before a number of quacks have been consulted. The patient is thoroughly convinced that he has spermatorrhea with an allied train of serious nervous disturbances, and last, but not least, he believes himself impotent. In- struction in sexual physiology and hygiene is absolute necessary for this class of patients. Particularly must they be impressed with the fact that they are not losing semen in the urine, else all of our efforts will be set at naught by their morbid psychic state. By far the larger proportion of cases suffer from constipation. The relief of this condition usually causes the prostatorrhea — the most prominent symptom, in the opinion of the patient — to disappear. Ergot and the bromids are exceedingly-useful in- ternal remedies. Hamamelis and hydrastis are serviceable from their known influence over unstriated muscular fiber and incidentally by controllijig vas- cular supply. Tonics — such as preparations of strychnin, iron, and arsenic, and the mineral acids — are very likely to be useful in this class of cases. The occasional passage of a cold sound or the psychrophor is a valuable local measure. The effect of instrumentation is, to a certain extent, moral, but its benefits are none the less marked. Its physical effect is probably the restoration of local vascular tone and relief of nervous irritability. Cold sitz-baths and injections of cold water into the rectum constitute a valu- able adjuvant. Counter-irritation to the perineum is likely to be beneficial. The application of astringents to the prostatic urethra may be alternated with the insertion of the steel sound. The silver nitrate in mild solutions, tannic acid, and hydrastin muriate are all serviceable drugs. Soluble ACUTE PROSTATIC INFLAMMATION AND SUPPUEATION. 643 bougies containing astringents are sometimes of service. Prostatic massage is often a most reliable measure. The local treatment in prostatic hy- peremia associated with so-called prostatorrhea is very similar to that of chronic follicular prostatitis in which escape of prostatic secretion is also a symptom. ACUTE PEOSTATIC INFLAMMATION AND SUPPUEATION. Acute Peostatitis. — Acute prostatitis is one of the most serious and painful of the acute affections of the genito-urinary system. The infection that most often gives rise to it is so prevalent that the disease is quite fre- quent. In a general way^ while acvite prostatitis may or may not be preceded by predisposing hyperemia of greater or less duration, the disease is rarely a primary affection excepting it be of traumatic or chemic origin or the result of pyogenesis produced by constitutional infection such as exists in variola and parotiditis. As usually met with, it is a complication, not a primary disease. The profound local and constitutional disturbances existing in a large proportion of cases of acute prostatitis, especially in those forms in whicli suppuration results, are entirely disproportionate to the size and physio- logic importance of the organ involved. The affected part, however, is ex- ceedingly sensitive from its abundant supply of general and special sensory nerve-filaments, and is of great importance because of its abundant sym- pathetic nerve-supply and consequent intimate relation with the various organs involved in the functions of organic life. In this respect it resembles its co-laborer in the generative function, the testis. Like the latter organ, it is surrounded by a tough resisting capsule, and in addition by an en- vironment of firm, resisting structures. Because of this anatomic arrange- ment the organ does not yield readily to the pressure of exuded inflamma- tory products or exaggerated blood-supply. This, in connection with the exceedingly sensitive and abundant nerve-filaments, is sufficient to explain the severe pain, nervous depression, and other constitutional disturbances in prostatitis. The same anatomic conditions, in connection with the close proximity of the affected organ to the rectum, explain the disturbance ref- erable to the latter viscus in acute prostatic inflammation. Etiology. — The causes of acute prostatitis, as outlined by some authors, are rather complex, presenting many elements of impracticality and con- fusion. Practical clinical experience shows that, while many predisposing elements demand consideration, acute prostatitis is due, in the majority of cases, to causes of quite common character. Thus, nearly all cases are due to extension of acute urethritis, usually gonorrheal. Other factors are to be taken into consideration, it is true, in suppurative cases, because of the clinical fact that in by far the larger proportion of cases of acute prosta- titis suppuration does not follow. The author bases this broad assertion upon the view that in the larger proportion of cases of acute inflammation 644 DISEASES OF THE PEOSTATE. of the prostate the process is limited to the glandular structures of the organ and partakes of the same characters as the original gonorrheal infection, with certain modifications due to anatomic and physiologic peculiarities of the affected part. Mechanic interference with the prostate in the treat- ment of acute or chronic bladder disease, or in vesical exploration, is re- sponsible for most of the remaining cases. Even here we have gonorrheal or other urethral infection as the principal etiologic factor, the instrument used or the abrasion produced by it acting merely as a carrier of infection, on the one hand, or a locus minoris resistentice, on the other. Experience has shown that in every case of urethral disease, acute or chronic, more par- ticularly in the acute, the patient is constantly liable to acute prostatitis. In view of the careless, routine, and often overvigorous treatment of gon- orrhea, to say nothing of the vicious, self-imposed unhygienic conditions of the patient, it is surprising that prostatic complications do not occur in nearly every case of gonorrheal infection. That patients with virulent specific urethritis should escape prostatic complications is remarkable, when we con- sider the high degree of infectiousness of the various microbial organisms found in that typically-mixed infection, gonorrhea. Acute prostatitis may be developed by trifling causes during the course of a gonorrhea. The jcause may consist of ill-advised attempts to cure the disease or misconduct on the part of the patient. It is especially liable to follow sexual indiscre- tions or excitement. Alcoholic and dietetic excesses, and overexertion play an important role in developing this complication. The following rather simple classification may give a somewhat clearer insight into the etiology of acute prostatitis than the foregoing remarks. ETIOLOGY OF ACUTE PEOSTATITIS. / C Gouty and rheumatic diatheses. General I Alcoholic and dietetic excesses. I Exposure to cold. Predisposing causes Highly-acid urine. Hyperemia from whatever cause. Acute or chronic urethritis. Stricture. Chronic prostatic disease. Cystitis or other vesical disease. Local < Vesical calculi. Eectal and anal disease. Portal obstruction. Constipation or diarrhea. Overexertion, and such forms of ex- ercise as bicycling and horseback- ridincf. ACUTE PKOSTATIC IXFLAMMATIOX AND SUPPUEATIOX. 645 Gonorrhea and its congeners^by direct exten- sion, or indirectly by absorption of in- fections materials — i.e., germs or their products. Traumatism. Surgical or accidental, chemic or Exciting causes ^ mechanic. Sexual indulgence. Chemic irritation. Vesical or prostatic calculi. Transportation of infectious material by deep injections or instrumentation. Broadly speaking, by far the majority of cases of acute prostatitis are due to infection in some form. This being accepted, it is obvious that many of the causes outlined in the above table are secondary and subordinate to infection. If we add to the cases produced by infection the relatively much smaller number of cases produced by mechanic and chemic violence, we have practically covered the etiology of acute prostatitis. It is to be un- derstood also that in many instances chemic and traumatic injuries of the prostate produce inflammation solely by carrying infection or by opening up avenues for the absorption of infectious material. It is, of course, dif- ficult to separate these cases from those in which the inflammation is im- mediately due to traumatic or chemic causes. It is safe to assume, however, that, in those cases in which suppuration occurs, chemic or traumatic in- jury to the prostate, if it exists at all, is a factor subordinate to infection. Exposure to cold unassociated with a gouty or rheumatic diathesis is not, in the author's opinion, a sufflcient cause for acute prostatitis, unless infection exist. That profound disturbance of the circulation of the pros- tate may result from chilling of the surface of the body, particularly of the lower extremities, is admitted. But that this will cause acute prostatitis where some source of infection is not present cannot be accepted in the light of our present knowledge of the germ-origin of disease. If, however, infection of the urethra, prostate, or bladder exists, the circulatory disturb- ance produced by exposure may lessen resistance to germ-infection on the part of the prostate, with consequent acute prostatitis, with or without ab- scess. Cases are frequent in which patients presumably have had no in- fectious disease of the genito-urinary tract, but in whom irritation of the vesical neck results from exposure to cold. It will be found, however, that in such eases there usually exists a more or less marked tendency to rheu- matism or gout. Many cases of so-called prostatitis consist merely in irri- tation of the mucous membrane of the prostatic urethra due to an excess of uric-acid crystals in the urine incidental to chilling of the surface of the body. Such cases are frequently diagnosed as acute prostatitis. In the majority of them, however, not only is there no inflammation of the pros- 646 DISEASES OF THE PEOSTATE. tate proper, but no inflammatiorL even of the prostatic urethra; the condi- tion is merely local irritation of highly-sensitive nerve-filaments due to dis- proportionate increase of the solid constituents of the urine, involving irri- tating erj^stals of uric acid and possibly calcium oxalate. The prolonged contact of the perineum with a cold, damp surface is said to cause acute prostatitis. While this may be a secondary cause, it is probably incapable of inducing acute inflammation unless there is some source of infection. The gouty and rheumatic diatheses, either alone or associated with exposure, may develop prostatic irritation and possibly acute prostatitis in cases in which infection already exists. Gout and rheuma- tism not only produce aberration of the quality and quantity of urinary solids, and alteration of urinary reaction, but also intrinsic irritability of nervous and vascular structures, by virtue of which they react more promptly and markedly to sources of irritation. It is obvious that an individual exposed to psychic or physical causes of sexual excitement is especially predisposed to acute prostatitis in the pres- ence of infectious genito-urinary disease. It is certain that, if this predis- posing cause could be eliminated in the majority of cases of acute or chronic genito-urinary disease, the proportion of cases in which a complicating prostatitis develops would be materially reduced. Acute or chronic ure- thral disease is a constant menace to the prostate. Stricture is especially worthy of consideration in this regard. Acute or chronic urethral inflam- mation leads to acute prostatitis through comparatively trifling exciting causes. Chronic prostatic disease, especially those forms in which a focus of infection exists in the prostatic urethra or bladder, is very liable to be complicated by acute prostatitis. Especially is this true if traumatic inter- ference, in the form of violent or often-repeated catheterization, be added as an exciting cause. Acute prostatitis or paraprostatitis is a rather fre- quent complication of prostatic hypertrophy. What has been said of acute and chronic disease of the prostate also applies to cystitis. The infectious products of vesical inflammation may, at any time, under the exciting in- fluence of traumatism or through the medium of a secondary infection of the prostate and prostatic urethra, produce acute prostatitis. Eectal and anal disease exert so profound an influence over the vas- cular and nervous supply of the prostate that their importance as etiologic factors predisposing to acute inflammation of the organ is readily under- stood. Ph5^sical exertion — particularly that involved in walking, running, lifting, bicycling, and other forms of athletic exercises in which more or less strain is brought to bear upon the perineum — tends to produce irritability and hyperemia of the prostate, in the presence of which any source of in- fection is apt to lead to acute inflammation of the organ. In by far the majority of cases of acute prostatitis there exists some urethral source of infection, either patent or obscure, as a direct cause of the acute inflammation. True suppurative inflammation of the urethra is ACUTE PROSTATIC INFLAMMATION AND SUPPUEATION. 647 not, however, absolutely necessary in order that infection of the prostate by germs or germ-products may occur. Thus the infection may consist of the products of decomposing urine, or the secretions of urethral or prostatic catarrh confined behind some obstruction of the canal, such as is afforded by prostatic hypertrophy or stricture. The cause is most likely to be a recent gonorrhea of acutely-virulent type, but the infective inflammation may be subacute or chronic. Simple urethritis, acute or chronic, presents a secretion teeming with germs and their products that may at any time produce acute inflammation of the prostate. It must be remembered, in this connection, that it is probably the mixed character of the gonorrheal infection that is responsible for the cases in which suppuration of the pros- tate or periprostatic tissues occurs. Laying aside acute follicular prostati- tis, — i.e., posterior urethritis occurring in the course of acute or chronic gonorrhea, — the pus-microbe and its products are responsible for prostatic complications. It is safe to assert that in most cases of acute prostatitis an area of bacterial infection exists in the deep urethra. This may consist of acute suppurative or chronic infective inflammation of the bulbous or bulbo-membranous region. In the presence of such conditions the slightest traumatism or the occurrence of active hyperemia may at any time produce acute inflammation of the prostate. One of the most frequent causes is mechanic disturbance of the pros- tate in sexual intercourse. During the venereal orgasm the muscular tis- sues of the perineum, and incidentally of the prostate, act somewhat like the bulb of the ordinary soft-rubber syringe. The spasmodic contraction incidental to the orgasm alternates with relaxation, during which the deep perineal muscles and prostate exert an aspirating effect upon the urethra. The superfluous semen is drawn back into the deep urethra preparatory to the occurrence of the final spasmodic muscular contraction by means of which the last few drops of semen are to be expelled. During the back- ward aspiration of the semen into the deep urethra any infectious materials that may be present in the anterior portion of the canal are forcibly drawn into the deeper parts, where they produce acute inflammation. This, while primarily an acute follicular prostatitis, may be followed at any time, per- haps within a very short period, by acute diffuse inflammation and possibly abscess. Patients developing acute prostatitis in the course of gonorrhea often confess sexual indulgence or a nocturnal emission as the immediate exciting cause. In the author's opinion the foregoing constitutes a logical explanation of its occurrence. In quite a proportion of cases prostatic infection in the course of gon- orrhea or urethritis results from deep injections or the passage of instru- ments. While it is true that in some instances the exciting cause would seem to be a high degree of chemic irritation produced by the injection, it is probable that in most instances in which the prostatitis can fairly be at- tributed to injections the fluid used is only indirectly responsible for the 648 DISEASES OF THE PEOSTATE. prostatitis, inasmiicli as it serves merel}^ as a carrier of germ-infection. It is probable that the injection of pure water would be even more effective in this respect. It has been the experience of the author that the frequency of prostatic complications is directly proportionate to the vigor with which acute gonorrhea is treated. Some of the worst cases are due to the passage of instruments for the relief of retention or treatment of the urethritis. Soluble bougies and deep urethral irrigation, used during the acute stages of urethral inflammation, have been responsible for many cases. The solu- ble bougie or the tube used in deep irrigation acts as a carrier of germs which the injected solution is too weak to destroy. Then, too, we have the abrading effect of the instrument or soluble bougie upon already degen- erated and readily removable epithelium. This opens up avenues of infec- tion that otherwise might possibly never develop. The excessive use of terebinthinate and balsamic preparations has been said to cause prostatitis. It is possible that in immense toxic doses these (Jrugs in combination with an already existing infection of the deep urethra may be operative in the production of acute inflammation, but under no other circumstances. Cantharides in poisonous doses produces inflamma- tion of the prostate in common with all the other structures composing the genito-urinary tract. In concluding the etiology of acute prostatitis the author desires again to impress the paramount importance of infection as a factor, and to again insist on the subordinate character of by far the larger proportion of the causes enumerated, the simple etiologic classification herein suggested. A further practical point of great importance is the clinical fact that, given an acute or chronic source of infection, and especially the former, very slight interference with the urethra and bladder may cause acute inflammation and perhaps abscess of the prostate. Vaeieties of Acute Peostatitis. — Acute prostatitis presents itself in several forms, according to the method of causation and the structures in which the inflammation is mainly localized. "With no disposition to dogmatism in classification, the author inclines to the view that the follow- ing forms of acute prostatitis are capable of a clinical differentiation that is of vital importance in their study and management. 1. Follicular — i.e., parenchymatous — prostatitis, having its point of departure in posterior urethritis due either to extension or' transference of infection to the deep urethra. 2. Diffuse prostatitis, usually resulting from extension of the acute follicular form. It may occur as a primary condition. The presence and degree of interstitial inflammation in the diffuse form depends upon the method of causation: i.e., whether it is due to traumatism, extension, or lymphatic infection. Diffuse prostatitis may be associated with localized or disseminated pyogenic infection. 3. Prostatitis with circumscribed suppuration, — i.e., acute suppura- VARIETIES OF ACUTE PKOSTATITIS. 649 tive prostatitis, — due to extension of nrethral inflammation, infection from local absorption, or infection via the blood. 4. Prostatitis with disseminated foci of snppnration, — i.e., miliary abscesses. In all forms of suppurative prostatitis more or less diffuse interstitial inflammation is invariably present. 5. Paraprostatitis. This is usually, but not necessarily, followed by abscess and is associated with one or the other of the foregoing forms. The basis for classification 1 is due to the author's belief that the most important ultimate anatomic element of the prostate is the secreting gland- ular tissue. According to this view, the glands, ducts, and follicles of the organ constitute the true parenchyma. The acute follicular or parenchy- matous form of the disease embraces most of the cases of so-called acute posterior urethritis, and varies in severity from an involvement of the fol- licles alone to that of all the secreting structure of the organ. The acute in- flammation of the prostatic urethra in these cases is relatively unimportant in the pathologic ensemhh, save as the point of departure of the prostatic in- flammation. Most of these cases should be classified as acute follicular or parenchymatous prostatitis. In practically all cases of so-called acute poste- rior urethritis from gonorrhea or other source of mixed infection the in- flammation of the mucous membrane of the deep urethra is but a minor part of the morbid condition resulting from such infection. The author cannot conceive of an acute inflammation of infectious origin limiting itself to, the mucous membrane of the posterior urethra. A few subacute and chronic cases may possibly be met with in which the bulbo-membranous region is involved without extension or transference to the prostatic ure- thra. It is the author's belief, however, that in all cases, acute or chronic, in which the prostatic urethra is involved, the glandular elements of the prostate become affected sooner or later. In acute inflammation extending beyond the bulbo-membranous Junction it does not seem possible that the glandular elements of the prostate can escape involvement. It is certainly open to argument whether the consideration of so-called posterior urethri- tis as acute or chronic follicular inflammation of the prostate rather than a disease of the urethra per se might not be of great practical clinical impor- tance as explaining the extreme obstinacy of the disease and the impossi- bility of curing it completely by applications to the relatively small and unimportant infected area presented by the mucous membrane lining the prostatic urethra. Looking at posterior urethritis from this stand-point, the question might arise whether deep injections of astringents may not defeat the very object that the practitioner strives to attain in such cases, by impeding drainage from the glandular elements and ducts of the prostate constituting the principal seat of the infectious inflamma- mation. Associated with these cases there is usually more or less involve- ment of the interstitial tissue surrounding the ducts and glands, the re- 650 DISEASES OF THE PEOSTATE, suiting mechanic conditions depending entirely upon the degree of involve- ment. From a clinical stand-pointy, there would seem to be a broad line of dis- tinction between the acute cases of follicular inflammation from extension of infection from the prostatic urethra and those that result from lymphatic absorption or infection of an abraded surface produced by traumatism, and leading to prostatic or periprostatic abscess. On the one hand, we have pri- marily all of those symptoms characteristic of irritation and inflammation of the true vesical neck, — i.e., the prostatic urethra; while, on the other hand, we have much less vesical irritability with the development of more or less sudden obstruction to the outflow of urine. In acute follicular in- flammation retention of urine is rare; not so in cases in which severe inter- stitial inflammation develops. So frequent, however, is the association of retention with prostatic abscess that the latter is to be strongly suspected in all cases of acute prostatitis in which retention is a prominent factor.^ In diffuse prostatitis there is usually, as a result of extension of infec- tion from the prostatic urethra, very severe glandular inflammation. As- sociated with this is pronounced involvement of the interstitial tissue. In these cases, on account of the anatomic conditions already outlined, pain and constitutional symptoms are more marked than in the acute follicular form. Diffuse prostatitis may be the result of lymphatic absorption, in which event pain, rectal tenesmus, and urinary obstruction may develop without preliminary vesical irritability. Abscesses may or may not occur in the diffuse variety of acute prostatitis. When they do occur they may be the result of a general infection of the organ, or an occluded duct or follicle may constitute the primary focus of infection, subsequently ruptur- ing and infecting the surrounding prostatic tissues. Acute Suppueative Peostatitis. — According to the classification already given, acute suppurative inflammation of the prostate may occur in any one of three forms, viz.: 1. Circumscribed abscess, single or multiple. These abscesses may involve any particular portion of the prostate; they may be of considerable size, and one or more may coalesce, forming a large abscess. 2. Disseminated suppuration: i.e., miliary abscesses. 3. Peripro- static abscess, with or without suppuration in the prostate proper. Etiology. — While usually due to local sources of infection, any of these forms of abscess may result from general pyogenic infection and may be caused by such infectious diseases as variola and mumps. Some abscesses are primarily due to extension of suppurative inflammation, while others are due to lymphatic absorption and infection of the pro- static tissues. In some instances, in all probability, one or more of the numerous ducts of the prostate become occluded by the inflammatory ^ Due consideration should, however, be given to the possibility of spasmodic retention in deep-seated inflammation. ACUTE SUPPURATIVE PROSTATITIS. 651 swelling incidental to virulent inflammation, with consequent retention of infectious pus in the form of a small abscess-cavity the walls of which are composed of the walls of the duct or follicle involved. Such circumscribed retention-abscesses constitute foci of infection of the surrounding tissues. Forming at the periphery of the organ, they may rupture into the para- prostatic tissue, with resulting abscess outside the prostate proper. Disseminated foci of suppuration in the prostate constitute the variety that is most likely to occur from constitutional infection. The rupture of such a focus, however small, into the periprostatic tissue will almost inevi- tably result in abscess in this situation. It is unnecessary to expatiate at length upon paraprostatitis; the most important points have already been dilated upon. It generally occurs as a secondary factor in some one of the foregoing forms of acute inflammation. Suppuration usually occurs, and in some cases the amount of pus may be rather startling, the pus burrowing extensively about the rectum. Eeten- tion of urine is usual in marked cases. The subject of acute prostatic abscess is intimately blended with that of acute prostatitis; there are several points, however, in connection with prostatic suppuration that merit special attention! Abscess of the prostate in connection with hypertrophy of the organ is more frequent than ordinarily supposed. It may occur spontaneously from infection, although this is extremely rare. Most often it is the direct result of traumatism inflicted during the treatment of the disease, or dur- ing catheterization for the relief of retention produced by it. The author is of opinion that, in quite a proportion of cases of death following reten- tion of urine dependent upon hypertrophied prostate necessitating pro- longed and frequent instrumentation for its relief, the immediate cause is general septic or pus infection from suppuration of the prostate induced by the surgical interference. Several cases have come under the author's observation in which the patient developed constitutional manifestations of sepsis, and finally sank into a typhoid condition and died, as a conse- quence of extensive prostatic and periprostatic abscess that was directly traceable to bunglesome and injudicious catheterization. In some of these eases the abscess is subacute or chronic and of prolonged duration. Rupture may finally occur into the urethra, rarely externally, in which event there may be sudden relief of obstruction. It is noteworthy, that some cases of prostatic abscess occurring in enlarged prostate are ultimately followed by great benefit to the primary condition. The destruction of prostatic tissue by the abscess is followed by cicatricial contraction and diminution of the mechanic obstruction produced by the enlargement. In some instances, however, the abscess-cavity does not become obliterated, but remains as a suppurating pocket, opening more or less freely into the lumen of the ure- thra and giving rise to successive reinfections of the posterior urethra and bladder or even infection of the anterior portion of the canal. This is true 652 DISEASES OF THE PEOSTATE. of all forms of prostatic abscess. In abscess occurring in prostatic hyper- trophy it is interesting to note the marked diminution in the size of the portion of the prostate that happens to be the seat of suppuration. In a case recently seen an abscess in the right lobe of the prostate in a middle- aged man with' prostatic hypertrophy had produced so much shrinkage of the organ that it was hardly, if at all, larger than the normal, while the oi)posite side was still markedly hypertrophied and indurated. The occasional occurrence of prostatic abscess in prostatiques consti- tutes a very practical point in the study of prostatic hypertrophy. It is by no means unusual for the first severe symptoms of prostatic obstruction in old men to occur coincidently with the formation of prostatic abscess. Inasmuch as after evacuation of the pus the symptoms practically disap- pear, an erroneous diagnosis may be made, the case being considered as ab initio one of prostatic suppuration. That a fatal result may follow prostatic abscess not only in old, but in young, subjects must be borne in mind. A case recently came under the author's observation of a young man, 35 years of age, who died of what was diagnosed as typhoid fever, but which, as the autopsy showed, was sep- sis due to a large prostatic abscess. It is well in all cases of serious pro- static disease to keep a close watch for both local and constitutional symp- toms of suppuration. Free incision and drainage would probably have saved the life of the patient to whom allusion has been made. In all cases of acute prostatic inflammation, especially, it is the duty of the surgeon to be on the alert for symptoms of suppuration. Oftentimes, however, a diag- nosis can only be made after the pus has discharged into the urethra, blad- der, or rectum. Healing of prostatic abscess after such evacuation is often quite prompt, but in many cases the admixture of urine with the contents of the abscess causes serious trouble by subsequent decomposition and sep- tic absorption. Ano-rectal fistula may result in cases in which the abscess opens or is evacuated by the knife via the rectum. Urinary fistula communicating with the rectum or with the ano-rectal fistula may also develop.^ Urinary fistula following evacuation of the pus via the perineum is not infrequent. MoEBiD Ain'atomy OF AcuTE Peostatitis, Simple axd Suppueative. — Comparatively little is known of the early stages of acute prostatic inflam- mation, especially of. the follicular or parenchymatous form. The condition is not fatal, and opportunities for observation are consequently not numer- ous. So far as determined, however, the process appears to be at first lim- ited chiefly to the mucous membrane and the follicles and glands imme- diately tributary to the prostatic urethra; hence a description of the morbid ^ The author has imder his care a gentleman in ■whom a long-standing fistula exists bet-sveen the rectum and prostatic urethra from this cause. MOEBID ANATOMY OF ACUTE PROSTATITIS. 653 anatomy of acute follicular prostatitis in its incipiency is also that of acute posterior urethritis. In the follicular form there is always a varying degree of involvement of the interstitial tissue, largely dependent upon the dura- tion of the disease. The infectious inflammation probably never limits itself to the prostatic urethra; if the inflammation does not extend below the membranous urethra, however, it may possibly become limited if not acute. In acute bulbo-membranous inflammation the prostatic u.rethra is almost inevitably involved sooner or later. The mucous membrane of the prostate is reddened and thickened, as is true of all inflamed mucous membranes. There is almost invariably thickening of the tissues surrounding the lym- phatics and blood-vessels. Ulceration does not occur, and resulting stricture is so exceedingly rare that it is hardly worth consideration. The mouths of the prostatic and ejaculatory ducts are involved in the inflammation, thus serving to explain the facility with which it extends to the glandular tissues of the organ. In acute parenchymatous or follicular prostatitis the organ is swelled accord- ing to the degree of circulatory disturbance and periglandular swelling. If the process extends to the interglandular, muscular, and periprostatic tis- sues, the diifuse form of inflammation, as interpreted by the author, is de- veloped. This corresponds to the parenchymatous form as described by Thompson. The organ is swelled in some cases to three or four times its natural size. The veins of the prostatic plexus are distended by dark blood. The arterial vascular supply is also engorged. The mucous membrane of the prostate is of a darker-red hue than usual. Pressure causes exudation of a cloudy, reddish fluid containing blood from the engorged capillaries and venules, inflammatory lymph, and fluid from the prostatic glands, with a small quantity of pus. Brissaud and Segond give a very clear description of the pathologic anatomy of acute diffuse prostatitis, as observed in a man dead of complicating pleuro-pneumonia. The glandular tubes were the seat of inflammation varying in intensity at different points. The internal wall of the ducts at points where the inflammation was most intense appeared to be blended with the muscular tissue by inflammatory exudate. The inequal- ity of the inflammatory process was especially noticeable. In different places, notably at the periphery of the organ, marked pathologic changes in some of the glandular tissues co-existed with a healthy condition of neighboring glands and ducts. The epithelium lining the glandular cul-de-sacs and ducts was replaced by an agglomeration of new tissue-elements, often filling the ampullse of the glands completely. In some instances the degenerative changes had obliterated the normal glandular outlines. Prostatic suppuration presents itself in several forms. In the follicular form it is similar to that in gonorrhea or urethritis: the pathologic condi- tion from which the process in the prostate was originally derived. Cir- cumscribed abscess may form in follicular prostatitis. One or more glands become infected, and incidentally their ducts are involved. Occlusion of 654 DISEASES OF THE PKOSTATE. the latter may occur and a suppurating-cyst-like accumulation of pus re- sult. One or more of these accumulations may rupture and contaminate the remainder of the gland. Such abscesses are often responsible for re- current infection. Miliary abscesses may result from acute suppuration. They may be single or multiple, and more or less disseminated. Large abscesses may be found in some cases. Abscess may occur in the cellular tissue surrounding the prostate: periprostatic abscess. Some prostatic ab- scesses are very large. Guyon reports a case in which the urethra was com- pletely dissected out of the prostate, and the urethra completely surrounded by pus. Abscess-cavities are generally multilocular and trabeculated. These abscesses may open into the urethra by one or numerous openings. Lallemand many years ago called attention to the fact that in acute prostatitis the ejaculatory ducts may be dilated and thickened from in- volvement of the mucous membrane. They may be ulcerated or their lumen diminished or even occluded. The seminal vesicles are usually thickened, dilated, and contain reddish or puro-sanguinolent fluid. Eegarding the accuracy of Lallemand's observations a certain element of doubt is war- rantable; many of his patients were subjected to treatment by the yorte- caustique, which in itself was not only likely to set up acute prostatitis, but followed by occlusion of the ejaculatory ducts. In some cases of suppuration the entire glandulo-muscular structure of the prostate is destroyed, as in the case outlined by Guyon. Such a case has come under the author's observation. It is a matter of regret that the autopsy in this case was not made with more care, the specimen being by no means perfect. The prostate, however, was practically replaced by a suppurating cavity with quite thick walls, apparently representing the cap- sule of the prostate in conjunction with inflammatory new growth. The specimen was so damaged in removal that it was impossible to obtain a clear idea of the relation of the urethra to the abscess. Symptoms. — In acute follicular prostatitis the symptoms are mainly subjective. Frequent and painful urination, pain being especially marked at the termination of the act, and in some cases a certain amount of blood mixed with the last few drops of urine constitute the principal local symp- toms. A feeling of perineal distress with pain radiating along the urethra into the spermatic cords or down the inner aspect of the thighs is frequently experienced. In some cases there is more or less rectal pain and tenesmus. The stools are likely to be somewhat painful. There may be considerable constitutional disturbance, but, as a rule, this is very slight, excepting where there is more or less diffuse inflammation. In the diffuse and suppurative varieties there is more or less urinary obstruction. Complete retention may come on and persist until the abscess is evacuated, when speedy relief is experienced. When pyogenic infection occurs independently of follicular inflammation, there may be comparatively little vesical irritation, the sjonp- toms of urinary obstruction preponderating. This is especially apt to be SYMPTOMS OF ACUTE PEOSTATITIS. 655 the case in acute abscesses that develop in the course of prostatic hyper- trophy. In diffuse and suppurative prostatitis, pain and constitutional symp- toms are especially marked. Depression is likely to be profound, and in prostatiques especially the patient may sink into a typhoid state and die with all the symptoms of constitutional pyogenic infection. True pyemia may result as a consequence of localized suppuration. The formation of pus is likely to be heralded by a distinct chill, followed, in some cases, by a succession of chills. In some cases of acute prostatitis the disease develops very suddenly; in others a few hours, or possibly several days, may elapse before the symp- toms become prominent. During this period the patient experiences pre- monitory sensations of weight and fullness in the perineum, with frequent micturition and a certain degree of depression incidental to irritation of the vesical neck. If abscess forms severe throbbing pain is likely to come on. This may be lancinating rather than throbbing, radiating, as already stated, into the urethra, groins, and thighs. The slightest exercise tends to ag- gravate the symptoms. The patient very often finds quite early in the course of the disease that slight perineal pressure elicits considerable pain and tenderness, and possibly vesical irritability. Cystitis may co-exist with acute prostatitis, but in the opinion of the author this is infrequent, all of the symptoms being usually explicable by in- flammation of the prostatic urethra. In cases having their point of departure in follicular inflammation, the urine contains muco-pus from two sources: 1. That which is directly washed out of the prostatic urethra by the out- flowing urine. 2. That which has taken the directio» of least resistance backward into the bladder during the intervals of micturition. The first and last portions of the urine in follicular prostatitis are likely to contain considerable muco-pus, the midstream being comparatively clear. When there is no follicular inflammation, the condition being primarily diffuse inflammation or localized inflammation incidental to infection and followed by suppuration, the urine contains nothing characteristic until the abscess ruptures into the urethra or bladder. The patient then experiences sudden relief in the perineum and ano-rectal region, the urine flows with perhaps its usual freedom, or at least much more easily than before the rupture of the abscess, and pus suddenly appears in the urine. It does not usually escape from the urethra during the intervals of micturition unless secondary infection of the anterior urethral mucous membrane occurs, or the point of rupture is located anterior to the bulbo-membranous junction. The objective symptoms of acute prostatitis vary with the degree of diffuse inflammation. Where the pathologic process is largely follicular, as in a certain proportion of cases of so-called posterior urethritis, local ex- amination elicits very little save more or less tenderness on deep perineal pressure and manipulation of the membranous and prostatic portions of 656 DISEASES OF THE PROSTATE. the urethra per rectum. Deep pressure behind the pubes may elicit some tenderness referable to the vesical neck. In the more severe types of dif- fuse and circumscribed suppurative inflammation^ more or less heat, swell- ing, tension, and tenderness of the perineum are noticeable. The prostate jDresents itself as a hot, tender tumor projecting into the rectum antero- posteriorly. The degree of enlargement varies with the extent of inter- stitial inflammation and may be so marked that the finger cannot be intro- duced into the rectum without considerable difficulty and the infliction of severe pain. When suppuration has occurred a boggy, edematous, uniform, or circumscribed bulging of the prostate and periprostatic tissues into the rectum is noticeable. Later on, fluctuation may be evident. Diagnosis. — Although the main diagnostic points in acute prostatitis have been outlined in the foregoing symptomatology, a resume and con- sideration of certain special points in the differential diagnosis are requisite. The patient, generally the subject of acute or chronic urethritis or chronic prostatic disease, complains for several days of heaviness and pain in the perineum, which he is quite likely to attribute to fatigue or overexertion, or possibly, if he be exceptionally honest, to sexual stimulation or indulgence. In some cases he complains for several days of loss of appetite, possibly slight chilliness, and well-marked malaise. Considerable mental depression may exist for several days before definite symptoms referable to the perineum develop. Vesical and anal tenesmus with dysuria, and in the majority of cases painful and difficult defecation, soon come on. In other instances the first indications of impending prostatic inflammation is vesical irrita- tion. In still another class of cases the first and most prominent sj^mptom consists, not in vesical irritabilit}^, but in urinary obstruction that grows more and more prominent and may lead to complete retention. It is ob- vious that the symptoms are governed largely by the amount of inflam- mation of the prostatic urethra. Where inflammation of the posterior urethra is not the point of de- parture, as is true of many suppurative cases, there may be little or no vesical irritation throughout the course of the case. Digital exploration of the rec- tum and perineum shows perineal fullness and tenderness and a degree of bulging of the prostate into the rectum, due to enlargement of the organ, proportionate to the severity of the inflammation and the degree to which the interstitial and periprostatic tissues are involved. Cowperitis may be mistaken for inflammation of the prostate. Palpa- tion of the perineum, however, shows lateral swelling and, if examined early, a distinctly circumscribed spheric tumor. The prostate, on rectal examination, is found to be either normal or only moderately enlarged. The urinary symptoms may be nil. The possibility of follicular prosta- titis, without much enlargement of the prostate, existing as a complication of cowperitis, or vice versa, should be taken into consideration. Acute prostatitis complicated by retention may require differentiation PEOGNOSIS OF ACUTE PEOSTATITIS. 657 from stricture, especially that variety in which retention comes on sud- denly from hyperemia and spasm. The history of the case, digital explora- tion of the rectum, and the location of the obstruction generally serve for differentiation. It mast be remembered, however, that stricture of the urethra is quite likely to be complicated by prostatic inflammation. Many cases of acute genito-urinary disease are likely to present features that are, to say the least, decidedly mixed. Enlargement of the prostate, as a cause of retention, may usually be differentiated from acute prostatitis by the age and history of the patient, and the peculiar feel imparted to the finger in rectal exploration. The tenderness elicited by the latter method may be very slight in prostatic hypertrophy. The possibility of acute pros- tatitis with suppuration or the formation of chronic abscess as a complica- tion of prostatic hypertrophy is to be borne in mind. Acute cystitis may be mistaken for inflammation of the prostate. It is probable that a majority of cases of so-called acute gonorrheal cystitis are really instances of acute follicular prostatitis. The vesical mucosa proper is rarely involved in gonorrheal inflammation; indeed, it has been claimed that the vesical mucosa is immune to the gonococcus. Be this as it may, gonorrhea is a mixed infection and the vesical mucosa may become infected by germs other than the gonococcus. It is not, however, particularly sus- ceptible to simple pus-infection. When abscess of the prostate is definitely formed, the diagnosis is gen- erally easy if the collection of pus is not quite small; it is especially easy when the abscess points toward the rectum. In some cases, however, the diagnosis is not only difficult, but the abscess is not detected until the pus has escaped by the urethra. The author has observed a number of cases in which, although prostatic abscess was strongly suspected, the symptoms were of moderate intensity; no incision was made and the diagnosis was only cleared up by the sudden escape of a greater or less quantity of pus from the urethra. Zeissl calls attention to the possibility of confusion of prostatic with ischio-rectal abscess. In the latter, however, there are no special symp- toms referable to the bladder, as a rule, and the unilateral position of the tumor, with its distinct point of departure in the ischio-rectal fossa, serves to clear up the diagnosis. In some rarer instances ischio-rectal abscess is associated with more or less reflex vesical irritation. This may prove a source of confusion. The author has observed one case in which ischio- rectal abscess occurred coincidently with acute follicular prostatitis. The possibility of the co-existence of the two conditions is to be borne in mind. In prostatic phlegmon, and in all forms of well-marked prostatic inflam- mation, especially where suppuration occurs, the gravity of the constitu- tional symptoms and the profound nervous depression are valuable points in the differential diagnosis. Peognosis. — The prognosis of acute prostatitis in otherwise-healthy 658 DISEASES OE THE PEOSTATE. subjects is quite faTorable as regards immediate recoTery of tlie patient, Arlietlier suppuration oc-euis or not. As already indicated, some cases of suppuration prove fatal, this being especially true of tbe phlegmonous form that occurs sometimes in young subjects, but more often in prostatiques, in whom general debility is more marked, on the average, than in younger men. The local symptoms are likely to be improved in this class of cases after the STacuation of the abscess. According to Segond, the prognosis of generalized prostatic phlegmon is grave. In 114 cases collected by this authority, there were 34 deaths, 10 cases in which permanent fistula followed, and 70 recoveries. Segond's statistics, however, are not a fair criterion of the gravity of prostatic ab- scess taken as a whole. In many cases, even of prostatic phlegmon, an in- correct diagnosis is made, yet the patient eventually recovers after evacua- tion of the pus. In the milder cases of prostatic abscess pus very frequently discharges into the deep urethra and bladder and apparent cure results, the true condition of affairs being unrecognized. It is the opinion of the author that many cases in which subsidence of the prostatic symptoms is coinci- dental with a sudden and marked recurrence of urethral discharge come under this head. In such cases the recurrence of urethral discharge is due, first, to the escape of the abscess-contents: second, to autoinfection of the urethra by the prostatic pus. In both young and old subjects with prostatic abscess persistent p}-uria with exacerbations of cystitis and urethritis may supervene. The abscess, after evacuation into the urinary tract, instead of closing down and becom- ing obliterated, remains as a suppurating sac with one or more openings into the urinary canal. Decomposing urine and products of suppurative in- flammation may perpetuate this condition of affairs indefinitely. In most eases in which abscess forms without marked follicular inflammation, the patient recovers completely. In the follicular form of the disease, how- ever, and in those diffuse and suppurative forms in which follicular in- flammation is the primary condition, the case is apt to become very stub- bom. It is probable that no patient who has ever suffered from acute fol- licular prostatitis ever recovers completely. The proportion of patients who have chronic inflammation of the prostate following acute follicular pros- tatitis of gonorrheal origin is much greater than ordinarily believed. Cases taken at random and studied upon the post-mortem table in our large cities will substantiate the accuracy of this assertion. In a careful study of nearly two hundred prostates, taken in this way, the author found, in by far the larger proportion, evidences of more or less recent inflammation in which, apparently, the primary condition had been acute follicular inflammation. Practical observation tends to show that a prostate, the glandular tissue of which is once infected, is likely to be always more or less diseased, whether there are symptoms or not. Teeatmext. — The treatment of acute prostatitis should be active. A TREATMENT OF ACITTE PE0STATITI3. 659 brisk mercurial purge should be given, followed by a full dose of some saline in the course of three or four hours. This will unload the portal circulation and produce general depletion. An excellent plan is to administer tablet triturates of calomel, ^/^ grain every three hours until four or five doses have been given. Coincidently 4-ounce enemas of saturated solution of sulphate of magnesia, containing glycerin in the proportion of about 1 to 3, should be given. This may be repeated until a number of watery evacua- tions have resulted. This is the ideal method of pelvic depletion, and is quite as valuable in prostatic disease as in pelvic and abdominal inflamma- tion in the female. Having fulfilled this indication, there are several spe- cial measures that are essential. The febrile symptoms call for aconite or veratrum viride, remedies far more reliable than antimony — recommended by Thompson. Ergot and hamamelis are probably beneficial. They are certainly philosophic remedies from a theoretic stand-point. These reme- dies may advantageously be combined with gelsemium and the bromid of potassium: anaphrodisiac remedies ha^ang a special sedative effect upon the inflamed organ. Hypodermic injections of pilocarpin are serviceable, this remedy being a powerful derivative. After the bowels have been thoroughly evacuated opium is the most effective remedy. It relieves pain and strangury, lessens the frequency of micturition, and counteracts nervous depression. All anodynes act best in acute prostatitis when given by suppository. If the rectum be irritable, the anodyne may be injected into the gut in the form of a thin ointment. Iodoform or europhen may be combined with morphin and belladonna or hyoscyamus, and administered by suppository. Caution is necessary in using anodynes per rectum, as most patients are very susceptible to them when so given. If the administration of anodynes p&r orem be considered preferable to rectal medication, codein will be found reliable and much less disagree- able than other preparations of opium. The diet should be restricted to milk or other unstimulating fluid aliment, and the patient should lie quietly upon his back with the hips slightly elevated. He should be impressed with the absolute necessity of perfect rest for some weeks, for in no disease is movement more likely to aggravate the condition than in prostatitis. In many cases in which acute prostatitis assumes a subacute or chronic form and persists indefinitely, movement, sexual excitement, and alcoholic and dietetic indulgence are in great measure responsible. Too much stress cannot be put upon the necessity of perseverance in the rules of genito-urinary hygiene. Local depletion should be resorted to early and repeated from time to time as required. This is best accomplished by means of leeches. Five to eight leeches should be applied to the perineum and about the anus, and the bleeding encouraged by warm fomentations. The rationale of this treat- ment is obvious, if the intimate association of the prostatic and inferior hemorrhoidal plexuses be considered. After hemorrhage has ceased hot 660 DISEASES OF THE PROSTATE. poultices or fomentations may be applied to the perineum. Ice has been advocated, rectal suppositories of ice being sometimes useful. Hot water containing laudanum is often serviceable as an enema. Simple hot ene- mata, several quarts of water being used at each sitting, may be given sev- eral times daily with great advantage. Interference with the urethra should be avoided, the usual treatment for gonorrhea being suspended during the course of the prostatitis. The use of injections may determine the formation of an abscess in an otherwise- slight inflammation. Hot sitz-baths, twice or thrice daily, are of marked benefit in pros- tatitis. They must be very hot and continued for from half an hour to an hour. Should retention occur and opium and hot sitz-baths fail to relieve, then, and then only, is catheterism permissible. A small, soft catheter should be carefully used. This failing, aspiration may be required. Eectal exam- inations should be made as infrequently as possible. The surgeon is usually overanxious to observe the progress of the case and in his misplaced enthu- siasm is apt to do injury. As the acuteness of the inflammation becomes less manifest, counter-irritation with iodin or blisters to the perineum may be of great service. Systematic and repeated blistering may perhaps pre- vent the supervention of chronic inflammation. Under careful treatment the inflammation usually begins to subside and the symptoms improve within a few days, but it is likely to be several months before the prostate assumes anything like its normal size. The slightest excess is apt to cause a relapse, and the patient is ever after pre- disposed to fresh attacks of inflammation — reinfection — ^from apparently trivial causes. Slight indiscretions are liable to prevent resolution and cause the inflammatory process to become chronic. Prostatitis may conse- quently be a very unsatisfactory affection to treat, even in the most tract- able and conscientious patient. Eecurrent infection of the urethra simu- lating a fresh gonorrhea is one of the most annoying features of the disease. In a general way the liability to suppuration in acute prostatitis de- pends upon the degree of thoroughness with which the foregoing measures are carried out. Where the inflammation is due to the absorption of pus- microbes and their products through the medium of an abrasion or via the lymphatics without abrasion, with resulting interstitial prostatic in- fection, suppuration is almost inevitable. In the ordinary diffuse form of inflammation, however, and in the follicular form which precedes it, energetic treatment may prevent abscess. The treatment of acute abscess of the prostate is obviously that of acute prostatitis. Until pus is known to have formed or a strong suspicion of its presence is justifiable, surgical intervention is contra-indicated. "While con- servative treatment by means of poultices to the perineum and rectal injec- tions of hot water may be justifiable in cases in which the presence of pus is extremely doubtful, the practitioner should beware of carrying conserva- TEEATMEXT OF PEOSTATIC SUPPUEATIOX. 661 tism too far. Serious results occur from a large accumulation of pus in and about the prostate long before fluctuation is manifest. Fluctuation should always be carefull}^ sought for, but in many cases operation is demanded long before perineal fluctuation can be detected. When the abscess involves the periprostatic tissue or burrows toward the rectum, digital examination via the gut is likely to detect either well-marked fluctuation or the peculiar edematous condition characteristic of the presence of pus. As soon as the diagnosis of abscess is justified by the development of perineal induration and swelling, characteristic edema, or distinct fluctua- tion on rectal examination, a free incision in the direction of the prostate should be made in the perineal raphe. This locality should always be se- lected even where well-marked fluctuation on rectal examination indicates the presence of pus in the periprostatic tissue. If pus is not found by the perineal incision, the surgeon can console himself with the reflection that he has adopted the best means possible to prevent abscess. Should suppura- tion eventually occur the incision supplies an outlet in the most favorable direction. If several foci of suppuration be found they should be freely opened and drained. lodoform-gauze drainage should be adopted after evacuation of the pus. Infiltration of urine may possibly occur after the opening of prostatic abscess, but is very rare. When a prostatic or periprostatic abscess is opened or discharges spon- taneously via the rectum, extensive infection, with the formation of ischio- rectal abscess and external fistula or a permanent internal fistula, may re- sult. In all cases in which the abscess has been evacuated into the rectum antiseptic irrigation is necessary. Care should be taken, however, to avoid poisoning the patient by too-strong antiseptic solutions. Carbolic acid and mercury bichlorid are especially open to impeachment on this score. A saturated solution of boric acid is much safer, although necessarily not so efficient. It may become necessary to divulse the sphincter ani to relieve rectal tenesmus or secure perfect drainage. By putting the sphincter at rest it may be possible to induce healing without the necessity of more serious operative procedures. In the event, however, that a permanent fistula results, it should be dealt with as in ordinary cases of ano-rectal fistula. When the abscess ruptures, or is evacuated by the perineal route, there is danger of permanent urinary fistula. When the pus is evacuated in the direction of the urethra, the repeated formation of deep periurethral abscesses may eventually result in perineal fistula. When the pus is external to the prostate in the paraprostatic tissue, there is less danger of infiltration of urine and urinary fistula than in cases in which the prostate proper is involved. General supportive measures and possibly the administration of stimu- lants may be necessary after the evacuation of a prostatic abscess. This course should be invariably adopted in cases of prostatic abscess in pros- tatiques. Should general pus-infection occur in the course of prostatic ab- 663 DISEASES OF THE PROSTATE. scess, as it is likely to do in old, cachectic, and debilitated subjects, death is practically inevitable. In retention from prostatic inflammation or abscess, especially in old subjects, it may be impossible to evacuate the urine with the ordinary catheter. The catheter coude of Mercier may be introduced much more readily than the ordinary variety. The soft Nelaton catheter is often unsatisfactory. In passing the elbowed catheter the superior urethral wall is so closely hugged by the beak of the instrument that there is com- paratively little danger of its penetrating the abscess-cavity. Instances have been known where the cavity of the abscess has thus been penetrated and mistaken for the bladder. The important fact to be remembered is that it is far better to evacuate an abscess by external incision than to produce an internal opening into the urethra or allow such an opening to occur spontaneousl3^ It is admitted that, in many cases in which the ab- scess opens in the direction of the urethra, the patient speedily recovers, but in a certain proportion of cases permanent infection results, with all the dangers of urethritis, cystitis, and recurrent prostatic abscesses. In all cases of prostatitis after the acute symptoms have subsided deep urethral and vesical irrigations are necessary for some time to remove the infection upon which the prostatic inflammation depended and which may bring about its recurrence. CHAPTEE XXYIII. Chronic Peostatic Inflammatiox and Suppueation. CoNSiDEEiNG the frequency of chronic infiammation of the prostate, it is rather remarkable that it was practically unrecognized until the early part of the present century. It must be acknowledged moreover, that con- siderable confusion on this subject exists in the minds of clinicians even at the present day. Vaeieties. — Chronic prostatitis presents itself in three forms, viz.: — 1. The follicular or parenchymatous, involving chiefly the glandular tissvies of the organ. 2. The diffuse, involving the lymphatics, connective and muscular tis- sues of the prostate proper, and also, as a rule, the seminal vesicles, vasa deferentia, and paraprostatic tissue. 3. The suppurative. ETIOLOGY. ' Masturbation. Ungratified sexual desire. Sexual excess. Passage of instruments. Urethral or bladder disease, p \ Prostatic hypertrophy. Chronic ) Ano-rectal disease, hyperemia ( Constipation, with consequent straining at due to 1 stool. Frequent defecation in chronic diarrhea and dysentery. Overexertion. Bicycling and horseback-riding. Dietetic and alcoholic excesses. \ Exposure to cold. Predisposing causes Diatheses | G-out}^, rheumatic, and tubercular. (663) 664: CHEONIC PEOSTATIO INFLAMMATION AND SUPPUEATION. Aeute inflammation from any cause, usually from infec- tion. Repeated traumatism from urethral instrumentation or external blows. Infection from instrumentation. Gradual extension of chronic inflammation from the ure- thra or bladder. Infection by the products of cystitis. Infection by the bacillus tuberculosis. Infection by pus-microbes without traumatism. Eepeated overstimulation by irritant applications to the prostatic urethra. Overstimulation by drugs taken internally, as canthar- ides, turpentine, etc. Exciting causes It is hardly necessary to expatiate upon the role of hyperemia in the etiology of chronic prostatitis. It is not likely that any of the factors enu- merated as predisposing causes can, when acting alone, produce the disease. Several of them taken together may, however, act as exciting causes. Thus, sexual excess and alcoholism in combination with the gouty or rheumatic diathesis, particularly if associated with frequent exposure to cold, may pro- duce chronic prostatitis. It must be remembered, however, that in by far the majority of cases in which these factors are apparently responsible for the chronic inflammation there is some source of infection or direct irrita- tion of the prostate. The more carefully these cases are studied, the more essential infection appears to be in the causation of chronic prostatitis, this being especially true of the follicular form. It is not denied that cases of chronic diffuse prostatitis are met with, especially in middle-aged men, where no history of gonorrheal or instrumental infection can be elicited. Careful investigation, however, determines some source of infection in by far the majority of cases. The possibility of autoinfection from deep ure- thral catarrh brought on by the numerous predisposing factors that have been outlined is here to be taken into consideration. Middle-aged patients presenting themselves with symptoms of prostatic disease, and in whom an enlarged, moderately soft, tender, and obviously inflamed prostate is found, are usually gouty or rheumatic, high-livers, and, as a rule, acknowl- edge sexual excesses. That such a condition is a foimdation for senile hy- pertrophy of the prostate is highly probable. In some instances the devel- opment of chronic inflammation, particularly of the interstitial variety, is so insidious that the patient's attention is not directed to the condition until many years after its inception. He may or may not recall a gonorrhea oc- curring during his years of indiscretion. If he does recall it, it is generally with the idea that he was perfectly restored to health after the gonorrhea. CHRONIC FOLLICULAR PROSTATITIS. 665 when, in reality, the foundation for Ms later trouble was laid at that time. Cases are occasionally met with, on the other hand, in which a history of continuous vesical irritation is related, and referred by the patient to his old-time gonorrhea. The injudicious passage of instruments into the bladder is often re- sponsible for chronic prostatitis. Instrumentation acts in two ways: 1. By producing mechanic irritation and hyperemia or even abrasion. 2. By carrying infection from the anterior urethra to the deeper parts of the canal. The hyperemia excited by instrumentation supplies the necessary suscepti- bility to germ-infection. The microbes and their products conveyed by the instruments thus have an excellent culture-bed prepared for them. Irritation of the lower bowel and the bruising incidental to chronic constipation or frequent defecation in bowel disease are potent factors in the production of chronic prostatitis. The slightest infection or exposure superadded to the irritation and hyperemia already existing is likely to set up a low grade of inflammation that usually becomes chronic. The same may be stated regarding the effects of excessive indulgence in bicycling and horseback-riding. The exciting causes of chronic prostatitis that have been enumerated are, with few exceptions, effective only through the medium of infection. Even in the case of repeated overstimulation of the prostatic urethra by irritant drugs infection may play a very important role; secondary, it is true, but none the less important. Infection, however, in such cases is probably not absolutely necessary to the production of inflammation. In suppurative prostatitis it is obvious that pus-microbes play the most im- portant part. The pyogenic organisms may enter the organ via its ducts and glands or by lymphatic absorption. Lymphatic absorption is generally precipitated by traumatic abrasion of some portion of the urethral tract, most generally the prostatic portion. It may, however, in all probability occur through the intact mucous membrane. That it may occur via the general circulation is occasionally shown in variola, measles, and parotiditis. In such cases the suppurative process is generally acute. It may, however, be chronic and is very likely to be unrecognized until serious damage has resulted. A fatal issue without special symptoms referable to the prostate is possible. Chronic Follicular or Parenchymatous Prostatitis. — The no- menclature of this variety is based upon the proposition advanced in the consideration of acute follicular prostatitis, viz.: that the secreting glandu- lar structures and ducts of the prostate constitute its essential anatomic elements and should therefore be regarded as its true parenchyma. Chronic parenchymatous prostatitis necessarily involves the glandular structures of the organ and usually the prostatic urethra, the latter being the point of departure of the inflammation in nearly, if not quite, all cases. The mu- cous membrane of the prostatic urethra may eventually become approxi- 666 CHKOXIC PKOSTATIC IXFLAMMATIOX AXD SUPPL'EATIOX. mately normal, while the glandular inflammation continues indefinitely. Chronic follicular or parenchymatous prostatitis embraces a variety of er- roneously diagnosed affections. Cystitis, urethral stricture, neuralgia of the vesical neck, posterior urethritis, prostatorrhea, spermatorrhea, and ca- tarrh of the bladder constitute some of the diagnoses under which chronic follicular prostatitis is likely to masquerade. The disease is often associated with a certain amount of chronic diffuse inflammation. Many cases are met with in which the glandular inflammation is the essential condition, the interstitial involvement being a subordinate and apparently secondary feature. In some instances chronic parenchymatous j)rostatitis has been preceded by well-marked acute parenchymatous inflammation associated ■«ath difl'use involvement of the prostatic tissue, yet the interstitial inflam- mation has practically subsided without appreciable improvement in the glandular inflammation. As already remarked in connection with acute follicular prostatitis, this variety of inflammation has a greater tendency toward chronicity than the interstitial. Chronic follicular prostatitis is generally due to infection and usually follows acute inflammation. In most cases the patient gives a history of gonorrhea with some complication that has been referred to the deep ure- thra, bladder, or prostate. Broadly speaking, a patient who does not give a history of some acute disturbance of the function of micturition during the course of a gonorrhea is not very likely to be suffering from this form of prostatic inflammation. If, however, such a history be given, it is safe to infer that some morbid condition of the prostate is still present. The exceptions to this rule the author believes to be rare. In some few instances, perhaps, the deep urethra becomes infected and the inflammatory process limits itself to the pars membranosa. Such cases, however, must be ex- ceptional. In a large majority of instances of deep infection the prostatic urethra and almost inevitably the glandular structures of the prostate become involved sooner or later. Once the prostate is infected, whether diffuse inflammation develops or not, it is the author's firm conviction that restoration to a normal condition never thereafter occurs. The frequency of chronic prostatitis is much greater than generally believed. This may be demonstrated by careful dissection of prostates taken at random, especially among hospital j^atients. ^Yhen we consider the multitudinous glands and ramifications of ducts constituting the most important structure of the prostate, and the poor facilities for drainage afforded these tissues, the prolonged duration of in- fectious processes is by no means remarkable. The subjective signs of pro- static inflammation depend largely upon the degree and duration of the in- flammation of the prostatic urethra. The objective signs depend mainly on the degree of interstitial involvement. Careful examination may fail to detect any alteration in the size, consistency, form, and sensibility of the prostate, even when well-marked chronic follicular inflammation exists. SYMPTOMS OF CHRONIC FOLLICULAR PROSTATITIS. 667 The urinary symptoms having subsided and the prostate having apparently assumed its normal condition, so far as rectal examination enables us to determine, it will still be found that upon the slightest indiscretion or ex- posure vesical irritation and tenesmus develop, which usually pass as ex- acerbations of cystitis. Symptoms. — The patient usually gives a history of more or less recent gonorrhea with complicating deep-seated inflammation referred to the posterior urethra, bladder, or prostate according to the notion of the phy- sician who has happened to have the case in hand. There is often a his- tory of complicating epididymitis that is, in itself, trustworthy evidence of prostato-urethral inflammation. The symptoms of vesical irritation at the neck characteristic of follicular or parenchymatous prostatitis may have subsided and the patient may assert that he has been perfectly well for some little time, a relapse having been brought on by indiscretion or exposure to cold. On careful questioning, however, it will be found that slight symptoms referable to the neck of the bladder and the region of the prostate, consisting of more or less weight, voluptuous sensations with slight increase in the frequency of micturition, and, in a general way, symptoms of hyperesthesia of the prostatic urethra, have persisted since the original acute inflammation. In other instances the patient gives a history of con- tinuous vesical irritation of greater or less severity since the primary involvement of the prostatic urethra. The principal symptoms are fre- quency of micturition with more or less pain and perhaps a slight quan- tity of blood at the termination of the act as the deep perineal muscles contract upon the tender prostate. The urinary symptoms in general are not unlike those of vesical calculus. The sexual function is more or less disturbed. Nocturnal pollutions, premature and perhaps painful ejaculations may exist. The seminal discharges may be mixed with a greater or less quantity of blood, especially if the seminal vesicles are in- volved. A sensation of fullness with perhaps a tinge of voluptuous sensa- tion in the perineum, itching and tickling sensations in the perineum, ure- thra, anus, and rectum are frequent. There may be frequent and persistent erections and excessive sexual desire. Patients sometimes go to the other extreme and complain of complete loss of sexual appetite and power. More or less congestion or inflammation of the anterior urethra is likely to exist, either as a consequence of simple irritation and circulatory disturbance or infection from the deeper portion of the canal; as a consequence there is more or less oozing of muco-purulent discharge from the meatus. This is most profuse during defecation and at the end of micturition, and may be noticeable only at such times. It is to be distinctly understood that when- ever discharge appears from the meatus during the intervals of micturition and defecation some morbid condition of the anterior urethra necessarily exists. More or less backache with neuralgic pains along the spermatic cord, in the testes, groins, thighs, and radiating into the urethra may exist. 668 CHEOXIC PEOSTATIC INFLAMMATION AND SUPPUEATION. The patient is quite likely to complain of pain located an inch or so behind the meatus on the under surface of the urethra. This is apt to be mislead- ing both to the patient and practitioner, and is ver}^ similar to that experi- enced in vesical calculus. The mind of the patient is rarely tranquil, and he is usually imbued with the idea that he has spermatorrhea. The dis- charge may contain spermatozoa where the stool is difficult and much press- ure is brought to bear upon the seminal vesicles; as a rule, however, it is muco-purulent in character and composed of pus, mucus, and fatty detritus with more or less epithelium. Where the vesical neck is profoundly im- plicated the peculiar ovoid epithelium characteristic of this location is apt to be found. The urine contains muco-pus and epithelium, the characters varjdng with the degree of posterior urethritis present. The so-called trip- per-fdden and the peculiar horseshoe-nail-shaped filaments or flocculi char- acteristic of inflammation of the prostatic follicles are usually found. Ex- ercise increases the symptoms; there is more or less discomfort attending the act of defecation, and the patient is very likely to apply for relief for rectal and anal disease, his symptoms being almost altogether referable to this region. If the prostatic trouble be complicated by piles, fissure, or fistula, an erroneous diagnosis is quite likely to be made; especially is there an interdependence between the condition of the prostate and that of the ano-rectal region. The author has at present under observation a patient who states that there is a very peculiar oscillation in his symptoms. When the symptoms referable to the neck of the bladder and prostate are most severe there is less discomfort in the region of the rectum, and vice versa. As has already been asserted, the parenchymatous form of the disease is apt to be associated with a greater or less degree of diffuse inflammation. The severity of the symptoms is in direct proportion to the degree of dif- fuse inflammation present in cases in which the two conditions are asso- ciated. The symptoms of the diffiise form are obviously essentially the same as those already outlined, with certain exceptions, due to a difference in etiology. Where the glandular inflammation follows acute infection, which usually occurs in comparatively young subjects, the principal con- dition is one of chronic inflammation of the glands and ducts of the pros- tate, and the disturbance of the urinary and sexual functions is more marked than in cases occurring in middle-aged men in whom the gouty or rheu- matic diathesis, high living, excesses, and a comparatively mild infection are responsible for the condition present. In these patients the urinary symptoms may be comparatively mild -until such time as mechanic dis- turbance of the function of micturition supervenes. In these cases, too, discharge may not be present, although the urine may give evidence of a low grade of chronic inflammation of the prostatic urethra. In some in- stances there is not only no discharge, but the urine is normal. While in parench}Tnatous prostatitis there may be little or no enlargement of the pro&tate, in the variety at present under consideration it is distinctly and MOEBID ANATOMY OF CHKOXIC PROSTATITIS. 669 sometimes considerably enlarged. In both, forms of tbe disease there is more or less tenderness upon pressure in the perineum, and decided tender- ness with urgent desire to micturate on digital pressure via the rectum. The psychic disturbance in middle-aged subjects with diffuse chronic inflammation of the prostate is either subordinate or entirely absent. Aber- rations of the sexual functions, however, are frequently met with, although they are not likely to be regarded by the patient with the solicitude char- acteristic of younger men. Digital examination is likely to show in these cases thickening, and perhaps tenderness of the seminal vesicles and vasa deferentia. This diffuse hyperplasia may be mistaken for the condition of arteriosclerosis so strenuously insisted upon by Guyon and his school as the essential feature of prostatic hypertrophy; indeed, it may perhaps lead to interstitial fibrosis. That chronic diffuse inflammation is the foundation for many cases diagnosed as hypertrophy of the prostate the author is firmly convinced; that such chronic inflammation may result from abuse of the organ, not only by high living, but by oversexual indulgence in early life, the author also believes. Morbid Anatomy. — About thirty years ago the elder Gross said that the morbid anatomy of chronic prostatitis was something which did not exist. If we were to accept many of the so-called cases of prostatorrhea as chronic prostatitis the opinion of this distinguished surgeon might still be accepted as authoritative. As already indicated, however, a large proportion of these cases should not be termed chronic prostatitis, consisting, as they do, merely of hyperemia of the prostate with attendant hypersecretion. Inasmuch as chronic prostatitis is not essentially fatal, opportunities for its post-mortem study are relatively rare. A sufficient number of observations have been made, however, to prove that chronic prostatitis not only exists as a patho- logic entity, but that its morbid anatomy is well marked. In chronic follicular — i.e., parenchymatous — -prostatitis there may be little or no alteration in the prostate body, as shown on clinical examina- tion, yet post-mortem section of the tissue shows an increased consistency of the prostatic tissue incidental to more or less periglandular thickening, — i.e., interstitial, connective-tissue hyperplasia. This is more marked in middle-aged patients. Long continuance of the glandular inflammation eventually determines a greater or less degree of diffuse chronic inflamma- tion. Diffuse inflammation, with considerable enlargement of the prostate in men of middle age is probably often due to long-continued chronic gland- ular inflammation or chronic hyperemia. Hyperplasia of the epithelium lining the ducts and glands is constant. The lymphatics may be thickened and hyperplasic. The conditions of glandular thickening and h^^perplasia are likely to lead to an irregularity of contour of the prostate that may be misr taken for tuberclilosis. The follicular and racemose glands and their ducts are often dilated — irregularly so, as a rule. Complete or partial occlusion may occur here and there, producing retention-cysts containing muco-pus 670 CHBOXIC PBOSTATIC ESTLAJOCATIOX AXD SUPPUEATIOX. and epiihelinTTi. The urethial orifices of tlie prostatic ducts are usually dilated and thickened, although their Itimen is sometimes more ot less con- tracted. Pre^nre upon the gland causes the exudation of a muco-punilent duid mixed with epithelial debris. The mucous membrane of the prostatic urethra may he normal, hut it is litely to be thickened, hyperemic. and pos- sihly granular. This condition exists where chronic prostato-urethritis has been the chief feature of the case. The foregoing changes are to be ex- pected in practically all indixiduals who have ever experienced acute in- fammation of the prostate. That such changes are frequent the author has demonstrated by a large number of post-mortem dissections. These dis- sections showed that well-marked diffuse prostatitis iuTolves not only the prostate body proper, but the prostatic urethra, the prostatic glands and ducts, the seminal Tesicles, xasa deferentia, and the periprostatic tissues iq- Testing the prostate, neck of the bladder, seminal vesicles, and Tas deferens. Thickening and induration of the inrolxed tissues are a marked feature. Desnos and Kirmisson hare directed especial atiention to the thickening of the submucous rectal tissue contiguous to the prostate and of the cellular tis- sue lying between the prostate and rectum. Adenitis with enlargement of the lymphatic glands and resulting nodulation of the prostate — discernible from the rectum — ^is more likely to occur in diffuse than in follicular or parenchymatous prostatitis. This condition is probably the one most often mistaken for prostatic tuberculosis. In suppurative prostatitis there may be extreme dilation of the ducts and racemose glands, constituting an advanced stage of parenchymatous in- fammation. The pseudocysts are distended with the products of supptira- rion — i.e., muco-pus and epithelial dihris — ^in conjunction with prostatic secretion. The prostatic tissue may be relatively atrophied by pressure malnutrition, while actual increase of bulk from the neoplastic formation exists. The cavities formed by occlusion of the prostatic ducts and glands and accumulation of pathologic products may open into the interstitial tis- sue, producing infection and extensive abscess. True abscesses occur in several forms, viz.: (a) there may be one large abscess circumscribed from the beginning or formed by fusion of several smaller ptis-cavities; (&) dis- seminated small foci of suppuration; (c) the periprostatic tissue may be the seat of the abscess. In such cases a peripheral prostatic abscess has in all probability ruptured into the periprostatic rissue and, produced secondary infection therein. Thompson has encountered eases in which several ab- scises from the size of a grain of sago to that of a large pea were found in the substance of the gland. The prostatic utricle is sometimes dilated and filled with pus. Large or small abscesses often communicate with the ure- thra, in which event they are likely to contain the products of .urinary de- composition. The abscess-cavity may communicate with the rectum, peri- neum, bladder, or urethra. Abscess^ may be found where no svmptoms of prostatic suppuration existed during life. Civiale relates the case of an TEEATMENT OF CHEO^STIC PE03TATITIS. 671 old man who^ for twenty days, was under careful observation in tlie Hopital Xecker. There was no suspicion of prostatic abscess, yet among many seri- ous lesions of tbe genito-nrinary tract found upon autopsy was a large abscess of the prostate. Sucb abscesses are not infrequently found in almost any chronic disease of the genito-urinary tract, perhaps most frequently in strict- ure of the urethra. Prostatic suppuration may occur as a result of infection in cystitis, prostatic hjrpertrophy or vesical calculus. TVhen suppuration has occurred in the course of prostatic hypertrophy the prostate presents the or- dinary characters of hypertrophy associated with suppuration. The prostate sometimes atrophies completely under the pressure of pus, the capsule of the prostate and the periprostatic tissues undergoing fibroid transformation, forming a pseudocyst containing pus, perhaps conununicating with the prostatic urethra. Tubercular deposits may be found in connection with chronic prostatitis, which condition is classified by some authors as tuber- culous prostatitis. T7nder such circumstances the abscess is due to one or both of two conditions, viz.: (a) caseation of tubercular tissue: (5) pus- infection. Tubercular prostatitis merits fuller consideration, which will be given it in the next chapter. It is possible that in some cases chronic prostatic abscess is due to sup- purative adenitis from mixed infection. Periprostatic abscess is especially likely to form in this way. TEEATiLEifT. — Chronic foUicular or parenchymatous prostatitis is to be regarded essentially as infection of the mucous membrane of the pro- static urethra and the epithelium lining the ducts and follicles of the organ. Its treatment is largely that of so-called posterior chronic urethritis. It is to be remembered, however, that in some instances the prostatic mucous mem- brane becomes comparatively healthy, while the infections process and its results in the glandular structures of the organ persist indefinitely. By regarding the condition as chronic follicular prostatitis rather than posterior urethritis it is likely to be treated upon more logical principles than at the hands of those who beKeve that the infectious process limits itself to the posterior or prostatic urethra alone. The therapeutics of the disease may be divided for consideration into : — r Hygienic and dietetic measures. (A) General J Eemedies having a special action on the genito-nrinary tract. I Eemedies to correct diathetic conditions. Mechanic treatment by sounds and massage. Irrigations. (B) Local ^ InstiQations. I Medicinal applications by ointments or soluble bougies. [^ Counter-irritation. 672 CHEOXIC PKOSTATIO II>rFLAMMATION AND SUPPUEATION. The general treatment should comprise careful attention to genito- urinary hygiene, with especial reference to the sexual function, and the ad- ministration of remedies having more or less marked special action upon the prostate and the genito-urinary mucous membrane. There is little hope of securing much benefit from treatment unless the patient leads a life of continence and dietetic temperance. While from a pathologic stand- point a perfect cure of chronic prostatitis rarely, if ever, occurs, the patient, in a large proportion of cases, may become practically well if due considera- tion be paid to the time-element in treatment and judicious instruction in genito-urinary and sexual hygiene be given and conscientiously followed. Dilation of the prostate by means of the steel sound is curative in a certain proportion of cases where the inflammation is chiefly parenchyma- tous or follicular. Caution is necessary in selecting the time for beginning the use of the sound. It is likely to be injurious before the primary acute inflammation has subsided. It is by no means unusual for the early use of the sound to excite a recurrence of acute inflammation. Should penile strict- ure exist, urethrotomy is usually indicated. Stricture at or near the meatus is especially liable to aggravate prostatic inflammation on account of the reflex irritation and hyperemia it excites in the deep urethra and its mus- cular environment. In such cases the first indication is to free the ante- rior urethra of all points of irritation and contraction. Many previously rebellious cases of chronic prostatitis yield very speedily after internal ure- throtomy. The results of the operation in these cases are sometimes ex- tremely gratifying. The author desires to call especial attention to this feature of certain cases of chronic prostatitis. Inasmuch as in a majority of cases of chronic prostatic inflammation there exists, either primarily or secondarily, infectious inflammation of the prostatic urethra and the glands and ducts tributary to it, some form of antiseptic treatment is indicated. Internal medication with eucalyptus and balsamic preparations aids somewhat in antisepsis of the prostatic urethra, but more direct measures are usually necessary. Where it is possible to em- ploy it, deep irrigation via a short urethral nozzle is best. In most patients, after a little training, water can be readily forced from the anterior into the deep urethra and bladder without the aid of either catheter or irri- gating tube. In this manner alone can the urethra and bladder be thor- oughly irrigated. There are but three remedies which are likely to prove effectual by irrigation. These, in order of efficiency, are potassium per- manganate, silver nitrate, and mercury bichlorid. Potassium permanganate may be used in the strength of from 1 in 5000 to 1 in 1000. The water should be only comfortably warm and should be employed in a quantity of not less than two quarts at each irrigation. In the larger proportion of cases the potassium permanganate is successful. Sometimes, however, it has little effect, in which event silver nitrate in weak solutions often acts admirably. The solutions ordinarily recommended are too strong. From ^/^ to 1 per TBEATMENT OF CHEONIC PKOSTATITIS. 673 cent, is usually all the urethra and bladder will tolerate. It is worthy of re- mark that a ^/2-per-cent. solution by irrigation excites more pronounced reaction in the deep urethra and bladder than much stronger solutions used by instillation. Where the silver nitrate fails, mercury bichlorid may be used. Deep-urethral instillations of antiseptic and astringent remedies come next in order. They are highly extolled by many of our genito-urinary au- thorities, though often disappointing. As used with the ordinary Ultzmann syringe, the injection of a few drops of silver-nitrate solution into the pro- static urethra for the cure of follicular prostatitis, or so-called posterior urethritis, is the height of absurdity. The area medicated by the solution is but a small part of that which is infected, and a few drops of a more or less powerful solution of silver nitrate are not likely to accomplish much good. Where the instillation method is used the syringe should hold a dram or two of fluid. The orifices in the injecting tube should be numerous, permitting the fluid to escape simultaneously in all directions, flushing the prostatic urethra thoroughly. Such a syringe is very convenient where it is desirable to leave a certain quantity of antiseptic or astringent fluid in the bladder. Silver nitrate, mercury bichlorid, thallin sulphate, protargol, and zinc chlorid are the most reliable of the remedies in vogue for instillation. Astringent and antiseptic remedies applied in the form of ointments or solu- ble bougies are often of service. Iodoform is probably the most valuable medicament for use in this manner. Silver nitrate in combination with lanolin 5 to 20 grains to the ounce, is frequently efficacious. Local medica- tion of the prostate via the rectum is also useful. Iodoform, europhen, and ichthyol in combination with anodynes are often efficaciously used in this manner, especially where well-marked diffuse inflammation exists. In such cases, also, massage of the prostate and seminal vesicles via the rectum is a sine qua non. Counter-irritation of the perineum by blisters is a valu- able adjuvant. Frequently repeated hot enemata in combination with hot sitz-baths are of service. In obstinate cases prolonged rest in bed is indi- cated. Many cases of chronic inflammation of the prostate might be prac- tically cured by rest. Due attention should be paid to the condition of the bowels. Hepatic torpor especially must be counteracted. The pelvic cir- culation, in short, should be kept as active as possible by appropriate reme- dies. In cases of severe diffuse chronic inflammation that resist all other measures a cure may be effected in a large proportion of instances by putting the prostate and vesical neck completely at rest by combined suprapubic and perineal section with through-and-through drainage. Perineal drain- age should be persisted in for several weeks, after which time the supra- pubic opening alone is to be relied upon. Speedy subsidence of the prostatic inflammation is to be expected in most cases. This method of treating stubborn cases is especially successful in those occurring in middle-aged men. Massage is by far the most valuable therapeutic procedure in all forms 674 CHEONIC PEOSTATIC INFLAMMATION AND SUPPUEATION. of chronic prostatitis. It should be practiced several times weekly, as a rule. In some cases daily massage is demanded. It might be well to suggest that the prostate cannot be massaged through the perineum as some physicians seem to think. It is unnecessary to enumerate here the various internal remedies that are likely to prove of value. Anaphrodisiacs, ergot, and, in brief, most of the remedies that will be suggested as useful in prostatic hypertrophy, and some of those recommended in acute inflammation of the organ, may be beneficial. One of the most important points regarding chronic inflammation of the prostate is the fact that the follicular form of gonorrheal origin may afford an infectious secretion for a prolonged period. A patient who has been apparently well for many months may infect the female, not neces- sarily with true gonorrhea, though this is possible, but with some form of mucous inflammation that is at least a derivative of the original specific process. The patient should be duly impressed with this feature of his dis- ease, that he may appreciate the necessity for prolonged treatment and strict attention to hygienic rules. Chronic suppuration of the prostate should be treated upon the same principles as abscess elsewhere. Evacuation as soon as detected, followed by drainage, and the liberal use of tonic and dietetic measures of consti- tutional support are the main features of treatment. CHAPTEE XXIX. Tuberculosis of the Prostate. Cancer of the Prostate. Calculus of the Prostate. tuberculosis of the prostate. Tuberculosis of the prostate was recognized many decades ago by the great French clinician Louis. The first contribution clearly setting forth its pathologic anatomy was that of Verdier.^ Since the appearance of Verdier's hrochure many contributions upon the subject have appeared, and tuberculosis, not only of the prostate, but of the genito-urinary tract as a whole has come to be fairly well under- stood. The subject has been much more clearly defined since the establish- ment of the germ-origin of disease. It must be confessed, however, that the knowledge of the possibility of primary and secondary tuberculosis of the prostate has added an element of confusion to the study and treatment of prostatic disease. As is true of all new fields of pathologic research, genito- urinary tuberculosis has become somewhat of a fad; it is now quite fashion- able to classify most obstinate chronic cases of genito-urinary disease as tubercular — of which more anon. Varieties.- — Prostatic tuberculosis occurs in three forms that are clinically quite readily differentiated where a positive diagnosis is possible. 1. Primary, in which no focus of infection more or less distant is discover- able. In these cases the tuberculosis is usually ingrafted upon chronic follicular inflammation. Tubercular disease, may, however, occur without pre-existing symptoms of chronic inflammation. 2. Involvement of the prostate secondary to tuberculosis in distant organs, the infection occurring by way of the general circulation. 3. Prostatic tuberculosis secondary to disease of contiguous and correlated tissues or organs. This is the most fre- quent form. With regard to the primary form, it is questionable whether antecedent chronic inflammation is not a necessary factor in the etiology. Etiology. — In the primary cases it is possible that hereditary or ac- quired tubercular predisposition may exist, but the most important, and possibly necessary, factor is the local one of chronic follicular infection. That the patient's general health is usually below par is a matter of almost universal clinical experience. In such cases the point of lessened resistance to bacillary infection is afforded by the long-continued chronic inflamma- tion. In some eases the patient has either had no antecedent symptoms or has been affected by acute deep-seated inflammation of the prostate and ^ "Observ. et refl. sur la phlegmons de la prostate," Paris, 1838. (675) 676 TUBERCULOSIS OF THE PllOSTATE. posterior urethra so long since that it seems unwarrantable to attribute the tubercular infection to the almost-forgotten gonorrheal inflammation. In such cases it is possible that the tubercular infection is not preceded by chronic inflammation. It is probable, however, that hyperemia due to sexual excess or ungratified desire and alcoholism, or pelvic or prostatic congestion from whatever cause, associated with constitutional debility, affords the requisite soil for prostatic infection. ^More often the pro- static tuberculosis is secondary to tuberculosis of associated organs, such as the penis, testes, bladder, seminal vesicles, rectum, or kidneys. Sec- ondary infection from testicular tuberculosis is most frequent of all. In- volvement of the prostate secondary to renal tuberculosis may occur in two ways: 1. By the lodgment of the bacilli carried downward by the urine. 2. By infection via the general circulation as in tuberculosis of the lungs. Prostatic tuberculosis secondary to infection of distant and unassociated organs is obviously not of so great clinical importance as the preceding varieties, inasmuch as the primary infection, especially in the case of the lungs and peritoneum, is usually intrinsically fatal. Prostatic tuberculosis under such circumstances is of pathologic rather than clinical importance, save for the necessity of palliation of the urinary symptoms. MoEBiD Anatomy. — The morbid anatomy of prostatic tuberculosis is essentially the same as that of other organs and tissues similarly affected. The characteristic grayish granulomatous infiltration, caseating j'ellow gran- uloma, cavities formed by caseation and liquefaction, diffuse infiltration and miliary deposits, cretaceous degeneration, fibrosclerotic change, and cica- trization of cavities are all found in different cases at different stages of the disease. It is a noteworthy fact that pronounced lesions are most likely to be found in primary prostatic tuberculosis, or in that secondary to dis- ease of contiguous and correlated organs. Patients with prostatic tuber- culosis secondary to pulmonary or other serious forms of tubercular disease usually die from the general affection long before the prostatic tuberculo- sis has had time to develop serious lesions. A greater or less degree of enlargement of the prostate is likely to be foimd sooner or later in prostatic tuberculosis. Enlargement appears earlier where the periprostatic lymphatics and glands are primarily involved, or in cases of primary interstitial deposit, than in cases in which the disease first appears as a tubercular prostatitis limited primarily to the mucous and submucous tissues of the prostatic urethra. The enlargement may be dif- fuse or limited to one or the other lobe. Earely, if ever, is it symmetrical. The enlargement is due to two factors, viz.: 1. A deposit of tubercular elements. 2. Consecutive inflammation, with interstitial proliferation of young connective tissue. The ordinary features of prostatic tuberculosis may at any time be modified by acute inflammation or abscess from mixed infection or traumatism. In primary prostatic tuberculosis the enlargement is likely to involve MOKEID ANATOMY OF TUBEKCULOSIS OF THE PEOSTATE. 677 both lobes^ although unequally. In the secondary form of the disease one lobe only may be primarily affected, although both may become involved later on. In eases secondary to tuberculosis of the testicle, and where one testicle only is enlarged as a condition secondary to a deposit in the prostate, only one lobe is likely to be implicated, at least primarily. In some cases in which the prostatic disease is secondary to general tuberculosis, gray granu- lomatous deposits may be the initial process. It would appear, however, that most often the initial deposit consists of characteristic yellowish granu- lomatous nodules. These undergo sooner or later more or less softening, perhaps liquefaction, forming the so-called tubercular abscess, the charac- ters of which may closely approximate ordinary abscess, provided secondary infection with pus-microbes occurs. The caseating nodules or yellowish granulomatous nodules may remain comparativelj^ quiescent for a long time. In cases in which secondary mixed infection occurs and pus-mi- crobes play the most important role the process may assume a more or less acute form, and an erroneous diagnosis is likely to be made. Primary tuber- cular deposit most generally occurs about the acini of the glands. It may, however, first invade the submucous tissue of the prostatic urethra. The deposit soon undergoes caseation and invades the epithelium of the pro- static urethra, with resulting ulceration and perhaps perforation. This con- stitutes the so-called tuberculo-ulcerative prostatitis, and is the form in which a positive diagnosis is most easily made. In other instances a caseat- ing cavity at some distance from the mucous membrane softens and burrows toward the free surface, finally opening into the urethra. Abscess-cavities and ulcers of the prostatic urethra are soon followed by secondary mixed infection and perhaps by infiltration of urine, urinary abscess, and fistula. These lesions present no tendency to cicatrization and spontaneous cure. When the entire gland or one entire lobe is involved, the process may ex- tend chiefly toward the rectum. Xodules are found in the substance of the gland perceptible in rectal exploration. These may soften, with or without secondary mixed infection, and form tubercular abscesses opening into the periprostatic cellular tissue— chronic periprostatic abscess. This may eventually open into the rectum. The pus may burrow upward and later- ally, forming large tubercular cavities in the perirectal tissues. In other instances they may open into the urethra, after which ordinary urinary abscess forms. Several caseating foci may coalesce, forming one large ir- regular cavity with rigid, and perhaps eventually calcareous, walls. Cal- careous transformation or fibrosclerotic change of the walls of the cavities with absorption of their contents, fibroid degeneration, and contraction of the entire mass occur exceptionally and result in a spontaneous cure. In such cases the condition of the prostate is one of atrophy, with cicatricial contraction and partial destruction of the' normal glandular and muscular tissues. In extreme cases of tubercular abscess the entire gland is represented 678 TUBEECULOSIS OF THE PEOSTATE. by a pus-sac. This may or may not invade the urethra. When it does, the urine enters the cavity; and decomposition, local and perhaps general septic infection, and a more or less acute urinary abscess may result. The sinuses that form as a result of tubercular abscess may burrow in various directions. They most often open upon the perineum in the neighborhood of the anus, their next most frequent direction being toward the rectum, into which they finally emerge. They have been known, however, to open in the hypogastric region or some distance away upon the abdominal walls or thighs. A small primary focus or perhaps several small foci may remain quiescent in the prostate for many years, possibly for an indefinite period. This explains the extremely slow progression of many cases in which a diagnosis of prostatic tuberculosis is made, admitting that at least a fair proportion of such diagnoses are correct. The rule is, however, that gen- eral infection and a fatal result occur sooner or later. It is obvious that a fatal result occurs much earlier where the prostatic disease is secondary to tuberculosis of other and more important organs. It is not easy to determine the primary seat of infection in prostatic tuberculosis. It is often a perplexing problem to decide whether the pri- mary deposit occurred in the prostate or in some other organ- or tissue. Even when secondary to tuberculosis of contiguous and correlated organs and tissues, it is not always a simple matter to determine the precise relation between the prostatic and contiguous disease: e.g., if the prostatic tuber- culosis is associated with a similar process in the testicle, it is not always easy to determine the primary seat of the disease. From a clinical stand- point, it is probably most generally believed that the prostatic disease is secondary to that of the epidid^anis. In many cases, however, it seems logical to infer that the tubercular infection has traveled from the prostatic urethra via the ejaculatory duct and vas deferens to the epididymis. This may be inferred especially when the symptoms of prostatic disease precede for some time the morbid changes in the testicle, and where both epididymes are involved at about the same time. It must be remembered, however, that small tubercular nodules and slight infiltration of the epididymis may exist for a long time prior to the development of prostatic symptoms without attracting the patient's attention, the first objective manifestation of dis- ease being referred to the urinary function. From a pathologic stand- point, it is fair to infer that when the process in the prostate is far advanced and that of the testis is insignificant, the prostatic tuberculosis is the pri- mary condition. This, however, is not to be accepted without qualification, inasmuch as the process in the testicle is always slow, often innocuous, and not likely in a large proportion of cases to go on to extensive destruction unless some source of mixed infection occurs. The condition of the sper- matic cord is apparent^ not a fair criterion from which to decide the pri- mary or secondary relation of the prostatic to the testicular disease. It would appear that infections of all kinds may expend their violence upon SYMPTOMS AND DIAGNOSIS OF PEOSTATIC TUBEECULOSIS. 679 what may be termed for practical purposes the two extremities of the semi- nal tube, while the intervening cord remains healthy. Tubercular adenitis and lymphangitis are very important factors in prostatic tuberculosis. As Lannelongue pointed out, the lymphatic glands between the bladder, pros- tate, and rectum may be the initial point. In such cases speedy softening with early opening into the rectum may occur. In some cases of prostatic tuberculosis there is general genito-urinary infection, primary or secondary. The kidneys, bladder, and ureters may be involved, the infection traveling up from the prostate to the kidneys, or vice versa. Instead of this gradual ex- tension, upward or downward, the kidneys may be the primary seat of tuber- cular deposit, the prostate presenting secondary tuberculosis from bacillary infection, either by the urine or in a more roundabout way via the general circulation. Symptoms and Diagnosis. — -When the prostatic urethra is the seat of tubercular deposit, with or without involvement of the bladder, the symp- toms are essentially the same as in any chronic inflammation of this part. Pain referred to the region of the bladder, perineum, thighs, groins, urethra, testes, and rectum may be complained of in different cases. Frequent and painful micturition, increasing in severity as the vesical neck becomes in- vaded, is the most uniform symptom. Some hematuria is sometimes ob- served. This is not profuse, as a rule, and is limited to the last few drops of urine. Sometimes, however, it is moderately free, and if the urethra is in- volved anterior to the triangular ligament urethrorrhagia may occur. The fusiform clot characteristic of prostatic hemorrhage is sometimes seen. Acute retention of urine may occur from the supervention of hyperemia, simple inflammation, spasm, or the formation of a mixed abscess. The urine contains muco-pus, epithelium, thready filaments, and sometimes, if ulcera- tion exists, particles of tuberculous tissue. Discharge of a muco-purulent character is present where the anterior urethra is involved. This may be constant or recurrent. Bacilli may or may not be present; they are rarely to be observed unless ulceration or abscess exists. In general, the discharge is that of a stubborn so-called posterior urethritis, — i.e., follicular prostatitis, — and creeps back into the bladder or is intermittent, occurring only during stool, in the coup de piston, or on digital pressure via the rectum. When the discharge escapes spontaneously from the meatus the anterior urethra is also involved, not necessarily in a tubercular urethritis, but sometimes in simple chronic inflammation. Sometimes a large quantity of pus suddenly appears in the urine. This is indicative of the evacuation of an abscess pe?' uretliram. When the tubercular deposit is at the periphery of the prostate or in the periprostatic tissue, there may be no symptoms for a long time. The patient is not likely to complain unless the bladder, urethra, or testes be- come involved. There may be some pain and weight in the perineum, with tenderness upon pressure, a moderate amount of rectal tenesmus, and pain in defecation; but these symptoms are usually noticeable only after suffi- 680 SYMPTOMS AND DIAGNOSIS OF PEOSTATIC TTJBEECULOSIS. cient tubercular material has become deposited to produce more or less mechanic disturbance. As will be observed, there is nothing pathognomonic about the fore- going symptomatology. The most definite symptoms are objective, and determinable only by rectal exploration. The prostate is found to be the seat of an irregular nodular enlargement with perhaps areas of softening. A granular feel of the periprostatic tissue has been described. The seminal vesicles are sooner or later involved, as a rule, and are thickened, nodular, and tender. Distinct abscess may be found. After evacuation of the tuber- cular abscess relative atrophy and perhaps sclerosis of the prostate are ob- served. Catheterization may result in the detection of the abscess-cavity, which is usually situated upon the floor of the prostatic urethra. It is obvious that it is quite easy to make diagnostic errors where there is no softening or ulceration of the prostate. The presence of bacilli in the urine or urethral discharge constitutes the only positive sign of tuber- culosis. Since so much has been written upon tuberculosis of the genito- urinary tract many mistakes in diagnosis have been made. With some sur- geons, more or less hardness of one or the other epididymis and a little enlargement, tenderness, and nodulation of the prostate are sufficient to warrant a diagnosis of prostatic tuberculosis. It must be remembered, how- ever, that simple chronic inflammation of the epididymis may present the same signs, so far as the testes are concerned. Simple adenitis or peripro- static adenitis with chronic follicular prostatitis may afford all of the other signs upon which the diagnosis of tubercular disease of the prostate is fre- quently based. In the experience of the author, it is not unusual to meet with such cases that have been pronounced tuberculosis of the prostate. Under the ordinary measures of treatment of follicular prostatitis many of these cases readily yield. The inference is obvious: either many cases of tuberculosis of the prostate are mild, comparatively harmless, and readily amenable to treatment, or else frequent mistakes in diagnosis occur. The latter is the author's inference. When a sluggish, slow developing, comparatively painless and insen- sitive enlargement of one or both epididymes exists, with symptoms of chronic prostatic inflammation, and nodular enlargement of the prostate determined by rectal examination, a diagnosis of probable prostatic tuber- culosis is warrantable. The detection of bacilli in the urine or discharge, or the formation of characteristic tubercular abscesses and sinuses are neces- sary, as a rule, for a positive diagnosis. In a case presenting the prostatic s3'mptoms just described and at the same time evidences of tuberculosis of the lungs, peritoneum, bones, or general lymphatic system, the inference regarding the prostatic disease is obvious. The heredity of the patient and his general condition are important factors in the diagnosis. Koch's tuber- culin affords a diagnostic test. There is no regularity in the course of the disease. Some patients suf- CANCEE OF THE PEOSTATE. 681 fer acutely at an early period, where the urethra and bladder are involved. Others, especially when the urethra is not primarily or early invaded, may tolerate the condition for a very long time. Complete arrest of the disease and spontaneous cure may result, as shown in the description of its morbid anatomy. Teeatment. — In prostatic tuberculosis secondary to disease of other important organs, the treatment is that of the primary disease, excepting in so far as local measures of palliation may be instituted. Where it is primary, or secondary to tuberculosis of contiguous organs, the treatment of the local difficulty assumes a more prominent position. General treat- ment should be based upon the same principles as in tuberculosis elsewhere, due consideration being given to tonic and alterative treatment, nutrition, and change of climate. The method of hypodermic medication by iodin and ehlorid of gold in the form of Clark's solution offers some hope of benefit or even cure. The same may be said of nucleins and tuberculin. The local treatment should consist first of irrigation of the bladder and prostate with warm solutions of boric acid, followed by the instilla- tion of iodoform-and-ether emulsion. Iodoform in the form of rectal sup- positories has seemed beneficial. Instillations of silver nitrate and other irritant astringent drugs are rarely beneficial, and are most likely to prove injurious; it has even been asserted that such treatment may precipitate ulceration. Where possible, it is best to irrigate the bladder and prostate by means of a short urethral nozzle rather than by instruments necessitating more or less mechanic irritation of the prostate. Although not universally accepted, the author is convinced that putting the bladder at rest and pro- viding through-and-through drainage at an early period of the disease is likely to prove curative in quite a proportion of cases. When abscesses form, they should be evacuated, scraped, and packed with iodoform gauze; all sinuses should be thoroughly curetted and treated with iodoform. In- terstitial injections of iodoform emulsion into the affected gland constitute a logical method of treatment. Cases are reported where large tubercular abscesses of the prostate have been opened, curetted, and drained, with re- sulting cure; but in marked cases of prostatic tuberculosis recovery is rare. Sooner or later, the bladder, kidneys, or distant organs become secondarily affected. When prostatic tuberculosis is secondary to tubercular disease in other important organs the death of the patient is inevitable. CANCEE OF THE PEOSTATE. Malignant disease of the prostate is rare, yet it is probably more fre- quent than ordinarily supposed, being often erroneously diagnosed. His- tologically, malignant disease of the prostate occurs in two forms, viz. : sar- coma and carcinoma. It is found at the two extremes of life, being excep- tional between the ages of ten and fifty years. It is occasionally found in very young children. In something over 85 per cent, of cases the malig- 683 SYMPTOMS or cancer of the peostate. nant affection assumes the form of carcinoma, the remainder being of a sarcomatous character. Sarcoma is the form that is most likely to be met with in young patients. Cancer of the prostate occurs clinically in three forms, viz.: (1) pri- mary; (2) as an infection secondary to malignant disease of contiguous organs; (3) by infection via the blood. The form most often seen is sec- ondary to malignant disease of the penis, testes, bladder, or kidneys. As Guyon has shown, primary prostatic cancer has but little tendency to in- vade the bladder, but speedily involves the lymphatics, especially of the pelvis. This latter clinical fact suggested to Guyon the term prostato- pelvic cancer. The disease may be at first circumscribed. It is usually, however, diffuse. The capsule of the gland may alone be affected, at least primarily. Eventually extensive pelvic invasion occurs, with involvement of the seminal vesicles, base of the bladder and sometimes its mucous mem- brane, the rectum, and urethra. Mixed infection and suppuration may eventually develop. The following case, although open to impeachment as regards post- mortem study, is, in the author's opinion, an illustration of primary cancer of the prostate secondarily involving the bladder. Case. — W. H., aged, 43, merchant, suffered from painful micturition, and hematuria coming on at the end of the act of micturition. The pain accompanying this part of the function was excniciating. The family history was excellent. He had never had any illness of any kind, and was absolutely free from lumbar pain, or any indications of disease of the kidney so far as subjective symptoms were concerned. His habits had always been good. During the war, in which he was a soldier, he had a slight attack of ague, and had never been under the doctor's care since until the jDresent trouble began. About six months or more before consult- ing the author the patient developed pain in the penis and testes, gradually increas- ing in severity, until finally, in conjunction with frequent and painful micturition, he was kept awake at night. His urine had been normal, and had been carefully examined many times during the course of his trouble. Shortly before consulting the author, however, his hematuria began. He had been examined several times for stone in the bladder. He experienced frequent desire to defecate, though having but one movement daily. Examination showed the prostate to be enlarged and somewhat tumefied, with some suspiciously resistant points here and there. Cystoscopy was not feasible because of extreme vesical irritability. Despite the fact that there was no history of venereal trouble, and because of the age of the subject, the case was con- sidered as one of chronic prostatitis, although a slight suspicion of malignancy was entertained. This patient was afterward lost sight of, but the ease finally went on to a fatal result, and the author was informed by the attending physician that cancer of the bladder was found upon autopsy. As a report of the condition of the other organs was not given, there are no means of proving the primary nature of the prostatic disease. This case is a very striking one, as suggestive of the caution necessary in the diagnosis and the prognosis of cases with similar symptoms, on account of the age of the patient and the absence of symptoms elsewhere. Symptoms. — Frequent and painful micturition with hematuria — and, if ulceration of the prostate exists, more or less purulent discharge — con- CALCULUS OF THE PEOSTATE. 683 stitute the main sj'mptomatic features. Pain is likely to be most severe at night, and is often referred to the region of the rectum. As the pelvic tissues become extensively involved, pressure irritation and resulting pain in one or both sciatic nerves is likely to develop. Intrapelvic pressure also may produce more or less obstruction of the iliac veins, with resultant edema of the limbs. Constipation from mechanic pressure upon the rectum may be observed. Marked cachexia comes on at a comparatively early period. A fatal result is inevitable. Diagnosis. — In the differential diagnosis tuberculosis and prostatic hypertrophy only are worthy of consideration. A hard, nodular enlarge- ment of the prostate with cachexia, pronounced symptoms referable to the vesical neck, and extreme pain suggestive of pelvic involvement, taken in connection with enlargement of the pelvic lymphatic glands and those of Scarpa's triangle, warrant a diagnosis of cancer. When cancer exists else- where in the body, and especially if it has invaded organs contiguous to or correlated with the prostate, the diagnosis is a very simple matter. Teeatmext. — Treatment must necessarily be palliative. All radical attempts at surgical relief have thus far failed of their object. The author believes that early suprapubic section and the establishment of a permanent artificial urethra is the principal surgical indication. Great relief of some of the most annoying symptoms of the disease and prolongation of life are likely to result from the rest and relief from mechanic irritation thus secured. CALCULUS OF THE PEOSTATE. Prostatic concretions or calculi are sometimes seen. These occur in four forms: 1. A variety due to inspissation of the secretion of the pro- static follicles, in combination with the deposition of earthy salts. These comprise the so-called corpora amylacea, first described by Morgagni in 1723. 2. Small calculi of urinary formation, which have formed in the kidneys or bladder and have become lodged in the prostatic urethra. 3. Calculi due to the deposition of urinary salts and mucus in some pathologic crypt or behind some obstruction of pathologic formation in the prostatic urethra. 4. Phleboliths. Concretions of the first variety are found in the prostate on post-mor- tem in cases in which there have been no symptoms referable to the organ during life. Minute concretions of this kind are sometimes found in the urine. They are at first of microscopic size, and in the majority of cases never attain sufficient dimensions to be of any practical importance. As seen with the microscope, they are small, ovoid bodies of a light^yellow tint and pearly luster. In the large concretions the color is a dark orange. When first formed they are soft, but later on they become calcified and hard. They are somewhat similar to the concretions that form in the fol- licles of the tonsil and are occasionally coughed up by patients with chronic 684 CALcrrrs of the peostate. lancial disease. In elderly patients they may attain tlie size of a pea or larger, and may be Tery abundant. Tbompson describes a ease iq wbicb seTeral tbonsand of these concretions were visible microscopically. Tbey are fonnd in the secreting follicles and excretory ducts, constituting tbe parenchyma of the prostate. The earthy material is deposited very slowly in concentric laminae, as is the case with phosphatic vesical calculi. The walls of several ducts and follicles may be absorbed and form a single cav- ity within which a number of such concretions may be found. When they become larger and the opening of the cavity containing them communicates freely with the prostatic urethra, the salts of the urine are deposited about them, and they become genuine prostatic calculi. Cases have been reported in which the entire prostate was converted by absorption into a sac com- JPro state Fior. 130. — Prostato-vesical ealeulus. (After Bryant.) pletely distended with small calculi that could be felt rolling under the fingers lite beans in a bag. Prostatic calculi sometimes fuse together and form a sort of cast of the prostatic ducts and urethra. A length of four or five inches has been said to have been attained. Thompson refers to a case in which there were nine fragments weighing alt-ogether 3 ^/^ ounces. Chemically, true prostatic calctili are composed chiefly of calcic phosphate and a email quantity of ammonio-magnesian phosphate. They never give rise to trouble unless they are exceptionally large, in which event they occa- sion a certain amount of mechanic disturbance and urinary obstruction. Small prostatic calculi should not be disturbed even where their existence is recognized unless they give rise to definite symptoms. Should they do so, they may be removed by perineal section. In rare instances they may CALCULUS OF THE PEOSTATE. 685 cause ulceration and abscess, and finally be discharged into the urethra, bladder, perineum, or rectum. Prostatic concretions are quite generally believed to be characteristic of senility; the author has however found them to be not infrequent in yoimg subjects. Eastman has had a similar experience,^ finding them in very yoimg subjects, and in twenty-two out of twenty-four prostates ex- amined. Eastman holds for the amyloid character of the corpora amylacea and claims that they are largely of epithelial origin. He apparently shows that the laminated formation of these bodies is due to their origin in con- centric rings of epithelium. Calculi are often found in the tissues about the prostate and neck of the bladder at some distance from the prostate proper. The author has found them several inches above the vesical neck. ^ "The Origin of Corpora Amylacea in the Prostate Gland." Joseph E. Eastman, B.Sc, M.D. Journal of the American Medical Association, July 24, 1897. This is a valuable trocTiure, and worthy of more-extended mention than can be accorded it here. zrT^EiTE TOEreBSr .: — : nf J ASTTEneec saset in Terr lui s^i^ie^^s "B"Ji£if scn ..r z^^L- i^i :_ii- Sht- '-'iriiSiaaiJiifi cesi. inn palliaxixs -mfiaFiirg fiTt =~: : : — :Tv^ AriT^EiiDefi eases irr^eenx^ m Jtge ia ^wioeb. r — . i ^-^.=r. ion pt)T!^ i.i t-^ nHafamnee are iwrSfsg, , f ) Cas^ nm i-HTi 49M i p^*^ is v^oaa wriial pow^r i£ Iqbi- (-1 C^^ efiHUf^caSiBi Irv' T^£al fiaTffalnf.. laa Ois « v«E imve to deal Mjjji hieb M inii \mr JIhim iw deveis^ angL vMle tibe emsiitaiian of the •yap pgt:W»«aGc j^BTtnawa ia Oaas i «y iMiNirainy i1>p legTJaBMte safiBeSBOg fii CSuE A. TSas aoQf iB^ei^asiK &r opooiaaa. pane'iaiL C^^ « tfusmrji rmpf -^ casEE jwr gng fl BBoe ja vfia^ moAmg \mi paHia- Saos KiGBsaesE ^asoaM Be t^otadesied. Tbef fimwf r rwp ^pdie a funfiutlifla of eme^ ^bS, -vnbi^ in seiBs <^ liwaw ^peaaaMs. »»i»i«*^ bav^ beia pnfified at as eas^ pesasti. m eoiamlT 5s 1101 so ai a m^ate adhtaaeeS ^ckid Q%tiflrasflK~ 9£t«S hw ribese s^BEd»^: !?tt xlDer a ssobt ri>ed llie Us i iwaamftfssied lis |Bm j j*iH. :>9iCHK it k a «at£te of mne to dalbf vifk sid^^^i oei!2»aBiL X«Kr.T £_ ^f liie »aii.ai!wieai lemedi^ leeoiiaBeiided Sbr SLKaaE* loaw litesBa «€ am aBlfcalliwip dsaiactieE. Ciievalacr bes^g tlie fiist to call e^Bccial atseaaitasn w tlae ¥a!ne «3!f aHalaes m edcnloos dssease. Hie Tadsf" %EiB^ ba^ne bees lu^jili- indassiBd m. ealenlos, arad are of some Tifaie IB &e latAiBe difldbesK. boc obIt hr Timae of tls€ar aOEaliaurr. bnt ateo from ijbe &es ^m. ib ib^' laise ■qpaaifiTirw^ sfstallhr lalseB liafr i^eBder tihe mine wfSfr ®6B6EBQafi£OL Af aa iIS^saai5«iB <^ tiae inpSscii saiili im Ihltoffitriiiiticg poeBeseed br . 'liSae im jDacBter dav^ dae eeieiiaated BOESi^m of Joanna St^besE is ^•:>f;: .snriMBg. TTiiBg uttKE ' - : posed to be so Jin^lHhi** Ibat in 1739 a Acwjiad «£ iSid@0 vae paic :.. : ._ '^otor br tlae T&wgtipli guic»r ^lla^TroTria TMTm — «f t^ ■sstsse by leaaec ' - _^r i^add^c Sir Senjamin dL.-i. __.-_ „ i'_- -__-:_ sf HL. iij to tJie OTznce of ■BSSKff iffi ;piBS^SBa&ie eakalL l>!Ka4)d^ t^t^ ^rr-fsmmpmt is beiitf-da] -s-iierB ^ifiS' ffeffl^isiie d^i ■ r_-^, i^- as a f: '_e of stiinsie in ad- Jiiast fftJRiftina ioa lSi»: UfaganB- miM —ig V .jl IJo^aactifSiK. TEZ-iTirFATT or VZilCAJl CajLCCjIUS. T&l Attempts KaTc been made to enre calenH by electrQlyss, bxtt wife, in- different success. Brrant has reG-omnLettded a sfrnp le proceiiire that SQine- tLoies sncc-eeds in rem.0Ting gmaTT caLcnK as foRown: — Patients wiio are prone to tfie passage of renal caleali into tKe IsIaddeTj" and ta the formation of KtMe add or otKer graveL stould be directed once a day wien. tie fall bladder is abont to discharge its contents, to arrest the &yw of nrfne by holdrng the penis, and then anddenly to aHo-sr the stream, to liow-. In this way the witter, passing with a rash, carries with it any gmaTT stone or sand which may be restrng in. the bladder. Old men should do this upon their hands and knees. It is Tmfominate diat th.e Tarions non-snigieaL methods of treatnieiit of TesicaL c-aLcnlTis are so seldom snc-c-essfnL Operatfon is necessacy sooner or later in nearlv all cases: a fact that is som.etiiing of a reproach, to scien- tific medicine. 5EJLECTI05" OF 0PEBAII05" ZQS aTO^TE. The selection of c-ases for the seTexal operatLons for stoite Is a mafccer of Tital importance. In children Kthotomr is the most generalLy applicahlff, because of its safety and the small size of the bladder and nrethra. which, renders Hthotrity mnch m.ore ditn.ctilt than in the adnlt. Lithotomy shotild be performed as soon as practic-able after the diagnosis of stone has been determined. The dangers of c-alcnlns depend upon the dttration of the dis- ease and the size of the concretion. The dangers of &tal renal or bladder complications and the fatality of operations are directly dependent npon these two- eircnmstances: henc-e the earlier the operation is performed, the better. The fatality of lithotomy in children is quite smaTT ^ and it is prtib- able that one death in thirty operations is a very liberal estimate of the m.or- tality-rate in patients nnder pttberty operated by eom^petent surgeons. TTis vrilL be allnded to again more specifically. The mortality of Ktholapaxy yaries with the age of the sobjeets. the rate being about 3.5 in children. 5.3 per cent, in adnlts. and S per cent, in old men. The improvement in mortality-rate over the old operatioiL of Kthotrity is marked. Thompson lost tweitty-nine eases ont of seventy-eight adults operated by Hthotrity. _Li fisidy good eeaadrfcioiLed adults with moderate amount of bladder and renal CQmplic-ations. and a stone of in inch and a half or less in diameter. lithotrity is the preferable operation. The operation is to be taken into eonsLderation. as the QpsatiiKi «xl eleetion in all cases in adults. The hardness of the stone may compel the surgeon, to resort to lithotomy^ bnt this can only be determined by trial wEch a Hthotrite. The suprapubic operation is so safe in favorable eases m. adul-fe that it is preferable to Ktholapaxy unless the surgeon is expert in. its per- formance. The mortality of litholapaxy depends greatly on the care with. which cases are selected- Thompson. lost abotEfc one ease in thirteen oe- f ore he realized the necessity of a more careful selection of cases as regards the size of the stone, condition of the bladder, etc. Under favorable cir- 793 UEIXAEY CALCULUS. cumstances there is no more danger in litholapaxy than in any case of in- strumental interference with the urethra and bladder, and when we con- sider the occasional deaths from simple catheterization a certain degree of mortality in litholapaxy is by no means surprising nor an argument against the operation. , When severe bladder complications or indubitable renal dis- ease exist, litholapaxy does not offer so many advantages as suprapubic lithotomy; hence the latter is to be preferred. When for any reason it is found difficult to introduce and manipulate the instruments necessary for litholapaxy, the cutting operation must be resorted to. This is likely to be the case in some cases of prostatic disease, bar at the vesical neck, strict- ure, and in extremely nervous and cowardly patients. Under all these con- ditions the author acknowledges a preference for suprapubic section. In the rare cases of calculus in which no operation whatever is practicable, life may at least be greatly prolonged and made more comfortable. To epitomize briefly: 1. Lithotomy seems still to be the standard oper- ation in children, litholapaxy being indicated only exceptionally. 2. Lithol- apaxy is to be the rule in adults, the cutting operation being j)erformed only when the crushing operation is impracticable. 3. Stones above an inch and a half in diameter, very hard stones, stones with foreign bodies as nuclei, most cases of multiple calculi, cases with complicating stricture, and severe bladder, prostatic, or renal disease require lithotomy, preferably the supra- pubic operation. Litholapaxy gives the best results in old men in whom the stone is accessible and the bladder and kidneys in fair condition. Amer- ican surgeons are perhaps inclined to attack larger stones by litholapaxy than are considered by European surgeons to be removable by crushing. Keyes concludes upon this point as follows: — 1. When stone complicates enlarged prostate, if the condition of the latter be such that were the stone absent no operation would be called for, then the whole question is to be solved by deciding whether the obstructive quality of pi'ostatic en- largement, the size of the bus, the depth of the Ms-fond, the irritability of the pro- static urethra, and its resentment of instrumental interference — whether any of these factors be sufficiently accentuated to make litholapaxy impossible, or to make it possible only at the expense of leaving the patient (as to his subjective symptoms) worse than before. If such conditions do obtain, then the stone should be removed by the knife. 2. In short, the main matter is one of diagnosis by the searcher, the cystoscope, rectal touch, and the tentative testing of the prostatic urethra with instruments. 3. The size or position of the stone is not a factor, except in the case of encysted stone, or one too large for the lithotrite to grasp, or in the case of a foreign body. The smallness alone of the stone is relatively an argument against litholapaxy, since the symptoms in such a condition must be ascribed rather to the prostate than to the foreign body. 4. If lithotomy be performed, the suprapubic route should be selected, since this opens the door to more perfect work, and allows the surgeon to remove obstructions, such as third lobe, interstitial growths, outstanding horse-collar enlargement, bar, and to lower the vesical end of the urethral floor, thus accomplishing all that could be LITHOTRITY AND LITHOLAPAXY. 793 done by a more extensive prostatectomy, without very seriously increasing the operative risk. 5. Finally, here, as elsewhere in surgery, the only safe, practical guide is surgical judgment, based upon diagnosis, guided by experience/ LiTHOTRiTY AND LiTHOLAPAXY. — History of Litlioirity . — It is prob- able that lithotrity is a very ancient operation. According to Ultzmann;, it was performed as early as the ninth century. To what degree of per- fection the operation attained, history does not show. So far as the re- searches of those who have given the history of the operation especial attention have gone, it would be inferred that the procedure and the instru- ments for its performance were very crude. The operation evidently fell into desuetude, for it was not seriously proposed in modern times until the early part of the present century. In 1813 Gruithuisen, of Salzburg, Bavaria, proposed an operation for crushing stone in the bladder by means of a loop of wire passed through a metal tube into the bladder; the stone was to be caught in the loop of wire, drawn tightly against the vesical end of the tube, and crushed by means of a sharp-pointed stylet passed through the tube and made to impinge forcibly against the stone, which was thereby split in two. The operation of splitting was to be repeated until the frag- ments were sufficiently small to be evacuated per urethram. It is hardly necessary to say that the performance of such an operation would demand superhuman skill and ingenuity. The first experiments in crushing stones in the human body were performed upon the cadaver by Fournier, of Paris. The first' systematic work on the subject was published in 1818, one year later than Fournier's experiments, by the brilliant young surgeon, Civiale. The first lithotrite was invented by Civiale. Elderton, a Scotch surgeon, perfected a method of lithotrity and published a description of his opera- tion in 1819. Elderton has frequently been styled the father of lithotrity, but, as will be seen, he was merely following in the footsteps of Fournier and Civiale. Fournier should really have the credit that has been given Elder- ton. Civiale, however, was the first surgeon to crush a stone in the living subject. This operation was performed in 1824. Since that time the oper- ation has been greatly improved by Civiale himself, Heurteloup, Sir William Ferguson, Dittel, Nelaton, and Sir Henry Thompson. No great improve- ment was made in the operation of lithotrity by any subsequent operator until the late Prof. H. J. Bigelow, of Boston, perfected his operation of rapid lithotrity, or litholapaxy. The greater popularity- of the crushing operation in our own, as com- pared with foreign countries, is mainly due to the untiring efforts of Bige- low, who w^as one of the first to advocate and the first to systematize and perfect the technic of complete removal of the stone at one sitting, instead of by successive operations and irrigations. By his modified lithotrity — or ^ Annals of Surgery, May, 1898. 794 UEIXAEY CALCULUS. litholapaxy — Bigelow demonstrated not only the tolerance of the bladder for prolonged manipulations within its cavity, but the feasibility of intro- ducing practically straight tubes into the bladder for the purpose of wash- ing out the calculous detritus produced by crushing. Prior to Bigelow's demonstrations the foundation for litholapaxy was laid by Fessenden Otis, who showed the tolerance of the urethra for instru- ments of large size. Great credit is due Bigelow, but it should be remem- bered that the indefatigable labors of Otis paved the way for litholapaxy. Lithotrity, like many other excellent procedures of a surgical char- acter, has suffered greatly at the hands of its overenthusiastic friends. The sudden transition from the necessity of a cutting operation to the possibil- ity of a bloodless method of dealing with calculi turned the heads, not only of the surgeons who accepted it with undue confidence in its safety and simplicit}^, but of the patients as well. Carelessness, on the one hand, and oversanguine expectations on the other, necessarily led to disappointment, and it was not long before the profession began to realize that lithotrity was not invariably applicable, was often fatal, and, moreover, required con- siderable skill and Judgment in its performance. As a corollary, the neces- sity for a judicious selection of cases was soon recognized. The operation of litholapaxy, or rapid lithotrity with evacuation of fragments, has completely supplanted the ordinary operation of lithotrity. The advantages of removing the detritus at once, and thus completing the operation at one seance instead of allowing the more or less pulverized frag- ments to remain in the bladder are sufficiently plain. In the old operation a number of sittings were required, all equally dangerous and painful, such fragments as had been pulverized to a sufficient degree of fineness being al- lowed to escape at will with the urine after each crushing, large fragments being reserved for future crushings. Later on in the history of the opera- tion some of the detritus was washed out at each sitting. When the sur- gical world learned from Bigelow the extreme degree of tolerance of opera- tive manipulations possessed by the bladder, and from Otis the possibility of using tubes of considerable caliber in evacuating the fragments after crushing the stone, the more primitive operation of interrupted crushings went to the dead-lumber room. Techxic of Litholapaxy. — -The patient should be prepared for at least a week prior to the operation, by alkalies, diluents, rest, and a milk diet; in short, such measures as have already been suggested in connection vrith the subject of genito-urinary hygiene. Urinary antiseptics should be given, eucah'ptus and salol being the best. If the bladder be irritable and the urine ammoniacal, it should be washed out twice daily until it will hold from four to six ounces of urine and has become accustomed to instru- mental interference. Aperients and an enema should be given before the operation. The instruments necessary for litholapaxy are two or more lithotrites, LITHOTEITY AND LITHOLAPAXY. 795 evacuating tubes of several sizes, and an evacuator. Bigelow devised special patterns of all these appliances, the modifications of which are the best now in use. Clover's evacuating apparatus or its modifications may, however, be used if preferred. It is well to have at least two lithotrites of different sizes, with perhaps an extra one to provide for accidental breakage of an instrument. Operation. — When the bladder is infected it should be irrigated thor- oughly before the operation is begun, and distended by a warm antiseptic Fig. 172. — Modified Bigelow lithotrite. solution: bichlorid of mercury, 1 to 10,000; or boric acid. If the urine is healthy, from 4 to 6 ounces may be allowed to remain in the bladder in lieu of the antiseptic solution. Some surgeons prefer to use the solution in all cases, believing that the bladder tolerates the antiseptic fluid better than urine. The correctness of this view is doubtful; if, however, cocain be used, the injection of water greatly facilitates the operation, and renders it practically painless. In some of the author's cases most satisfactory results have been obtained by the use of 1-per-cent. solution of cocain. Fig. 173. — Clover's evacuating apparatus and tubes. in the urethra and a V2-per-cent. solution in the bladder. The cocain should be dissolved in 1-per-cent. solution of carbolic acid. Antipyrin, 10 per cent., adds to the anesthetic effect of the solution, and is perfectly harmless. It is not necessary to give a general anesthetic in a certain proportion of cases. Where it can be avoided it is better to do so, as the sensations of the patient are a valuable guide in the operation. If the pa- tient is very nervous, the urethra extremely tender, the prostate enlarged, or the bladder irritable, general anesthesia may be advisable; but even in 796 UKIXAEY CALCULUS. such cases the use of cocain will often obviate the necessity of general anesthesia. Where it is unavoidable, chloroform is best. The patient should be placed upon a narrow operating-table covered by a quilt or hair-mattress of firm texture, with his knees slightly flexed and separated, and a cushion or pillow under his hips, care being taken not to expose any more of the body than is absolutely necessary, chill being very dangerous in these cases. The lithotrite should next be warmed and lubricated and introduced into the bladder, being allowed to pass into the organ by its own weight. Fig. 174. — English method of seizing the stone in lithotrity. (After Brodie.) Great care is necessary in the operation lest the mucous membranes be abraded, thus affording atria for the absorption of toxic materials with re- sultant septic or urine-fever. The instrument having entered the bladder, its convexity should be pressed downward toAvard the rectum, and the blades of the lithotrite sep- arated slowly and carefully, thus permitting the stone to fall between them, as it will do in by far the majority of cases. Should it not do so readily, the hips may be elev,ated, and failing in this they may be depressed, in the hope of catching the stone. Before each of these maneuvers the blades LITHOTEITY AXD LITHOLAPAXY. 797 of the instrument should be opened, else the male blade may push away the stone as it rolls into the desired position. If the prostate is not greatly enlarged and the las-fond is not deep enough to conceal the stone, these procedures are usually successful in grasping it. If not, an attempt should be made to pick up the stone by rotating the beak of the lithotrite from side to side successively, the angle of deflection being about 45°. Finally, the beak of the instrument may be turned directly downward behind the prostate, thus searching the las-fond. The essential points in these manipu- lations are (1) to avoid bringing the instrument in contact with the ves- ical walls so far as possible, and (2) to open the jaws of the lithotrite before changing its j)osition from side to side. So far as the main principles of the technic of stone-crushing are con- cerned, little or nothing of importance has been added since the systematic descriptions of it published by Heurteloup and Civiale, save certain minor modifications instituted by Sir Benjamin Brodie and Sir Henry Thompson. As described by the latter, the "English method" is as follows: — The patient lying on his back, the handle of the lithotrite is elevated, thus bringing the convex part of its curved extremity in contact with the posterior surface of the bladder. The lithotrite is then to be opened to a greater or less extent, accord- ing to the probable size of the calculus, the fixed blade being at the same time pressed gently downward in the direction of the rectum. The object of this maneuver is to bring the lithotrite below the level of the other parts of the bladder so that the calculus may fall between the jaws of its own weight, and is generally successful. If it should fail, the lithotrite, without being moved from its situation, may be gently struck on one side of the handle or on its anterior part; the slight coneussioii thus commimicated to the bladder will probably be sufficient to dislodge the calculus, and bring it within the grasp of the instrument. If it should be otherwise, the instrument, being closed, may be very gently and cautiously turned to one side or the other, so that the curved extremity of it may make an angle of 25° or even 30° with the vertical line of the body, then opened and pressed in the direction of the rectum in the manner already described. When the prostate gland is much enlarged there is sometimes difficulty in seizing the calculus, arising either from its lying under that part of the gland which projects into the bladder or from the impediment which it offers to the elevation of the handle of the instrument. For such cases the operating-table invented by Heurteloup, which enables the patient's shoulders to be suddenly lowered, is very convenient. The cal- culus is then seized, not in that part of the bladder which adjoins the rectum, but in the fundus, this being rendered the lowest point by the elevation of the pelvis. In the classic operation of Civiale the principle followed is the reverse of the foregoing: — By the position of the patient, the center of the bladder and the space beneath it are selected as the area of operation; no depression of the lithotrite is made; contact between the walls of the bladder and the instrument is, as much as possible, avoided. The instrument is applied to the stone in the situation in which it naturally falls, and the operator carefully avoids moving it. Movements of concussion, how- ever slight, are apt to produce serious injury. The instrument, having entered the bladder, glides smoothly down the trigone, which in the normal living viscus is an 798 UKIKAEY CALCULUS. inclined plane. In many instances the stone is touched by the lithotrite in passing, and the slightest lateral movement of the beak shows on which side it lies. In this event the operator should be careful not to disturb it, but should incline the beak slightly away from the stone and pass the instrument gently onward to the posterior vesical wall, while slowly opening its jaws. It should be remembered that so long as the blades are close to the vesical neck they cannot be opened without pain or traumatism. The widely-opened lithotrite should be inclined toward the stone and slowly closed. The stone is almost certainly seized. If no stone is felt on entering the bladder the surgeon should simply withdraw the male blade an inch or more in the median line, incline the blades to the right side about 45°, and then close them without otherwise disturbing the angle or central position of the shaft. It will be seen that in almost all positions the stone is seized sidewise. If no stone is felt, the Fig. 175. — French method of seizing the stone in lithotrity, (After Civiale.) blades should be opened, turned to the left, and again closed in a similar manner. The blades are always to be opened before they are turned. If the turn is first made and the blades subsequently opened, the male blade, as it is withdrawn, will prob- ably move the stone away. If, however, the blades are inclined while open, the stone will quite likely be seized. The stone very rarely eludes the maneuvers thus far described. Should it do so, however, the handle of the lithotrite should be depressed half an inch or so, thus raising the blades very slightly from the floor of the bladder. They should now be turned horizontally to the left. If this maneuver is not success- ful, the blades should be gently turned to the right horizontal position and closed. As Thompson points out, the five positions of the blades of the litho- trite embraced in the foregoing description of the teehnic of lithotrity — viz.: the vertical, right and left inclined, and right and left horizontal — LITHOTEITY AND LITHOLAPAXY. 799 constitute a thorough exploration of the cavity of the bladder, and enable the surgeon to find with almost absolute certainty any stone of moderate or large size, providing the conformation of the bladder be normal. Thomp- son especially enjoins the surgeon to avoid communicating any jerk or con- ciission either to the instrument or bladder. It is only necessary in the various movements outlined to barely touch the walls of the bladder with the lithotrite. There should at least be at no time sufficient roughness of manipulation to excite any especial degree of pain or produce vesical con- traction. When the prostate is sufficiently enlarged to alter the form of the vesical floor, and especially to change the conformation of the true vesical neck — i.e., the prostatic urethra — it may be necessary to reverse the posi- tion of the lithotrite-blades in such a manner that they point downward toward the trigone. In this manner a concealed calculus, a very small stone or a fragment, may often be picked up, although it has eluded the grasp of the instrument in every other maneuver and position. In searching for small calculi or fragments Thompson recommends a lithotrite with short blades, which, he claims, and with reason, can be more readily reversed than those of a larger instrument. The technic of picking up fragments and small or concealed stones from the las-fond is described by him essen- tially as follows: — The handle of the lithotrite should be depressed another inch or so between the patient's thighs so that the axis of the instrument, instead of being directed obliquely a little upward, is in a horizontal position, or even a little below it. The blades, which are supposed to have been already brought to a horizontal position, are turned to the right in such a manner as to point obliquely toward the vesical floor, which should be very lightly touched by them. No pressure should be made on this part of the bladder, and it is easily avoided by depressing the handle of the lithotrite. The blades during this maneuver should be open until they have been turned to the proper degree, and then they should be closed. They should now be reopened and turned back — i.e., upward and to the left— and again closed. Finally they may be brought around to the reversed vertical position, with the beak pointing directly downward and the floor of the viscus lightly swept. This last maneuver requires considerable depression of the handle, and is only necessary in picking up small frag- ments with a short-bladed instrument. When the prostate is considerably enlarged, necessitating search for a calculus or fragments behind it, the position of the beak of the lithotrite is reversed Avithout depressing the handle. These maneuvers should be executed at or beyond the center of the vesical floor — the proper area for oper- ating. There should be no hurry, no rapid movements, nor any manipulation what- soever characterized by jerk or concussion. If the bladder be fairly healthy, the various manipulations described should not be attended with any particular amount of pain. The operator's eye should be so familiar with the scale marked on the sliding rod of the lithotrite that he knows at a glance the exact interval between the blades in the bladder. It is essential while manipulating the lithotrite to maintain its axis, so far as possible, always in the same direction. The blades only are to be moved; the shaft should occupy the same inclination unless when necessary to alter it for some specific purpose. In screwing home the small blade the operator is very apt to move the lithotrite also at each turn of the screw, unless apprised of the 800 URINAEY CALCULUS. care necessary to avoid it. All lateral movements, all vibration and concussion neees- saiily react on the neck of the bladder and prostatic urethra, where the instrument is most closely embraced and its mobility most limited. To that part of the lithotrite which occupies the anterior portion of the urethra much freedom of lateral move- ment is permitted, and in the bladder the instrument is also free, although in less degree; but the axis, or fixed point, as regards lateral movement, is at the vesical neck, which is also the most sensitive part of the entire canal. The aim of the operator should therefore be to produce in this situation no motion of the lithotrite whatever, except that on its own axis. Few details of the operation require more patience for its mastery than this. Thompson gives several original and very valuable practical hints re- garding the location and method of seizure of the calculus. He says: — The larger the stone, the more likely it is to be found near the vesical neck when the patient is in the ordinary recumbent position. A small stone is usually found at the back of the trigone. The position of the large stone requires a special method, and it will be found almost invariably successful. The lithotrite should not be pushed onward to the bottom of the cavity as soon as it enters the bladder. First let the blades be inclined away from the side on which the stone is felt, then push on the female blade only, as far as it will go, maintaining the male blade at the neck of the bladder. It is now only necessary to incline the beak toward the stone, and it will almost certainly be seized at once. If the operator commences by pushing on the whole instrument and then withdraws the male blade according to the ordinary custom, the blade is infallibly drawn against the large stone, fails to catch it, and presses it back against the neck of the bladder, producing pain, irritation, and perhaps bleeding. In both the French and English methods of seizing the calculus the principal point is the extreme gentleness required to avoid injury to the delicate structures about the prostate and vesical neck, for in direct pro- portion as this is avoided will be the success of the operation. In the Eng- lish method, as will be observed, an attempt is made to keep the female blade in one position, all necessary movements in grasping the stone being made so far as possible by withdrawing or closing the male blade. If the handle of the lithotrite be elevated and the point thus depressed, the male blade may be moved in and out without bruising the vesical neck, and a good-sized stone may thus be crushed without producing severe pain or vesical irritation. After having been grasped in the jaws of the lithotrite, the stone is to be crushed by turning the screw slowly and steadily until the stone is felt to crumble and the jaws of the instrument are observed to be closed or quite near together — according to the thoroughness of the crushing. The screw must be turned firmly, but slowly, else fragments may fly about, or the stone slip and do injury to the vesical walls. The size of the stone when grasped, and the degree of approximation of the blades of the litho- trite after the crushing, may be measured by the scale upon the shaft of the instrument. It is at this point that the difference between lithotrity and litholapaxy LITHOTRITY AND LITHOLAPAXY. 801 begins. In the former operation the surgeon makes a second or third crush- ing of the larger fragments and then leaves the operation for another sitting, either trusting to the flow of urine during micturition to bring away the detritus or, if he be more modern, washing it away with an evacuator and tube. In the latter method the surgeon proceeds to complete the operation by crushing every fragment large enough to be grasped by the jaws of the lithotrite, and finally evacuating the debris completely by Bigelow's evacu- ator and tubes. Time is scarcely an object in this operation, as a sitting of several hours' duration is generally well tolerated. The time which may be safely occupied depends upon the expertness and technic of the operator and the condition of the patient's kidneys and bladder. On withdrawing the lithotrite care should be taken that no fragments are caught in its jaws, and that the male blade is screwed tightly home. It has been recommended to elevate the blades of the instrument by de- pressing its handle, open them and tap smartly upon the end of the handle, thus freeing any particles of stone that may be adherent to the blades. In the perfected operation of litholapaxy, if skillfully performed, frag- ments and no danger of impaction of fragments in some portion of the traction; hence there is no danger of injury to the urethra by sharp frag- ments, and no danger of impaction of fragments in some portion of the canal to give serious after-trouble to both surgeon and patient. The ad- vantages of immediate removal as compared with leaving until a future operation sharp fragments that cause more severe irritation than did the stone before the crushing are sufficiently obvious. If the fragments of calculus have been crushed with sufficient thor- oughness, the evacuation of debris is usually a very simple procedure. In the performance of this part of the operation as large a tube should be used as it is practicable to introduce. Any obstructions that may exist in the urethra should be removed by incision. The meatus will very frequently be found contracted to an extent sufficient to obstruct the passage of the tube. Where it is practicable to introduce the lithotrite without incising the meatus, it is well to reserve the incision until the introduction of the evacuating tube. A straight and, where it is practicable to introduce it, a comparatively short tube should be used. The tubes in general use are longer than necessary excepting in such cases as present aberrant conforma- tion of the prostatic urethra and vesical neck. The shorter the tube, the greater the facility of washing out the fragments. In the pumping process involved in the evacuation of the debris, Watson advises the following maneuver : — When there is much debris it is well to commence pumping with the point of the tube held, a little above the floor of the bladder. During this earlier part of the operation there should be no interval between the compression and expansion of the bulb. The object at this time is to set the fragments whirling, and to catch them while they are suspended. If the end of the tube is buried too deeply in the 803 UKIXAET CALCULUS. detritus, it is apt to be clogged at the outset, and evacuation thereby hindered. Later, when the fragments are few, the tube is carried to the floor of the bladder, and a few moments should elajDse after pressing the bulb to give the fragments time to settle into the depression about the end of the tube before the expansion which is to suck them into it. "\Mien any particular aspiration brings frag- ments, the position of the tube should be kept unchanged until they cease to come. Eeferring to obstruction of the tube by the vesical \\^allSj which are sometimes sucked into the orifice, TTatson says: — The stopjjage from this cause is usually not continuous, but the walls flapping against the opening give the instru- ment a series of jerks that remind one of a fish-bite. When this is felt, the instrument should be moved to another part of the bladder. If it ag-ain occurs, the bladder is not suffi- ciently distended, and Mater should be added to the hose at the top of the bulb. The pumping process should be persisted in so long as gravel or sabulous debris continues to come away. As soon as the fragments cease coming, the lithotrite should be reintroduced and further crush- ing performed, after which the evacuator is used as before. The principal difficulty in the operation of litholapaxy is the crushing of the final fragment. It sometimes haj^pens that a single small fragment eludes discovery and crushing, and remains in the bladder to form a nucleus for a new calculus. This fact has accounted for much of the criticism to which litholapaxy has been subjected. Careful search with the beak of the lithotrite, alternating, if necessary, with a current of water thrown through the evacu- ating tube, usually succeeds im locating the fragment, after which it is comparatively easy to pick it up with the lithotrite and crush it. Chismore's lithotrite is a very ingenious device for catching small fragments. It has a central tube traversing the male blade and opening at its base. To this tube an aspirating bottle is attached for the purpose of exerting suction upon the contents of the bladder, thus drawing the fragment between the blades where it may be crushed with great facility. Chismore has also devised a hammer or percussor for fracturing the calculus after it has been caught in the jaws of the lithotrite. Fig. 176. — Chismore's lithotrite. LITHOTEITY AXD LITHQLAPAXT. 803 In withdrawing evacuating tubes great care should be taken lest a frag- ment of calculus should be impacted in the eye of the instrument and pro- duce laceration of the neck of the bladder and urethra as it is withdrawn. Should such impaction occur, the calculus material may be removed by a stylet. In cases in which straight tubes are with difficulty introduced, tubes with a short, curved point, corresponding to the ordinary deep urethral curve, may be used. Fig. 177. — Chismore's pereussor for fracturing calculi. Accidents During LitJiolapaxy. — There are really no very important complications of the operation of litholapaxy. Hemorrhage may occur under certain special conditions, but with proper delicacy of manipulation it certainly should be rarely experienced. The same remarks apply to laceration of the urethra. Should, however, the latter accident occur, a retained catheter, or, better, perineal drainage, should be instituted for a few days. The bladder is sometimes injured by its walls' falling between Fig. 178. — Chismore's washing bottle and tube. the jaws of the lithotrite. This is not apt to occur when the viscus is dis- tended with fluid to the required extent. In the normal bladder it is almost impossible to catch the walls of the organ in the lithotrite. When, how- ever, it is the seat of diverticula, or is considerably columnated, as it occa- sionally is in old men, such an accident may occur. Eough manipulations with the lithotrite or overdistension with fluid may produce rupture. Wat- son relates a case in which the bladder ruptured by its own spasmodic con- 804 UEINARY CALCULUS. traction when containing but an ounce or two of urine. In sucli cases laparotomy should be performed at once. The chief danger is the impaction of fragments in the eye of the evacuating tube or between the jaws of the lithotrite, already mentioned. Such fragments may become dislodged from the instrument and impacted in some part of the urethral tract. The favorite points of lodgment are the prostatic urethra, bulbo-membranous Junction, and fossa navicularis. The maneuvers for avoiding such accidents have already been mentioned. In case a fragment should become impacted in the urethra in spite of all pre- caution, it may often be removed by properly-constructed forceps. Peri- neal section may be necessary. In some instances the fragment may readily be pushed back into the bladder. The lithotrite occasionally breaks, in which event perineal section, or even suprapubic cystotomy, may be neces- sary. As a rule, there are no untoward results of the operation. Inflamma- tion of the bladder, prostate, urethra, and testes may occur. Peritonitis follows more often than might be supposed. Urine-fever occurs in a cer- tain proportion of cases. The sounder the kidneys, the less the danger of both infection and uremia. On the completion of the operation the patient should be given a little whisky or brandy in a copious draught of hot water and put to bed. If there is any particular degree of shock, warmth should be applied to the extremities. Morphia and quinia may be administered to prevent chill. It is an excellent plan to give the narcotic by the rectum in the form of sup- positories. The diet should be limited strictly to milk, and urinary anti- septics kept up. If there are no injurious effects from the operation, the patient may be allowed to get about within forty-eight hours. Many sur- geons allow the patient to get up at the end of twenty-four hours, but the author does not consider this wise. Freyer pronounces litholapaxy the safest and best operation for calculi of all sizes in patients of all sorts and conditions, provided only that the operation is feasible. When litholapaxy is not practicable, he considers that calculi up to about three ounces in the adult, and of corresponding weight in the child, are best removed by perineal lithotomy; beyond that, supra- pubically. He states that six and one-eighth oimces is the largest stone he has removed by Bigelow's method. He holds that in no case should a stone, large or small, be subjected to a cutting operation till, after trial, litholapaxy is found not to be feasible. Freyer's lithotrites vary from No. 4 ^/o up to 18, of the English scale. Only the larger sizes, from No. 11 up to 18, are of any practical use in deal- ing with large stones. His lithotrites combine the handle and locking ac- tion of Bigelow's lithotrite, with the fully fenestrated blades of Weiss and Thompson. They have a ball handle that affords a much firmer grip to the hand than the old-fashioned wheel: a grip necessary in dealing with large LITHOTEITY AND LITHOLAPAXY. 805 and hard calculi. The locking action is of the simplest character, the in- strmnent being locked or unlocked by a quarter turn of the wrist, to the right or left, respectively, the left hand being free to grasp the female blade, and hold it steady in the bladder during the various manipulations. The tilting of the instrument that is liable to occur when the button-lock- ing action is employed is thus obviated. The cannulas used by Freyer for large calculi in the adult vary from Nos. 14 to 18 English. Exception should certainly be taken to Ereyer^s statement that, where litholapaxy is not practicable, perineal lithotomy should be performed for calculi up to three ounces in weight in the adult. The statistics of the im- proved suprapubic operation are by no means complete or extensive, but, so far as they go, indicate the superiority of suprapubic section in adult patients below middle age. Litholapaxy is the operation of election in all cases of vesical calculus in the female. The shortness, and anatomic and physiologic unimportance of the female urethra, greatly enhance the facility and safety of the crush- ing operation. Peeineal Lithoteity. — A modification of lithotrity involving an opening in the perineum was devised in 1862 by Dolbeau. Eeginald Har- rison has recently revived and improved this operation. He speaks of it as follows^: — "The name of perineal lithotrity was given by Dolbeau to an operation, com- pleted in one sitting, by which the membranous portion of the urethra is opened, the prostate and the neck of the bladder dilated instead of being cut, and a large stone crushed and its fragments immediately evacuated. "The chief features of the operation are: (1) the mode of obtaining access to the interior of the bladder from the perineum, and (2) the mechanism connected with crushing and evacuating the stone. From a number of experiments I made upon the dead subject, as well as from the performance of median cystotomy on the living, for various purposes, it seemed unnecessary to do more than make an opening from the perineum into the membranous urethra at the apex of the prostate on a grooved staff passed along the urethra, sufficient to admit the introduction of Wheelhouse's small tapering gorget, and subsequently the index finger, into the bladder, as for digital exploration or as is done in the hontonniere or Cock's opera- tion; more than this is not necessary. In Dolbeau's operation direct access was obtained by this route, aided by the use of an expanding instrument, by means of which the prostatic urethra and neck of the bladder were dilated. It seems to me, from experiments upon the cadaver, that the latter means of dilation is not only unnecessary, but is open to the objection that, unless used with the greatest care, it is possible to inflict serious damage by it. Further, I succeeded in demonstrating that by means of crushing-forceps, shaped somewhat like the blades of the lithotrite, and not exceeding by actual measurement in circumference that of an ordinary index finger, sufficient power might be provided to crush and assist in evacuating any stone that could be fairly seized in this way. These forceps are provided with a cutting rib within the blades, and the more powerful instruments are fitted with ' Lancet, September 22, 1888, and April 7, 1894. 806 UEIXAEY CALCrLITS. a movable screw on the handle. The fragments may subsequently be withdrawn by means of aspirator-catheters passed through the wound, or even by forceps. If care is taken to make the perineal wound correspond in size with the evacuating catheters, which should be of about the size of an ordinary index finger, there is no difficulty in keeping the bladder distended during the necessary manipulations. The chief points that Harrison gives in favor of this operation are these: (1) it enables the operator to crush and evacuate large stones in a short space of time; (2) it is attended with very little risk to life as com- pared with other operations where any cutting is done^ such as lateral or suprapubic lithotomy; (3) it is well adapted to old and feeble subjects; (4) it permits the operator to wash out the bladder, and any pouches con- nected with it, more effectually than by the urethra, as the route is shorter and the evacuating catheters employ^ are of much larger, caliber; (5) the surgeon can usually ascertain, either by exploration with the finger or by the introduction of forceps into the bladder, that the viscus is cleared of all debris; (6) it enables the surgeon to deal with certain forms of pro- static outgrowth and obstruction, complicated with atony of the bladder, in such a way as not only to facilitate the removal of the stone, but to restore the function of micturition; (7) by the subsequent introduction and temporary retention of a soft-rubber drainage-tube, cystitis due to the retention of urine in pouches and depressions in the bladder-wall is either entirely cured or at least permanentl}^ improved. The retention of ammoniacal urine in a bladder that cannot properly empty itself after lithotrity favors the formation of recurrent phosphatic stone. Harrison claims that he has never known the wound to remain unhealed, except in those cases where, for some reason or other, it has been desired to construct a low-level urethra. It is well adapted for some cases of stone complicated by deep urethral stricture, as it facilitates operation upon both conditions at the same time, and does not expose the patient to danger incurred by lithotrity via a weakened or permanently damaged urethra. LITHOTOMY. The operation of litholapaxy has unquestionably greatly narrowed the field of usefulness of all cutting operations for stone. The extent to which lithotomy has been restricted in the practice of some of our leading au- thorities is well illustrated by the statement of Sir Henry Thompson that, whereas he formerly found it necessar}^ to cut 25 per cent, of patients with calculus, he now performs lithotomy in a little over 3 per cent, of cases. It is the author's opinion, however, that the advocates of the crushing op- eration have become oversanguine on account of the remarkable success attained by relatively few extraordinarily expert operators. The statistics of litholapaxy in the hands of such operators as Thompson, Keegan, and Freyer are somewhat misleading, for the reason that their opportunities have been such as to give them a manifest advantage in perfecting their LITHOTOMY. 807 operative technic and acquiring the tactile skill necessary to the highest degree of perfection of operative manipulations. Operations for stone, how- ever, cannot be restricted to the practice of the few. The general surgeon and the specialist of lesser opportunities than the extremists in the advocacy of litholapaxy must necessarily be called upon to operate for stone. The feasibility of one or the other operation, and the comparative merits of the cutting and crushing methods cannot be decided, therefore, by statistics obtained by the fortunate few. Under certain circumstances, and with cer- tain operators, lithotomy must necessarily be given the preference. It must also be remembered that what has been said regarding the relative expert- ness of litholapaxists applies with equal force to lithotomists. There are certain operators in whose hands the perineal operation for stone, especially in children, yields statistics that are in nowise inferior to those afforded by litholapaxy in the hands of a limited number of expert operators. It is true that accidents are more apt to occur, on the average, during the performance of the cutting operation than during litholapaxy. Here, again, however, comes into question the relative merits of different operators. In the matter of statistics much depends upon the method of selection of cases. The results obtained by lithotomy in the practice of Benjamin Dudley, of Lex- ington, left little to be desired from a statistic stand-point. In one series of one hundred cases of all ages he did not have a death. As is well known, however, Dudley exhibited great care in the selection of his cases and in the preliminary preparation of the patient. The records of such American operators as the late William T. Briggs, of Nashville, Tenn., taking into consideration the multitudinous variety of cases upon which he operated, are such as the advocates of the cutting operation have no cause to be ashamed of. The old-time operation of suprapubic lithotomy, as recently revived, with all the advantages of modern surgical asepsis and antisepsis, may be said to be still in its infancy. All statistics of this particular opera- tion formulated prior to the antiseptic and aseptic era of surgery should be thrown aside as worthless. The statistics of the operation as modified and improved of recent years are too meager as yet, and too obscured and viti- ated by operations performed by surgeons for whom the principal attrac- tion of the method has been its apparent simplicity, to permit of any deduc- tions regarding the comparative merits of this operation in suitable cases and those of litholapaxy. It were wise, therefore, not to be too sweeping in the advocacy of litholapaxy to the exclusion of lithotomy. Yaeieties of Lithotomy. — The methods of cutting for stones are (1) perineal lithotomy, lateral or median, or a combination of the two; (2) suprapubic lithotomy; (3) combined perineal section and crushing; (4) combined suprapubic section and crushing. Indications for Lithotomy. — 1. In children. In a general way the selection of the operation must depend, to a certain extent, upon the experi- ence of the operator. It is questionable whether an operator who has been 808 UEIN-AET CALCITLUS. extraordinarily successful with perineal lithotomy in children would be justified in beginning his experience with litholapaxy in young subjects. Where the surgeon has acquired a fair amount of dexterity in litholapaxy upon the adult, however, he may properly enter the newer field of lithola- paxy in children. At the hands of operators of average experience perineal lithotomy is likely to continue to be the operation of election. As for the surgeon of limited experience with calculus, both as regards lithotomy and litholapaxy, the former operation is likely to yield the best results. Despite the optimistic views of the more enthusiastic litholapaxists, there is the ever-present danger of leaving fragments behind, to form nuclei for recur- rent calculus. This occurs far oftener than some writers would have us believe. 2. Stones complicated by deep stricture. Here perineal lithotomy dis- poses of both stricture and stone simultaneously. 3. Stones complicated by serious prostatic or vesical disease. (Supra- pubic lithotomy.) 4. Very large stones of whatever consistency in adults. (Suprapubic lithotomy.) 5. Very hard stones of moderate size. (Perineal or suprapubic lithot- omy.) 6. Encysted calculi. (Suprapubic lithotomy.) 7. Cases where a lithotrite has broken during litholapaxy. (Perineal, suprapubic, or combined high and low lithotomy.) 8. Cases where atony or paralysis of the vesical walls so interferes with the expulsive power of the viscus that it cannot be relied on to assist in the expulsion of fragments in litholapaxy. (Suprapubic lithotomy.) 9. Cases of contracted bladder where it is impossible to distend the viscus with fluid. (Perineal lithotomy.) 10. Cases of vesical hyperesthesia (irritable bladder) in old subjects, where the bladder will not retain sufficient fluid to permit of the manipula- tions necessary in litholapaxy. In most such cases, anesthesia will relieve the difficulty, but anesthesia so prolonged as is likely to be required for crushing is extremely dangerous save in young adults with sound kidneys. (Suprapubic lithotomy.) Within the last five years there has been considerable change in the attitude of the profession toward lithotomy in children. It is not so many years since the author stated in his lectures that children under puberty with calculus must always be subjected to lithotomy if the best results were desired with the least inconvenience and danger. The profession, in general, accepted until recently the dictum of Aston Key: — In children it is difficult to mention any operation in surgery so uniformly successful as is lithotomy. The incomplete development and the consequently little susceptibility of the parts involved, the small size of the vessels and the little risk of hemorrhage, the yielding nature of the textures, rendering force unnecessary in LITHOTOMY. 809 the extraction of the stone, are circumstances that combine to divest the operation of much of the danger that surrounds it when performed in the adult. The chief objections offered to the crushing operation in children have been hitherto: (1) the difficulty of controlling the patient without a gen- eral anesthetiC;, (2) the prolonged anesthesia often necessary, (3) the small size of the urethra and vesical neck, (4) the weakness of instruments inci- dental to the small size necessary to the work in the child, and (5) the relative hardness of stone in children. The first reaction against perineal lithotomy in children was based mainly upon the results obtained by Keegan, who claimed that litholapaxy should be the operation of election even in children. Keegan's dictum, being supported by the moderate experience of a few litholapaxists, has im- pelled some authors to accept litholapaxy as the only operation in children. Taking Keegan's own statistics as a basis, let us see whether the claims for litholapaxy are as yet substantiated. It must be remembered that, in com- paring Keegan's results with those of other operators, we are necessarily comparing the results obtained by the man who should be the most expert in its performance with those obtained by operators of less experience and skill. In 115 cases of litholapaxy in children, ages not stated, Keegan lost 4, or 3 Vio per cent. On the other hand, in a total of 355 cases of perineal lithotomy in children, performed by four operators, and at the Massachusetts General Hospital by several different operators, the mortality was 11, or 3.1 per cent. Freyer's tables, comprising 987 cases of perineal lithotomy occurring in 1883 in the Northwest provinces of India, showed the rate of mortality up to 20 years to be 5.1 per cent. These figures give very little assistance in estimating the mortality in children. Eosenthal, from a study of 400 cases, estimates the mortality as follows: — From 1 to 5 years of age, 3.5 per cent. From 6 to 11 years of age, 2.1 per cent. From 12 to 16 years of age, 8.4 per cent. It must be taken into consideration that the statistics compiled by Keegan and Freyer from operations upon native Indian children are not to be taken as an accurate index of the results to be expected in operations by European or American surgeons. In any event, they are not superior to the statistics of lithotomy in children. Climate and racial resistancy prob- ably make a difference in results. This is equally true of litholapaxy and lithotomy. The author ventures the opinion that, despite the advances that have been made in the operation of litholapaxy, and the sweeping claims that are being made for the operation by some of its enthusiastic advocates and their inexperienced disciples, perineal lithotomy is still, on the average, the operation of election in children until at or near the period of puberty, due 810 UEIXAEY CALCULUS. allowance being made for jDrecocity of development in its bearing upon the capacity of the urethra and vesical neck. Lithotomy in the adult may, on the other hand, be considered to be the operation of necessity, which is only to be performed when, for special reasons, already considered, litholapaxy is inapplicable. This statement may later demand modification as the op- eration of suprapubic lithotomy becomes more perfect in technic and more universally practiced. As litholapaxy is the operation of election in the adult, lithotomy being performed only when the crushing operation is, for one reason or another, inapplicable, the mortality-rate of the cutting operation must necessarily be greater at the present time than when it was practiced in cases of all kinds, including the favorable ones. As the limitations of lithotomy decrease, its mortality-rate will, of course, increase, although the increase will be limited somewhat by increasing perfection in aseptic and antiseptic technic in the cutting operation. Increasing experience with the sujDrapubie operation in the adult will, in all probability, offset, to a certain extent, the increasing mortality-rates of lithotomy incidental to the en- croachment of litholapaxy upon the operative field. History of Litliotomy. — Lithotomy is probably a very ancient opera- tion. The Hindoos were alluded to as lithotomists by Hippocrates. It is certain that Susruta. a learned Hindoo physician, described the operation 1000 B.C. He described the suprapubic as well as the perineal operation. Little was known of lithotom}^ however, until the middle of the Sixteenth Centur}^ when it was revived, mainly through the efforts of a Florentine monk, Frere Jacques, who performed perineal section. About this time, also, Pierre Franco performed not only the perineal operation, but also supra- pubic section. In 1560 he performed the latter operation on a child, and removed a stone the size of a hen's egg, which he had previously failed to remove by perineal section. Frere Jacques is credited with having done several thousand perineal sections for stone. It seems that the chief com- petitors of the monks in those ancient days were the barber-surgeons, one of whom, Eau, was said to have been a very successful operator. Perineal lithotomy was finally reduced to a scientific basis from both an anatomic and surgical stand-point by Cheselden, an English surgeon. The operation has since been modified to a greater or less degree by different surgeons, largely to suit their own ideas of the direction and length of the incisions and the instruments that are most useful in operating, but the operation of lateral section in vogue to-day is none the less essentially that of the distinguished Cheselden. The lateral operation, through one lobe of the prostate, practically displaced for a long time the Marian or median sec- tion introduced nearly four hundred years ago by Marianus Sanctus de Barletta. This operation in more recent years was revived and improved by Allarton, also an English surgeon. Allarton's median section is the type of that occasionall}' practiced at the present daj^, and was the progenitor of LITHOTOMY. 811 median perineal cystotomy as it now exists. Dupuytren modified the median operation by making a bilateral section of the prostate. Civiale de- signed and advocated a special variety of bilateral section that he termed the medio-bilateral operation. Special instruments were devised by both of these operators for the performance of their peculiar modifications of perineal section. The ancient operation that became most unpopular was the high, or suprapubic, section. Under recent aseptic and antiseptic sur- gical methods, however, the operation has been revived and is becoming deservedly popular with some of our most progressive surgeons. In a gen- eral way, it may be said that it is not wise for the surgeon to adopt any cutting operation as a matter of routine. To accomplish the best results Fiff. 179. — Clover's crutch. he should be familiar with all the various methods, and, while he may ex- hibit a preference for some particular method, he should modify his technic whenever any circumstances involving the age, constitution, or present con- dition of the patient seem to demand it. Especially should he be ready to modify his technic where the size of the stone indicates it. cheselden's operation of lateral lithotomy. The instruments and appliances necessary for lateral lithotomy are as follow: — 1. An operating-table high enough to reach the level of the opera- tor's breast when in the sitting posture. 2. Several roller bandages of heavy flannel, four inches wide and four 812 . TEIXARY CALCULUS. yards long^ for the purpose of tying the patient in position. These may be substituted by a sort of yoke or crutch (Clover's) with leathern leg- and wrist- bands devised for this purpose (Fig. 179). 3. Two straight-backed, sharp-pointed, stiff scalpels of different sizes. 4. A slightly curved, probe-pointed scalpel. 5. Several lithotomy-staffs with lateral groove. 6. Lithotomy-forceps. 7. Scoops of various sizes. 8. A Thompson searcher. 9. A large fountain-syringe or glass irrigator. 10. A grooved, angular lithotomy-director. 11. A blunt gorget. Fig. ISO. — Position of patient and line of incision in lateral lithotomy. (After Bryant.) 12. Half a dozen hemostatic forceps. 13. Perineal tube grooved for a petticoat. If it be advisable to modify the operation in any way, as by making bilateral incisions, etc., the special, instruments devised for the purpose may be used. Their necessity, however, is questionable, as all necessary cutting can be done with an ordinary scalpel in the hands of a careful operator. Instruments for crushing and evacuating should be at hand. The prep- aration of the patient should be precisely the same as outlined in connec- tion with urethral operations and lithotomy. Just prior to the operation the urine should be drawn off, and if the LITHOTOMY. 813 bladder is infected it should be irrigated with a warm solution of bichlorid, 1 to 20,000, or of boric acid, until tolerably clean. Six to 8 ounces of this solution should be allowed to remain in the bladder. Having been placed upon the table upon his back, in a good light, and anesthetized, the patient's hands and feet are strapped or bound together, and each leg supported by an assistant in such a manner that the nates Fig. 181.— Lithotomy-staff. project over the edge of the table (Fig. 180). The perineum is supposed to have been shaved, scrubbed, and aseptized, and the rectum emptied before the patient is placed upon the table. A staff with a left lateral groove, as large as the urethra will admit, is next introduced and made to strike the stone. If the instrument cannot Fig. Probe-pointed straight lithotomy^knife. be made to impinge upon the calculus, the operation should be abandoned for the time being, as there is always a possibility of a small stone's having escaped since exploration. The staff, having been placed in the desired position, is given to an assistant, who also holds the penis and scrotum up out of the way. A nurse or assistant should stand at the surgeon's right, and hand him the instruments as required. Some surgeons, however, pre- fer to take the instruments from the tray as required. The average nurse Fig. 183. — Probe-pointed curved lithotomy-scalpel. or assistant is something of a nuisance in selecting and handing instruments to the operator. The Incision. — The external incision is now made by entering the point of the knife in the direction of the groove of the staff one and a half inches in front — i.e., above — the anus in the perineal raphe. The knife is then made to cut downward and outward to a point corresponding to the junction of the outer with the middle third of the space between the tuber- 814 TJEIXAET CALCULUS. osity of the ischium and the anus, tlie knife being drawn out of the tissues gradually as the cut is being made, thus leaving the tail of the incision, so to speak, at the lower angle. Oftentimes the membranous urethra is en- tered at this first stroke; generally, however, it is simply exposed. The forefinger of the left hand now feels for the groove in the staff, and, the finger-nail being engaged in the groove, the knife is passed over it and made to open up the urethra. Having engaged the point of the knife in the groove of the staff', with the edge of the blade turned downward and to the right, — parallel with the ischiatic ramus, to avoid cutting the rectum on the one side and the internal pudic artery upon the other, — the blade is pushed along the groove of the staff into the bladder (Fig. 185). The angle of separation between the heel of the knife-blade and staff should be slight, as this angle will regulate the extent of the deep wound in great measure. Fig. 184. — Conventional diagram of the j^erineuui and the incisions in lateral lithotomy. (After Thompson.) In withdrawing the knife the handle may be depressed a little, thus slightly enlarging the prostatic incision. Another excellent plan is to withdraw the staff until the point is barely covered by the tissues between the incision and the vesical neck, and then, fixing the point of the knife at the desired angle with the staff, passing both into the bladder simultaneously. As the knife enters the bladder, the fact will be announced by a gush of antiseptic fluid, or urine, from the wound. Having entered the bladder, the knife is to be carefully withdrawn, still hugging the groove of the staff; the left forefinger is then to be substituted for the knife and pushed with a slightly boring motion into the bladder along the staff and line of incision; and an attempt is made to feel the stone. Should the operator be unable to reach the bladder on account of a large prostate, deep perineum, or the shortness of his forefinger, a blunt gorget, or grooved director, should be LITHOTOMY. 815 passed in and the prostate dilated. This was the practice of Cheselden and Martineau. To recapitulate the steps of the operation up to the time the operator has reached the stone: — 1. The knife is entered at a point in the perineal raphe about one and one-half inches in front (above) the anus, the point being pushed toward the groove in the staff. It is then swept downward and outward to a point just below the anus, terminating about one-third — preferably a little more than one-third — nearer the tuberosity of the ischium than the anus, and becoming superficial as it is withdrawn. The upper end of this incision Fig. 185. — Lateral lithotomy with a curved staff. (After Bryant.) is about three-quarters of an inch to one inch in depth. By this first in- cision are divided the skin, superficial fascia, and fat, and the inferior hemorrhoidal vessels and nerves. 2. Any undivided structures between the first incision and the mem- branous urethra are divided by the knife, the left forefinger guiding the knife in the wound so as to protect the rectum. In this step the trans- versus perinei muscles, some areolar tissue, and a few small vessels are cut, and the space between the accelerator-uringe and erector-penis muscles opened up. The triangular ligament is also incised, opening its cavity and exposing the membranous urethra. In thin subjects the author does not hesitate to cut through these structures in the first incision. There is no 816 UEIXAEY CALCULUS. danger in so doing, providing the operator is steady, and strikes the groove of tlie staff accurately. 3. The left foretinger-nail is engaged in the groove of the staff, which is readily felt through the membranous urethra. 4. The membranous urethra, if not already opened, is incised just in front of the prostatic apex. 5. The point of the knife is engaged in the groove of the staff and made to hug it firmly. It is then passed along it at a slight angle, with the blade turned laterally and to the right — through the prostate into the bladder, penetration of the bladder being announced by a gush of fluid. 6. The knife is slowly withdrawn, the cut in the prostate being en- larged slightly by depressing the handle. The left forefinger is then bored carefully through the prostate into the bladder, and an attempt made to Fig. 186. — The bony pelvis in its relations to perin,eal lithotomy. (After Thompson.) feel the stone. If this cannot be done, a blunt gorget or director should be used. Once the bladder is entered by the finger, the staff may be removed. The principal danger in lateral lithotomy is in incising the prostate so freely that its investing capsule is divided. This may always be avoided by taking care not to have too great an angle between the blade of the knife and the groove of the staff in pushing the former into the bladder, and avoiding separation of the knife from the groove during withdrawal. Should the accident happen, either through incision or laceration during rough efforts at the extraction of a large stone, urinary extravasation — pelvic — and death are considered almost inevitable. It is possible, however, that this accident happens, and is followed by recovery, more frequently than is gen- erally supposed. LITHOTOMY. 817 Extraction of the Stone. — The next step in the operation is the ex- traction of the stone. Having determined its size and position, the opera- tor passes a forceps, of a size proportionate to that of the stone, into the bladder, guided by his left forefinger, which has never been allowed to leave the wonnd for an instant. This latter is a very important point, especially in children, as it may not be an easy matter to enter the blad- Fig. 187. — Incision in the prostate in lateral lithotomy. (After Erichsen.) der again when once the finger has been removed. When the forceps has entered the bladder, the finger is withdrawn, and an attempt made to seize the calculus, this being usually immediately successful. If the stone be small, it may be grasped regardless of its form, but if of mod- erate size, it must be grasped transversely: i.e., by its short diameter. This is very necessarj' if the stone be oblong. Should there be difficulty in grasp- Fig. 188. — Broad-grooved lithotomy-director. ing it, the finger of an assistant passed into the rectum may be of service. When necessary, the operator may pass his own middle finger into the rec- tum, and press the stone into the jaws of the forceps. He should take care, however, not to insert the same finger into the wound. This advice may seem superfluous, but the author recalls the maneuvers of a distin- guished gynecologist who is something of a monomaniac on the subject of 818 UEIXAKT CALCULUS. antisepsis, but who passes liis imwashed finger alternately into the rectnm and vagina during both operations and labor. The author also recalls see- ing a well-known Eastern surgeon do what was much worse, although not fraught with equal danger: operating for a fistula in ano and enlarged tonsils in succession, without washing his hands. When the wound is so deep that it is impracticable to reach the blad- der with the finger, the forceps may be passed along the groove in the staff, or a director may be passed, the staff withdrawn, and the forceps passed along the director. Care should be taken not to fracture the cal- Fig. 189. — Combined, lithotomy-scoop and lithotomy-director. cuius in grasping it with the forceps, although it must be admitted that this accident is often unavoidable on account of the friability of the stone. Should the stone be fractured despite all caution, the pieces are best re- moved by means of the finger and a scoop. This procedure is necessarily attended by more interference with the bladder than where the stone is extracted whole. In exceptional instances it is necessary to fracture a large calculus intentionally — perineal lithotrity — as the safest procedure under existing circumstances. Whenever fracture occurs, free washing of the bladder and removal of detritus via an evacuating-tube are necessary. Warm antiseptic solutions should be used for washing. After the stone has been Fig. 190. — ^Lithotomy-forceps: double curved. successfully grasped in its most favorable diameter, it is to be extracted slowly, the traction being directed in the axis of the pelvis, with a slight degree of lateral movement. In a measure, the maneuver is like the ap- plication and use of the obstetric forceps. It is here that the careless sur- geon is most apt to do damage by tearing the prostate, with consequent invasion of the tissue-investments that lie between the operator and danger. After the stone has been extracted, it should be carefully examined for facets, which are indicative of companion-stones. The bladder should be carefully explored with the finger and sound, lest some small stone, or frag- LITHOTOMY. 819 ment;, be left behind. The smallest fragment suffices for a nucleus for a future large stone. The bladder having been emptied of calculous material, is to be thor- oughly washed out with a warm antiseptic solution, after which a drainage- tube, or special lithotomy-tube, should be introduced and tied in with tapes. This tube prevents infiltration of urine, and at the same time affords free drainage to the wound. Siphon-drainage should be instituted. After lithotomy has been completed, the patient is to be put to bed, and a restricted regimen prescribed for four or five days, unless, as is occa- sionally the case, there is great prostration or debility, in which event egg- nog or punch may be allowed. Quinin, for its tonic effect, and at first small doses of morphin to prevent chill and relieve pain are indicated. Euca- lyptus and salol should be persisted in, if tolerated by the stomach. At the end of forty-eight hours the drainage-tube may be removed, as the possi- bility of urinary extravasation has by this time been prevented by the glazing of the wound with lymph-exudate. The urine usually escapes through the wound for two weeks or more. Sometimes, however, it sud- Fig. 191. — Lithotomy-forceps: single curved. denly stops flowing through the perineal opening within three or four days, and passes per urethram; this is due to inflammatory swelling and closure of the prostatic wound. This soon subsides, and the urine again flows through the perineum. Should the wound become unhealthy, or sloughing be threatened, iodoform, benzoin, or Peruvian balsam may be applied. Should it heal tardily, it must be stimulated with silver nitrate. Fistulas are rarely left after closure of the wound. When they do form they require caustics, iodin, or the actual cautery to stimulate the tissues to renewed healing. Earely a plastic operation may become necessary. Should the stone be too large for extraction, there are two methods of dealing with it, viz.: bilateral incision and crushing. In the light of our present knowl- edge of lithotrity, the latter plan should be selected. The fragments may be scooped out, or crushed very finely and evacuated by the wound via a tube, in very much the same manner as in the ordinary operation of lithol- apaxy. Dangers of Perineal Lithotomy. — -The dangers of perineal lithotomy are several, hemorrhage being naturally the first to be considered. Hemor- rhage from the superficial perineal vessels is rarely important, but, should 820 TEINAET CALCULUS. the internal pudic or artery of the bulb be wounded, serious consequences may ensue. Earely, indeed, can these vessels be ligated, on account of their depth; hence we are compelled to resort to pressure to control the bleeding. This may usually be accomplished by plugging the wound tightly about the perineal tube, a gauze "petticoat" enabling us to do this with some facility. Styptic cotton or ordinar}' lint may be used, but the best substance is dentists' spunk, which spongy material swells to a moderate degree, thus enhancing pressure. An inflated condom is sometimes suc- cessful. Failing in these measures, relays of assistants should control the bleeding b}' pressure with the aseptized fingers in the wound; it being necessary to persist in this for some hours. Erichsen indorses this pro- cedure very highly. Troublesome hemorrhage of this kind is not likely to occur if the operation be properly performed, unless, as is unfortunately sometimes the case, there is an anomalous distribution of the arteries. Serious venous hemorrhage occasionally occurs. The veins of the pros- tate are sometimes dilated and varicose, 3'ielding considerable blood. This condition is usualh' found in long-standing prostatic disease. Plugging with st3'ptic lint or cotton is very efficacious in these cases. Careful at- tention is necessary to avoid hemorrhage into the bladder. Concealed vesical hemorrhage may be very serious, and yet so insidious as to fail to attract attention until great loss of blood has occurred. It bears a close resemblance in this respect to certain cases of post-partum hemorrhage. Obstinate oozing is usually controllable by hot water. Packing with lint saturated with 20-per-cent. antipyrin solution is often efficacious. Turpen- tine is sometimes of service used in the same manner. Suprapubic section and through-and-through packing may be necessary. Several other accidents that may occur in lithotomy deserve mention. A careless operator may miss the prostate altogether, or thrust his knife so freely through the prostate, instead of carefully following the staff, that the base of the bladder is opened up. Pelvic inflammation (septic cellulitis) and urinary extravasation with a fatal issue are the usual sequences of this blunder. The rectum is liable to injury, and such an accident may be followed by recto-vesical fistula: a very embarrassing result indeed. Slight rectal wounds, however, may granulate nicely along with the perineal and pro- static wound. Cases have been known in which the operator has thrust his knife clear across the bladder, wounding its posterior wall. This is an inex- cusable accident, but may easily occur, especially in children, if the knife be thrust too far, or if the bladder does not contain a moderate quantity of urine. The neck of the bladder in children may be torn across and the blad- der pushed bodily up into the pelvis by the surgeon's exploring finger. This accident is not likely to occur if the deep incision be sufficiently free. It LITHOTOMY. 831 may usually be avoided by introducing a good-sized director along the groove of the staff into the wound. By separating the director and the staff with a moderate degree of pressure, the track of the wound may safely be considerably dilated. The staff may then be withdrawn and the fore- finger passed along the director. It is especially important in children not to withdraw the staff before either the finger or a director has been passed into the bladder. The exploring finger should be well lubricated with some antiseptic ointment before inserting it into the bladder. Geneeal Considekations of the Moetalitt Following Perineal Lithotomy. — The fatalities following perineal lithotomy are most often due to morbid conditions that complicate vesical calculus rather than to the intrinsic severity of the operation itself. The operation is quickly per- formed, as a rule, and in competent hands is not attended by special danger, the various accidents that have been described being very exceptional. Peri- neal section performed under favorable circumstances, as, for example, in removing foreign bodies from the cavity of the bladder prior to the occur- rence of secondary infection of that viscus, is very rarely followed by an unfavorable result. When, however, the urethra, bladder, and kidneys are affected by the various pathologic conditions incidental to prolonged uri- nary obstruction, irritation, and secondary infection, the mortality is rela- tively considerable, and its rate increases pari passu with the duration and severity of the complicating and secondary conditions. There is a marked difference in the danger of wounds bathed with healthy urine and those that are brought in contact with the unhealthy secretions that characterize cases of pyelocystic infection. The chronic urinary toxemia incidental to renal derangements must also be taken into consideration. The system is ill fitted to withstand the shock that necessarily attends all operations of gravity, its severity varying with the nervous constitution and character- istic susceptibility of the individual. Again, the effect of this shock upon the already-damaged kidney is sometimes productive of acute uremia and death. This condition has been sufficiently expatiated upon in connection with the subject of urine-fever. The relatively favorable average results of perineal lithotomy in children may be ascribed to the fact fbat in them the genito-urinary apparatus is usually comparatively healthy. This rela- tively greater local resistance offsets the inferior general resistancy of ex- tremely young subjects as compared with the adult with respect to opera- tions. It will, of course, be understood that there are certain cases in young and middle-aged adults in which the bladder is healthy and the prognosis consequently good, providing the kidneys are sound. The con- trast between young children and adults is only fair as respects advanced cases in subjects well along in years, and those cases in relatively young adults in which infection and renal disturbance — one or both — have oc- curred early. Causes of Death Inciderdal to Lithotomy. — In a general way, the deaths 832 UEINAET CALCULUS. following lithotomy are due to one or more of the following causes, viz.: (1) shock; (2) hemorrhage; (3) uremia; (4) septemia; (5) septic cystitis; (6) diffuse pelvic cellulitis, with or without urinary extravasation or gangrene of the cellular tissue; (7) general peritonitis. One of the most frequent causes of death is the action of the anesthetic upon the kidneys. Acute nephritis, or at least acute renal hyperemia from this cause, may occur immediately, or it may he delayed for some days, or perhajDS two or three weeks. IsTephritis ex vacuo occurs in some cases of removal of a very large stone that impinges upon the vesical neck or ureters in such a manner as to produce marked backward strain upon the kidney. The same holds good in cases in which a small stone is forced against the vesical neck during micturition. In some instances uremia is due to light- ing up of an acute infectious inflammation of the vesical mucous membrane that extends upward along the ureter to the pelvis of the kidney, producing either acute pyelitis or pyelonephritis, or an acute exacerbation of already existing pyelonephritis. Some of the untoward results Just enumerated are due to accidents occurring during the performance of the operation. Most of them, how- ever, as already stated, are due to unavoidable local or general conditions complicating and, as a rule, secondary to the stone. Urine-fever in its various phases covers quite a projoortion of the fatal cases of lithotomy and is of especial importance with relation to the pre-existence of what the author has ventured to designate chronic urinary fever. MEDIAN" PEKINEAL SECTION. The median section for stone in the bladder was in vogue long before Cheselden's time, and is said to have been the operation most often prac- ticed by the monks in those dark and barbarous days when the art of sur- gery was held to be more or less disreputable, and none but monks were permitted to "cut for the stone." As already stated, the operation has been attributed to Marianus Sanctus de Barletta, who described the method in 1543. Wliether justly attributable to this ancient surgeon or not, his name has probably been immortalized by his connection with it. It has come down to the latter-day surgeon as the Marian, or Mariani's operation. The operation at present in vogue is the modification of the old Marian operation suggested by Allarton, which is a great improvement upon its ancient predecessor. With Marianus the principal object seems to have been to extract the stone in a manner involving a maximum degree of dila- tion with a minimum amount of cutting. To the mind of Marianus dilation was apparently synonymous with tearing, judging from the fact that he devised dilators the function of which was evidently to tear the prostate in a most unsurgical and reckless fashion. It was this fallacious and dangerous flaw in the technic of the operation as originally devised that caused it to fall into desuetude, the median being LITHOTOMY. 823 finally almost entirely supplanted by the lateral operation. The advan- tages of the lateral section over the old method of median lithotomy were so evident that it is surprising that surgeons should have failed to recognize the danger of mechanic laceration of the prostate long before the lateral operation was perfected by Cheselden. Opeeation. — The improved median lithotomy is performed in the fol- lowing manner: The patient having been placed in the orthodox lithotomy position, a staff grooved upon its convex surface is introduced into the bladder and held steadily in position by an assistant. The left forefinger is next introduced into the rectum to determine the position of the apex of the prostate and to act as a guide to the knife, thus protecting the rectum. A straight stiff-backed bistoury is now entered in the raphe half an inch above the -anal margin, and pushed directly forward to the groove of the staff at the apex of the prostate, thus opening up the membranous urethra. As the knife is withdrawn it is made to cut upward to a slight extent, thus opening the membranous urethra more freely and enlarging the wound in the skin and cellular tissue. A probe or grooved director is now pushed along the groove of the staff into the bladder, and the staff withdrawn; after which the finger — carefully cleansed and made aseptic — is made to enter the bladder by dilating the prostate with a slightly boring movement. The subsequent steps of the operation are the same as in lateral section, but greater care must be taken in withdrawing the stone, else serious lacer- ation of the prostate and the surrounding tissues may occur! A rectangular staff has been suggested in lieu of the ordinary curved instrument, and is claimed to be much more convenient, inasmuch as the angle of the staff when in position corresponds with the apex of the prostate, and it is almost impossible to miss it. A rectangular grooved guide set in a stout handle is safer than a probe or ordinary director for the guidance of the finger in dilating the prostate, as there is less liability of pushing the neck of the bladder before the finger. The median operation is not so generally applicable as the lateral, but is simpler and safer where practicable. It can only be used for small stones — either single or multiple. Stones larger than one inch in diameter cannot safely be removed by it, and, as such stones are usually reserved for lithola- paxy, the scope of the operation is necessarily limited. The indications for the median section as given by Erichsen^ are: (1) foreign bodies; (2) stones of one inch or less in diameter in which the bladder is too irritable for lithotrity; (3) small stones behind an enlarged prostate; (4) detritus remain- ing after incomplete lithotrity; (5) in combination with lithotrity in stones too large for simple lithotrity, and which do not offer a favorable prospect for the lateral operation; (6) in anemic patients in whom the small amount of blood lost in the median section renders it the preferable operation. 'Science and Art of Surgery." 824 UEINAKT CALCULUS. These indications as presented some years since by a world-wide sur- gical celebrity in themselves demonstrate that the median section for stone is something of a surgical superfin.ity. Most of the indications given can be better met by suprapubic section or litholapaxy. The application of median section for stone should be limited to young adults with small stones and very irritable, but otherwise fairly healthy, bladders. In such cases the involved dilation of the vesical neck is highly beneficial, aside from the extraction of the stone. In foreign bodies and very small stones median section will doubtless always have a field of usefulness, although suprapubic section may often be preferred. If litholapaxy be properly performed, lithotomy will rarely be necessary for the removal of fragments. Stones too large for litholapaxy had best be removed by suprapubic .section, although Eeginald Harrison has recently revived Dolbeau's operation of perineal lithotrity. Litholapaxy has practically done away with all discussions as to the relative merits of different cutting operations in anemic patients. In comparing the advantages of the median and lateral operations nearly all surgeons of experience yield the preference to lateral lithotomy, under the age of puberty, and this is certainly wise, considering the statis- tics of lateral section. The hilateral section of Dupuytren and the medio-hilateral section of Civiale are merely modifications of the Cheselden and Marian operations, and have never become popular. It is well, however, for the surgeon to familiarize himself with them as described in some of the older elaborate treatises upon operative surgery. As in all other surgical procedures;- familiarity with all the various operations for stone tends to liberalize the operator, and renders him more capable of adapting himself to unexpected circumstances arising in the course of operations. SUPEAPUBIC LITHOTOMY. The high operation for stone is an illustration of the mutability of surgical fashion. The operation was introduced about the middle of the sixteenth century by Pierre Franco, but fell into disuse and was known chiefiy traditionally until quite recently, when it was revived, mainly through the efforts of Petersen, whose modification has made the method quite popular. Considering the great strides that have been made in ab- dominal surgery, it is not surprising that the simplest and most direct of all operations for vesical calculus should become a recognized and safe oper- ation. The objections that were formerly advanced against the operation do not hold good at the present day. Modern antiseptic and aseptic surgery has modified the prevailing ideas regarding suprapubic lithotomy quite as markedly as other operations. The only unfortunate circumstance in the revival of the suprapubic operation is the fact that the neglect of the method exhibited in past years LITHOTOMY. 825 has been replaced in our own generation by overenthnsiasm. So reckless has this enthusiasm become that some of our surgeons propose the high operation as a matter of routine, irrespective of the size of the stone or the condition of the patient. When we consider the small mortality-rate at- tendant upon litholapaxy and lateral lithotomy in young subjects^ it is hardly fair, as j^et, to ask that we substitute for them the high operation in all cases of stone. It should be noted that in children the mortality has been 12 per cent., which record will doubtless be improved upon ere long. In some severe cases suprapubic section, if properly performed, affords the best chance of recovery. Cases of serious kidney complication where the patient insists upon operation, very large stones with severe cystic inflam- mation, tumors with or without stone, foreign bodies in the bladder, and insacculated stone are best. suited to the high operation in both male and female subjects. With many surgeons the favorite operation for foreign bodies will, however, probably always be the median section on account of its simplicity and safety. Very large stones — i.e., those of a diameter of one inch and a half or upward, stones too hard for crushing, and stones with known uncrushable nuclei, or nuclei that cannot safely be crushed — should usually be operated by the high method. Stones may be successfully removed in this way in cases in which the lateral operation would probably yield a fatal result. The dangers of lateral lithotomy increase rapidly with the size of the stone, which is not so true of the suprapubic operation, although on account of associated conditions the prospect may not be quite so good in large as in small stones. Interference with the urethra, prostate, and vesical neck involved in lateral section is much more likely to produce some form of urine-fever than suprapubic section, and this is especially true where secondary involvement of the kidneys is pronounced. The explana- tion for this lies in the extreme sensitiveness and close association of these parts with the sympathetic system, as compared with the structures in- volved in the high operation. Opekation. — Petersen's operation is performed as follows: The patient is prepared as for ordinary lithotomy. After thorough scrubbing the ab- domen is cleansed with a weak bichlorid or strong carbolic solution as for celiotomy and the hair is shaved off the pubes. Instead of the lithotomy position the patient is placed upon his back. The bladder is now washed out with a warm antiseptic solution (ac. carbol., ac. boric, borax, or salic- ylate of soda) via a soft catheter. Petersen's rectal bag (colpeurynter) is now introduced and filled with 10 or 12 ounces of water, thus pushing the bladder forward and upward. Care is necessary in this procedure, as the injection of an excess of water or too rapid filling of the bag may rupture the rectum — this has happened to several competent operators. The bladder is next filled with from 8 to 12 ounces of a mild antiseptic solution, thus bringing the viscus upward and forward still more prominently. Caution is also necessary at this point. 826 UEINAEY CALCULUS. for the bladder — especially if much diseased — may be ruptured by over- distension. An incision is now made in the median line just above the symphysis pubis; this should begin about three to three and one-half inches above, and terminate at, the symphysis, involving the skin and cellular tissue down to the recti muscles; its length necessarily varies a little according to the corpulency of the subject. The deep incision should next be made; if practicable, exactly between the recti muscles; but there should be as little tearing and bruising of the tissues as possible. After the muscles have been cut through the transversalis fascia is exposed and should be carefully incised upon a director, beginning at the lower angle of the wound, at which point it is impossible to pick up the peritoneum in the majority of cases. Beneath this fascia in the prevesical space — cavity of Retzius — is a quantity of fat that should be pushed or rolled upward out of the way, — enroulement, — as practiced by Guyon. Should the peritoneum be ac- cidentally cut, the wound is immediately sewed with fine catgut and the operation proceeded with. The bladder is now brought plainly in view. Curved needles threaded with heavy silk are next passed through the bladder-walls, one upon each side and parallel with the line of incision, and brought out so as to leave a long double thread; the ends of these threads are tied so that the blad- der may be held against the edges of the woimd by the loops in the hands of assistants. A free vertical incision is next made into the bladder and its interior thoroughly examined both by the eye and finger. Should the parts be seen with diificulty, the Trendelenburg position will draw the bladder into plainer view by the suction-force of the receding abdominal viscera. The stone having been removed by fingers or forceps, the bladder is once more washed out, a catheter introduced, and the bladder sutured, care being taken to suture through the muscular walls only, and not through the mu- cous membrane. A small quantity of gauze is left just above the pelvis to drain the prevesical space, and the external wound sutured as in ordinary abdominal section. It is recommended by some that a suprapubic drainage-tube be left in the bladder; but this is unnecessary where the bladder is sutured. When- ever the vesical wound is closed, a drainage-tube should usually be inserted through a toutonniere in the perineum, though a soft catheter per urethram may suffice. Experience has led the author to modify the Petersen method some- what. The rectal bag is unnecessary and also dangerous. The bladder is always accessible unless contractured and hardened, in which event the rectal bag is of but little assistance anyway. The fingers of an assistant in the rectum fulfill the indications much better than the rectal bag. With the Guyon method of enroulement, the peritoneum is rarely seen. Should it be cut, it should be stitched, and the wound packed for two or three days LITHOTOMY. 827 before entering the bladder. This operation in two stages^ — first employed in France — should be the operation of election in feeble patients with septic bladders. The danger of infection is made practically nil by it. Where the section a deux temps is deliberately chosen the bladder should be ex- posed over as wide an area as possible, and the packing allowed to remain for five days. In very large stones, in tumors, and where the peritoneum is low down or the bladder contracted, the author has practiced the follow- ing method: The bladder is exposed in the usual manner, and the peri- toneum deliberately incised for as great an extent as deemed necessary. The bladder is drawn out of the incision to the required extent and the peritoneum stitched around it, temporary retention sutures being placed in the sides of the bladder and edges of the abdominal wound. The bladder is packed about with iodoform gauze and the usual dressings applied. On the fifth day the operation may be' proceeded with. There is now plenty of room, a large surface of the bladder being uncovered by peritoneum. Stitch- ing the bladder is thus made a very simple matter. In the ordinary operation a deux temps both the preliminary and secondary incisions may be done under Schleich's method, thus obviating the dangers of general anesthesia. As already noted, the Trendelenburg posture greatly facilitates all operations upon the bladder, and especially intravesical operations upon the prostate. In extremely septic bladders through-and-through drainage is best. The author does not advocate vesical suture save in exceptional cases where in- fection is not to be apprehended. Where suture is performed, the wound leading down to the line of suture should be carefully packed, secondary silk-worm-gut sutures being utilized for the closure of the external wound as soon as it is deemed safe to do so: i.e., in four or five days. Even then it is wise to leave a bit of gauze drainage in the lower angle of the wound, leading down to the cavity of Eetzius. Observations made during experiments on intestinal suture in 1881, showing the ready repair of accidental wounds of the bladder, led Eydygier, of Krakow, to the idea that the tendency to adhesion of the peritoneum could be utilized in cystotomy. To prove this he made a series of experi- ments on dogs, and, encouraged by the results, operated on a boy thirteen years of age. Eydygier's method of operating is, briefly, as follows: — The patient is prepared as for laparotomy, a catheter is passed into the bla(ider, and the latter is washed out with a warm solution of boric or salicylic acid, and then partly filled with the same solution. A section is made on the linea alba, as usual. After letting out the solution by means of a catheter, the bladder is drawn out by a silk noose, and iodoform gauze is solidly packed in between the bladder and the edge of the wound. An incision one and a half inches long is made in the bladder, and the finger is inserted and along it the forceps. The bladder is again washed out by the catheter with the above solution, which may overflow the wound of the bladder without entering the cavity of the abdomen. Eydygier recommends applying the furrier's suture according to Czerny's method. This suture has this advantage: that the more the bladder distends, the more the suture tightens. It is necessary to keep 828 UEIXAEY CALCULUS. the catheter in the bladder for eight to twelve days. Rydygier's method can par- ticularly be applied to the entire removal of tumors of the bladder, and it may also be of use in wounds of this viscus.^ The after-treatment of suprapubic cystotomy consists of ordinary anti- septic dressings, changed as required, siphon-drainage with daily vesical irrigation, and removal and cleansing of the catheter or drainage-tube. At the end of a week or ten days it is usually safe to allow the perineal tube or catheter to remain out for forty-eight hours. If no urine escapes through the abdominal wound at the end of that time, the drainage-tube may be dispensed with permanently. The patient should be instructed to urinate at short intervals for a few weeks, to prevent undue tension upon the ves- ical cicatrix. The bladder should be washed out daily with a weak borated or carbolized solution for some time. In occasional cases either a truss or a radical operation will be neces- sary sooner or later on account of hernial protrusion consequent upon yield- ing of the cicatrix. . Fig. 192. — Irregular calculi removed by suprapubic section from case of X. Uric-acid nuclei Avith phosphatic laminae. (Author's case.) Occasional cases will be met with in which removal of large stones suprapubically is followed by a fatal result because of certain conditions in which the presence of the stone is apparently necessary to the preservation of the integrity of the vesical wall. The pressure of the stone, while dis- astrous, apparently prevents sloughing of the portion of the bladder on which it rests. The following case would appear to be an illustration of this : — Case. — X, a man, 65 years of age, consulted the author regarding vesical irritation of nearly ten years' duration. Exploration revealed stone of large size, whether one or more could not be determined because of the large size of the cal- culous mass and the contracted state of the bladder. Suprapubic section was per- formed and two large stones weighing 1500 grains (Fig. 192) removed with some difficulty, but without injury to the incised portion of the vesical wall, save that ^Przeglad Lekarski, Nos. 6 and 7, 1888. I LITHOTOMY. 829 incidental to the incision itself. A lithotomy-scoop and the fingers only were used in extracting the calculi. The bladder was adherent to the edges of the stones where they came in apposition. The peritoneum was not seen during the operation. The patient died of septic peritonitis on the fourth day after operation. On the second day the vesico-rectal septum sloughed, and enemata passed freely from the rectum into the bladder. No autopsy could be secured. In the foregoing case sloughing of the yesical wall was probably due to the sudden removal of the pressure of the calculi and incidental acute sepsis, the phenomena being similar to those occurring after the sudden evacuation of retained urine in old septic bladders. The peritonitis was due, in the author's opinion, to slight laceration of the degenerated and friable vesical wall, with its peritoneal investment, by the tearing away of the adherent calculi. Adhesion of calculi to the vesical walls is certainly a very rare con- dition, but one that undoubtedly existed in this case, as shown both by the conditions found during removal and the appearance of the calculi after removal. CHAPTEK XXXV. NEUROSES OF THE BLADDER. Vesical Hypeeesthesia; Vesical Neuealgia; Vesical Atony and Paealysis; Hysteeia of the Bladdee; Incontinence of Ueine. vesical hypeeesthesia. Uxdee the term hyperesthesia of the bladder the author desires to call attention to an affection that is not generally recognized, but which is of the greatest importance, not only as a morbid condition per se, but as a complication, or perhaps sequel, of other vesical diseases. Hyperesthe- sia of the vesical mucous membrane is necessarily a feature of acute inflam- mation and chronic obstructive diseases of the genito-urinary tract, but under favorable circumstances it constitutes merely a subordinate element, its management being that of the organic disease. It is only when it exists independently of organic disease, or is greatly disproportionate to the or- ganic changes present, that it becomes worthy of special nomenclature and consideration. Vesical hyperesthesia has been described under the various terms of "cystitis without catarrh," "irritable bladder," and "neuralgia of the ves- ical neck." To each of these terms the author takes exception. Cystitis without catarrh is a pathologic paradox, and, as such, incomprehensible. Irritability of the bladder is a better term, but implies only intolerance of the vesical mucous membrane for the contents of the bladder, which con- tents may be normal or pathologic. Xeuralgia of the vesical neck is a term that should be reserved for another condition. Neuralgia, moreover, does not accurately describe conditions of hyperesthesia. The morbid condition existing in vesical hyperesthesia is simply an exaggeration of the normal physiologic sensibility of the organ. The proper performance of the vesical function depends in great measure upon the sensibility of the mucous membrane. When in its normal condition the viscus will hold a considerable quantity of urine, the amount varying in different individuals; when, however, the organ is moderately distended by its contents, a sense of fullness, and perhaps pain, with a more or less urgent desire to urinate, are experienced. When this normal sensibility is decreased, overdistension is likely to occur; when it is increased, the blad- der becomes proportionately intolerant of its contents, necessitating fre- quent micturition. It is probable that the principal seat of the desire to iirinate is the mucous membrane lining the true vesical neck, — i.e., the deep urethra; hence a relatively greater degree of hyperesthesia from morbid conditions (830) VESICAL HYPERESTHESIA. 831 of this portion of the yesical lining than in those chiefly involving the superior portion of the bladder is to be expected. As might be supposed, the muscular structure of the bladder eventu- ally participates in the abnormal increase of sensibility, and consequently exhibits a tendency to spasmodic contraction. This spasmodic contraction is the principal cause of the severe pain experienced in bladder disease. From what has already been said, the clinical division of vesical hyperesthesia into general and local will be readily appreciated. Cases often occur in which moderate distension of the bladder will immediately produce pain and a strong desire to urinate, but in which the presence of a small amou^nt of urine is well tolerated. These cases are explicable only upon the supposition that the vesical neck is not involved to any great extent. More frequently, however, cases are met with in which the desire to urinate is almost constant, pain being slight or absent because of the fact that the bladder is rarely allowed to become sufficiently distended to produce mechanic pressure. These cases comprise those that several writers have termed neuralgia of the vesical neck, and involve the prostatic ure- thra — the true vesical neck — as well as the false vesical neck. A certain degree of chronic inflammation exists in a large number of these cases, and it is safe to assume that in cases of long standing the frequent bruising of the parts about the neck of the bladder caused by frequent straining efforts at micturition has produced inflammation, even if it did not primarily exist. Etiology. — The possible causes of vesical hyperesthesia are quite numerous. The majority of cases result from pre-existing acute or chronic inflammation. Frequent efforts at micturition due to inflammation cause the bladder to acquire, from sheer force of habit, intolerance of its contents. As a result, the organic disease does not subside completely, but becomes subordinate to the hyperesthesia; thus cystitis, gonorrhea, or prostatitis may constitute the exciting cause of chronic hyperesthesia of the bladder. A neurotic constitution underlies many cases, and under such circum- stances comparatively slight causes may disturb the nervous supply of the bladder. Associated with this neurotic constitution, perverted sexual phys- iology is apt to constitute an important element in etiology. Such patients will be found to suffer either from sexual excess, or, what is quite as harm- ful, constant ungratified sexual desire. Intemperate habits of eating and drinking are apt to act injuriously upon the bladder, by inducing an irri- table state of the tissues in general, as well as by the production of irri- tating properties in the urine. Oxaluria, phosphaturia, and lithemia are often associated with hyper- esthesia of the bladder. The gouty or rheumatic diathesis is responsible for many cases: a point that has received too little attention. The author has met with a number of cases of rheumatism of the bladder with conse- quent hyperesthesia due to exposure to cold and wet. It is noteworthy 832 NEUEOSES OF THE BLADDEE. that the majority of cases are affected injuriously by atmospheric changes. Some patients are annoyed mostly during the changeable weather of the spring and fall^ being at other seasons quite free from trouble. Hyper- esthesia of the bladder is occasionally the result of reflex nervous irrita- tion, either from contiguous or more or less remote pathologic changes. Diseases of the anterior portion of the urethra, of the rectum and anus, or of the uterus and ovaries may constitute the source of the reflex disturb- ance. Phimosis, teething, and worms may cause it in children. Eenal calculus or pyelitis are occasionally reflex causes. Symptoms. — The symptoms of vesical hyperesthesia vary somewhat, as has been stated, according to the general or local character of the mor- bid condition. When it is general, there is more or less pain, and perhaps tenderness, over the hypogastrium when the bladder becomes distended with urine. If, however, the vesical neck and prostatic sinus are chiefly involved, the bladder is so intolerant of urine that distension and hypo- gastric pain cannot occur. There is an almost constant desire to urinate in cases of this character, and in most cases a sensation of impending dis- charge of urine during intervals between the acts of micturition. Irrita- tion in the prostatic sinus sometimes gives rise to voluptuous or tickling sensations in the perineum. The urine may be highly concentrated and acid, neutral, or perhaps phosphatic, according to the condition upon which the hyperesthesia depends. There is little or no mucus or muco-pus unless inflammation be a prominent factor in the case. Great nervous irritability or depression are usual, hypochondria being often the most prominent feature, particularly if oxaluria be present. There are some peculiar features in the symptomatology of vesical hyperesthesia, especially when limited to the neck of the organ. Mental worry or strain is apt to ag- gravate the condition or even produce it primarily. Overworked students who have consulted the author for this difficulty have laid particular stress upon this feature of the case. The sound of running water, or the sight of another individual in the act of urination, often occasions an almost un- controllable desire to empty the bladder. A physician of the author's ac- quaintance experiences this symptom whenever a patient describes bladder symptoms to him. When attention is diverted, and during sleep, the pa- tient is not annoyed, as a rule, unless there is actual cystitis. Sometimes, however, frequent nocturnal micturition from vesical hyperesthesia will continue, as a matter of physiologic habit, for a long time after the dis- appearance of primary organic disease upon which it originally depended. Teeatment. — The treatment of vesical hyperesthesia requires a careful study of its possible causes, for much depends upon the prominence of in- flammatory complications. Genito-urinary and sexual hygiene require at- tention in all cases. Morbid conditions of the urine require attention as a preliminary to all other means of treatment. When strongly acid, with deposits of uric acid and urates, a milk diet, with alkaline diuretics, is VESICAL HYPEEESTHESIA. 833 required. In some cases, however, the condition is either oxalnria or a highly-acid and concentrated state of the urine due to malassimilation : i.e., Htheniia. In such cases the digestive and hepatic functions are perverted, and dihite nitromuriatic acid should be substituted for the alkalies. Col- chicum is indicated in full doses if the gouty tendency be pronounced. The salts of lithia are also ver}'' serviceable. Some of the various alkaline mineral waters should be recommended as a constant beverage. In patients of a neurotic constitution, ergot, gelsemium, and the bromids are indicated. These drugs should be combined with tonics, such as the dilute phosphoric acid, quinin, iron, and strychnia in debilitated patients. Sexual hygiene demands attention in most instances. Marriage will often cure the most stubborn cases of hyperesthesia of the vesical neck. The only local treatment required in the majority of cases is the pas- sage of the steel sound. This is to be used cautiousl}^, however, for, while it is almost a specific for cases of a purely nervous type, it is apt to aggra- vate the difficulty if infectious inflammation about the vesical neck exists. The instrumentation, if beneficial, acts by squeezing out the blood from the vesical neck, thus relieving congestion, and by stretching the delicate nerve- filaments lessens their irritability. When the sound proves useless or detri- mental, irrigation with mild warm lotions will give great relief. The short urethral nozzle should be used, if practicable. Instillations of silver nitrate are of service where infection exists. These should be given in a strength of from 2 V2 to 15 grains to the ounce. Cold s|)onge-baths and ph3^sical exercise in moderation are essential in most cases. Stimulants and tobacco are apt to be especially injurious, and should be strictly interdicted. Eest in bed and the api3lication of blisters to the perineum and hypo- gastrium are necessary in some stubborn cases. The application of iodin to the perineum and hypogastrium is always admissible. Opium is often necessary where the disease is troublesome. It should be given pref- erably in the form of suppositories or the deodorized tincture in small doses, and should be dispensed with after sudden exacerbations of the dis- ease have been controlled. Hyoscyamus, cocain, and belladonna are occa- sionally of service. The fluid extract of pichi has proved beneflcial in some cases. Cantharides in small doses is sometimes of benefit. • The following formulas are among the most reliable that the author has tried in vesical hyperesthesia: — IJ Potass, citrat §j. Infusi buchu Bviij. M. Sig. : Bss quor die. Infusions of slippery elm, linseed, or triticum repens may be substi- tuted for the buchu. 834: NETJEOSES OF THE BLADDEK. IJ Tr. canthar m. Ixxx. Potass, acetat §j . Syr. limonis q. s. ad giv. M. Sig. : 3 every three hours. IJ Tf. opii deed 3ii m. xl. Potass, bicarb 3vi 3 j. Syr. Tolu q. s. ad giv. M. Sig.: 3j every three hours. IJ CodeinEe gr. iv. Ext. pichi fld giss. Lithii carb 3iv. Syr. acacise q. s. ad §iv. M. Sig.: 3ij every two hours. 1$. Cocain mur.^ Ext. belladon., Morph. sulph of each gr. ^U. Pulv. camph gr. 1. M. Ft. rectal suppos. Sig.: Use at bed-time. Indicated in cases of vesical irritation from whatever cause. Ijl Vini colch. sem 3ii m. xl. Liq. potass 3ii m. xl. "Tr. hyoscyami Bj. Kalii brom. §j. Elix. simpl q. s. ad Biv. M. Sig.: 3ij in water every four hours. Where it is necessary to allay sexual irritability, the following com- bination "usually acts well: — I^ Kalii brom 3iv. Ext. ergotse fl 3iv. Tr. gelsemii m. Ixxx. Syr. Tolutani q. s. ad §iv. . M. Sig.: 3ij every three hours. Extreme dilation of the vesical neck is often successful in curing cases in which hyperesthesia of this region predominates. VESICAL NEUEALGIA. True neuralgia of the bladder is infrequent, and when it occurs is likely to be mistaken for other vesical diseases. Where it chances to be associated with morbid conditions of the urine, it is especially liable to be mistaken for malignant disease. Vesical neuralgia may be general or local, and may or may not be' associated with hyperesthesia. Its causes are much the same as those of the latter condition, gout, rheumatism, malaria, and cachexias of various VESICAL HYPEKESTHESIA AND NEURALGIA. 835 kinds liaviug a very prominent place in the etiology of different cases. It may attend upon^ or follow, inflammatory diseases of the genito-urinary tract. The symptoms consist of pain of a paroxysmal and irregular character. This may be intermittent, or more or less constant, and is referred to the hypogastrium and perineum. In some cases it radiates to the rectum, ure- thra, and lumbo-ahdominal region. In simple and uncomplicated cases there are no symptoms or signs referable to the urine, but in others there are phenomena characteristic of the conditions with which the neuralgia is associated. In some cases the urine is perfectly normal and micturition is not abnormally frequent, yet the act is attended by severe cutting pains. The act of ejaculation is also attended in some cases by similar symptoms. The symptomatic tout en- semble is quite suggestive of vesical calculus, and some care is necessary to avoid error in diagnosis. Treatment. — The treatment of true neuralgia of the bladder neces- sarily varies, according as the condition is primary, secondar}^, or reflex in character. Tonics are invariably indicated, and in malarial cases depend- ence is to be placed chiefly upon quinin. Arsenic, phosphorus, iron, strych- nin, and the mineral acids are indicated in different cases. A change of climate may be required. The local treatment is that of the primary or- ganic disease, if such be present, with the addition of galvanism in some cases, particularly when the neuralgia appears to be independent of serious structural disease. Hot irrigations of the bladder and bowel, with anodyne fomentations and poultices to the hypogastrium, are of service when the pain is very acute. Anodyne suppositories are always useful. vesical hyperesthesia and neuralgia in women. Hyperesthesia of the bladder in women is quite common, and is fre- quently either overlooked or erroneously diagnosed as cystitis. Etiology. — The causes are the same, in a general wa}^, as those of the same condition in the male. In addition, however, women are subject to the special causes of reflex tubo-ovarian and uterine irritation and pressure from uterine displacements. In some cases there exists no special cause. Nearly all of the severe cases of uterine displacement met with in practice are associated with vesical hyperesthesia, and this condition is apt to be localized chiefly about the vesical neck. Oftentimes- a certain degree of actual inflammation exists, and where it is not primarily present it is quite apt to occur sooner or later as a result of the mechanic conditions that cause the hyperesthesia, in conjunction with frequent micturition. ISTeuralgia of the bladder in women is essentially the same as in the male. Treatment. — The treatment of vesical hyperesthesia and neuralgia in women is the same, in a general way, as in the male. Dilation of the neck 836 XEUEOSES OF THE BLADDEE. of the bladder by short urethral sounds is usually effectual. In many cases the relief obtained is really remarkable. Uterine displacements re- quire most careful consideration in cases of this kind. In some cases ex- treme dilation of the vesical neck imder anesthesia is necessary. This radical measure rarely fails. VESICAL ATOXT. Atony of the bladder implies a partial paresis or exhaustion of mus- cular power — a loss of the normal muscle-tonus — of the vesical Avails: i.e., of the detrusor-uringe muscle. Etiology. — The cause of vesical atony may be said to be, briefly, over- stretching of muscular tissue. This overstretching of the vesical walls is due either to prolonged acute retention of urine or continual obstruction to its escape. Should either of these conditions prevail in a debilitated in- dividual, vesical atony is apt to supervene quite promptly, for the general tone of the system has much to do with the tonicity of the vesical walls. Conditions of chronic debility and long-continued acute diseases are, there- fore, apt to be complicated by atony of the bladder. Eetention of urine, for even a short time, is always followed by a greater or less degree of atony. It is quite apt to complicate organic stricture, and often persists after the obstruction has been removed. This should be remembered, as patients are often dissatisfied with the condition of their urinary organs after the cure of stricture, and an explanation of the lack of power experi- enced in micturition should be given them. Atony of the bladder must not be confounded with vesical paralysis from injury or disease of the spinal cord, and should receive due consideration as an important factor in all cases of obstructive disease of the urinary organs. There is a certain amount of physiologic atony that always occurs in the healthy bladder as the individual grows older, its expulsive power being greater in the young boy than in the adult. The normal distension to which the bladder is subjected gradually diminishes its muscular^ power. Vesical atony may result pathologically from voluntary retention for a length of time. This can be easily verified by experiment upon one's self. It will be found that the urinary stream is not only delayed, but lacks its usual force. In persons of sedentary habits habitual neglect of the calls of Xature will produce permanent atony. True retention may result from voluntary suppression of the call to urinate, the bladder refusing to contract even when the op- portunity occurs. Symptoms. — The symptoms of an aggravated case of atony are chiefly dribbling of urine and the usual signs of retention. The amount of paresis of the sphincter vesicse — which may or may not be involved — determines the question of retention. After prolonged retention the power of the ves- ical sphincter is overcome, and the urine dribbles away involuntarily. This condition is termed "retention with overflow," and should be promptly VESICAL ATONY. 837 recognized. Surgeons are very often delnded into the belief that there is no retention because the bladder appears to be constantly emptying itself. This mistake is often made in retention from prostatic disease, with a fatal result. In the lesser grades of atony the patient experiences difhculty in com- pletely emptying the bladder, and endeavors to supplement the detrusor urinse by bringing the abdominal muscles into play. Very often the patient discovers that the bladder can be assisted in emptying itself of its contents by pressing upon the hypogastrium with the hand. In some slight cases no symptoms are noticeable save dribbling of urine after the act of mic- turition has been apparently completed. This symptom is liable to suggest urethral stricture. Dribbling of urine at night is not unusual, in even mild cases of atony. This shows a complicating atony of the true vesical sphinc- ter. Marked and progressive atony eventually leads to complete retention, with or without overflow, and, secondarily, cystitis usually develops from infection. Eetention from atony may be differentiated from that due to organic obstruction by the passage of a catheter. In simple atonic retention the instrument passes with little or no difficulty, and the urine escapes in a passive, uniform, down-trickling stream, save when pressure is made upon the hypogastrium and during deep inspiration. In ordinary retention there is usually marked obstruction at some jDoint, and the flow of urine from the catheter is comparatively forcible. In prolonged obstructive retention this means of differentiation may not be available on account of secondary and pronounced aton3^ The results of severe atony are serious. Germ-infection and inflamma- tion of- the bladder generally supervene sooner or later, with consequent ac- cumulation of muco-pus and the products of urinary decomposition upon the vesical mucosa. More or less absorption of these materials occurs, pro- ducing chronic toxemia, as stated in connection with urine-fever. These materials, being thrown out by the skin, may produce eczema in some of its various forms. More or less impairment of the renal functions develops after a time, and actual renal disease, with consequent uremia, is not rare. Acute cystitis, and even sloughing of the vesical walls, sometimes occurs, under which circumstances the typhoid state and death generally super- vene. This result is very apt to occur if the distended bladder be too sud- denly emptied after prolonged retention, for reasons elsewhere given. Tkeatmext. — The treatment of vesical atony involves many measures already suggested in connection with other vesical diseases. Whenever an obstructive cause is foimd, it must be removed. Incision of a narrow meatus sometimes works wonders. In one of the author's cases meatotomy speedily cured a case of vesical atony of several years' standing, although the meatus was not especially small. The atony in this case was evidently the result of reflex inhibition of the detrusor urinae from meatal contraction 838 XEUEOSES OF THE BLADDEE. and irritation. In conditions of debility or cachexia, tonics, especially the nervines, are indicated. Strychnin is nsnally the main-stay of treatment. It should be given preferably by hypodermic injection. The faradic cur- rent is apt to prove beneficial. In all cases of atony the urine should be drawn off twice or thrice daily, and the bladder washed out with a mild antiseptic solution, whether re- tention or inflammation are present or not. In some cases of simple atony injections of cold sterilized water give good results in the restoration of vesical tonicity. TESICAL PAEALYSIS. True paralysis of the vesical walls is an infrequent affection, differing markedly in this respect from vesical atony, which enters so largely into the clinical history of organic urinary affections. Etiology. — Vesical paralysis only arises from disease or injury of the brain or spinal cord, the latter being the structure most often involved. There is a possible exception to this nde, in the cases described by Brown- Sequard as "reflex urinary paralysis." Anything that will cause paraplegia is apt to develop vesical paralysis. Thus, it is met with as a consequence of spinal trauma, inflammations of the spinal marrow, and pressure of spinal apoplectic or meningeal effusions. Syphilomata, vertebral displace- ments or caries, cancer, and sarcoma of the spine may cause vesical paralysis. As a rule, vesical paralysis comes on quite suddenly, but in cases due to the gradually increasing pressure of neoplasms or the products of spon- dylitis, and in some cases of myelitis, it comes on very gradually, and the stream of urine grows less and less forcible, until finally complete retention results. Wlien paralysis occurs, residual urine is always left after urination, and undergoes decomposition, with the usual train of evils met with in such conditions of the bladder. The urine soon becomes thick, ill smelling, and full of ropy mucus or muco-pus, and the patient is compelled to urinate very frequently until such time as the bladder loses, in great measure, its sensibility. Complete paralysis may supervene suddenly in a case hitherto slowly progressing, in which case retention occurs immediately. Eesults of Vesical Paralysis. — The local results of vesical paral- ysis may be retention with overflow, acute cystitis, vesical gangrene, ulcer- ation, or calculus. Great depression and nervous irritability are usual. True incontinence of urine is likely to exist as a consequence of involve- ment of the sphincter vesicae. The urine upon examination presents an excessive quantity of mucus, or muco-pus, triple and earthy phosphates, and, under the microscope, swarms of vibrios. The odor is usually strongly ammoniacal. The kidneys become involved by ascending infection in most pro- longed cases. Oftentimes the patient becomes completely worn out by all VESICAL PAKALTSIS. INCONTINENCE OF TJEINE. 839 these unnecessary evils, and dies as the direct effect of what might have been avoided, in most instances, by careful attention on the part of his physician. Vesical paralysis per se is of but little moment, if proper treat- ment be adopted to prevent its secondary evils. Treatment. — The treatment of vesical paralysis is chiefly proph- ylactic of cystitis. The bladder should be regularly evacuated and irri- gated, as suggested in the treatment of atony. In this manner urinary stagnation and overdistension of the vesical walls, with their resultant inflammation, may be prevented. When retention and cystitis occur, they require the same treatment as under other circumstances. Internal uri- nary antiseptics are often useful. Little or nothing can be accomplished in the treatment of the paralysis per se, excepting when the paraplegia is amenable to treatment, which, unfortunately, is rarely the case. INCONTINENCE OF UEINE. This disagreeable and annoying afi:ection consists of an involuntary escape of the urine, either constantly or at intervals. It occurs in connec- tion with spinal paralysis in some cases, this being the only form of incon- tinence that the surgeon is likely to meet with often in the adult. True incontinence without spinal paralysis is seen but rarely in adult life. The form of inability to retain the urine that results from inflammatory states of the vesical neck is, however, often mistaken for true incontinence. True incontinence of urine is frequent among children. It is usually due to weakness or atony of the sphincter vesicae and adjacent muscular structures: i.e., the cut-ofl: muscle. The trouble may be either active or passive, this being dependent upon the tonicity of the detrusor urins. If this be normal, the urine comes away in a forcible stream whenever the cut-off muscle and vesical sphincter are off guard, as they are during sleep. This is the form generally met with in children. When, however, the detrusor is atonic, or paralyzed, and the cut-off and sphincter weakened or paretic, dribbling of urine is constant. This form is observed in spinal paralysis. ' In a large majority of cases of active incontinence in children the cause is reflex irritation of the vesical neck from contiguous or remote pathologic conditions; thus, it may be due to diseases of the rectum and anus, ascar- ides recti, or to vesical calculus. Stricture in the adult male sometimes produces incontinence. In reflex incontinence the patient often dreams of urinary desire and involuntarily yields to it. In this respect there is a strong resemblance between incontinence of urine and nocturnal emis- sions. Struma is sometimes productive of uricemia in children, and the re- sultant irritating crystals of uric acid in the urine occasionally cause incontinence. In women, uterine disease, urethral caruncle, vesical calculus, and hysteria are the chief causes. As a rule, it will be found that the 840 XEUEOSES OF THE BLADDEE. subjects of incontinence of urine are neurotic, strumous, cachectic, or de- bilitated, or perhaps suffering from local disease of the urinary organs, either as a primary condition or secondary to spinal disease. It is to be remembered, therefore, that there are both local and general conditions to be taken into consideration in the etiology of urinary incontinence. Teeatmext. — The treatment of incontinence requires careful consid- eration of the causes of the disease. These are often such as are readily removed, with resulting immediate relief of the urinar}^ symptoms. If ascarides, calculus, stricture, rectal or anal diseases exist, they require at- tention. General debility, cachexias of various kinds, hysteria, and struma demand measures of a general character, such as cold baths, nux vomica, codliver-oil, iron, quinin, and jDhosphorus in the way of tonics, and, such sedatives and antispasmodics as valerian, asafetida, jDotassic bromid, and belladonna. If the patient does not tolerate plunge-baths or shower-baths, cold sponging should be advised. A change of air and scene is sometimes necessary. "When the urine is highly acid, showing a tendency to lithemia or gout, the citrate or acetate of potassium, lithia, colchicum, and a large daily quantity of water are indicated. By increasing the secretion of urine in the day-time we may often so habituate the bladder to the pressure of a large quantity of water, that it becomes tolerant of its contents at night. When paralysis of the bladder exists, the treatment is that of the pri- mary disorder. When incontinence is associated with inflammatory affections of the mucous membrane of the urinary tract, the balsams are beneficial. In the adult, the combined use of faradism and cantharides is most often success- ful in true incontinence. The author has used the faradic ciirrent by means of the urethral electrode with considerable success. Old persons require the regular use of the catheter and vesical irrigations. In children much may be done to break up the habit by awakening the little patient and inducing him to urinate several times during the night. In young pa- tients the best internal remedy is belladonna in full doses, in combination with the citrate. of potassium. Santonin often acts well, whether intestinal worms exist or not. It has been recommended that the preputial orifice be sealed with collodion at bed-time in boys suff'ering from incontinence, thus breaking up the habit by preventing the escape of the urine. There is a rare form of the disease sometimes seen in children suffering from chorea. It is choreiform in character, — chorea of the bladder, — and its treatment is that of the general neurosis. The author has obtained the best results from asafetida, santonin, and the valerianates in these cases. There is a question whether quite a proportion of cases of apparently simple incontinence in children are not due to a mild local chorea affecting the detrusor and cut-off muscles. Valerian, santonin, and bromid of potassium certainly act very promptly in many cases. Lest the advocates of the "worm'^ theory of all the ailments to which childhood is subject advance INCONTIXEXCE OF UKIXE. 841 it in exj)lanation of the beneficial effect of santonin in such cases, the author will state that this drug has proved, in his hands, one of the most reliable of antispasmodics. In epilepsy it is far superior to the bromids, on the average. Chorea of the bladder is sometimes met with in the adult unassociated with general chorea. Circumcision or meatotomy are often required. The occasional pas- sage of the cold sound, followed by silver nitrate in weak solution, is some- times very successful in toning up the weakened sphincter and relieving reflex irritation of the vesical neck. Anal or rectal disease, and especially ascarides recti^ may require attention. PART IX. SUEGICAL AFFECTIOXS OF THE KIDXEY A.\ D UHETER. CHAPTER XXXYI. SURGICAL AFFECTIONS OF THE KIDlSTEY. SUEGICAL AXATOMT, MaLFOEMATIOXS, AXD AxOMALIES OF THE KiDNET; Floatixg axd Movable Kidxey; Eenal Calculus; Pyelitis; Ptoxepheosis; Peeixepheitic Abscess; Suegical Xepheitis. suegical axatoily of the kidxey. AccuEATE knowledge of the gross anatomy of the kidney is more essential to a correct understanding of the surgical diseases of the organ than of its strictly medical diseases. The kidne5'S are designed for the secretion of urine and the excretion of important products of the retro- grade metamorphosis of tissue. They are situated in the lumbar region posterior to the peritoneum, one upon each side of the spinal column, ex- tending from the eleventh rib almost to the crista ilii. The left kidney extends do\m-ward a little farther than the right. Each organ is about four inches long, two and a half inches in breadth, about an inch and a quarter thick, and weighs from four to five ounces. The kidneys are surrounded by cellular tissue and a liberal padding of fat. In a general way the kid- neys are shaped something like a large bean, the concavity of which, the hilum, is directed toAvard the spinal column, and contains the upper ex- panded portion of the ureter known as the pelvis of the kidney. The kid- ney is invested by a proper fibrous capsule of dense connective and elastic tissue. The pelvis of the kidney subdivides into several dilations, the calices, into which the tubuli of the organ empty. The kidney-structure proper is divided into a medullary portion composed of reddish conic masses, the pyramids, these again being composed of straight tubes that open into the calices, and a cortical portion constituting the surface of the organ and containing the blood-vessels and terminations of the uriniferous tubules. In the cortical substance are found the glomeruli, or Malpighian bodies, little spheroidal bodies that form the most distinctive feature of the secreting structure of the organ, the function of which is to form the urine. The blood-supply of the kidneys is derived from the renal arteries, which enter at the hilum and divide into four or five branches supplying the kidney-structure. The concave border of the kidney is occupied by the pelvis of the (842) MALFOEMATIOKS AND ANOMALIES OF THE KIDNEY. 843 organ, which consists of a membranous, or bag-like, expansion of the ureter, large at its base, or attachment to the kidney, and small at its opening into the ureter proper. The ureter is a membranous tube about the size of a goose-quill and from sixteen to eighteen inches in length, the function of which is to convey the urine from the pelvis of the kidney to the bladder. MALFOEMATIONS AND ANOMALIES. Malformations and anomalies of the kidney are not of great pathologic importance, being chiefly anatomic curiosities. Supernumerary kidneys have been seen, and a case is related in which an extra pair of kidneys Fig. 193. — Single median kidney lying below bifurcation of the aorta. (After Moullin.) situated below what were apparently the normal ones were the seat of in- tense inflammation, while the latter were perfectly healthy. Cases are not infrequently seen in which one kidney is congenitally absent. Two cases of this kind have come under the author's observation that were discov- ered accidentally during autopsy. Anomalies in number, size, and direction of the ureter are by no means uncommon. In one of the author's cases there was a double ureter upon one side, both tubes being rather smaller than their single fellow. In another case there was a supernumerary ureter on each side. Anomalies of the ureter — such as atresia, stricture, kinking or twisting of the tube — bear a very important relation to cystic kidney, especially the hydronephrotic form. Single kidney is more im- su SUEGICAL AFFECTIONS OF THE KIDXEY. portant than other anomalies, from the fact that if the organ becomes dis- eased there is no companion-organ to act compensatorily. Instances have been recorded in which nephrectomy has been performed npon one organ with a fatal result, and on autopsy no kidney was found upon the opposite side. Such cases, although extremely rare, should put the surgeon on his guard as to the possibility of the existence of the anomaly, and consequent caution and conservatism should be exercised in the performance of ne- phrectomy. HoBSESHOE KiDXEY. — The most interesting anomaly of the kidney is what has been termed the horseshoe lidney. In this malformation there is more or less fusion of the two organs in front of the spinal column, their blood-vessels inosculating and the kidney-structure being continuous from one to the other. This anomaly is only to be discovered post-mortem, as a rule. Fig. 194. — Horseshoe kidney. (After Morris.) TRAUMA OF THE KIDXEY. The kidney is usually injured by direct violence, although severe con- cussion has been known to contuse or lacerate one or the other organ. The author recalls a case in which a fall upon the buttocks from an elevation of about fifteen feet produced more or less extensive injury of the right kidney, with hematuria and swelling in the loin lasting for several weeks. Eecovery occurred without operation, hence the exact nature of the trau- matism could not be determined. The extent of the injury varies from slight contusion or laceration to complete disorganization. Symptoms. — The kind and severity of the symptoms depend upon the degree and character of the injury and the nature and extent of damage sustained by surrounding structures. Hemorrhage is severe when the large vessels are injured, but, if the ureter be torn across, little or no blood may appear in the urine. In cases in which the large vessels at the hilum are TEAUMA OF THE KIDNEY. 845 rujDtiired, especially if the investing peritoneum is torn, fatal internal hemorrhage ma_y occnr. In some eases blood does not appear in the nrine immediately, but only after an interval of several hours. Ureterform clots may be passed, their journey down the ureter being heralded by colic re- sembling that produced by the passage of a stone from the kidney. Ure- teral obstruction and lij^dronephrosis sometimes result from blocking up of the duct by clots. The quantity of blood entering the bladder may be sufficient to distend that viscus Avith coagula. This, however, is rare. In some instances a large hematoma forms about the kidney in the loin. The hemorrhagic effusion sometimes extends downward to the pelvis, passing out of the inguinal ring into the scrotum. Where the ureter or renal pelvis is torn, urinary extravasation occurs in the loin. If the peritoneum be lacerated, the urine escapes into the peri- toneal cavity, causing fatal peritonitis and death within a few days. When limited to the loin, septic cellulitis develops and, if unrelieved by operation, results fatally. Suppurative nephritis or perhaps pyonephrosis may occur in rare instances. Complete suppression of urine is likely to occur where both kidneys are injured, and sometimes results from the reflex effect of in- jury of one kidney. Peognosis. — If the peritoneum is not torn and where there is no urinary extravasation, recovery is the rule. Severe laceration of the large blood-vessels is likely to result in fatal hemorrhage. Eecover}^ may occur after suppuration. In such cases a fistula of greater or less duration is liable to result. . Treatment. — In cases of slight or moderate severity, complete rest, with milk diet and the application of ice-bags to the loin are usually all that is required. Turpentine internally is of service in checking the renal hemorrhage. Ergot is, of course, the most universally used remed}^, but in the authors experience it has been inferior to turpentine in urinary hemorrhage. Where general symptoms of severe hemorrhage or hematuria continue, an exploratory incision is required. The hemorrhage should be checked by ligature and antiseptic-gauze packing where possible. When packing fails, nephrectomy is demanded. When a large hematoma exists, or suppuration is imminent, an attempt may be made to relieve it by aspira- tion. This must not be done too early, else recurrence of the hemorrhage may follow. If at any time urinary extravasation or suppuration be sus- pected, aspiration will usually clear up the diagnosis. Both suppuration and extravasation demand free incision. Where extravasation or symptoms of sepsis exist, there should be no delay in cutting, '\^^len the peritoneum is involved, celiotomy and lumbar incision are both demanded. The ab- domen should be flushed with sterilized water and the wound in the peri- toneum closed. The kidney may be dealt with from either front or rear. Both anterior and posterior drainage are necessary. Wounds of the kidnev, gunshot or punctured, should be managed upon the same principles as the 846 SUEGICAL AFFECTIOXS OF THE KIDXEY. class of injuries already dealt with. In sneli Avounds, however, there is greater liabilit}' to complicating conditions, that must be dealt with upon their merits, than in contusions and lacerations of the organ. MOVABLE KIDXEY. Like some other conditions of the organ, movable kidney is probably more frequent than is generallj'' supposed, and it is probable that the af- fection really constitutes quite a proportion of cases of obscure abdominal disease. Inasmuch as the organ is by no means firmly bound in its nor- mal position, but is allowed more or less freedom of movement — under pressure at least, and undoubtedly with the respiratory movements, — it would be surprising if displacement of the organ did not occasionally occur. The affection is most frequent among females. W. jSTewman found in 290 cases, 252 in women and 38 in men, a proportion of about one in seven. ^ Henry Morris makes a very similar statement.^ The right kidney is more frequently affected than the left, although both are sometimes involved. In 173 cases of Newman's 152 were on the right side, 12 on the left, and 9 involved both organs. In a general wa}', renal displacement and mobility seem to bear a more or less definite relation to muscular strain and exertion. In Germany, in particular, movable kidney is observed quite frequently among the lower classes, among whom a large proportion of the hard phys- ical work is carried on by women. The influence of pressure is well shown by the manner in which the tumor formed by a dislocated kidney will move about in the abdomen under sources of mechanic disturbance. It may press forward against the ante- rior abdominal wall and be mistaken for some form of abdominal tumor, or it may be pushed downward into the pelvis, where it may be confounded with uterine or ovarian growths. Mistakes are especially liable to happen if adhesions form, fixing the organ in its abdominal position. In many instances of wandering kidne}- the affection is congenital. ISTewman divides renal displacements into two classes, viz.: movable kidney — the most fre- quent variet}^ — in which the kidney moves behind the peritoneum, and true floating kidney, Avhich is attached to the spine by a mesonephron and floats about freely in the peritoneal cavity.^ Etiology. — The causes of wandering kidney are several. It is prob- able that an exposed position of the organ from a sparsity of connective tissue about it or an unusual laxity and flabbiness of its areolar capsule exists as a predisposing cause in quite a number of cases. When the ab- dominal walls are lax and flabby, thus affording a poor support to the abdominal viscera, there is likely to be a tendency to displacement of the ^ "Surgical Diseases of the Kidney/' W. ISTeAvman. - "Surgical Diseases, of the Kidney," Henry Morris. ^ Op. cit. MOVABLE KIDNEY. 847 kidney that may result in its actual occurrence under the influence of com- paratively slight causes^ such as moderate muscular exertion. Eepeated pregnancies seem to have a direct influence in the causation of renal dis- placement, by producing pendulous abdomen and diminishing support to the kidney. Falls, hard riding, shocks, and strains experienced in athletic exercises have been known to cause the affection. A cause that has been said to be effective among the working-classes is the use of a tight strap or band to support the clothing. Corsets, if laced tightly, may possibly have the same effect. The most important etiologic factor is absorption of the perirenal fat. The kidney is but poorly supported at best, and, once this fatty cushion is removed, a certain degree of movement is almost inevitable. In some cases a congenital defect of development of the fatty capsule may exist. Dis- eases that produce profound nutritive disturbance, with consequent wast- ing, may act as a predisposing cause of movable kidney. Once the normal support of the kidney becomes impaired, very slight causes may produce dislocation of the organ. Blows upon the lumbar region may possibly displace the kidney; cases attributed to this cause have been recorded. A moderate degree of dis- placement having occurred, the movements of respiration, the weight of the clothing, or the pressure of the pregnant uterus will assist in increas- ing the displacement. The right kidney occupies a more exposed position than the left, and this, in combination with its relation to the liver already alluded to, especially predisposes to displacement, and explains why it is more frequently displaced than its fellow, as shown clinically by the re- corded cases. It is probable that counter-pressure by the liver may favor dislocation of the kidney under strain or abdominal compression. The right kidney slips from between the abdominal wall and the liver just as a bean slips from between the thumb and finger when pressed upon. Symptoms. — The symptoms of wandering kidney are very variable and by no means characteristic. In some cases a very moderate degree of dis- placement is sufficient to produce quite severe symptoms, while in others marked displacement is productive of comparatively little discomfort. One reason for the obscurity surrounding the diagnosis of these cases is that the function of the kidney is rarely, if ever, disturbed, the organ being appar- ently perfectly normal and performing its functions as under ordinary cir- cumstances. Symptoms referable to the uterus and bladder have been noted in connection with wandering kidney and are probably dependent upon reflex nervous disturbance produced by the displacement of the organ rather than upon any direct influence exerted by it. G-eneral nervous dis- turbances such as hysteria in the female, melancholia, and hypochondriasis have been referred to wandering kidney. Such cases, however, are attrib- utable to the psychic disturbance incidental to a knowledge of the exist- ence of some abdominal derangement rather than to any direct influence 848 SUEGICAL AFFECTIONS OF THE KIDNEY. upon the nervous system or general nutrition. In common with other af- fections of the abdominal viscera, all of which organs have an intimate anatomic and physiologic association with the sympathetic system, wander- ing kidney produces more or less disturbance of the digestive functions, as often evidenced by colicky pains referred to the stomach and bowels, and dyspepsia, with or without flatulence. Certain cases of flatulence, dyspepsia, and dilation of the stomach have been attributed to pressure of wandering kidney upon the duodenum, this pressure being supposed to cause reten- tion of a portion of the contents of the stomach, which, decomposing, pro- duces gaseous distension of that organ and irritation of its mucous membrane. Abdominal pains of a dragging or tugging character, and a sensation as of something falling down or moving about in the abdominal cavity, particularly when the patient rises from a sitting or lying to a standing posture or makes unusual muscular exertion, constitute the most charac- teristic symptoms of wandering kidney. Severe pains with tenderness of the tumor formed by the displaced organ occasionally occur, and have been attributed to a localized peritonitis of the serous investment of the organ or to simple neuralgia. Disturbance of the hepatic functions due to press- ure and irritation of the liver produced by the kidney-tumor have been noted. The disease, as a rule, is not fatal to life. Cases have been reported, however, in which the patient has apparently died from exhaustion due to chronic stomachic disturbance, continual pain, and nervous depression. The most serious menace is the possibility of malignant disease's developing in the displaced organ. This danger is often of the most important con- sideration in deciding the question of operation. Diagnosis. — The diagnosis of wandering kidney is, as a rule, quite readily made. In some instances the surgeon is first consulted regarding an abdominal tumor, the character of which is easily determined upon j)hysical examination by its form and extreme mobility. The tumor is usu- ally found between the free border of the ribs and the crista ilii, being most readily detected by bimanual examination with the patient lying upon the face. In thin subjects the displaced kidney may be grasped between the hands and outlined quite readily. In fat subjects, however, it is not always easy to detect the kidney. When the tumor has been discovered it will be found that it can easily be pressed back; indeed, it will often recede spontaneously into the normal position of the kidney if the patient be placed in the dorsal decubitus. There are several affections for which floating kidney may be mistaken. When the organ becomes displaced downward into the pelvic cavity it may be erroneously diagnosed as a small ovarian or fibroid tumor. Operations have been performed for the removal of ovarian tumors which, upon open- ing the abdomen, have been found to be displaced kidney. This has hap- pened to very expert operators. The possibility of mistaking a distended gall-bladder or movable liver for wandering kidney must be remembered. MOVABLE KIDNEY. 849 Tumors of the omentum may be mistaken for wandering kidney, a diagnosis being perhaps impossible without opening the abdomen. En- largement and displacement of the spleen simulate movable kidney to a certain extent, but the peculiar shape and relatively large size of the splenic tumor usually make the diagnosis comparatively easy. Pelvic tumors of various kinds may often be excluded by vaginal examination and by aspira- tion — the latter procedure being, however, rarely wan-antable. Teeatment. — The treatment of wandering kidney should be, in the majority of cases, strictly conservative, surgical interference being unwar- rantable save in extreme cases. The patient should avoid muscular strain, and if constipation exists it should be relieved, to prevent pressure's being brought to bear upon the kidney — through the medium of the intervening viscera — by the abdominal muscles during defecation. An abdominal band- age of knitted elastic is often serviceable in retaining the kidney in its nor-- mal position. Pads and trusses of various kinds have been suggested and have been indifferently useful. In cases in which mechanic support fails to hold the kidney in place, or if pain, hypochondria, dyspepsia, flatulence, and inconvenience in locomotion continue in spite of abdominal support, the only recourse is a surgical operation. Two methods of operating for movable kidney are in vogue, viz.: (a) nephrectomy — complete removal of kidney; (b) nephrorrhaphy — fixation of the kidney. Nephrectomy has given only fair results; thus, in one early series of 16 cases, 6 were fatal; of the 6 fatal cases, however, the kidney was diseased in 3.^ Although, as is well known, a single kidney is sufficient for the needs of the economy under normal circumstances, it must be admitted that in case the sole remaining kidney is unsound or should ever become diseased the patient's chances of recovery are likely to be slight. Again, the operation of nephrectomy through the lumbar incision might ^Dossibly be performed without the operator's having ascertained whether or not the patient has more than one kidney, and, inasmuch as nephrectomies have been performed that have proved fatal because the patient's only kidney has been removed, it is well to seriously consider this particular objection to nephrectomy for wandering kidney. The operation should certainly never be performed until ureteral catheterization, cystoscopy, or the Harris method has proved that the patient has two kidneys. Neither should it be performed where both kidneys are diseased. It is better practice to attempt fixation of the kidney in all cases unless the affected organ has undergone malignant degeneration. This is best performed by making a lumbar in- cision and stitching the fibrous and adipose capsule of the kidney to the lips of the lumbar wound, following the method hereafter to be described. The literature of this operation is not yet extensive, but is daily increasing and, so far as it goes, offers considerable encouragement for the future of ^Harris, American Journal of the Medical Sciences, July, 1882. 850 SUEGICAL AFFECTIONS OF THE KIDNEY. the procedure. The method is certainly well worth a trials the more espe- cially as it is not very dangerous in competent hands in the majority of eases. Should it fail, there will still be left the dernier ressort of nephrec- tomy. An operation of this kind, which has for its object not only the cure of invalidism and the relief of great physical suffering, but also the pres- ervation of an important excretory organ, is certainly well worthy of con- sideration in all serious cases of floating kidney, now that we have the benefit of modern aseptic surgical methods. The success thus far attained has been sufficient to obtain general recognition of the method as a rational surgical procedure. There are several diseases of the kidney that properly fall to the con- sideration of the surgeon, because of their greater or less amenability to strictly surgical methods of treatment. From a numeric stand-point the surgical diseases of the kidney preponderate over those of a purely medical character, although, on account of the comparative ease with which morbus Brightii is detected, the physician is more often called upon to treat renal disease than the surgeon. NEPHEALGIA. Pain referable to the kidney is necessarily always symptomatic, yet certain cases arise in which we are unable to determine the cause, even approximately. In by no means rare instances pain in the region of the kidney is probably a true neuralgia and should be regarded from that stand- point, although, as in all forms of neuralgia, the surgeon should occupy himself with a careful search for the exciting cause of the pain. As a rule, renal pain of a neuralgic character is dependent upon some irritating property of the urine. It is therefore met with most frequently in patients affected by a gouty or rheumatic diathesis. Lithemia is especially liable to develop it. It is by no means necessary that a definite calculus should exist in order that the solid matters of the urine may produce pain in the kidney. The sharp crystals of uric acid or calcium oxalate axe all-sufficient to pro- duce a painful degree of irritation of the renal pelvis, the more especially because the local irritation acts upon tissues that the gouty blood condi- tion has made hyperesthetic and. irritable. Nephralgia may be brought on by exposure to cold and partake of the characters of ordinary rheumatism. In this event it may or may not be associated with rheumatic symptoms elsewhere. It is probable that in some cases of so-called lumbago the kidney is the seat of most of the rheumatic pain, the renal disturbances being of a congestive character. Congestion may in all probability exist without urinary symptoms. That the urine may acquire properties by virtue of which it acts as an irritant to the kidney is well shown by the severe nephralgia so often pro- EENAL CALCULUS. 851 duced by the oil of sandal. This is generally associated with considerable pain and lameness — probably reflex — of the lumbar muscleS;, which, so far as it goeS;, is confirmatory of what has been said regarding the occasional coincidence of lumbago and nephralgia. Eecurrent attacks of nephralgia are usually due to some serious organic cause, such as calculus, cancer, or tuberculosis, a definite calculus being the most frequent factor in its etiology. Teeatment. — The cause must be removed where possible. Where the cause is not removable, and in cases in which none can be found, nephralgia demands attention upon its own merits. In general, nephralgia demands anodynes just as does neuralgia in any situation. The application of anodyne poultices over the lumbar region is of great service. Dry cupping is one of our most reliable remedies, a single application often being sufficient to give complete relief. In supposedly rheumatic cases salicylate of soda is demanded. Lithemia demands the dietetic and medicinal measures elsewhere recommended. Diuretics and large quantities of pure water are especially indicated. EENAL CALCULUS. Stone in the kidney is one of the most important of the surgical diseases of the organ. The causes of this disease have been outlined in the general remarks upon the etiology of urinary calculus and do not require detailed repetition. As a result of a special diathesis — usually the lithic or gouty, but sometimes the oxaluric — a deposit of crystalline material — uric acid, urates, or calcium oxalate — occurs in the renal tubuli. From the tubuli the deposit may be washed into the pelvis of the kidney, in which event it forms the nucleus of a calculus. Earely the material forms by accretion a calculus in the parenchyma of the organ. The condition often first manifests itself by a copious deposit of reddish-brown — brick-dust — deposit of sandy material in the voided urine, with or without additional symptoms in the way of pain in the back — nephralgia — and a greater or less degree of cystitis, with frequent and painful micturition. These latter symptoms are a natural result of the irritation of the mucous membrane produced by the chemic and mechanic properties of the sharp crystals of the special urinary deposit. Given the special diathesis, it is probable that apparently trivial causes may give rise to a precipitation of the solid matters of the highly concen- trated urine. It is claimed that sudden chilling of the surface of the body will produce it: a view that seems reasonable enough, for crystals which will remain in solution in warm urine precipitate when it cools. It would seem especially liable to occur from this cause if the patient be markedly rheumatic or gouty. It is quite likely that a cold draught striking the back is most apt to cause the difficulty, for in this direct manner the kidneys may become chilled. Eeasoning from the fact that, as a consequence of cooling of the urine in the renal tubuli, uric-acid crystals are often found in the kidneys of subjects recently dead, this view seems rational and sound. 852 SUKGICAL AFFECTIOXS OF THE KIDXEY. It is by no means easy to explain the deposition of crystals in all cases, for, even when the nrine is very concentrated, its solid matters are not apt to crystallize under ordinary circumstances; when a foreign body is present, however, the process is a simple one and is precisely like the crystallization of rock candy upon a string. It is possible that in some cases of gravel a slight catarrh or thickening of the tubules exists, which aids mechanically in the deposition of solid matters from the urine. Such a condition of catarrhal or hyperemic thickening may possibly appear and disappear within a very short time and leave no effects save the deposit of gravel. A prolonged debauch, or the ingestion of an excessive quantity of nitrog- enized food at some particular time, may act as the exciting cause of renal deposits. "When sabulous material has once formed in the kidneys, it may become agglutinated by mucus, with the resultant formation of a formed calculus. This often occurs without the intervention of mucus. After a definite concretion of appreciable size has formed, it may lodge in any por- tion of the genito-urinary tract, and by successive accretions of solid urinary matters may attain an unlimited size. Secondary phosphatic calculus may form in the renal pelvis in disease of that structure with retention of decomposing residual urine. This con- dition is, however, rare. Symptoms. — "When a stone of any size exists in the kidney, it is likely to produce considerable irritation, with more or less constant pain in the back and paroxysms of nephralgia of greater or less frequency and severity. If small, it may give no symptoms while in the kidney, the first sign of its existence being renal colic as it passes downward through the ureter. Sometimes the kidney is extensively destroyed without special symptoms, perhaps without the slightest pain referable to the kidney. Pressure over the kidney may elicit pain, but there is no special objective diagnostic sign indicating the existence of kidney-stone in the majority of cases. In the matter of diagnosis Keyes says: — In kidney-stone it may sometimes be noticed tliat the blood-disks, oval, round, and spindle-shaped epithelial and scattered pus-cells, which the urine is pretty sure to contain, become increased in quantity after exercise, while they sensibly diminish or perhaps entirely disappear after rest in bed for a few days. Pain and discomfort referable to the lumbar region on physical exertion are occasionally observed, but are not characteristic. The same may be said of the sensation of tenderness sometimes experienced by patients with kidney-stone on leaning the back against a firm body such as the back of a chair in sitting or of a buggy in riding. The latter symptom, however, is sometimes complained of by lithemic patients in whom no stone exists. In a case of the author's the gentleman — a physician — complains of this symp- tom quite constantly, being annoyed by it especially while making his calls. In this case there have never been any other symptoms that might be fairly EEXAL CALCULUS. bOO termed suspicious of stone. Tlie tenderness and pain incidental to lumbo- abdominal neuralgia may possibh' be mistaken for renal symptoms. Hematuria is frequent, but not constant. Wliile hemorrhage taken alone is no more than a symptom which should lead to inquiry as to the possibility of renal stone, it is quite im- portant when associated with certain other symptoms. Especially is it of value when it occurs coincidently with or follows nephralgia. In some cases the issuance of blood from one or the other ureter, as seen via the cystoscope, enables the surgeon to determine not only the renal origin of the hemorrhage, but also whether one or both are involved. Many cases of renal stone are never productive of hemorrhage. The x-ray has been shown to be serviceable in the diagnosis of renal calculus. The extent to which the method is applicable is, of course, un- determined as yet. That extensive renal calculus may exist without pain or tenderness referable to the kidney is Avell shown by the following case of the author's:- — Case. — A man, now aged 46 years, came under treatment about ten years ago suffering with deep and, for a time, surgically impermeable traumatic stricture. It was some weeks before a filiform could be passed into the bladder, on account of the tortuous formation of the stricture. The bladder could be evacuated fairly well after prolonged straining. Aside from the stricture, the patient had always been healthy. His habits were temperate, and his history was excellent. There was no history of hereditary gout, rheumatism, tuberculosis, or other constitutional disease. After some weeks of careful treatment the stricture was dilated to a caliber of Xo. 30 French. Since his first course of treatment the patient has appeared occasionally for the passage of the sound. There was a moderate aiiiount of cystitis, secondary to the stricture. Pyelitis was present; hence the urine did not clear up perfectly after the successful treatment of the stricture, but remained quite cloudy. Exacerbations of cystitis occurred from time to time, necessitating irrigation and the usual general and local treatment for that condition. The cystitis was finally apparently under control when, without increase in the symptoms referable to the bladder, the urine began to show a marked deposit of pus. This increased, there being no attendant constitutional symptoms. Careful examination showed the origin of the sudden in- crease of pus to be the pelves of the kidneys. The pus gradually increased until the urine contained the largest proportion the author had ever seen, aside from certain exceptional cases of evacuation of an abscess into the cavity of the bladder. There were no casts, the urinary deposit consisting of pure pus mixed with a small amount of epithelium from the bladder and renal pelvis. This profuse discharge of pus continued for some months without having any specially deleterious effect upon the patient's health. Suddenly, however, he began to have moderate fever, loss of appe- tite, emaciation, night-sweats, and diarrhea. Within a week he became extremely debilitated, but not sufficiently so to necessitate his going to bed. There was no clear indication for surgical interference; hence the sole reliance was internal medication, the usual urinary antiseptics, tonics, and stimulants being given. After this con- dition had lasted for several weeks without material improvement, Clark's solutions of iodin and chlorid of gold were administered hypodermically with most excellent results, the patient soon regaining his usual condition of health and the pus in the urine being reduced to a minimum. From the beginning of his urethral trouble the patient had never made the slightest complaint of pain in the back or symptoms 854 SUEGICAL AFFECTIOXS OF THE KIDXET. referable to the kidney or ureter, nor had he ever been affected by anything tliat might be termed renal colic. There was at no time, nor has their ever been excepting after the operation upon the kidney that will shortly be described, the slightest trace of blood in the urine. The patient remained in a condition of health quite satisfactory to himself until the onset of the difficulty for which the operation under consideration was performed. The urine remained quite cloudy, and contained, at all times, a moderate amount of muco-pus. Some months afterward, however, recurrent chills and fever, vomiting, loss of appetite, and night-sweats suddenly developed. Five days later, for the first time since he came under treatment, the patient, was compelled to take to his bed, where he remained several days, after which he arose and remained an ambulant patient until operated upon. There was still no pain or tenderness in the vicinity of the kid- neys, and it was difficult to convince him that even a suspicion of a collection of pus in one or the other loin was warrantable. After careful study of the case for about a week, the author became convinced that there was suppuration in the vicinity of the right kidney, and, as the liver was considerably enlarged, a complicating hepatic abscess was suspected, this suspicion being otherwise justified by slight rig. 195. — Renal calculus removed in the author's case of hepato-nephrolithotomy. jaundice. The tongue was heavily coated; temperatui-e ranged from 102° F. in the morning to 103° F. in the evening. As there was no definite tumor in the flank and no well-outlined local symptoms, the diagnosis was not clear until nearly a week later, when pus was found anteriorly just below the free border of the ribs, after repeated attempts to detect it with the aspirator. An operation was decided upon, and the author determined to open anteriorly with the view of first operating upon the hepatic abscess that was believed to be present, the intention being to leave the abscess in the region of the kidney for future consideration. Operation. — An incision was made in the abdominal wall just beyond the outer border of the rectus muscle, extending from the free margin of the ribs to the crest of the ilium. On cutting through the fascia transversalis, the peritoneum was found to be adherent to a coil of intestine, which in turn was adherent to the anterior surface of the greatly-enlarged liver. Only cautious dissection prevented injury to the bowel. Repeated attempts at aspiration were necessary before pus was finally encountered, the needle being passed backward and inward in the direction of the spine. Pus was found at a much greater depth than had been anticipated from the results of the aspiration performed before the abdomen was opened. The needle was left in position and an incision made in the thickened visceral and parietal peri- EEXAL CALCULUS. 855 toneum, which were closely fused together over the surface of the liver. On turning down the inferior edge of the incised peritoneum, it was found to be firmly adherent to the liver and to the coil of intestine already alluded to, the general peritoneal cavity thus being effectually walled off. The Paquelin cautery was now made to follow the needle and the pus-cavity was finally entered, this being rather difl&cult because of the small area of the operation-field. On entering the abscess-cavity in the liver, about 4 ounces of creamy pus escaped. On exploring the cavity Avith the finger, it was found to extend backward so that its long axis was directed toward the region of the kidney. Detecting fluctuation in the posterior wall of the abscess, the finger was deliberately pushed through the thin wall, opening into a second abscess, evidently perinephritic in character. On opening the perinephritic abscess, a large quantity of pus escaped, and with it a small amount of sabulous material, which ex- cited the suspicion that renal stone was present. With great effort the finger reached W M5*aP^ Fig. 196. — Calculus imbedded in lower portion of renal pelvis. (After Moullin.) the pelvis of the kidney, which was found enormously dilated, presenting an opening toward the perinephritic abscess-cavity. The region of the pelvis of the kidney was no sooner touched than a hard body was felt, and on passing the finger through the incapsulating wall of the renal pelvis a calculus was distinctly outlined. Thinking that the calculus was not of large dimensions because of the small size of the present- ing part reached by the finger, an attempt was made to extract it with a pair of forceps, and, the presenting point breaking off, a calculous mass was extracted which, as shown by its facets, Avas evidently a secondary calculus fused upon one of larger size. Several particles of calculous material now escaped from the pelvis of the kidney into the abscess-cavity, and were removed with the finger. It was decided to remove the larger mass of calculus entire if possible, and finally, by the aid of long curved pedicle-forceps and a lithotomy-scoop, the remainder of the calculus was removed unbroken. The wound was deeply tamponed with iodoform gauze for drain- 856 SUEGICAL AFFECTIONS OF THE KIDNEY. age, this being substituted in a few days by rubber tubing, the latter being entirely removed at the end of four weeks. The illustration shows the calculus, natural size. The entire mass weighed 746 grains. As will be observed, it is ovoid in form and tuberculated. It is composed of a number of uric-acid calculi fused together by phosphatic laminae. The subsequent history of the case was uneventful. Three months after the operation the wound was almost closed, there being but a small amount of pus and no urine escaping from the resulting fistula. The patient gained rapidly in weight and strength, the urine vastly improved in appearance, and it was evident that his life had been greatly prolonged by the operation. At 'the present time, four years after operation, and eleven years since he first consulted the author, he is in good health, although the urine is not clear nor the fistula completely closed.^ The case is exceptional: — 1. Because of the large size of the calculus. 2. The entire absence of all symptoms referable to renal calculus, notwithstand- ing the fact that the patient Avas most carefully observed for some years. 3. The difficulty of diagnosis incidental to pyelitis from ascending infection secondary to a condition entirely independent of the renal calculus. 4. The extraordinary method of opei-ation necessitated by the exigencies of the case. The enormous size to wliicli renal calenli may attain is shown by the following unique case, reported by Charles Adams, of Chicago: — Case. — Mary D. G., aged 38, first seen in July, 1895, suffering from severe renal colic. She had suffered from similar attacks at irregular intervals for seventeen years. After the first colic in 1878 there were several attacks during the succeeding eighteen months; then for three months the attacks were frequent — sometimes tAvo or three weekly. Following this was a long quiescent period. In 1888 a brief attack occurred. During the last three months of a pregnancy that came to term in December, 1889, suffering was severe and almost continuous. Two weeks after delivery an especially severe attack was followed by the expulsion, per urethram, of four calculi. Five years elapsed without severe paroxysms Avhen, in the spring of 1895, the attacks became severe and frequent until the time of operation. There had never been absolute freedom from pain in the left renal region since the first attack, but the patient had considered herself well when not confined to bed by acute colic. At the time of my first visit there was no question as to the diagnosis, but the affected region was so sensitive that palpation was unbearable; hence no idea was gained of the size of the calculi. Operation was advised and preliminary catheterization of the ureters suggested to ascertain the condition of the right kidney, as the left was prob- ably worthless and required removal with the calculi. The patient recovered quickly from the acute att-ack, and went to Colorado, returning in improved health in October. In November another attack occurred, followed by attacks in January, February, and March. In April, 1896, I was again called and found the patient prostrated by an attack of two Aveeks' duration attended by continual vomiting, steady emaciation, and severe pain, demanding large and frequent doses of morphia. The urine contained pus and considerable blood. Operation was advised, but the patient would not consent until after the subsidence of acute symptoms. Her condition, however, became worse from day to day and on May 1st I was again called. There was at this time an ^ Since the above was written the author has removed some calculous material from the track of the fistula, and it is now closed. EENAL CALCULUS. 857 increase of intensity of the condition above noted, plus an exhausting diarrhea. There was a tumor in the left iliac region as large as two fists; the affected kidney was secreting urine and the ureter was blocked at the renal end. The patient was 197. — Enormous segmented renal calculus, natural size. (After Adams.) in most unpromising condition for operation, but it was evident that if anything was done it must be done quickly. I urged immediate removal to hospital, and that being safely accomplished the operation was performed in the afternoon. 858 SUEGICAL AFFECTIONS OF THE KIDNEY. Under chloroform anesthesia, incision was made, parallel to and just below the last rib, from the sacro-lumbalis forward and downward to the extent of three inches. This incision, being carried through the parietes, exposed the peritoneum anteriorly. The peritoneum protruded into the wound, but was not cut. The weight of the calculi had displaced the kidney downward and forward to such an extent that it was necessary to have it pushed up into the loin by pressure through the anterior abdominal wall. The kidney, being cleared of fat, was incised at the upper third of its convex surface and the calculous mass exposed. Incision was followed by the escape of some urine, and free hemorrhage. The latter being checked by hot water and pressure, and the edges of the renal wound held up to the external incision by forceps, the upper calculus was carefully enucleated. It Avas intimately adherent to the kidney in places. Next, with a slight enlargement of the renal incision, the smooth, spear-shaped stone was extracted. With infinite diflficulty and pains to avoid laceration of the kidnev, the large central mass was finally freed from its adhesions Fig. 198. — Enormous renal calculus, reduced; segments separated, showing facets. (After Adams.) and removed. This necessitated enlarging the parietal wound by a vertical cut from the center of the first incision to the crista ilii. On account of the closeness of the last rib of the ilium this incision was only two and one-fourth inches long, but by extreme care the mass Avas extracted without lacerating the tissues to any great extent. The interior of the kidney was now the shape of a pouch about six by three inches, from the bottom of which were extracted the nine smaller stones that filled the lower portion of the renal cavity. Exploration revealed no other cal- culus. The cavity was irrigated with sterile hot water, the kidney sutured to the fascia in position, a rubber drainage-tube passed to the bottom of the renal cavity and packed around with strips of iodoform gavize, the external wound closed so far as possible by sutures, and dressings applied. Although done as quickly as compatible with safety, the operation consumed an hour and twenty minutes, during which time the patient was in imminent danger of collapse, but was freely stimulated by hypo- dermics of strychnia and whisky. The stones are represented, actual size, in Fig. 197, fastened together as they EENAL CALCULUS. 859 lay in the kidney. In Fig. 198 they are separated, showing their principal facets. The nine smaller calculi were compactly packed together in the bottom of the kidney below the level of the ureteral opening. The spear-shaped calculus fitted into the ureter, and as it was movable on the large mass on a highly polished surface, I sup- pose it produced occlusion only up to a certain point, when by the changes in pressure produced by the distension by urine it was shifted upward slightly, allowing the urine to escape. The stones are uric acid in composition, with some incrustation of phosphates. The total weight was 226 grams dry. For forty-eight hours after opera- tion the patient hung between life and death, but since that time she has done well. The urine is normal, and save some vesical irritation she has had no symptoms. At the date of writing the patient has passed forty days since operation, is gaining in flesh, and doing well in every particular. An instructive feature of this remarkable case is the preservation of the function of the affected kidney under the prolonged pressure of the enormous mass of calculous material. MosBiD Anatomy. — The first pathologic result of renal stone is neces- sarily more or less pyelitis. This condition becomes aggravated as the stone increases in dimensions. After the stone attains a size sufficient to produce a certain degree of pressure upon the renal tissue, atrophy of the latter commences. In extreme cases a huge stone will be found inclosed in a fibrous sac that was once the kidney. Abscess may result, and this may rupture into the cellular tissue about the kidney, forming perinephritic abscess. If the ureter be blocked up, hydronephrosis or pyonephrosis may result. Much depends upon the extent of the secondary renal disease and its character as regards pus or tubercular infection. If one kidney be com- paratively healthy, it may carry on the eliminative function perfectly enough for all practical purposes; but if both be diseased, uremia must result sooner or later, its degree depending entirely upon the amount of pathologic change in the renal tissues. Treatment. — The therapeutics of renal calculus embrace both med- ical and surgical means of relief. The medical treatment comprises (1) prophylactic measures; (2) curative remedies (rarely); (3) palliation. Prophylaxis, palliation, and cure by internal medication are all sub- served by the various measures suggested in the chapter on genito-urinary hygiene. Of special importance are exercise, bathing, a non-nitrogenized regimen, and total abstinence from alcoholics of whatever kind. Of more importance than the quality of the diet is the question of its digestion and assimilation. A moderate quantity of proteids well digested and properly assimilated is safer than a vegetable diet where the latter is not normally digested. Abstinence from meat alone will not effect the desired result. As Henry Morris states, the poorer classes, who are often of necessity vege- tarians, are none the less subject to calculus.^ That gout may develop under a vegetable diet is shown by the fact that gouty deposits are found in parrots. How far nervous disturbance may enter into the etiology of calculus in ^ Op. cit. 860 SUKGICAL AFFECTIOXS OF THE KIDXET. human beings is an ojDen question. The anthor snspects it to he more important than is generally believed. The enratire medical treatment of renal calculns is xevx unreliable, 3^et excellent results are apparently secured in not a few cases. The treatment is based upon the theory of the possibility of dissolving the stone in loco by remedies the action of which is chiefly to increase the solvent properties of the urine. Obviously, the urine is best adapted for the solution of con- cretions when its specific gravity most nearly approximates that of pure water. Constant study of the urine enables the surgeon to determine whether his treatment is maintaining its specific gravity at the desired low standard. The solvent treatment for calculus should include, in addition to dietetic and hygienic measures, the free ingestion of large quantities of pure water — of which distilled water, with or without lithia, is the type — and the administration of such alkaline diuretics as citrate and acetate of potassium. These drugs, to be efi^ective, should be given in doses of from 30 to 60 grains three or four times dail3^ Lithia in full doses is also serv- iceable. Potassium iodide has seemed to be of service. A cure is never to be promised from the solvent treatment, though exceptional cases have resulted favorably under it. Wliile the so-called solvent treatment is rarely curative, it is usually palliative, and prophylactic of further calculous deposit. Additional measures of iDalliation consist of narcotics, anti- spasmodics, and rest, as exemplified in the treatment of nephritic colic. The surgical treatment is, of necessity, operative, and will be discussed later. Nepheitic Colic. — The more or less constant pain over a kidney affected by stone is often varied from time to time by acute exacerbations due to efi'orts on the part of the kidney to exjDel the intruder, efforts that are sometimes successful. When the calculus is of very small size it may pass through the ureter into the bladder with little or no pain; but, if large enough to irritate the ureter, pain of most agonizing character may result. The pain is referred to the loin that has been the seat of irritation, and radiates along the sper- matic cord, into the testicle, and down the inner aspect of the thigh of the affected side. The testicle is drawn snugly up to the external ring b}^ spas- modic retraction of the cremaster muscle. These phenomena are a result of reflex irritation of the genital branch of the genito-crural nerve, being analogous to the knee-pain experienced in disease of the hip. Like all of the abdominal organs, the ureter is intimately associated with the sym- pathetic system: consequently any injury of, or morbid impression upon, it produces profound de^Dression and the patient feels weak and faint; in short, he presents the cool, moist skin and general appearance of shock. This condition always results when a sensitive tissue is pinched or strangu- lated, as is best shown in strangulated hernia. Nausea and vomiting are usual, and constipation is apt to supervene. The urine is scanty, high- colored, and often bloody, the calls to urinate being frequent and sometimes RENAL CALCULUS. 861 more or less painful. Complete suppression may occur. In prolonged eases a rise of temperature may be noted. The pain continues with more or less marked remissions and exacerbations until the stone reaches the blad- der^ when the symptoms suddenly cease and the patient is soon as well as ever. This descent may last only a few hours, but often it requires several days. The author has recently seen in consultation a case of three weeks' duration. The phenomena just described are known under the names of nephritic colic and "gravel." Whenever an attack of this kind has been experienced the patient should be apprised of the probability of its recurrence, and the possibility of the development of a vesical calculus sooner or later. If the stone does not pass out through the urethra with the urine, it will inevitably become by ac- cretion a vesical calculus of greater or less dimensions. This is the origin of most of the nuclei found in stone in the bladder. It is important, there- fore, to watch the urine carefully for several days after an attack of gravel. The discovery of the concretion will permit the surgeon to reassure the patient to a certain extent regarding his future comfort, so far, at least, as the stone in question is concerned. Treatment. — The treatment of nephritic colic is necessarily chiefly palliative, as we cannot immediately modify the existing condition. At- tention should be directed to the relief of pain and spasm until such time as the condition becomes cured spontaneously. Morphin or other opiates should be given freely. The surgeon can at least relieve the intense pain. The drug should be given in sufficient quantity to allay the pain. It should be remembered, however, that pain is an antidote for opium; hence, if the pain should suddenly cease soon after the patient has taken a huge dose of morphin, fatal narcotism might result. Opium relieves spasm as well as pain, and is therefore doubly effective in renal colic. Chloroform inhala- tions may be given if necessary. A full hot bath assists the passage of the stone by promoting general relaxation. Hot poultices should be applied to the loin and side. The bowels should be relieved by enemata. A remedy that has been highly recommended in renal colic is hydrangea in the form of the fluid extract. This should be given in a dose of 5J every two hours. In the author's experience this remedy has been of service. It is claimed that hydrangea has a special effect upon the ureter. Diluents and diuretics with large quantities of water should be freely given for the purpose of affording mechanic assistance to the passage of the gravel. When a renal calculus remains in the pelvis of the kidney it sometimes attains an enormous size, filling the pelvis and calices completely, and event- ually causing atrophy as well as inflammation, and perhaps abscess, of the secreting structure of the kidney. The stone may become impacted in the ureter, causing hydronephrosis or pyonephrosis, pyelitis, or perinephritic ab- scess. In either event the patient is finally worn out by pain and urinary toxemia, unless the case should prove amenable to operation. 863 SURGICAL AFFECTIONS OF THE KIDNEY. It is worthy of note that in some cases of nephritic colic the pain is due to the temporary impaction of a calculus in the uretero-pelvic orifice. The stone, being too large to pass, suddenly slips back after a time, giving almost instant relief. SUEGICAL PYELITIS. Pyelitis is so rarely idiopathic — being, as a rule, secondary to diseases of the genito-urinary tract of a distinctively surgical character — that it has come to be looked upon as an almost exclusively surgical affection. It has even been asserted that pyelitis is never an idiopathic disease: an opinion with which the author cannot agree. Fig. 199. — Calculous pyelonephritis, with destruction of renal tissue, removed and shown at a. (After Moullin.) Calculus Idiopathic or non-surgical pyelitis is not common; still it is more fre- quently met with than is generally believed. Eich, highly-seasoned food, intemperate habits, habitual overdistension of the bladder from neglect of the physiologic function of micturition, acid urine, and exposure to cold are the chief causes that may contribute to the production of a catarrh of the mucous membrane lining the renal pelves. The prolonged ingestion of the balsams, cantharides, or turpentine may produce the same condition. Secondary infection occurring in the course of the exanthemata is sometimes an efficient cause. Etiology. — The causes of surgical pyelitis may be classified as fol- lows, it being understood that some of the etiologic factors in the first SUEGICAL PYELITIS. 863 series may co-exist with any of the others and that the inflammation is generally of the chronic type: — 1. The influences just enumerated as productive of idiopathic and sim- ple (medical) pyelitis. 3. Obstructive affections of the urinary tract, such as .stricture and prostatic hypertrophy, producing backward pressure and strain upon the renal pelvis, with, sooner or later, ascending infection from the bladder. 3. Acute or chronic inflammation of the urinary tract, producing pyelitis by simple extension. 4. Eenal calculus, perhaps associated with infection, either from below or through the medium of the blood. 5. Tumors and tubercular deposit in the renal structure or pelvis, with or without associated mixed infection. 6. Pyemic abscesses — i.e., abscesses from general pus-infection — in the renal substance opening into the renal pelvis. The most frequent causes of obstruction to the flow of urine are ves- ical calculus, stricture, and enlarged prostate. Very few cases of these con- ditions remain free from more or less severe pyelitis. Indeed, the existence of chronic pyelitis should be taken for granted in every long-standing case of the kind. As a rule, the pyelitis is of low grade and due to continual congestion and pressure irritation associated with mild infection, the in- flammation of the bladder which nearly always exists, extending gradually upward to the kidneys. In some cases as a consequence of a debauch, ex- posure to cold and wet, or surgical interference with the urethra or bladder, acute pyelitis with its characteristic symptoms is set up. This may extend to the secreting structure of the kidney — pyelonephritis. Acute or even chronic gonorrheal inflammation is especially apt to extend suddenly in this manner. According to Keyes, the supervention of acute pyelitis may not be announced by chill, fever, pain, of other symptoms referable to a possible invasion of the renal pelvis. If this be true, constant care should be exercised lest pyelitis be overlooked altogether. Pyelitis is sometimes a serious complication of pregnancy, although simple renal congestion or even nephritis with resulting albuminuria are more frequent. The pyelitis is probably due to the same cause as disease of the renal tissue proper, viz.: simple pressure by the gravid uterus pro- ducing obstruction to the escape of urine into the ureters; there is also, undoubtedly, more or less bruising from the uterine pressure. The remaining causes of pyelitis act alike. Calculi, abscesses, tumors, and tubercular deposits produce pyelitis: (1) by their irritating influence as foreign bodies; (2) by producing mechanic obstruction to the escape of urine; (3) by associated infection. Blood-clots, hydatids, or cheesy masses of pus may block up the ureter and produce pyelitis. Pyelitis is an occa- sional accompaniment of typic Bright's disease, but more often precedes nephritis, being under such circumstances a source of confusion in urinal- 86i SUEGICAL AFFECTIONS OF THE KIDXET. ysis. In such cases the urine ■«'ill show a certain amount of albumin after the inflammation of the renal structure jjroper has practically disappeared. Acute nephritis is not infrequently followed by pyelitis. Symptoms. — The s}Tnptoms of pyelitis are chiefly pain in the loin on one or both sides and discharge of pus with the urine. The severity and type of the pain depend mainly upon the character of the surgical cause of the pyelitis. Calculi usually cause pain and tenderness to a degree pro- portionate to the size of the stone. Pain is more severe when the ureter is occluded than when the contents of the renal pelvis are permitted to escape more or less freely. It is also more severe on movement where calculus exists. Attacks of nephralgia or true nephritic colic are frequent when the pyelitis depends on renal calculus. Cancer or sarcoma usually cause severe pain. Many cases of chronic jDyelitis develop without any pain referable to the kidney, the symptoms being apparently entirely vesical and con- sisting of strangury and frequent micturition. The vesical symptoms are due to two causes, viz.: reflex irritation of the vesical neck and direct irri- tation produced by pus and detritus — neoplastic or calculous — in the urine. So prominent does the vesical irritation become in some cases, that an error in diagnosis is made and treatment instituted for cystitis alone. The urine is highly acid early in the course of pyelitis, unless sec- ondary to chronic bladder disease, but later on, if secondary cystitis de- velops, it may be ammoniacal. A small amount of blood may be present and yield albumin to the heat and nitric-acid tests. Under the microscope, mucus, blood-corpuscles, and the characteristic epithelium of the renal pelvis are first seen in the simpler cases, and later on pus is found. The urine is not always reliable as a means of diagnosis, because of its con- tamination by the products of cystitis, gonorrhea, etc. When the urinary pus-deposit of pyelitis is characteristic, it forms a thick, powdery, greenish layer 'at the bottom of the vessel. When pro- nounced cystitis co-exists, however, the pus occurs as is usual in that dis- ease — mainly in stringy, ropy clots and gouts. If these be decanted oft', a greenish, oily la^^er is often left behind, showing the co-existence of pye- litis. Allien no cystitic ropy clots are present the pus is evenly disseminated throughout the urine. The constitutional s}"mptoms of pyelitis depend for their severity upon the amount of pus in the renal pelvis. In general, they are those of ordi- nary hectic. In some cases distinctly intermittent chills occur, closely simulating malarial paroxysms: in others no constitutional symptoms ex- cept, perhaps, slight malaise are noticeable. In some rare cases of calculous pyelonephritis pain will be experienced in the loin corresponding to the comparativeh'-healthy kidney, as seen in a case that will shortly be de- scribed. Ptoxepheosis. — When the exit of pyelitic pus into the ureter is ob- structed, it accumulates in and distends the renal pelvis, forming the con- PTOITEPHEOSIS. 865 dition known as pyonephrosis. This is one of the most important — al- though not the most frequent — varieties of surgical kidney. In some cases the entire renal pelvis is not involved, the pus having accumulated in a sacculus which from time to time bursts, giving exit to the pus into the renal pelvis and thence into the ureter. This condition gives rise to a marked variation in the amount of pus in the urine, the deposit at one time well-nigh disappearing, only to again appear in large amount; this variation is especially marked when the condition is unilateral. Quite often only one kidney is pyonephrotic, the other acting vicariously and being sufficient for the elimination of waste. Yery often in cases of surgical kidney a very thin layer of cortex seems to be sufficient to carry on the amount of elimination of urea and other waste-matters necessary to ex- istence. When pyonephrosis develops certain special symptoms arise, due to the mechanic disturbance produced by the tumor. The bowels are quite likely to be more or less pressed upon, with consequent interference with their functions. The chief characteristic of advanced pyonephrosis is the presence of a tumor in one side of the abdomen. The structures of the lumbar region are very dense and resisting; hence the sacculus can only protrude mainly forward and slightly laterally. Palpation and percussion demonstrate the existence of a tumor quite readily, but careful study of the history of the case and aspiration of the contents of the tumor are necessary to a positive diagnosis. Tenderness and obscure fluctuation are additional signs, but the latter may be absent in tumors of small or moderate size. The general symptoms become very prominent in severe cases, hectic being especially pronounced. The patient is apt to finally succumb to the exhaustion produced by prolonged suppuration, and in very protracted and exceptional cases lardaceous deposits may occur in various organs. Uremia is a factor in all severe cases of pyonephrosis. Its severity depends upon the extent of renal tissue involved, disease of both kidneys being almost certain to produce a greater or less degree of uremia. A moderate amount of uremia may perhaps be tolerated, but when a sudden strain is thrown upon the small portion of renal tissue yet remaining it is apt to suspend work altogether, with a consequent fatal result. The results of pyonephrosis are variable. In some cases the kidney- structure and walls of the renal pelvis become enormously dilated and sac- culated, perhaps filling the abdomen almost completely. The walls of the pus-sac may finally become so thin that rupture occurs at some point and the pus, decomposing urine, and deposited sabulous matter escape into the perirenal cellular tissue. This course is especially apt to be followed where renal calculus exists, for the pressure of the stone is quite likely to produce ulceration and rupture of the already thin and weakened walls of the sac- culus. 866 SUEGICAL AFFECTIONS OF THE EIDNEY. Wlien the contents of the renal pelvis escape into the surrounding tissues, inflammation and abscess invariably occur — perinephritic abscess. An abscess of this kind usually burrows in different directions, and may open in the most unexpected and remote situations; thus it has been known to open into the lungs, intestine, and bladder. In the more fortu- nate and favorable cases it points in the lumbar region or flank, where it is easily reached and evacuated. Cases have been noted in which the abscess came to the surface below Poupart"s ligament, following the usual course of psoas-abscess, for which it is quite apt to be mistaken under such cir- cumstances. When the abscess has finally opened spontaneously or has been evacu- ated, a fistulous track usually remains for an indefinite time. Through this track urine as well as pus may escape, and in some cases small stones finally become extruded or are detected and extracted. When a stone exists in the renal pelvis these fistulas never heal until the source of irritation has been removed; quite often, indeed, nephrectomy is necessary, even though no stone be present, before closure of the suppurating track will occur. In some instances a fistula is perpetuated by sabulous deposit along its track. After removal of this material healing is sometimes rapid. Operation is often absolutely necessary to save the patient from death from prolonged suppuration and exhausting pain. The prospect of both surgical and spontaneous cure depends chiefly upon the condition of the opposite kidney. After evacuation the affected organ sometimes becomes obsolete: i.e., shrivels up and ceases to produce any disturbance. In such cases, if the opposite kidney be comparatively sound, complete restoration to health may occur. Evacuation of the pyonephrotic abscess is not absolutely necessary to spontaneous recovery, as shown by those rare cases in which the pus under- goes caseation and the morbid process ceases. This favorable ending can- not often occur in the presence of stone or in eases of double pyonephrosis. It would seem that perinephritic abscess may be produced by other causes than stone or other diseases of the renal pelvis. Bowditch has re- corded severaltypic cases of this kind attributed to cold, muscular strain, etc. It is probable that stone may produce perinephritic abscess without the intervention of pyonephrosis or rupture of the renal pelvis. This would seem to be demonstrated by the following interesting case occurring in the author's practice: — Case. — The patient was a young man, 19 years of age, who had previously been very healthy. Four weeks prior to the author's first visit the youth was sud- denly awakened one morning by a severe pain in the right ileo-lumbar region. This pain had been constant from that time on, and had been but imperfectly relieved by morphia. The urine was scanty and high-colored, and voided with severe strangury every few minutes. The pain radiated down the thigh and groin of the affected side, but did not affect the testicle. The appetite had failed completely. There had been exacerbations of pain from time to time, with at no time elevation of temperature or PYONEPHROSIS. 867 rigors. Such was the history given by the attending physician, by whom the author was called in counsel. Upon examination the temperature was found to be normal, the pulse about 60 and feeble. The patient was still suffering with agonizing pain in the right side and right lumbar region. There was considerable prostration. Pressure elicited great tenderness over the right kidney and in the course of the ureter both in front and behind. The liver was apparently normal. The urine contained no abnormal elements, but was still scanty and high-colored, micturition being frequent and painful. In view of the history and physical status of the case a diagnosis of passing renal calculus seemed justifiable, the stone having in all probability become impacted in the upper portion of the ureter or at the opening of the renal pelvis. This diagnosis was made more probable later on by the fact that, as the patient expressed it, the painful point had gradually descended toward the iliac fossa. The usual line of treatment by free doses of opiates, diluents, hydrangea, and the application of hot poultices was continued. Four weeks later the author Avas called to operate upon a large abscess that was pointing in the back at the right of the spine, midway between the last rib and the crista ilii. Upon incision this gave exit to about three pints of healthy-looking pus. Upon exploring the cavity with the finger, it was found to enter the abdomen at the free border of the ribs, extend- ing upward to the kidney, the lower portion of which could be plainly felt free in the abscess-cavity. Contrary to expectation, no stone or other apparent cause for the abscess could be found in the discharges or on palpating the course of the ureter. Under antiseptic dressings the abscess healed perfectly at the end of about five weeks. In this case it is probable that a small stone descended from the kidney, and, becoming temporarily lodged somewhere in the course of the ureter, produced irrita- tion in the surrounding cellular tissue, either reflexly or directly, with associated infection and consequent abscess. The source of pus-infection would be difficult to determine. No stone has ever escaped during urination so far as known; hence vesical calculus may develop sooner or later. Pyonephrosis may be the result of renal tuberculosis, with or without general infection. Even the non-tubercular form may eventually lead to general tubercular deposit, just as any chronic suppurative process may do. An interesting case of double calculous pyonephrosis was reported to the pathologic society of London, that the attending surgeon believed to have some bearing upon the question of so-called "sympathy" between the kid- neys. Case. — A man, aged 22, entered St. Mary's Hospital, London, in November, 1886. For ten years he had suffered pain in the region of the left kidney, with occasional attacks of left renal colic. In 1882 he began to pass gravel and to suffer from irrita- bility of the bladder, and in 1885 a small calculus was removed by lateral lithotomy. Symptoms of vesical calculus soon recurred, together with pain in the left loin, and his general health became much broken. His urine contained pus and occasionally blood. Left calculous pyelonephritis was diagnosed in addition to stone in the bladder, and the latter was accordingly removed by median incision on December 4, 1886. Ten days later the left kidney was exposed in the loin and two small calculi were removed from a large suppurating cyst. The amount of pus, however, did not materially lessen, and toward the end of January he began to have pain in the region of the right kidney, from which it was soon suspected that the pus now came. On February 18th he was attacked with violent pain in the right loin, Avith rigors, vomiting, and high temperature. At the same time the pus almost entirely disappeared, and his 868 SURGICAL AFFECTIONS OF THE KIDNEY. urine dropped from forty-two to twenty ounces. It was believed that this urine was furnished by the left kidney only. The symptoms increased and there was fullness in the right loin. On February 25th the right kidney was exposed; it was found much enlarged and surrounded by fetid pus, and there was an opening into the pelvis from which an abscess had probably burst into the perinephric tissue. No stones were found. He did well after this operation. The urine steadily increased in quan- tity, the pus diminished, and the pain ceased. He left the hospital on May 26th, and a feAV days afterward he passed four small calculi per iirethram. From that time he made steady progress toward recovery. The case is of interest from its bearing on the question of sympathy between the kidneys, and it was suggested that in this case the right kidney had in all probability contained calculi, though without giving rise to symptoms, for some con- siderable time, and that its condition was revealed by the operation on its fellow. From the theoretic stand-point of the reporter this case is valueless. As an example of bilateral calculo-purulent renal disease it is worthy of note. The term sympathy is very far-fetched in its relations to this case, which was evidently a plain, straight case of double consecutive jDyelone- phritic infection secondary to renal calculus. It seems peculiar that medical men are so frequently compelled to resort to the meaningless term, "sym- pathy," in attempting the explanation of various morbid processes. With our advanced ideas regarding the functions of the sympathetic system, par- ticularly those functions that we term trophic, we should be able to account for some of these phenomena in a more logical manner. Eeflex disturbance of nutrition suffices to explain many of the so-called sympathetic affections; infection explains the rest. The lines of thought expressed by Hilton in his valuable little work, are very instructive in this connection.^ The consistency of our modern bacteriologic notions depends so mark- edty upon a material source of irritation that we are apt to lose sight of the morbid possibilities of purely nervous influences, which, with or without superadded infection, may become of serious import. Prognosis. — The prognosis of pyelitis varies greatly in different cases. In a general way it depends upon: — 1. Whether it is idiopathic or secondary. 2. The presence or absence of stone. 3. The degree of freedom of drainage via the ureter. 4. Whether the condition be unilateral or bilateral. 5. The extent to which the se- creting structure of the kidney is involved. 6. The character of the pri- mary disease, wdiere the pyelitis is secondary. Simple pyelitis due to exposure or secondary to curable bladder, ure- thral, or prostatic difficulties usually disapjDears. A cure is necessarily im- possible in many cases until after all primary obstructive difficulties have been removed. Pyelitis dependent upon acute fevers, especially the exan- themata, does not per se destroy life, but recovers spontaneously as soon as the general disease subsides, or shortly thereafter. ^"Rest and Pain." TREAT:ME]SrT OF PYELITIS AND PYONEPHROSIS. 869 Pyelitis secondary to cancer, tumors of various kinds, and tubercular disease is never recovered from. Calculous pyelitis may subside if the stone is removed, but will persist as long as the foreign body is present. When both kidneys are involved a fatal result occurs sooner or later in almost all cases. Pyonephrosis was formerly inevitably fatal in the majority of cases and even with our modern surgical treatment double simultaneous pyonephrosis cannot be cured. In some happy instances in which one kidney is com- paratively sound a pyonephrotic kidney may undergo spontaneous cure. The occasional accidental post-mortem discovery of dried up renal pus-sacs, perhaps containing calculi, has demonstrated the possibility of spontaneous recovery. Treatment. — The general and medical treatment of pyelitis and pyo- nephrosis is not very satisfactory. Inasmuch as inflammation of the pelvis of the kidney is almost invariably dependent upon, and secondary to, chronic disease of other portions of the genito-urinary tract, or to renal or other disease acting mechanically, there are few cases that can be treated with direct reference to the condition of the renal pelvis itself. Pyelitis secondary to chronic cystitis, renal or vesical calculus, urethral stricture, hypertrophied prostate, or tumors producing obstruction of the genito-uri- nary tract is necessarily of minor consideration, treatment being directed chiefly toward the primary condition. The special measures for the relief of these various conditions have been or will be considered in their proper connection. It is, of course, necessary in all cases to attend to the condition of the urine, and this, as a rule, requires neutralization or perhaps alka- linization. The fact that the urine is ammoniacal as expelled from the bladder does not always contra-indicate the administration of combinations of alkalies with the vegetable acids, for the reason that the urine as found in the kidney is generally strongly acid and irritates the renal pelvis. The resultant mucus acts upon the vesical urine catalytically, and develops am- monium carbonate from the urea. Ammoniacal decomposition of urine in the bladder is a purely secondary affair. When pyelitis has existed for any length of time in cases in which the primary cause of the difficulty is lo- cated in the kidney, the bladder must necessarily become affected second- arily, as a consequence of the irritation produced by the purulent and acid urine as it enters that viscus. The fact that this urine decomposes and be- comes ammoniacal is no criterion of its reaction as it leaves the kidney and enters the ureter. Tonics are always indicated in pyelitis, the various preparations of iron and codliver-oil being the most useful. The mineral acids are also of serv- ice in some instances. Malt-extract in its different forms constitutes an excellent tonic in some cases. The malt preparations containing the least amount of alcohol are preferable. In certain cases of pyelitis dependent upon general affections, such as 870 SUKGICAL AFFECTIONS OF THE KIDNEY. the exanthematoiis or zymotic fevers and scurvy, and in tubercular, can- cerous, and calculous disease of the kidney, there is often a marked tend- ency to hematuria. This requires the administration of hemostatic reme- dies, such as ergot, hamamelis, hydrastis, tannic or gallic acid, acetate of lead (pil. plumbi et opii), aromatic sulphuric acid, or, best of all, turpen- tine. The natural alum-waters are of service in this connection. There are certain drugs that are likely to prove directly beneficial to the inflamed mucous membrane, the balsams and terebinthinate preparations being the best of these. The white or Canada turpentine is sometimes especially useful. Stimulants may be required, light wines being preferable to the heavier malt or stronger alcoholic preparations. There is usually no special harm and often much benefit to be derived from two or three glasses of claret daily at meal-times. In most chronic cases a very nourishing diet is required, the amount of food being regulated chiefly by the patient's digestive capacity, care being taken to give food that is readily assimilable and to avoid giving more than the capacity of the stomach. The prepara- tions of gold are well worth trial in every form of pyelitis, and in the author's experience have been of special service in a number of instances. Barclay's formulas alford a very reliable method for the administration of gold. In idiopathic pyelitis the range of remedies is limited, the balsams, guaiacol, eucalj^ptol, cantharides, muriated tincture of iron, and gold com- prising about all that are likely to prove serviceable. Counter-irritation over the lumbar region by means of blisters, and derivation by dry cupping are of service. A change of air and scene in combination with physical rest are often required. A sea-voyage is one of the best means to secure the de- sired change of air with comparative rest. When the patient is not debilitated, especially in cases of pyelitis in which the primary cause is readily removable and in idiopathic pyelitis, a restricted dietetic regimen is to be advised. A diet composed mainly of large quantities of milk prepared in various ways will, if persisted in, accom- plish more in the majority of cases than any form of medicinal treatment that could be advised. In acute inflammation of the renal pelvis there are more direct indi- cations than in the chronic form of the disease. Whenever during the progress of a case of acute or chronic disease of the genito-urinary tract, or following an operation upon the genito-urinar}^ organs, there occurs severe pain in the lumbar region, sharp pyrexia, frequent and perhaps painful mic- turition, the urine being more or less purulent and bloody, active measures of treatment are called for. Pilocarpin should be given hypodermically (1) to vicariously relieve the kidney, and thus, perhaps, prevent extension of the inflammation to the secretory structure of the organ; (2) to produce general derivation. Opium should be given for its anodyne effect and to relieve vesical sjoasm. Hot sitz-baths and dry cups over the kidney, fol- TKEATMENT OF PYELITIS AND PYONEPHEOSIS. 871 lowed later on by a large blister or hot poultices over the lumbar region, are reuuired. Demulcent and diluent drinks^ such as flaxseed or slippery- elm tea in combination with the citrate or acetate of potassiu'm should be given. Free and persistent saline catharsis is imperatively indicated in these cases. It will be seen from what has been said that the treatment in the majority of cases of pyelitis consists chiefly in palliation. In cases secondary to renal calculus nothing can be done save to make the patient as com- fortable as possible until such time as operative interference is deemed ex- pedient. That internal remedies will be apt to act upon the stone after serious inflammation of the pelvis of the kidney has developed is, in the highest degree, improbable, even though, as has been indicated in the solvent treatment of calculus, something may possibly be done in a small proportion of cases of simple renal stone. When the kidney becomes sac- culated and a tumor is perceptible, incision or possibly excision of the kidney should not be delayed. Where operative interference is imprac- ticable, there is nothing to do save to continue the means of palliation al- ready suggested, with perhaps, in addition, occasional aspiration of the abscess. In some rare cases such a line of treatment may eventu.ally result in renal atrophy and desiccation of the purulent contents of the sac. In by far the majority of cases, however, such a result is not to be hoped for. Opening or removing the kidney has, under our modern system of anti- sepsis, become an established and justifiable surgical procedure, and as com- pared with many other operations, — some of which are designed to relieve much simpler affections than that under consideration, — they are eminently safe. It is somewhat surprising that the surgery of the kidney should have been so long neglected. It is, nevertheless, a fact that cutting operations upon the kidney are of quite recent date. As an illustration of the novelty of nephrotomy up to a comparatively recent period, one of Bryant's cases related in the earlier editions of his surgery is suggestive: — On August 31, 1876, I cut down upon the right loin of a lady, aged 27, whom I saw in consultation with Dr. Moore and Dr. Pocoek, of Brighton, for a swelling which we diagnosed as renal, and evacuated three pints of fetid pus, the lady making a good recovery. In 1877 I cut into the loin of a man with a lumbar swelling and let out a quart of pus with marked benefit, my finger readily passing into the dilated pelvis of the kidney. The operation is not one of difficulty nor of danger. In both these respects it is on a par with lumbar colotomy, and it is probable that within a few years it wiU be as recognized an operation. Since about the year 1870 the surgery of the kidney has advanced by rapid strides, the number of recorded operations being now very large. The first nephrectomy was performed by Simon in 1867. Among the earlier contributors to the literature of renal surgery are 872 SUEGICAL AFFECTIONS OF THE KIDNEY. the followiag oiDerators: Bowditch/ Peters/ Brant/ A. Campbell/ Keustis/ Wieden/ Gibney/ and Zweifel.^ Keyes, Langenbeck, Parkes, and Ash- hurst operated very early in the history of renal surgery and deserve great credit therefor. The operative treatment of surgical affections of the kid- ney is now so firmly established that citation of authorities is a work of supererogation. The foregoing is simply a tribute to the pioneers in this important field. According to the prevailing views based upon the experience of our most reliable modern surgical authorities, it is never justifiable to permit a patient with a nephritic or perinephritic abscess to die without an effort at relief by means of nephrotomy or nephrectomy. Should the patient prior to coming under observation become so debilitated that there is little probability of survival after operation, or should both kidneys be involved to a serious extent, the management of the disease should lean toward con- servatism. It is not only remarkable that operations upon the kidney for the relief of its various surgical diseases were not earlier practiced, but it is little less than astounding to the latter-day surgeon that surgeons should have had such a horror of interference with purulent collections in this location. Nephrotomy may be performed as a preliminary to nephrectomy, the propriety of immediate removal of the kidney being still a matter of dis- pute among surgeons. It is considered best by some to perform primary nephrotomy in perhaps the majority of cases, nephrectomy being reserved for a more advanced period in the ease. Tliis has been the author's practice. Inasmuch as simple incision and evacuation occasionally results in complete cure, it would seem unwise to immediately remove the kidney, especially in view of the fact that the structure and function of the opposite kidney may be so impaired that removal of the organ in question may precipitate uremia. The technic of nephrotomy and nephrectomy will be considered hereafter. NEPHEITIS OF SUEGICAL OEIGIN. There are certain morbid changes occurring in the secretory structure of the kidney in the course of surgical affections of the genito-urinary tract that are of great importance. These changes sometimes occur independ- ently of complications referable to the pelvis of the organ. They almost ^American Journal of the Medical Sciences^ 1871. ^New York Medical Journal, Novemberj 1873. ^Wiener medicinische Wochensehriftj November, 1873. ^ Edinburgh Medical Journal, July, 1874. ° American Journal of the Medical Sciences, October, 1875. * Deutsches Archiv flir Klinische Medicin, November, 1878. ' Chicago Journal and Examiner, June, 1880. * Edinburgh Medical Journal, November, 1879. NEPHEITIS OF SURGICAL ORIGIN. 873 invariably, however, exist as factors in the ensemble of pathologic changes termed collectively "surgical kidney." Some of these changes result from obstructive backward pressure, others from septic or purulent infection of the renal structure, others again from combined pressure and infection, and still others from the direct extension of inflammation in combination with certain renal changes of a purely-reflex character. The pressure-changes consist in thinning of the cortex of the kidney associated with infiltration and proliferation of intertubular connective tissue. Early in the history of the renal changes young round connective-tissue cells begin to choke up the intertubular tissue; this finally organizes and becomes fixed connective tissue, and presses not only upon the blood-vessels, thus giving rise to an anemic appearance of the organ, but upon the renal tubuli, interfering with their function and lessening elimination of the retrograde products of tissue-metamorphosis. As the process goes on, the renal tissue proper is not only atrophied and thinned, but in great measure absorbed, so that in certain cases of hydronephrosis the remnant of kidney-tissue is very slight, the bulk of the structure of the sac being composed of a new growth of connective tissue thrown out to resist the strain incidental to urinary obstruction. After a time, as these changes go on, the pyramids become absorbed to a greater or less extent, the cortex in some cases becoming ex- tremely thin. The tubules are more or less dilated and the epithelium flat- tened. The morbid process may be tersely described as one of chronic interstitial inflammation and atrophy. Cortical abscesses may co-exist — pyelonephritis. It is obvious from a survey of the changes above enu- merated that the thinned and atrophied cortex is peculiarly susceptible to acute inflammation, and, moreover, that but a slight degree of inflamma- tion — or even hyperemia — is sufficient to completely annul the secretory and eliminative functions of the kidney with consequent fatal uremia. It is not necessary that direct irritation should occur in order that acute in- flammation may be produced in a kidney of this kind. Slight interference with the bladder or urethra in cases of stone or stricture often results in reflex hyperemia of the kidney, which in its weakened condition is unable to withstand the strain. Even the relief of obstruction secured by opera- tion upon stricture and similar obstructive diseases often precipitates renal hyperemia or even inflammation — nephritis ex vacuo. Complete suppres- sion of urine results and the patient speedily dies in uremic convulsions or coma. It is to be borne in mind that the condition of the kidney Just described is apt to exist in any case of chronic inflammation or obstructive disease of the genito-urinary tract. This should admonish the surgeon to be cautious in operations upon and manipulations of these parts, and should also impress him with the necessity of accurate knowledge of the condition of the urine in all cases of genito-urinary disease. The existence of such a condition of the kidney explains some of those mysterious cases of sudden death after the simple passage of a smooth steel sound into the urethra. 874 SUEGICAL AFFECTIOXS OF THE KIDX'EY. Symptoms. — The symptoms of chronic renal disease occurring in the course of surgical affections of the genito-urinary tract are not always plain, and are in many cases separable with difficulty from those produced by the diseases to which the renal complication is secondary. This is especially true of the characters of the urine. In the chronic form of interstitial nephritis without complicating pus-infection there is usually some increase in the quantity of urine with a marked diminution in its specific gravity. Erichsen mentions a case in which the patient passed nearly three quarts of urine daily, the specific gravity of which was less than 1004. This pecul- iarity of the urine, however, occurs in other conditions. The author has under treatment a young man, 28 years of age, with symptoms of nephro- lithiasis who, imder the influence of free ingestion of distilled water, has passed nearly four quarts of urine per diem for four months, of a specific gravity of 1000 to 1005. In order to determine approximately the condi- tion of the kidney in such cases it is necessary to collect and examine the entire quantity of urine j^assed during the twenty-four hours. In cases of this kind there is little or no albumin, very few casts, and frequently no epithelium. Uremia may or may not be manifest and is apt to be masked by a greater or less degree of toxemia from the infected bladder or urethra or both. Dry, sallow skin, headache, and more or less emaciation are usual. Acute Diffuse Interstitial Suppurative Nephritis of Surgical Origin — Acute Pyelonephritis. — This type of renal inflammation may occur at any time in the course of surgical diseases of the genito-urinary tract. In some instances it is a simple transition from the chronic form already described, due to various causes; in others it is ingrafted upon sim- ple reflex hyperemia and irritation. In still others it is the result of direct irritation produced by pyelitis or by the absorption of septic products or pus-cocci from the renal pelvis. Etiology. — The predisposing cause of the diffuse nephritis is some in- fective or obstructive disease of the genito-urinary tract. The exciting causes of the affection may be exposure to cold and wet, a prolonged de- bauch, operations upon the genito-urinary tract, or, more important still, the anesthesia necessitated by such operations, ether being most dangerous. Morbid Anatomy. — The kidney becomes soft and swelled, its surface becomes mottled and the proper renal capsule opaque and vascular. The capsule is normally easily separable from the renal substance, but is now more or less adherent and small particles of the soft and pulpy kidney- tissue adhere to it when torn away. The surface of the kidney presents a peculiar purplish, mottled appearance, and the "stars of Verheyn'^ are in- jected and prominent. Small 3'ellowish spots are sometimes visible to the naked eye, these parts being soft, and, in a more advanced stage of the process, undergoing transition into small abscesses under the influence of pus-microbes: acute. pyeloneiDhritis. The epithelium of the kidney is swollen, granular, and easily detached. In some instances small hemor- NEPHEITIS OF SUEGICAL OEIGIN. 875 rhagic points are visible in various portions of the cortex. Interstitial ab- scesses rarely occur in the course of acute interstitial inflammation, and then only in connection with pyelitis or general pus-infection, pyogenic sep- ticemia, or pyemia. In fact, in all cases the purulent process is probably dependent upon sejosis, the condition in pyemia being embolic, and in sup- purative pyelitis one of direct infection by the products of putrefaction plus the streptococcus lyyogenes. There is a difference in the appearance of the abscesses produced by acute suppurative nephritis dependent upon pyelitis — pyelonephritis — and those due to pyemic emboli. The latter are wedge-shaped, limited to the periphery of the organ, and surrounded or accompanied by hemorrhagic infarcts; the former are more or less rounded or irregular in form. Symptoms. — Acute renal inflammation, with or without suppuration, announces itself in a very decided manner. A marked chill usually first occurs, this being succeeded by sweating. The temperature often rises to a high point, 105° or 106° F. being not unusual. The fever soon subsides, but the temperature does not reach the normal standard. There may be a recurrence of chill and sweating; the tongue becomes dry, red, and cracked; appetite is lost, and the patient speedily emaciates. Nausea, vomiting, and diarrhea are frequent; the patient soon sinks into a typhoid condition that eventually merges into coma, not unlike narcotism. When coma sets in the temperature subsides to or below normal. Delirium and convulsions are occasional. The urine is usually suppressed; the presence of albumin is of no special importance because of the fact that it has usually been present in the urine prior to the occurrence of the acute inflammation. Its presence depends upon an admixture of blood and pus. Cases of this kind constitute one of the varieties of so-called urine-fever. Subacute Nephritis of Suegical Oeigin. — Another type of renal disease, secondary to chronic obstructive disease of the urinary tract, and only to be absolutely distinguished from the chronic form on the post- mortem table in a certain proportion of cases, is best described as subacute nephritis of surgical origin. In the chronic form Just described backward pressure plays the principal role, infection being subordinate to it. The reverse is true in the subacute variety, though the urine may be the same in its physical and chemic characters as in the chronic form. The condi- tion of the bladder and renal pelvis has much to do with the appearance and character of the urine. The products of mucous infection and inflam- mation are mixed with those dependent upon the nephritis per s&. This subacute condition of inflammation lasts indefinitely, being asso- ciated with more or less uremia, often with mental sj^mptoms such as mel- ancholia, hypochondriasis, or even mild psychic aberration, perhaps de- lirium, and unless the primal condition of disease be removed, finally wears the patient out. In most cases acute interstitial inflammation supervenes — possibly with suppuration — and proves fatal, perhaps very speedily. In 876 SURGICAL ATFECTICXS OF THE KIDXEY. all cases in Avliicli the general symptoms lead ns to suspect subacute renal disease^ it is necessary to await tlieir subsidence before undertaking any surgical operation; in fact, it is unwise to attempt even tlie simple passage of a sound while the patient is in this condition. '\\nien the. obstructive and infective condition originally causing sur- gical nephritis is removed, the kidney may so far recover itself as to per- mit of fairly good health. It is never the same kidney as before it became diseased, however, and comparatively slight exciting causes may at any time jDroduce acute renal congestion or inflammation that may prove fatal. When urinary obstruction is suddenly removed, as by operation, acute nephritis is liable to supervene, either immediately or within a few days or weeks, and prove fatal. A recent case of the author's is a most striking illustration of the dan- gers to which patients with chronic obstructive disease of the urinary tract are subjected, even though the obstruction may have been removed: — Fig. 200. — Histology of acute interstitial nephritis with disseminated abscesses. Case.— A gentleman, 62 years of age, had suffered from deep organic stricture for many years. Some twelve years before consulting the author an unsuccessful attempt to pass an instrument was made. Since then there had been no treatment. At the time of examination it was found to be impossible to pass a filiform, and scA^eral false passages were discoA'ered. The stream of urine was extremely small, and micturition required considerable time. There was marked cystitis, evidences of which were present in the urine. The filtered urine contained a email quantity of albumin, but no casts. There was slight chronic urinary fever.' Perineal section was advised as safer than repeated attempts at dilation. After several weeks' careful preparatory treatment the urine became normal. Perineal section without a guide was performed, it being impossible to pass a filiform even under an anesthetic. The operation was Avithout incident, and healing of the Avound Avas prompt, though a small fistula remained for some time. At the end of three Aveeks he was sitting up and dis- cussing the probable time of his departure for home, Avhen he began complaining of headache, and albumin reappeared in the urine. A few days later, almost complete suppression occurred, the quantity of urine falling as Ioav as six ounces in the tAventy- four hours. Vigorous measures apparently succeeded in restoring the function of the kidney, but acute mania dcA-eloped, and the patient finally became to all appearances hopelessly insane. The urine maintained its improvement. At the end of four months NEPHEITIS OF SURGICAL OEIGIN. 877 brain improvement began, and one month later the patient's mind was completely restored. His general health is now excellent, and his urinary functions are naturally performed. Teeatment. — The treatment of the renal complications secondary to surgical diseases of the genito-urinary tract is involved in the general and special management of the primary affection; it comprises chiefly attention to vicarious elimination of urea; the lessening of strain upon the kidney by regulation of the diet and habits; the avoidance of rough and ill-timed manipulations of the urinary apparatus, and the prevention of chill from exposure. The management of acute interstitial inflammation is embraced under the head of the renal or uremic form of urine-fever in the chapter on that subject. CHAPTEK XXXYII. SrsGiCAi ArpEcnoxs or the EIidxet (Co^s'TixrED). CYSTIC DISEASE, HYDATIDS, TTIBEBCULOSIS. CAKCIX03JA. SAECOilA, AND SYPHILIS OE THE XIDXEY. XEPHBOMTHOTOMY, XEPHEOTOiTT. XEPHEECTOMY, AXD XEPHEOPiPtAPHY. EEXAL CYSTS. Cystic kidnev implies either dilation of the organ as a whole, its contents being chiefly urine or modified "uxine. or the formation of circum- scribed collections of fluid approximating in its characters normal or patho- logic iirine in Tarious portions of the renal stnictnTe. When the wall of the cyst is composed of the secretory stnictnre and pelvis of the kidney as a whole, it is termed Jiy drone phrosis. the condition being from a mechanic stand-point essentially the same as in pyonephrosis, the only difference being in the contents of the sac. Etiology. — The eanses of cystic kidney may be entirely local, or may consist of some peculiar local condition dependent npon diathetic influences. Again, although local primarily, the importance of cystic kidney may be quite overshadowed by associated or resultant systemic states. 1. Congenital causes: (a) Movable or floating kidney, with consequent torsion or kinking of the ureter, (b) Hydronephrosis from congenital con- traction, angularity, valTular obstruction, or atresia of the ureter, (c) Der- moid cysts, {d) Congenital degeneration of glomeruli. (Danforth.) (e) Imperfect embryonal development. 2. Constitutional causes involving: {a) Excessive formation or deposit of the solid elements of the urine. (6) Tuberculosis, (c) Sarcoma, {d) Carcinoma. Heredity comes into play in the constitutional phases of the etiology of renal cysts. 3. Mechanic obstruction of the ureter due to inflammatory pressure or adhesions about the ureter. 4. Inflammation or tumors of the pelvic organs. 5. Traumatisms, involving the tubuli urinifer% renal pelvis, or, more especially, the ureter. 6. Pathogenic cysts: (a) hydatid: (I) cystic degeneration. It is unnecessary to enter minutely into the consideration of these numerous causes, it being merely necessary to call attention to them. The kidney may be converted into a single large hydronephrotic sac, (878) CYSTIC KIDXEY. 8T9 or, through, occlusion of the renal tubuli, it may become a mass of small cysts. In some cases of hydronephrosis there exist, in addition to the large sacculus, subcysts, or saceuli, produced by dilation of the calices of the kidney or occlusion of the renal tubules. As a result of maldevelopment and degeneration of the kidneys during fetal life, children are sometimes born with renal cysts of considerable size, these being usually conglomerate or polycystic in character. Injuries to the kidney may result in the formation of cysts, either through occlusion of the ureter or as a con- sequence of an accumulation of hemorrhagic effusion in the substance of the kidney that becomes subsequently absorbed and replaced by watery fluid. Dermoid and hydatid cysts are very rare. When, as a consequence of Fig. 201. — Hydronephrotic kidney without much enlargement. (After Moullin.) obstruction of the ureter, urine accumulates in the pelvis of the kidney, dis- tension of this structure with atrophy of the substance of the organ neces- sarily occurs, the condition of the cortex constituting what has already been described as chronic interstitial nephritis, there being, however, a pre- ponderance of atrophy of the kidney-substance as compared with those cases of renal disturbance secondary to moderate obstruction to the urinary outflow. The hydronephrotic kidney may continue to enlarge almost in- definitely, attaining an enormous size in some cases: so large has it become in some instances that it has been mistaken for peritoneal dropsy and ovarian cyst. A case is related by Eoberts in which something like thirty gallons of fluid were removed post-mortem from an hydronephrotic kid- 880 SUEGICAL AFFECTI0X5 OF THE KIDXET. nev, supposed to be of congenital origin. "WTien hydroneplirosis is nni- lateralj complete absorption of the cortex of the kidney may occur, the remaining kidney being sufficient to carry on the necessary elimination of urea. In some cases in which both kidnej's are affected a very small pro- portion of secreting renal tissue seems to be sufficient to carry on the amount of elimination necessary to life. This is probably due' to the con- servatiTe circumstance that the condition has developed gradually. The system has become accustomed to imperfect elimination of urea, and vicari- ous elimination has come to the rescue, there being, moreover, a much larger amount of urine secreted than by the normal kidney, albeit the urine is of low specific gravity. The sum-total of solids excreted is therefore sufficient for the ordinary eliminative necessities of the individual. A pa- tient with both kidneys in this condition may survive for an incredibly long time and be comparatively little the worse for wear. Let him, however, be subjected to operation, exposure, or the effects of alcohol, and he may die very speedily, with symptoms of acute renal inflammation. Hydronephrotic fluid is generally very pale, odorless, and of a decidedly watery appearance. It contaias no albumin, and is of low specific gravity. In the case mentioned by Eoberts the fluid was of a light-brown, or coffee, color. The various morbid changes that occur in typic surgical kidney are very well illustrated by the following case of hydronephrosis recorded by Eriehsen^ : — Case. — A case lately occurred at Unirersity College Hospital whicli afforded an opportunity of examing the uncomplicated effects of pressure with great advantage. The ureters had been pressed upon bv two enormous sacculi, which projected from the bladder immediately behind the trigone. The bladder was much dilated and hypertrophied, but the cause of disease was uncertain. There were no signs of old or recent cystitis, and no instrument had been passed during life. In this case both ureters were greatly dilated, and the pelvis on each side was expanded so as to contain many ounces of fluid. The kidneys were somewhat increased in size, and before being opened felt like great thick-walled bags of fluid, giving all over a distinct sense of fluctuation. On being cut open each presented the following appearances: The capsule was tough and opaque, and separated with difficulty from the kidney- substance, slightly tearing it in so doing, and leaving the surface coarse and irregular. The surface was uniformly pale, and whitish in color. Xo trace of the pyramids was to be seen, but where each shotild have been was a deep hollow lined with a smooth membrane continuous with the pelvis of the kidney. The cortex was of about normal thickness, but in some parts thinner than natural: it was somewhat tough in con- sistence, and presented a uniform opaque-whitish tint. The whole kidney was thus converted into a great sacculated bag, composed on one side of the dilated and thick- ened pelvis, and on the other of the expanded cortex of the kidney. There were no signs of past or present acute inflammation. On microscopic examination of a thin section of the cortex the chief change noticeable was an abundant small round-cell infiltration of the intertubular tissue of the kidney. Every tubule was separated from its neighbors by rapidly-growing young connective 'Science and Art of Surgerv." CYSTIC KIDNEY. 881 tissue, crowded with small round cells, and this, by pressing on the vessels, had given rise to the pale color above noted. The new growth was most abundant around the Malpighian bodies, the capsules of which were greatly thickened; so much so, that in many the vessels had been strangled and obliterated. The amount of change was not uniform, the new growth being more abundant in some parts than in others. The tubules themselves showed no great signs of change. They were slightly dilated in some parts, and the epithelium looked as if flattened by pressure, but in other respects it was perfectly healthy. This case shows that uncomplicated tension from partial obstruction of the ureter gives rise to a gradual absorption of the pyramids, and to a condition of interstitial inflammation of the kidney, probably varying in severity with the degree and acuteness of the obstruction. In more extreme cases than that above described the atrophy of the cortex becomes much more advanced till nothing may be left but a layer of kidney-substance, not thicker than a shilling. The microscope also shows more dilation of the tubules and flattening of the epithelium. It is an interesting fact to be noted that in the case above described the secretion of urine was abimdant, its specific gravity was 1009, and it was free from albumin and casts. It is also evident that, if such a kidney as this were exposed to any additional source of irrita- tion, more acute inflammation, incompatible with life, would readily be set up. Had pus-infection with resulting suppurative pyelitis occurred in tins case, pyonephrosis would have resulted. The presence of kidney-stone would in such a case quite likely determine the occurrence of pyonephrosis. The sudden removal of pressure would inevitably have proved fatal. The collateral changes in the secretory renal structure are the same in all cases in which similar mechanic conditions prevail. The presence of a calculus and pus in the renal pelvis, with an opening into the surrounding tissues and consequent secondary perinephritic abscess, are all that is neces- sary to complete the picture of morbid possibilities in the typic surgical kidney. It is remarkable that rupture of an hydronephrotic cyst is excessively rare in the absence of trauma or surgical interference. This is probably due to the slowness of development of the cyst and compensatory develop- ment of interstitial connective tissue, as the renal substance is gradually thinned and atrophied under pressure. Should the condition be unilateral and obstruction to the flow of urine from the renal pelvis be removed, — either spontaneously or as a result of surgical interference, — and the cyst evacuated, complete cure with shriveling of the sac may occur. Spencer Wells punctured a large hydronephrotic kidney and employed drainage; two calculi subsequently passed from the kidney into the bladder and the hydronephrosis was recovered from. Taylor reports a 'case of hydronephro- sis in which rupture of the sac occurred with extravasation of urine into the peritoneal cavity. Laparotomy was performed, a careful toilet of the peritoneum made, the margins of the sac stitched to the lips of the ab- dominal wound and the latter closed, with the result of complete recovery.^ ^ It must be remembered that hydronephrotic fluid is not so dangerous to the peritoneum as ordinary healthy urine; it certainly is innocuous as compared with infected urine. 882 SUEGICAL AFFECTIONS OF THE EIDNET. Symptoms. — The symptoms of cystic kidney are chiefly of a mechanic character and due to pressure upon neighhoring structures. The severity of the symptoms, therefore, necessarily depends upon the dimensions of the sac, and whether the condition is bilateral. Tumors of small or moderate size are apt to remain undetected unless both kidneys are involved, and even then they cannot be positively diagnosed unless a palpable tumor has formed. Marked hydronephrosis is evidenced by the existence of a tumor in the ileo-lumbar region extending forward into the abdomen. The ap- pearance of the tumor in one or the other side primarily is an important point in the diagnosis. On percussion of the abdomen the large intestine will be usually found to cross in front of the tumor. The tumor itself presents the usual signs of dullness on percussion and fluctuation. The condition is usually painless unless a calculus be present in the pelvis of the kidney or ureter, in which case there may be considerable pain. Aside from the mere existence of a tumor there are really no characteristic symp- toms in the majority of cases. Certain results of pressure are occasionally! evident, these being chiefly irritability of the bladder, pain in the abdomeni and loins, constipation, disturbance of the digestive functions, and perhaps! diarrhea. Dry skin, thirst, delirium, headache, emaciation, and othei uremic symptoms are likely to be present if both kidneys are involvedJ There is nothing characteristic, or, at least, pathognomonic, about the coni dition of the urine, the low speciflc gravity and limpid character of that fluid being the principal features. In some cases there occurs from time to time a sudden and copious discharge of urine coincidently with a sud- den diminution in the size of the tumor. This is an unfailing sign. Many cases of cystic kidney pass unnoticed during life, and are only discovered accidentally post-mortem. It is probable that cystic kidney is quite frequent, but as the cases in which post-mortems are held are very few as compared with the sum-total of deaths from all causes, it might be erroneously inferred that renal cysts are comparatively rare. It is by no means unusual for the pathologist to discover cysts of small or moderate] size in connection with perfectly healthy kidneys, in patients who have diedl of various diseases to which the renal cysts cannot possibly be referred.| Cysts of this character are filled with a limpid, watery fluid sometimes ap- proximating the urine in composition and appearance. They are formed] by simple occlusion of renal tubuli, and very rarely attain a sufficient size! to occasion any symptoms during life. As a rule, where cysts of this soi exist, both kidneys are involved. Cysts in connection with granular or con- tracted kidney (diffuse interstitial nephritis, cirrhotic kidney) are morel often seen than otherwise in healthy organs, although they give rise to quite as little inconvenience. Extensive polycystic degeneration of the kidneysJ has been seen, but is very rare, and usually, if not always, affects both organs^ beingr, therefore, inevitably fatal by progressive impairment of the renal| functions through pressure-destruction of the renal tissue. Inasmuch as ex- HYDATID DISEASE OF THE KIDXEY. 883 tensive miilticystic disease is usually congenital, it destroys life within a comparatively short period after birth. In very rare cases, indeed, does the disease occur during adult life. The diagnosis of hydronephrosis, or large renal cyst, is determined chiefly by the history of the development of the tumor in one or the other flank, its comparatively painless and insensitive character, its slow growth or congenital nature, and the presence of urinary constituents in the aspirated fluid. In doubtful eases an exploratory incision is always warrantable, the same rules being applicable in cases of this kind as in ovarian tumor and other surgical conditions of the abdominal cavity. Fortunately for both surgeon and patient, laparotomy for diagnostic pur- poses has become an established procedure. It is no longer necessary for us to blindly speculate upon the possible or probable character of abdominal growths and various morbid conditions; it is now permissible to open the abdominal cavity, and by means of exploration with the flnger, or even in- spection by the eye, to determine the precise nature of the disease. Ex- ploration is eminently safe where the kidney is suspected, as the operation may be made extraperitoneally. Teeatment. — The treatment of renal cysts should be rather conserva- tive on account of the innocuous character of the disease in the majority of cases. Occasional aseptic palliative tappings are all that should be re- sorted to in some cases. Tapping, followed by injection of such irritating fluids as the tincture of iodin, has been known to induce a cure. Billroth advises the use of a 50-per-cent.-iodin solution for this purpose. Should the sac, however, develop suppurative inflammation after tapping and in- jection, incision and drainage become necessary. As the condition often depends upon calculus, nephrotomy should be followed by exploration of the cavity of the sac with the fijiger, in the hope of finding the obstructing object. With its removal, followed by careful drainage of the sac-cavity, a cure may be accomplished. In cases in which conglomerate cysts exist, it is possible that nephrectomy may be required, with due consideration for the condition or possible absence of the other kidney. Incision and pro- longed drainage are sufficient to effect a cure in a certain proportion of cases. HYDATID DISEASE OE THE KIDNEY. Eenal hydatid disease is a very rare affection in America, although, like hydatids in other situations, it is probably not infrequent in such coun- tries as Iceland, in which entozoic affections are common on account of the peculiar habits of the people and the frequency of the Tcenia ecJiino- coccus in their domestic animals. As illustrative of the rarity of hydatid disease in this country, Janeway, during a period of ten years' service as curator to Bellevue Hospital, met with but three instances, and in none of these were the hydatid tumors of sutflcient size to produce anv injurious results. Two of the cases of hydatids were found in livers that had been 884 SURGICAL AFFECTIONS OF THE KIDKEY. lacerated by injury. The disease occurs less commonly than hepatic or pul- monary hydatids^, but ranks next to them in order of frequency. It is unnecessary to enter here into the minutice of the life-history and patho- logic results of the echinococcus, as the subject is ably and exhaustively dealt with in' various works on helminthology and treatises on practical medicine.^ Eesults of Hydatid Kidney. — These depend mainly upon the size of the tumor. In some cases inflammation and perinephritic abscess are caused by the pressure of the tumor, or by its rupture and the discharge of its contents into the surrounding cellular tissue. The vitality of the echinococci may be destroyed from unknown causes, with a resultant shriveling of the cyst. In some instances calcareous deposit in the walls of the cyst may occur, the resulting tumor being of small size and remaining for an indefinite period without producing dis- turbance. In some cases both kidne)^s are involved, but in the majority of instances the disease is unilateral. The tumor may become of considerable size, a diameter of seven to ten inches having been attained. It never attains so great a size as hydatid of the liver. After a variable time the cyst is apt to rupture, either spontaneously or as a consequence of external injury. As a rule, the rupture occurs into the pelvis of the kidney, and the contents of the tumor are discharged with the urine. Instead, however, of rupturing into the pelvis of the kidney, the cyst may take a less favorable course and open into the intestines or lung. Very rarely, if ever, does it open into the peritoneal cavity. Symptoms. — The subjective symptoms of hydatid tumor are very olj- scure and never characteristic, the physical characters of the tumor alone being depended upon for a diagnosis. Even these may be by no means dis- tinctive. After the tumor has attained sufficient size to press upon surround- ing parts, pain of a neuralgic character referable to the lumbar region de- velops, with perhaps reflex symptoms pointing to the bladder precisely the '.same as those produced by other non-malignant tumors. If inflammation occurs in or about the hydatid sac Ave have symptoms identic with those pro- duced by perinephritic abscess. When the tumor attains a sufficient size to be perceptible to the touch, it will be found to be rounded, smooth, and elastic, perhaps fluctuating, — this sign, however, being more or less obscure, — and it imparts to the hand a peculiar fremitus, or crackling sensation, known as the hydatid fremitus. This is a characteristic physical sign of hydatid disease occurring in whatever situation. In its absence there are no physical signs discoverable by the eye or touch that are indicative of hydatid cyst. When the contents of the cyst discharge into the pelvis of the kidney, which may be said to be the natural course of the disease, the booklets of the echinococci are discharged witli the urinary outflow and may be found ^ Graham's work on hydatid disease is a classic. HYDATID DISEASE OE THE KIDNEY. 885 in the urine by careful microscopic examination. Inasmuch as the hydatid fremitus or vibration may not be detected, or the surgeon may not be suffi.- ciently familiar with it to determine its existence, the presence of hooklets in the urine may be said to be the only positive sign of hydatid disease of the kidney that is obtainable without direct exploration by a cutting oper- ation. In all forms of cystic tumor of the kidney, however, it is always warrantable to make an exploratory puncture by means of the aspirator. Microscopic examination of the fluid withdrawn may clear up the diagnosis. As regards the diagnosis of hydatid cyst, Murchison says^: — The fluid which escapes from an hydatid, even if it contains no echinocoeci or shreds of striated hydatid membrane, will reveal its nature with absolute certainty. If the sac be not inflamed, it is limpid when running in a stream, with a slight opalescence when viewed in bulk; it is alkaline, and has a specific gravity of 1007 to 1010; it contains neither albumin nor urea, but throws down a copious white precipitate with nitrate of silver, owing to its strong impregnation with common salt. These characters apply to no other fluid in the body, whether healthy or morbid. Even if the case should turn out to be an aneurism or cancer, no harm is likely to result from an exploratory puncture. Treatment. — The treatment of hydatid tumor is necessarily of a strictly surgical character and should be resorted to promptly on account of several important considerations. In the tirst place, a spontaneous cure is not to be expected in the majority of cases, for, if the tumor ruptures into the pelvis of the kidney, the ecchinococci go on proliferating and the disease is kept up indefinitely. x\gain, suppuration, either within the sac- or external to it in the form of perinephritic abscess, is likely to occur, and even failing this there must necessarily be more or less destruction of renal tissue. Lastly, the cyst may rupture in some direction which will neces- sitate fatal disease of important organs. The necessary element in the successful treatment of hydatid disease in any situation is naturally the destruction of the echinocoeci and the mother-cyst. A very successful method of accomplishing this result is electrolysis. This is accomplished by the transmission of a powerful galvanic current through the fluid ht the sac by means of needles introduced into its cavity. Simple asjiiration is sometimes successful in destroying the echinocoeci, either by the re- moval of the pabulum necessary to their subsistence or by producing a certain amount of inflammation within the sac, which is inimical to the vitality of the parasite. Should a single aspiration be insufficient the op- eration may be repeated, i^ntiseptic incision and drainage may be resorted to when aspiration fails. During contraction and closure of the sac anti- septic solutions of considerable strength may be used. Should suppuration of the sac or perinephritic cellular tissue occur, free antiseptic incision is imperative. Internal remedies are of little or no service in hydatid dis- ease, although diuretics are recommended by some authorities. It has been "Diseases of the Liver." 886 SUEGICAL AFFECTIOXS OF THE KIDXEY. recommended to partially remove the fluid and replace it by antiseptic and irritant solutions;, the tincture of iodin having the preference, as a rule. After incision of the kidney-tumor through the loin, the walls of the cyst should be stitched accurately to the lips of the abdominal wound. EEXAL TUBERCULOSIS. Tuberculosis of the kidney occurs in three forms: 1. As a miliary deposit in the secreting structure of the organ secondary to general infec- tion with tubercle bacilli. This form is rarely detected during life, and is of pathologic rather than clinical interest, being a part of the general tuberciilar process. It occurs most usually in young subjects, and in the Fig. 202. — Tuberculous pyelonephritis. (After Moullin.) majority of cases affects both kidneys. Other portions of the genito-urinary tract and different portions of the sexual organs may be involved in the miliary tubercular process, but also as a part of the general infection and not secondary to the renal disease. The tubercular deposits affect chiefly the perivascular lymph-spaces of the capillary blood-vessels, the p5Tamids of Malpighii, and the glomeruli. The patient is alwa3'S destroyed by the general tubercular infection long before the changes in the kidney are suf- ficiently marked to give rise to symptoms referable to that organ. 2. This form, which is also termed tubercular pyelonephritis — '^scrof- iilous kidney" — occurs as a consequence of tubercular deposit beneath the mucous membrane of the pelvis of the kidney and in the parench^^ma of the organ secondary to caseous or suppurative tubercular processes in other EENAL TUBEKCIJLOSIS. 887 parts of the body. Thus, it may be secondary to a caseating cavity in the lung or a caseating lymphatic abscess. A process that is peculiarly liable to lead to infection of the genito-urinary tract is tubercular or pseudotuber- cular testis. 3. This variety, also a tubercular pyelonephritis, is a sub variety of the second form of the disease. In this form of tubercular kidney the caseous or tubercular process is secondary to suppurative inflammation of the pelvis of the organ. The bacillus-bearing products of this suppurative inflam- mation undergo caseation and infect the endothelium of the lymphatics and the perivascular lymph-spaces, causing a tubercular deposit in the secreting structure of the organ. ^ Infection also occurs by way of the veins. This caseous or tubercular material in the kidney eventually softens, breaks down, and forms cavities intercommunicating and opening into the calices and pelvis of the organ. This degenerative process closely resembles that of pulmonary phthisis, and progresses until the kidney is transformed into a lobulated, indurated capsule within which will be found on section an irregular suppurating cavity with a thick, pus-producing lining and contain- ing a greater or less quantity of pus and blood in various states of disin- tegration, and renal tubercular debris {caseous nephritis or nephrophthisis). In some instances true miliary tubercle may be found scattered throughout the secreting structure of the organ. Should the ureter become obstructed, the kidney assumes the condition characteristic of ordinary pyonephrosis. It will be observed that tubercular nephritis, or renal phthisis, is prob- ably never a primary affection, being always secondary to disease of the pelvis of the organ itself, or some more or less intimately associated portion of the genito-urinary tract, or to tubercular disease in distant organs. There may be in some instances a development of renal tuberculosis {caseous nephritis) secondary to suppurative pyelitis, and, secondary to the renal caseation, general tubercular infection may occur. Cases of this kind may lead to the inference that the renal tubercle is the primary process, whereas the starting-point of the pathologic cycle consists in ordinary suppurative inflam.mation of the pelvis of the kidney. For reasons unknown, renal tuberculosis is very rare in the female. Diagnosis. — The diagnosis of tubercular kidney is not at all clear, the subjective symptoms being precisely similar to those of chronic pyelitis or, in severe cases, nephralgia or nephritic colic. If pyonephrosis develops, both objective and subjective symptoms are precisely similar to that disease when occurring under ordinary circumstances. The general symptoms of hectic, wasting, and rigors are perhaps more marked in tubercular pyo- nephrosis than in the simple variety, but this alone is insufficient for a diaofnosis. ^ It will be observed in this connection that Buhl's theory of the rationale of tubercular infection is accepted as logical. SUEGICAL AFPECTIOXS OP THE KIDXET. The urine contains pus, more or less blood, epithelium from the mu- cous membrane of the urinar}^ passages, and in some cases casts of the renal tubuli. In some instances aggregations of caseous matter as large as a pin^s head may be detected, and perhaps by careful staining and examina- tion the bacillus tuberculosis may be found. The presence in the urine of caseous masses or of tubercle bacilli will at once clear up the diagnosis. The ensemble of clinical features is, however, often such that a diag- nosis can be readily made. For example, in cases of cachectic individuals with phthisic lungs or tubercular disease of the testes, prostate, seminal vesicles, or bladder, suppurative inflammation of the kidney may be in- ferred to be tubercular. Test inoculation of rabbits with the purulent sedi- ment of the urine is often a valuable means of diagnosing tuberculosis of the urinary tract. The general symptoms consist of chronic hectic or urinar}^ fever with loss of appetite, disturbance of digestion and nausea, dr}^ tongue, and fre- quently diarrhea. If the enlarged irregular kidney can be felt in the flank the diagnosis is aided to a certain extent, providing other than tubercular causes of pyonephrosis can be eliminated. Prognosis. — The prognosis is very unfavorable, although it has been asserted that shrunken and cicatrized kidneys have been found in cases in which renal tuberculosis was supposed to have existed. It is probable, how- ever, that such cases are not true renal phthisis. As a rule, the patient emaciates, and becomes exhausted from pain and the urinary irritation of secondary cystitis; he becomes thin and emaciated, and finally dies of asthenia, with or without uremic symptoms. The duration of the disease varies from two or three months to several years, depending largely on the character and importance of associated con- ditions. Teeatmext. — The treatment of tubercular kidney is necessarily very unsatisfactory. It involves the management of the general condition by tonics, codliver-oil, guaiacol, nucleins, and change of air. The Shurly Gibbes method of hypodermic injections of iodin and chlorid of gold and sodium has seemed valuable. The Barclay formulas of gold and arsenic form a very valuable means of administering gold per oreni. Operative measures are not generally considered warrantable if, as is usually the case, both kidneys are involved. When, however, we have reason to believe that but one is afi^ected (1) from the absence of tumor and pain upon the opposite side, (2) from the fact that an approximately normal quantity of urea is throAvn out in the urine, and (3) from cystoscopic study and catheterization of the ureters (in favorable cases), nephrotomy may be performed. Nephrectomy is not a wise operation in view of the doubt that must necessarily exist regarding the condition of the opi^osite organ. The various measures for determining the condition of the opposite kidney are in a general way unsatisfactory. It is to be noted, however, that catheter- EEXAL TUBEKCULOSIS. 889 ization of the ureter, as recommended by Simon and Winckel and perfected "by Pawlik and Kelly, especially for the diagnosis of renal conditions in women, is often satisfactory. Ureteral catheterization via the cystoscope is sometimes practicable in the male. If at any time we become satisfied that the condition of the other organ Avill warrant so serious a procedure, nephrectomy may be performed. Pyonephrosis and perinephritic abscess from tubercular disease are to be treated in the same manner as the same conditions occurring under other circumstances. Occasional cases of bi- lateral pyonephrotic kidney may arise, in which simple incision, curettage, and gauze drainage are warrantable in the hope of prolonging life. Only one side should be operated at a time, and if the condition of the first kidney operated on justifies hope of restoration of its functional integ- rity to a serviceable degree, the other kidney may be attacked later. After a nephrotomy has been performed, relatively strong solutions of antiseptics may be used for irrigating the cavity of the kidney, and pro- longed packing with iodoform gauze employed. Fig. 203. — Harris's device for collecting urine from the ureters separately. To facilitate accurate diagnosis in surgical diseases of the kidney, and especially to determine which kidney is affected in unilateral disease, M. L. Harris has devised a most ingenious instrument. By this instrument it is possible to determine the existence and functional capacity of the opposite kidney, upon which the patient's life must depend after removal of the diseased organ. The description of the instrument is as follows: — The instrument consists of a double catheter (Fig. 203), each separate, but in- closed in a common sheath resembling a single flattened tube. Each catheter is movable on its longitudinal axis. The sheath is nineteen centimeters long, gradu- ated on its upper surface. The proximal portion (in reference to the patient) is curved. This curved portion does not pass at once into the straight portion, but is set on a slight forward angular displacement three or four millimeters long. When the flattened surfaces of the curves of the two catheters are opposed the shaft is nearly round. The distal extremity of each catheter is round and curved in the same plane as the proximal extremity, resembling the curved end of a male sound. The curves of the two extremities being the same, the distal indicates the direction of the proximal end. Near the junction of the distal curve with the straight portion 890 fcCEGICAL AFFECTIOXS OF THE KIDXEY. is the small tube continued in the line of the straight portion and opening into it. The distal extremity of each catheter is connected by rubber tubing with a separate glass vial. The corks are doubly perforated, each vial being connected by rubber tubing with a rubber exhaust-bulb (Fig. 204). There is a metal lever (Fig. 204a) with a handle at one end, the opposite extremity being cur^-ed and flattened laterally. This is provided with a perforation near the handle, is flattened on its sides, and notched along its lower border. A detachable, cur^-ed, forked metal piece connects the catheter with the lever when in use. This piece has a spiral spring that catches in the notches on the under surface of the lever. The instrument is used as follows: The patient is placed in the lithotomy posi- Fig. 204. Fig. 204a. — Harris's device for collecting urine from the ureters separately. tion. The iastrument, with the flattened surfaces in contact, so as to form practically a single catheter, is introduced into the bladder. The connecting piece is then at- tached. The lever passing through the forked connecting piece is now introduced into the vagina in the female, the rectum in the male. The fork holds it in the midline. When introduced the proper distance, as indicated by the perforation in the lever coming opposite the perforations in the forked piece, the lever is fastened by passing the pin in the forked piece through the perforation in the lever. The instrument is now opened in the bladder by slowly and gently rotating each catheter about its longi- tudinal axis until each jjroximal end, as indicated by the distal end, is directed out- ward and backward. The angle subtended posteriorly by the ends of the catheters should be about 100 to 110 degrees. They are held in position by the spiral spring. MALIGXA^'T XEOPLASMS OP THE EXDXET. 891 In opening in this way, the end of the lever within the vagina or rectum passes up between the ends of the catheters so as to form, a septum, extending longitudinally along the base of the bladder. The lever end is held between the diverging ends of the catheters by the spiral spring catching in the notches on the under surface of the lever. The end of each catheter in the bladder now occupies the bottom of a little pocket, the pockets being separated by a perfect septum, or water-shed. The ureters open, one on either side of the water-shed, near the base of the declivity, in the immediate vicinity of the respective ends of the catheters. By exhausting the bulb the urine, as it escapes from the ureters, is made to enter the ends of the catheters and flows at once into the vials, right and left, respectively. ilALIGXAXT ?4"E0PLASiIS OF THE KED^TEY. Cancer and sarcoma of the kidney are usnallT and imaToidablj con- founded, clinically, and it is questionable whether their differentiation is of great practical importance, inasmuch as there is little or no difference in the malignancy of the two affections, and such distinctions as may exist are microscopic rather than macroscopic or clinical. Malignant disease of the kidney is an uncommon disease, and occurs in two forms, viz.: primary, in which the original deposit is in the renal structure, and secondary, in which the disease comes on as a consequence of renal infection by cancerous disease either in some portion of the genito- urinary tract or sexual organs — ascending infection — or in some tissue more or less remote. The majority of eases of renal cancer occur in childhood, the disease haying apparently a predilection for the male sex, this being particularly true when it occurs in adults. Old age is the next most favor- able period for renal cancer, youth and middle life enjoying relative im- munity. The disease is almost always encephaloid in character, and may present the peculiar and characteristic form of encephaloid known as fungus Jiema- todes. When secondary to cancerous disease of remote organs, cancer of the kidney is a part of the general infection and usually occurs in the form of cancerous nodules of greater or less dimensions scattered throughout the substance of both organs. Cases of scirrhus, colloid, and melanotic cancer of the kidney are considered unique. Cancerous deposit occurs primarily in the cortex or secreting stmctnre of the organ and invades with greater or less rapidity the remainder of its texture. The deposit may begin as a circumscribed collection of cancer- cells or an infiltration of the intervascular tissue. If the disease is pri- mary — as is very rarely the case — secondary deposits in various other organs of the body are to be looked for. Henry Morris states that, in 30 cases of malignant renal disease found in 2610 post-mortems, 25 were secondary and 5 primary.^ According to Moxon, cancerous disease does not begin in the kidney proper, but in the lymphatic glands and other structiires that sur- round and invest the organ: a very plausible view. - Op. cit. 892 SURGICAL AFFECTIOXS OF THE KIDXEY. The tumor formed by cancer of the kidney may grow to an immense size. In one case related by Eoberts the growth attained a weight of 31 pounds. An excellent and oft-reproduced illustration of this case may be found in Eoberts's' work on renal diseases. As cancer of the kidney progresses, the renal substance becomes en- tirely absorbed and replaced by cancerous material. The soft cancerous substance is permeated by large blood-vessels of considerable tenuity, that are easily broken, giving rise to the hemorrhages characteristic of renal cancer. It has been asserted that portions of the cancerous growth may break down and be carried through the medium of the blood in the renal vein to the heart, whence they are driven into the general circulation, forming pulmonary and other infarctions. Cases of this kind have been described. It is very rare for both kidneys to be affected simultaneously in renal cancer. The duration of the disease in children is, upon the average, from six to ten months. In the adult it may last eighteen months or two years or more, two years being, perhaps, the average. By comparison with other forms of visceral cancer it will be found that the renal variety is compara- tively slow in adults. Etiology. — The causation of the disease is similar in many respects to that of cancer in other situations. Injuries of the kidney seem to be par- ticularly apt to be followed by the development of cancerous disease. In a case mentioned by Morris that authority advances as a probable cause renal calculi. The case was one of renal scirrhus in a man 76 years of age. Floating kidney is markedly predisposed to malignant degeneration. Cohnheim's old-time theory of the origin of cancer seems to be particu- larly applicable to the renal form of the disease. Congenital deformities of the genito-urinary apparatus are relatively frequent, and it is nothing unu- sual to find upon autopsy aberrant forms of development of the kidney. A close resemblance to the fetal type of kidney is occasionally found in au- topsies on young children. This tendency to the failure of differentiation of the kidney-structure in fetal life may explain the occurrence of cancer in some cases. Cohnheim's theory implies that the fundamental cause of cancer is a persistence of the embryonal type of cells in some portion of the tissues. These cells have an inherent capacity of rapid development under the api3lication of the proper stimulus; this stimulus may be afforded by a relatively slight injury. Cancerous formations are particularly apt to occur if hereditary predisposition to the disease exists. In inverse proportion to the degree of differentiation of embryonal cells is their tendency primarily to proliferation and seeondarih^ to rapid retrograde metamorphosis. Con- stitutional infection by the rapidly proliferating and rapidly degenerating cells occurs with great facility. In view of the tender age of some subjects of renal cancer — and, indeed, it may be congenital — it is reasonable to sup- MALIGKANT NEOPLASMS OF THE KIDNEY. 893 pose that the disease is the direct result of the persistence of the embryonal type of kidney-cell formation. Whether or not an exciting cause is neces- sary for the development of cancer in such cases is, of course, difficult to determine. The autlior has recently seen a case of renal cancer that well illustrates the early period at which it sometimes occurs: — - Case. — The case was that of a delicate male infant whose mother had suffered from an attack of pneumonia just before confinement. The child was improperly fed, the quality of food being poor and the quantity insufficient for its nourishment. When first seen he was in a marasmic condition from simple inanition. Under proper feeding improvement occurred, but at about the age of three months the child began to cry incessantly and was evidently suffering from considerable pain. Hema- turia developed; the abdomen became swelled and tympanitic; the stomach refused to accept nourishment, and in a few days diarrhea supervened, wasting being con- sequently very rapid. In a few days the distension of the abdomen disappeared, and careful examination revealed the presence of a flat, lobulated tumor, corresponding to the situation of the left kidney. This occupied about one-half of the abdomen, was moderately movable, and presented the usual physical signs of renal tumor. After a day or two marked and persistent hematuria developed. A diagnosis of renal cancer was made. The child died within two weeks after the development of marked symptoms, but, unfortunately, an autopsy could not be secured. Sarcoma of the kidney is most frequent in children, and does not differ essentially from renal cancer in its clinical history, course, and results. Diagnosis. — The diagnosis of renal malignant disease is quite obscure at the beginning, excepting in those instances in which it is a complicating condition of the cancerous cachexia from malignant disease occurring in other situations. When, however, a tumor appears, co-existing with abun- dant hematuria occurring from time to time, the disease is comparatively easy of diagnosis. It is impossible, however, to differentiate sarcoma and cancer. The tumor appears between the free border of the ribs and the crest of the ilium upon one side, and may be felt anterior to the edge of the quadratus lumborum muscle early in the course of the case, if a careful examination be made. The growth enlarges upward, forward, and down- ward — in short, in all directions — and in some cases distends the entire abdomen. As is the case with all tumors involving the kidney, the trans- verse, ascending, or descending colon, as the case may be, lies in front, yielding the characteristic tympanitic resonance of the large intestine. A tumor of the abdomen across the front of which the colon passes, and which yields dullness in all directions save where it is crossed by the large in- testine, may be inferred to be a renal growth, and this inference may be made positive assurance by a careful study of the history of the case. In addition to blood in the urine the characteristic cancer-cells or per- haps masses of cancerous tissue may be detected: this is very rare. In some cases coagula or cancerous masses cause renal colic in passing through the ureter. Blood in the urine in conjunction with a tumor of the abdomen 894 SUEGICAL AFFECTIOXS OF THE KIDNEY. is patliognomonic of renal cancer^ although Eoberts has mentioned excep- tional instances in which an enormous enlargement was not attended by hematuria/ Blood in the urine does not occur at the outset in all cases of renal cancer. The case of the infant just described is an illustration of this fact. Many do not develop hematuria at all. More than 50 per cent, of cases, however, have hematuria as a symptom, and the quantity of blood is usually considerable. The following case is quoted as illustrating the early occurrence of hematuria in renal cancer: — Case. — A girl, 5 years of age, who had previously been well, suddenly had an attack of hematuria, the source of which could not be discovered. Three months later a swelling appeared in the right renal region, which was believed to be due to a ma- lignant growth on account of its rapid development. The swelling was punctured, and the fluid withdrawn was examined microscopically. It showed the characteristic evi- dence of renal cancer. The tumor was estii-pated by Bergmann's method, an incision being made upon the anterior aspect of the abdomen, the peritoneal cavity being avoided. The immediate results of the operation were sufficiently satisfactory; there was no evidence of shock, and after two months the abdominal wound had completely cicatrized. Eleven months later the child died from a recurrence of the disease in the cicatrix, with extensive metastases in the liver and lungs; the left kidney, however, was entirely healthy. The author suggests that one should always bear in mind the possibility of the presence of a malignant tumor in one or the other kidney when a child suffers from hematuria the cause of which is obscure. He further desires to say, with regard to surgical inter\'ention, that it is, of course, essential that a precise diagnosis should be made at the earliest possible moment.- The tumor in cancer of the kidney presents a smooth or irregularly lobulated surface, the latter being especially frequent in young children. In some instances it contains blood-vessels of sufficient size to impart a sense of pulsation to the hand. The same sense of pulsation may be ex- perienced from the impulse imparted to the tumor by the blood's coursing through the aorta. In some instances a feeling of semifluctuation may be detected that may give rise to a suspicion of the presence of fluid; this is especially true of sarcoma. The characteristic feature of the tumor is its fixedness of position. The pain dependent upon malignant disease of the kidney is not con- stant, the patient in some cases being comparatively free from it. In other instances it is very intense and resembles nephralgia of a severe t}^e. Ves- ical spasm may co-exist as a reflex manifestation of the presence of the tumor. Disturbances of the digestive functions are usual as a consequence of the mechanic pressure of the tumor and the general disorder of nutri- tion it produces. Dropsy of the lower extremities or peritoneal cavity may occur as a consequence of venous obstruction from pressure. In some in- ^ Op. cit. ^Alsberg: Eevue Mensuelle des Maladies de I'Enfance, June, 1888. DIAGNOSIS OF EEXAL TUMORS. 895 stances peritoneal inflammation co-exists and enhances the dropsical effu- sion. Morris's remarks on the diagnosis of renal tumors in general are well worth repetition^: — Eenal tumors are among the most difficult of abdominal enlargements to diag- nose correctly. They therefore demand close study. Ttie chief distinctive points are the following:- — • 1. The large intestine is in front of the tumor. Xormally the right kidney, unless enlarged, lies a little way from the lateral wall of the abdomen, behind and to the inner side of the ascending colon; not in close contact with the abdominal wall and outside the ascending colon as the liver does. When the kidney is enlarged the ascending colon is usually in front of and toward the inner side of the tumor. On the left side the descending colon is in front, and inclines toward its outer side below; in some cases coils of small intestine may overlie either right or left tumor, if the enlargement is not sufficient to bring the kidney into direct contact with the front abdominal wall. When the colon is empty, or non-resonant, it can be felt as a roll on the front surface of the tumor. Bowel is never thus placed in front of a splenic tumor, and but rarely in front of one of hepatic origin. Rarely — if ascites is present and the liver is enlarged in an irregular and misshapen manner — the small intestines may float between the liver and abdominal parietes. 2. There is no line of resonance between the kidney-dullness and the vertebral spines; and no space between the kidney and the spinal groove into which the fingers can be dipped with but little resistance, as there is between the spleen and the spine. 3. Eenal tumors do not project or protrude backward to any marked extent. They fill up the hollow of the loin, and may even cause some actual fullness there; but often there is nothing more than the effacement of the natural hollow of the loin. When the tumor attains a large size, the parietes may be projected laterally to a degree sufficient to be observed at a superficial glance. Sir William Jenner says: "Renal tumors never cause enlargement behind. A renal tumor is not visible in the back, it expands in front. A little greater fullness of the loin there may be, but nothing like tumor. Tumors due to disease of the kidney enlarge in front, while abscesses and other lesions which may simulate renal tumors often cause considerable posterior projection." This is an important feature in relation to diagnosis, and if stated a little too dogmatically it will serve the more to impress a pretty general fact. There are excep- tions, however, as I shall show farther on. 4. "The kidney is rounded laterally, rounded in front, rounded at its inner border, rounded at its upper border, rounded at its lower border. The inner border is usually lost against the spine, and the upper border cannot be felt unless the kidney is displaced. The kidney has no sharp edges. It is rounded on every side, and in disease never loses this peculiarity" (Jenner). AVhen solid or cystic, and of what- ever size, a kidney-tumor is prone to retain some, often much, of its natural outline. The absence of any sharp edges marks off renal from many hepatic and splenic enlargements. 5. Renal less frequently and less markedly than hepatic, splenic, and suprarenal- capsular swellings descend in inspiration. Hepatic and splenic, and more especially splenic, enlargements are depressed by the contraction of the diaphragm; whereas ^ "Surgical Diseases of the Kidneys. S96 SUBGICAX AFFECTIOXS OP THE EIDXEY. kidjaeT-swellings are oftea quite fixed in their position. If the kidney and circum- scribed tassnes liare been inflamed, the kidney will be bound down in its natural situation and there fixed. Sir W. Jenner remarks: ""When the kidney is enlarged by disease it is rarely moTable by respiration or palpation. When chronic changes snffid^it to exdaxge tJie organ have occurred, whatever their nature, adhesions suffi- cient to ptrevent -moTement usuaDy form between the capsule and adjacent parts." Withont doubt this is often so: but in eases of new growths, where the organ and parts aixHind have not been the seat of inflammation, there may be a considerable dcgi«e of morement. I hare seen a renal tumor desc-end as much as an inch by a deep in^iration. and fall forward or backward by its own weight, with the more- menls made by the independent enlargement of one or more lumbar glands not forming part of the tumor; by the abruptness of the outline of the swelling; and possibly even by a protrusion from the growth along the spermatic cord into the scrotum. (f) From flatulent or fecal accumulations in the cecum, sigmoid flexure, or colon renal tumors may be diagnosed by the absence of intestinal disturbance, ab- dominal pain and colic, and of the distension by flatus which characterize over- distension of the bowel. The proximity of the colon to the kidney renders the diagnosis between nephritic colic and intestinal colic sometimes difficult. Sir William Jenner wrote: "Nephritic colic will cause loss of power in the colon, and so induce constipation, thus favoring the idea that the patient has intestinal colic. Again, collections of stools in the colon may be mistaken for an enlarged kidney; a large enema will solve all doubt on this point." Before the surgeon commits himself to a definite opinion in any doubtful case of abdominal tumor, the bowels ought to have been well opened and the examination of the tumor made immediately afterward. It will be well to remember that just as there is incontinence of urine in retention, and incessant outpouring of fluid through the mouth in gastrorrhea, so there may be frequent discharge of small stools from a bowel overloaded with feces. An opinion should be deferred in some cases until after a second or third examination has been made, and until time has been allowed for the removal of fecal accumulations if there are any. (g) Fecal abscess, perityphlitis, or inflammation of the cellular tissue about the sigmoid flexure will be distinguished by the marked febrile disturbance, the asso- ciated intestinal symptoms, the tenderness over the front surface of the part affected, and the lower position of the swelling, which will be in the iliac rather than in the renal region of the belly. With reference to the diagnosis of cancer in particniar, Morris says: — The diagnosis has to be made, flrst, as to the seat of the tumor; second, as to its precise nature. 900 -v: -:cAi ArFBcnoxs of the elbx^t. Tfce e2caie& iti;»ri. - ™- " r wfc«« fiist aees, its direction of merease. and tlie fiae ctf sammBda^ -aBanw «a peratsaon will help to Sx. tbs mtai OK^n of the sweDiEiz ^^^ oi:^in in tiie fir-car, ^pleem, or avmry. But enars ■■ Ais Tsspen- Toidtahlp. and I ]iaiTi camcer ©i the kaontj is -:.:\;.:T\ii.i:elv aliiMiet aiiogietHier of a poJJiatiTe chancter. If the disease - rTiniiiff: iilj. nc^ureetoiiiT is a le^itimaite procedure, and should be . I' i&o often negieetcd. But. as a rule, bj the tune the diagnosis i: ]. is:* t^ j determined the tumor has piodnced seeondaiy infection of the neirh^crinr gjandsu and. nec-«s£aiil J. eomstiiiitional infection; hence opera: _ - : hope of success even thougji it be practicable of performance. Here a snr- gical operation vill only bring discredit upon oto* art. Ano^mes and hemostatie remedies are. of oomse, eseni: : :: _ r pi\QgrEffi