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THE SYSTEMATIC TREATMENT 
 OF GONORRHOEA 
 
THE 
 
 SYSTEMATIC TREATMENT 
 
 OF 
 
 GONORRHCEA 
 
 BY 
 
 N. P. L. LUMB 
 
 TEMP. CAPT. R.A.M.C. 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 
 1918 
 
S\ fi ») ,v o 
 
 [Printed in England] 
 
PREFACE 
 
 The commencement of an official campaign against 
 Venereal Disease has led to the production of this book. 
 Many of those assisting at Treatment Centres may have 
 had little opportunity, in the past, of gaining experience 
 of this work, and for such it is intended. 
 
 It was planned more than a year ago with the object 
 of providing a small volume which should contain a 
 description of the methods which are found, in practice, 
 to be most valuable in the treatment of gonorrhoea 
 and its complications. Active service conditions have 
 considerably delayed its production and somewhat 
 limited its scope ; but, throughout, the aim has been 
 to give practical details of methods which have been 
 fully tested in many thousand cases with satisfactory 
 results. 
 
CONTENTS 
 
 CHAPTER I 
 
 PAGE 
 
 GONORRHOEA, ITS COURSE AND SYMPTOMS : HISTORY, 
 
 DIAGNOSIS AND EXAMINATION ... I 
 
 CHAPTER II 
 
 PATHOLOGY AND BACTERIOLOGY ... 10 
 
 CHAPTER III 
 
 EXAMINATION OF THE URINE . . 15 
 
 CHAPTER IV 
 
 EXAMINATION OF THE PROSTATE; ACUTE PROSTA- 
 TITIS, CHRONIC PROSTATITIS ... 23 
 
 CHAPTER V 
 
 ROUTINE TREATMENT OF ACUTE GONORRHOEA . 38 
 
 CHAPTER VI 
 
 SPECIAL TREATMENTS: I. VACCINE. 2. ELECTRO- 
 CHEMICAL. 3. MERCURY COMPOUNDS . . 44 
 
 vii 
 
viii CONTENTS 
 
 CHAPTER VII 
 
 PAGE 
 
 COMPLICATIONS OF GONORRHOEA: EPIDIDYMITIS, 
 ARTHRITIS, COWPERITIS, PERI- URETHRAL 
 ABSCESS . . . . . . .58 
 
 CHAPTER VIII 
 
 GONORRHEAL CONJUNCTIVITIS .... 73 
 
 CHAPTER IX 
 
 GONORRHOEA CASES COMPLICATED BY SYPHILIS . 80 
 
 CHAPTER X 
 
 CHRONIC GONORRHOEA 87 
 
 CHAPTER XI 
 
 THE GONORRHOEA PATIENT — TEST OF CURE . . 1 10 
 
 INDEX . . 117 
 
THE 
 
 SYSTEMATIC TREATMENT 
 OF GONORRHOEA 
 
 CHAPTER I 
 
 GONORRHOEA : ITS COURSE AND SYMPTOMS 
 
 Until recent years this disease has never received the 
 attention it demands by reason of its ravages when 
 widespread. Now, however, with a scheme afoot, and, 
 in many places, working, for the provision of skilled 
 and adequate treatment for all classes there is a 
 hope of new and improved methods being widely 
 adopted. 
 
 Two facts need to be made as widely known as possible 
 for the benefit of all who may be sufferers from the 
 disease : 
 
 (i) Early treatment means early cure. 
 
 (2) " Gleet " is an infectious condition, and needs 
 treatment just the same as an acute case. 
 
 It can be proved time and again that a patient obtain- 
 ing correct treatment within the first twenty-four to 
 forty-eight hours of the discharge will, in the majority 
 of instances, develop no complications and will need the 
 shortest time on treatment. A good result is to be hoped 
 
 1 
 
2 TREATMENT OF GONORRHOEA 
 
 for from the venereal treatment-centres mainly for this 
 reason. 
 
 To get patients to attend systematically for treat- 
 ment for gleet will be more difficult, but increased know- 
 ledge and an enlightened public will help considerably 
 in this respect. 
 
 The organism causing the disease, Neisser's Gono- 
 coccus, has been dealt with under the chapter on 
 pathology and bacteriology of the disease. Once the 
 gonococcus has been implanted on the urethral mucous 
 membrane events follow in a definite sequence. The 
 incubation period begins, and during this time the 
 organisms are multiplying and extending beneath, as 
 well as along, the surface. The rate of progress depends 
 upon two variable factors : 
 
 (a) The virulence of the infecting gonococcus. 
 
 (b) The resistance of the urethral mucosa. 
 
 Thus it is that a common source of infection will 
 lead to attacks of varying severity in different indi- 
 viduals, some developing complications and others 
 having only the mildest manifestations. The usual 
 course may be briefly indicated. Following on infection 
 the gonococcus is free to develop. An interval occurs 
 between the exposure and the appearance of any symp- 
 toms. This incubation period varies and may be as 
 short as two days or as long as a month. The majority 
 of patients give seven days as the interval before the 
 appearance of a discharge. The first warning that all 
 is not as it should be is frequently a sensation of warmth 
 and tickling in the urethra, intensified after mictu- 
 rition. This increases gradually until a distinct 
 burning is perceptible and the tickling becomes actual 
 discomfort. 
 
 Micturition causes definite smarting and, later, 
 
ITS COURSE AND SYMPTOMS 3 
 
 pain. Frequency creeps on pari passu with the 
 pain. 
 
 The first visible sign of the disease is an increase of 
 moisture at the meatus, noticed by the patient on rising 
 in the morning, which often glues the lips together. 
 From this stage onwards the secretion becomes more 
 and more characteristic, until, twenty-four hours 
 later, there is usually a definite purulent discharge. The 
 pain becomes more acute on micturition and remains for 
 a considerable period after the act. The whole urethra 
 is tender when touched, and the lips of the meatus are 
 red and swollen. In severe cases the prepuce becomes 
 more swollen and cedematous, quite apart from the 
 presence of any sore. Chordee increases the discomfort, 
 the penis being drawn downwards owing to the infiltra- 
 tion of the urethra and the consequent loss of its normal 
 elasticity. Following on these attacks blood is frequently 
 seen either at the meatus or on subsequent micturition. 
 Painful erections occur at night, diminishing the patient's 
 sleep and often accompanied by seminal emissions. The 
 lymphatic nodes in the groin become enlarged and 
 slightly tender. In a small percentage of cases they are 
 exceedingly painful from the start and continue so for 
 several days, necessitating hot fomentations and rest in 
 bed. In the absence of soft sores suppuration does not 
 occur. 
 
 The general condition of the patient corresponds 
 with the mild febrile attack which always accompanies 
 the onset of symptoms, and resembles the beginning 
 of an ordinary cold. The temperature varies between 
 99 and 100 °, there is a feeling of lassitude, aggravated 
 by the discomfort and frequency of micturition. Con- 
 stipation is common. The discharge increases until 
 there is an almost continuous flow of thick yellowish- 
 
4 TREATMENT OF GONORRHCEA 
 
 green pus. Patients have usually reached this stage 
 before coming for treatment. 
 
 Three distinct types can be recognized in the acute 
 stage according to the severity of the invasion and the 
 patient's natural resistance to the infection : 
 
 (a) Hemorrhagic. 
 
 (b) Acute. 
 
 (c) Mild. 
 
 Hemorrhagic. — In this type, the invasion is very severe 
 and most often seems to occur in the individual of florid 
 type. Presumably the resistance is less than in the 
 majority of patients. There are intense pain on micturi- 
 tion and considerable swelling of the glans and prepuce. 
 Every symptom seems to be present in an aggravated 
 form. The discharge is thick, profuse, purulent, and 
 mixed with blood. It can be found at any time by 
 massage of the urethra, and frequently a few drops of 
 pure blood follow. The tenderness of the whole urethra 
 is extreme. Fortunately these cases are not numerous, 
 and respond quite readily to treatment. 
 
 Acute. — This is the commonest variety, where the 
 symptoms are very much as already described. There 
 are pain, frequency of micturition, and a free dis- 
 charge. 
 
 Mild. — A certain number of cases developing an 
 acute attack of gonorrhoea show very slight manifesta- 
 tions. The discharge is never profuse, little discomfort 
 is experienced on micturition, and the urethra is not 
 tender to the touch. Yet a film taken from the meatus 
 in the morning shows the typical acute picture, with 
 pus-cells containing numerous gonococci. These cases 
 often tend to subside spontaneously without treatment, 
 
ITS COURSE AND SYMPTOMS 5 
 
 the secretion amounting to little more than a morning 
 bead four or five days after the onset. If no treatment 
 be carried out the discharge rarely disappears com- 
 pletely, and the patient may seek advice when the acute 
 stage has passed off. The importance of these cases 
 lies in the fact that a cursory examination may lead to 
 the patient being told that he has not got gonorrhoea, 
 and, should inadequate treatment be given, he is liable 
 at a later date to develop epididymitis or to pass into 
 the chronic stage. When large numbers are dealt with 
 many cases of acute epididymitis are seen in whose urine 
 the gonococcus is readily found, but who are confident 
 that they have never had gonorrhoea. The possibility 
 of recent infection can be excluded in many, leaving a 
 number who have had gonorrhoea without appreciating 
 the fact. Such cases usually belong to the type just 
 described. 
 
 Once treatment of the disease is commenced, the 
 symptoms speedily abate, the discharge becomes thinner 
 and less in quantity, and the pain on micturition 
 diminishes. The initial pyrexia passes off, the general 
 condition rapidly improves, until, a week after the com- 
 mencement, the patient feels perfectly well, and should 
 be going about as usual. Complications occur in a 
 certain proportion which, in the past, has been high ; 
 but, with earlier treatment and improved methods, the 
 number should be considerablv diminished. 
 
 HISTORY, DIAGNOSIS, AND EXAMINATION 
 
 Case-recording of gonorrhoea patients needs to be 
 done systematically, both from the point of view of treat- 
 ment, and also the obtaining of statistics as to the 
 efficacy of different methods of treatment. The latter 
 
6 TREATMENT OF GONORRHOEA 
 
 have improved considerably in recent years, yet even 
 now it is unwise to promise to effect, a lasting cure in any 
 case. From experience of a large series it is found that 
 a considerable percentage of such cases have no return 
 of symptoms ; yet time alone shows, and there is, at 
 present, no test at all comparable with the Wassermann 
 Reaction in Syphilis to guide the surgeon as to his 
 patient's future outlook. The history of a patient 
 regarding past illness has little bearing on his sub- 
 sequent treatment for venereal disease, but may give an 
 idea of his power to resist or throw off an infection. The 
 venereal history, however, should be gone into carefully 
 and any previous attacks noted. Not infrequently a 
 history of past syphilis or a doubtful sore may be ob- 
 tained, and this information should lead to a blood-test 
 and suitable treatment if it prove positive. In gonorrhoea 
 the date and duration of previous attacks should be 
 recorded, and also complications or relapses, if any. 
 The incubation period of a recent infection, together 
 with the patient's age, often afford information of value. 
 The actual date on which the disease was contracted 
 should be obtained- whenever possible, so that the onset 
 of syphilis may not be overlooked in its early stages if 
 a double infection have taken place. 
 
 Diagnosis. — The diagnosis is usually a simple matter, 
 though occasionally, in the absence of a clear history 
 of exposure to infection and subsequent development 
 of the usual clinical signs, reference to the microscope 
 is necessary. It must not be forgotten that a non- 
 gonococcal urethritis may very occasionally be present, 
 simulating gonorrhoea. Its incubation period is similar, 
 but microscopic examination readily distinguishes the 
 two, the non-gonococcal variety being usually produced 
 by a diplo-bacillus or staphylococcus albus, 
 
ITS COURSE AND SYMPTOMS 7 
 
 When balanitis is present it may be quite impossible 
 to say at once whether a patient is suffering from gonor- 
 rhoea, owing to the profuse discharge from beneath the 
 prepuce. If the urethritis be in the acute stage, it may 
 be possible, after cleansing the glans, to express pus from 
 the urethra, but failing this no final opinion should be 
 expressed, for microscopically Gram negative diplococci 
 can be found in both conditions. The subjective test 
 of smarting during micturition is not a safe guide, many 
 cases of simple balanitis complaining of it owing to sore- 
 ness of the glans. Local baths several times daily with 
 syringing will usually enable the prepuce to be retracted 
 and the discharge cleared up. A two-glass urine test 
 can then be made, and, if necessary, a smear taken for 
 microscopic examination. Occasionally some difficulty 
 may arise in distinguishing between a gleet and the 
 exudation from a urethral chancre. A patient may 
 give a history of gonorrhoea some months previously, 
 and then the appearance of a small amount of glairy 
 discharge a little while after re-exposure to infection. 
 The incubation is usually uncertain, and the stage of 
 development too early for a Wassermann Reaction to 
 settle the matter finally. A chancre, if present, is 
 usually palpable in the urethra, and most of them are 
 situated within an inch of the meatus. In such cases a 
 scraping and dark-ground examination should be 
 made. Failing this, the urethroscope will reveal a 
 chancre lower down the urethra, whilst microsco- 
 pically the gonococcus is usually to be seen in a case 
 of gleet. 
 
 Examination. — The patient should be examined lying 
 down wherever possible, for thereby more accurate and 
 extended observations can be made, and there is much 
 more inducement to investigate thoroughly. A system 
 
8 TREATMENT OF GONORRHOEA 
 
 should be adopted and adhered to, just as in the case of 
 the examination of the chest or central nervous system, 
 so that a correct record of all cases may be obtained and 
 important signs not overlooked. A useful plan is the 
 following : Commence by palpating the groins and noting 
 the condition of the inguinal glands as regards size, 
 tenderness, and the presence of suppuration. A very 
 good guide as to the condition present is thus obtained. 
 In gonorrhoea they are moderately enlarged, though but 
 slightly tender, both sides being equally involved. 
 In some cases of acute gonorrhoea, however, these glands 
 (usually of one groin) become very painful, though the 
 enlargement is but moderate, the pain being referred 
 upwards along the cord and down the inner side of 
 the thigh. In soft chancre the glands are considerably 
 enlarged, tender and characteristic buboes are frequently 
 seen. In syphilis the enlargement is usually more than 
 in gonorrhoea, and, often, one groin is affected more 
 markedly than the other. The glands feel hard and move 
 freely under the skin, whilst there is a complete absence 
 of tenderness or suppuration. The whole of the group 
 is usually affected, and can be felt as an indolent chain 
 extending outwards along Poupart's ligament. When 
 a double infection is present the glands combine features 
 of both, and are not so useful in diagnosis. The prepuce 
 is next retracted, the glans and meatus being wiped 
 free from any accumulated discharge with small swabs 
 of cotton-wool wrung out of i in 1,000 perchloride of 
 mercury. The corona and fraenum are carefully in- 
 spected for the presence of a sore, then the lips of 
 the meatus separated so that a meatal chancre, which is 
 not uncommon, may not be overlooked. The urethra 
 is then massaged and the discharge seen, its character 
 being noted as purulent, muco-purulent, or gleet. After 
 
ITS COURSE AND SYMPTOMS 9 
 
 this the epididymis is palpated on both sides to 
 discover if there be any enlargement or tenderness. 
 In cases in which complications have already super- 
 vened when the patient is seen for the first time the 
 possibility of lesions of prostate, joints, ej/es, and skin 
 must not be forgotten. 
 
CHAPTER II 
 
 PATHOLOGY AND BACTERIOLOGY 
 
 The pathology of gonorrhoea can be considered very 
 simply under three headings : 
 
 (i) The incubation period. 
 
 (2) The acute stage. 
 
 (3) The chronic stage. 
 
 During the incubation period the invading organism — 
 the gonococcus — is spreading from its site of implantation 
 within the meatal area in two directions : (a) Along the 
 surface of the urethra towards the bladder, (b) Between 
 the columnar cells lining the urethra towards the sub- 
 epithelial connective tissue. The rate of spread in both 
 cases depends entirely upon the virulence of the organism 
 implanted and the natural resistance of the patient. It 
 is unusual for penetration of the surface to take place in 
 less than forty-eight hours. Following on this, the 
 gonococci work their way down between the interstices 
 of the cells until they begin to come in contact with 
 leucocytes, chiefly polymorphonuclear, poured out from 
 the capillaries to counter the invasion of the organisms. 
 The result is that many gonococci are taken up in the 
 leucocytes, which travel to the surface and are cast off 
 as pus- cells, giving rise to the purulent discharge. The 
 effect of the passage of gonococci and leucocytes is to 
 
 jo 
 
PATHOLOGY AND BACTERIOLOGY n 
 
 break up the epithelial lining of the urethra and desqua- 
 mation in numerous areas results. With the appearance 
 of a discharge the incubation period ends and the acute 
 stage begins. The rate of extension along the surface 
 cannot be determined accurately, but it must be rapid, 
 for statistics show that in, roughly, 70 per cent, of cases 
 the organisms reach the posterior urethra. 
 
 Acute Stage. — This is a continuation of the struggle 
 between the leucocytes and the gonococci, and, in addi- 
 tion, an extension of infection to the lacunar and glands 
 of Littre. The organisms lie between the cells sur- 
 rounding theglandmouthsand lead to one of two changes: 
 either sclerosis, with eventual obliteration and atrophy 
 of the gland, or obstruction of the duct by cast-off 
 epithelial cells and subsequent cyst-formation. 
 
 In the posterior urethra the process is exactly the same 
 as in the anterior portion, but, as a result of the greater 
 delicacy and increased vascularity, even a small denuda- 
 tion of the surface frequently leads to haemorrhage. As 
 the invasion is gradually overcome by treatment repair 
 of the epithelial surface begins, and cylindrical cells 
 cover the desquamated areas. Eventually the columnar 
 epithelium is restored in many instances, but, as will be 
 •seen, where prolonged inflammation has occurred this 
 condition is not fulfilled and secondary changes occur. 
 
 Chronic Stage. — The tissue-reaction has practically 
 subsided, and there is no longer a great outpouring of 
 leucocytes, whilst the gonococci are comparatively few 
 in number. To replace the epithelial lining several layers 
 of pavement epithelium develop, thus giving rise to a 
 more resistant and less delicate surface than was the 
 case before the infection. In the case of the glands the 
 organisms remain indefinitely, deep-seated, and difficult 
 to eradicate, yet liable to appear on the surface at any 
 
12 TREATMENT OF GONORRHOEA 
 
 subsequent period, rendering the patient a constant 
 source of infection. As the infiltration around 
 the glands subsides three different changes may 
 occur : 
 
 (i) The lining of the duct is shed and may give rise 
 to a discharge from the gland mouth. 
 
 (2) The gland itself becomes surrounded by newly 
 formed tissue, and is destroyed by the gradual contraction 
 of the latter. 
 
 (3) The duct becomes occluded and the gland con- 
 tents are shut in, leading to cyst-formation. 
 
 An outline only has been given, with the object of 
 indicating the changes which are of importance from the 
 treatment point of view. 
 
 Keratinisation and the developments leading to 
 stricture-formation are not discussed, since it is not 
 intended to deal with this aspect of the subject in the 
 space at disposal. 
 
 Bacteriology 
 
 The causative organism of gonorrhoea is Neisser's 
 gonococcus, a diplococcus and Gram-negative. It is 
 readily found in smears taken from the urethra in acute 
 cases, and can be easily identified. 
 
 Smears of a discharge for microscopic examination 
 should be taken as follows : The prepuce is retracted 
 and the glans wiped over with a swab of wool moistened 
 with methylated spirit, special attention being paid to 
 the lips of the meatus, which are separated and freed from 
 all discharge. The urethra is then gently compressed 
 until a small bead appears, when a drop of this is re- ' 
 moved from within the lips of the meatus on a platinum 
 loop and transferred to a slide. If very thick, a small 
 drop of water is next added, so as to enable an even film 
 
PATHOLOGY AND BACTERIOLOGY 13 
 
 to be spread. This is fixed by passing a few times 
 through the flame of a spirit-lamp and stained by Gram's 
 method. By careful cleansing of the glans and prepuce 
 beforehand all contamination is avoided and the organ- 
 isms of balanitis, which at times lead to confusion, are 
 removed. 
 
 Urine. — To be tested for gonococci. If any threads 
 or filaments are present they are removed by means of a 
 fine glass pipette and transferred to a slide, teased out well 
 with a platinum loop, fixed and stained as in the case 
 of smears. The bulk of the specimen is allowed to stand 
 for an hour and then a few c.cs. taken from the bottom 
 of the glass with the pipette. This is centrifuged and 
 two or three drops spread out on a slide and allowed to 
 dry slowly. It is finally fixed by heat and then a little 
 distilled water placed on the slide and allowed to remain 
 for five minutes. This clears the film considerably by 
 dissolving out the salts in the urine. The distilled 
 water is poured off and staining proceeded with in the 
 ordinary way. 
 
 Prostatic Smears. — After thorough irrigation of the 
 urethra the meatus is wiped over with spirit. The 
 prostate is then massaged in the ordinary manner and 
 one or two drops of secretion allowed to fall on a slide. 
 This is spread out by means of a platinum loop, dried, 
 and stained. 
 
 In the early acute stage the film shows epithelial cells, 
 pus-cells, and numerous gonococci, both intra-cellular 
 and extra-cellular. As the acute stage becomes fully 
 developed the epithelial cells disappear and the field 
 contains nothing but pus and gonococci. There are, 
 frequently, many Gram-positive organisms present in 
 the film, but with careful staining they are easily dis- 
 tinguished. As the infection is overcome and healing 
 
14 TREATMENT OF GONORRHCEA 
 
 is once more in progress epithelial cells begin to appear 
 again, the pus cells and gonococci being much reduced 
 in number. 
 
 In prostatic smears the gonococci are, often, not 
 numerous and need to be searched for carefully. 
 
CHAPTER III 
 
 EXAMINATION OF THE URINE 
 
 The systematic examination of the urine is the most 
 useful guide available in estimating the progress of a 
 case of gonorrhoea, and for that reason alone should 
 take a prominent place during treatment ; but it is 
 also of considerable value in diagnosis. When a case 
 comes under observation for the first time the urine 
 should invariably be examined in the manner described, 
 since a far more correct view of the extent of the infection 
 will thereby be formed. 
 For diagnostic purposes the most useful methods are : 
 
 (i) Two-glass method. 
 (2) Four-glass method. 
 
 An acute case, on first coming for treatment, should be 
 instructed to pass a two-glass sample of urine on rising. 
 Six to eight ounces of urine are passed into one glass and 
 the last few ounces in the bladder into the second glass. 
 The urine that has collected during the night is far more 
 valuable than that of several hours in the daytime, and 
 should always be taken as the standard for comparison. 
 Such a two-glass sample will show signs varying with 
 the stage to which the disease has attained. 
 
 Pus secreted into the anterior urethra cannot pass 
 back into the bladder because of the compressor urethrae 
 
 15 
 
16 TREATMENT OF GONORRHOEA 
 
 muscle, but it is free to pass forward (i.e. anterior to it) ; 
 whilst pus in the posterior urethra cannot pass forward 
 because of the same muscle, but is free to pass back into 
 the bladder. During sleep the discharge in an acute 
 case collects in the anterior portion of the urethra and 
 some of it flows away. In the posterior urethra it passes 
 backwards and mixes with the urine in the bladder. 
 
 When the two-glass test is made the first glass contains 
 urine from the bladder which has washed out the pus 
 from the anterior portion of the urethra. The second 
 glass contains the last contents of the bladder alone. 
 Consequently, the first glass is more cloudy than the 
 second. If both glasses are cloudy the whole extent of 
 the urethra is probably involved, i.e. anterior and 
 posterior urethritis. If the first is cloudy and the second 
 clear, the anterior urethra alone is affected. It must be 
 recognized that this is a rough test, and is to be inter- 
 preted only in the light of accompanying clinical signs — 
 For instance, in the case of an acute attack with profuse 
 discharge it is frequently found that in the early stage 
 both glasses are cloudy, though glass I more so than 
 glass 2. It does not necessarily follow that there is 
 anterior and posterior urethritis, for the quantity of 
 urine passed in such a test is often insufficient to wash 
 away all the thick pus from the anterior urethra, and 
 the last few ounces are cloudy with pus from the anterior, 
 not the posterior, urethra. 
 
 It will readily be understood that the second glass in 
 samples passed during the daytime will be clearer than 
 in an all-night specimen, for there is less opportunity 
 for pus to gravitate from the posterior urethra into the 
 bladder owing to the change of posture and the frequent 
 emptying of the bladder. This fact must be remembered 
 if a case is being judged on a specimen passed in the 
 
EXAMINATION OF THE URINE 17 
 
 daytime. In addition, it serves to distinguish cases of 
 cystitis, for in the latter condition the second glass is 
 just as cloudy as the first in both day and all-night 
 samples. 
 
 The four-glass test differentiates more accurately 
 the state of the anterior and posterior urethra. It is 
 carried out as follows : 
 
 Three or four ounces of urine are passed into Glass 1, 
 and then two ounces into Glass 2. The next two 
 ounces are passed into Glass 3, and the last few ounces 
 into Glass 4. 
 
 The first and second glasses contain the washings 
 of the anterior urethra, the third those of the posterior, 
 whilst the fourth includes, in addition, any material ex- 
 pressed into the prostatic urethra by the terminal con- 
 traction of the prostate at the end of micturition. In an 
 early acute case the first glass is usually found to be 
 cloudy, the second also cloudy, but less so than the first, 
 whilst the third and fourth are quite clear. This repre- 
 sents anterior urethritis alone. With a moderately 
 severe posterior urethritis in addition, all four are cloudy. 
 In some chronic cases all four glasses may be more or 
 less clear, the first and third containing a few flakes, 
 the second and fourth none. This is evidence of a 
 localised anterior and posterior urethritis, and will be 
 referred to again. The four-glass is more accurate than 
 the two-glass test, but to obtain the most satisfactory 
 differentiation of the affected portions of the urethra the 
 following method should be adopted : 
 
 The anterior urethra is irrigated with cold boric lotion 
 at a pressure of two feet. This will not pass the tri- 
 angular ligament, but washes out any material collected 
 anterior to it. The washings are collected in Glass i f 
 the glans and meatus are cleansed, and a sterile rubber 
 2 
 
18 TREATMENT OF GONORRHCEA 
 
 catheter passed into the bladder, the contents of the latter 
 being collected in Glass 2. Six to eight ounces of warm 
 boric lotion are introduced into the bladder and the 
 catheter withdrawn. The patient passes two or three 
 ounces of this into Glass 3. The prostate is massaged 
 and the remaining five or six ounces of lotion are passed 
 into Glass 4. 
 
 Glass 1 represents the content of the anterior 
 urethra. 
 
 Glass 2 that of the bladder. 
 
 Glass 3 represents posterior urethra. 
 
 Glass 4 the same as 3, with the secretion of the 
 prostate-. 
 
 This is a very accurate method ,of locating a focus of 
 infection, and is of most use in chronic cases. 
 
 For treatment purposes the two-glass test is quite 
 accurate enough, and the urine should, whenever pos- 
 sible, be that first passed on rising. This test, in an 
 acute case coming for treatment with a history of dis- 
 charge which has been present for four or five days, 
 will probably show: Glass 1, cloudy; Glass 2, cloudy, 
 though less so than 1. After a few days' treatment 
 with irrigations and vaccines the first glass becomes 
 less cloudy and the second more or less clear, depending 
 on the success with which the irrigation fluid has been 
 flushed through into the bladder. At this stage the 
 presence of flakes or filaments is not important from the 
 diagnostic point of view, but after about ten days' treat- 
 ment, when the first glass is hazy and the second clear, 
 their presence needs careful consideration. Various 
 names, such as " Sinkers " and " Floaters," have, from 
 time to time, been given to them, according to whether 
 they sink or remain suspended in the test-glass. For 
 practical purposes five varieties need to be recognized. 
 
EXAMINATION OF THE URINE 19 
 
 (i) Littre's gland filaments. 
 
 (ii) Platelets. 
 
 (iii) Plugs from the prostatic ducts. 
 (iv) Muco-purulent filaments. 
 
 (v) Threads. 
 
 Their respective characteristics are as follows : 
 
 (i) Littre's gland filaments are readily recognizable, 
 being light, delicate, and of a well-curved comma shape, 
 approaching almost to a semicircle. After the passage 
 of a straight bougie and massage of the glands these 
 filaments are readily found in the urine next passed, in 
 which they remain suspended for a time and then sink 
 slowly to the bottom of the glass. 
 
 (ii) Platelets are small flakes detached from the sur- 
 face of the urethra that remain suspended in the test- 
 glass for some time and sink very slowly to the bottom. 
 They come from various parts of the urethral surface 
 where the urethritis is still active. They are quite flat, 
 and the name of " bees' wings," which has been used 
 to describe them, is not inapt. 
 
 (iii) Plugs from the prostatic ducts are heavy flakes 
 which sink at once to the bottom of the glass. Like 
 Littre's gland filaments, they are comma-shaped, but 
 larger, coarser, and less curved. 
 
 (iv) Muco-purulent filaments consist of short and 
 narrow lengths of the mucosa stripped from their 
 attachments, frequently coiled up like the hair-spring 
 of a watch. They cannot be confused with any of the 
 other varieties. Sometimes they are longer and more 
 delicate, looking like two narrow strips held together by 
 a much finer intermediate strip. These readily break 
 up into several pieces, even as they sink to the bottom 
 of the test-glass. 
 
20 TREATMENT OF GONORRHOEA 
 
 (v) Threads are very fine filaments, varying con- 
 siderably in length, of the same nature as the last class, 
 but lighter. They often persist in the urine for some 
 days after all treatment has ceased and when there is no 
 evidence of discharge. 
 
 Mucus.— The presence of mucus and the form it 
 assumes is a very important guide, in addition to any 
 filaments there may be, in a sample of urine. In the 
 acute stage it is mingled with a large amount of pus and 
 is not distinctive in appearance ; but, as the discharge 
 becomes less profuse under treatment, the quantity and 
 form can be clearly seen. After five or six days' irrigation 
 the urine in the first glass is hazy, resembling frosted 
 glass when looked through, the mucus still being diffused 
 throughout it. Later it becomes more definite in form 
 and is seen as a dense opaque cloud which settles on 
 standing for half an hour. It frequently occupies the 
 whole of the lower half of the glass, and may contain 
 many small flakes such as have been described under (ii) 
 (Platelets). As treatment continues this cloud gradu- 
 ally diminishes in size, the flakes becoming fewer, until 
 when discharge has almost ceased and the mucosa is 
 approaching normal, all that is seen is a delicate trans- 
 lucent haze, strongly resembling a cumulus cloud. This 
 is frequently suspended in the glass, unlike the dense 
 earlier cloud which sinks to the bottom. It contains no 
 flakes, and, apart from being slightly more profuse, is 
 identical with that seen in normal urine. 
 
 Once these characters are clearly recognized it is an 
 easy matter to record the progress of any case under 
 treatment, and to form a correct estimate of the state 
 of the urethra and the glands communicating therewith. 
 
 Case 1. — Incubation, three days. Purulent discharge, 
 fifth day of disease. 
 
EXAMINATION OF THE URINE 
 
 21 
 
 
 
 Urine. 
 
 
 Date. 
 
 Irrigation. 
 
 1. 
 
 - 
 
 " 
 
 16-3-/ 
 
 1 in 8,000 permg. 
 
 Clear, mucus, m.p. 
 filts. 
 
 Clear 
 Mucus 
 
 Vaccine 2. c.c. 
 
 19-3-/ 
 
 1/6000 
 
 Clear, mucus 
 
 Clear 
 
 Vaccine 4 c.c. 
 
 22-3-/ 
 
 1/6000 
 
 Clear, mucus 
 
 Clear 
 
 Vaccine 4 c.c. 
 
 25-3-/ 
 
 — , — 
 
 Clear, mucus, two pro- 
 static filts. 
 
 Clear 
 
 Vaccine 4 c.c. Si 
 frequency 
 
 29-3-/ 
 
 
 Clear, mucus, one pro- 
 static flit. 
 
 Clear 
 
 Massage of Pr. Some 
 pus and normal 
 secretion 
 
 31-3-/ 
 
 
 
 Clear, s.m.p. filts. 
 
 Clear 
 
 Vaccine 4 c.c. 
 
 3-4"/ 
 
 
 Clear 
 
 Clear 
 
 Vaccine 4 c.c. P.Mas- 
 sage. A trace of 
 muco-pus 
 
 6-4-/ 
 
 No irrigation 
 
 Clear 
 
 Clear 
 
 Vaccine 4 c.c. 
 
 10-4-/ 
 
 No irrigation 
 
 Clear 
 
 Clear 
 
 P. Massage. Normal 
 secretion 
 
 12-4-/ 
 
 No irrigation 
 
 Clear 
 
 Clear 
 
 
 Case 2. — Incubation, seven days. Purulent discharge 
 fourteenth day of disease. 
 
 Date. 
 
 Irrigation. 
 
 Urine. 
 
 
 
 1. 
 
 2. 
 
 
 30-6-/ 
 
 3-7-/ 
 5-7-/ 
 
 9-7-/ 
 
 12-7-/ 
 
 14-7-/ 
 
 16-7-/ 
 20-7-/ 
 
 No irrigation 
 
 No irrigation 
 
 No irrigation 
 No irrigation 
 
 Clear, much mucus 
 Clear, mucous cloud 
 Clear, cloud of phos- 
 phates 
 Clear, s.m.p. filts. 
 
 (Platelets) 
 Clear very few s.m.p. 
 
 filts. 
 Clear 
 
 Clear 
 Clear 
 
 Clear 
 Clear 
 Clear 
 
 Clear 
 
 Clear 
 
 Clear 
 
 Clear 
 Clear 
 
 2. c.c. 
 
 4. c.c. (2-7-/.) 
 
 4. c.c. 
 
 4. c.c. 
 
 4 c.c. 
 
 Pr. Mass. Pr. not enld. 
 Normal secretion 
 
 These two cases show a method of recording the urine test from visit to visit, 
 but it has not been intended to show a complete case record. The above is 
 intended merely as a sample and, doubtless, individual methods will vary as they 
 suit the convenience and mode of nomenclature of the surgeon. The vaccine 
 dosage has been inserted as illustrating the method advocated in the chapter on 
 vaccine treatment. 
 
 In estimating progress it is important to take into 
 consideration, along with the urine test, the local con- 
 dition, i.e. the presence of a discharge, its type and 
 
22 TREATMENT OF GONORRHCEA 
 
 quantity. Without this, many mistakes in treatment 
 will be made. For instance, when prostatitis has 
 developed in a case under treatment with permanganate 
 irrigations, frequently the urine in both glasses will be 
 quite clear, but there is generally a little purulent or 
 muco-purulent discharge to be found on massaging the 
 urethra in the morning. Judged on the urine test alone 
 such a case would be considered clear, but in conjunction 
 with the persistence of the morning bead that conclusion 
 would be negatived and the prostate examined, when 
 pus would be found, and suitable treatment adopted. 
 Conversely, at the onset of epididymitis all discharge 
 will frequently disappear, and nothing is seen in the 
 mornings ; yet the urine generally shows a peculiar 
 cloudiness in both glasses and a tendency to deposit 
 phosphates very readily, the latter being no doubt due 
 to the developing febrile condition. This can often be 
 noticed, if the patient be under regular observation, as 
 long as forty-eight hours before the testicle commences 
 to swell, and suitable treatment, administered at once, 
 will usually assist in moderating the severity of the onset. 
 A careful consideration of clinical signs, together with 
 an accurate interpretation of the urine-test, will enable 
 the treatment of any case to be carried out in a manner 
 satisfactory alike to patient and surgeon. 
 
CHAPTER IV 
 
 EXAMINATION OF THE PROSTATE 
 
 The prostate should be examined in every case of 
 gonorrhoea if the patient is to have the best possible 
 prospect of freedom from relapse when treatment has 
 been concluded. The exact part played by this organ 
 in the reappearance of a discharge some long time 
 after active signs have disappeared is not yet evident, 
 but it is significant that, in a very large number of 
 such cases, the prostate is found enlarged and pus is 
 obtained on massage. In the acute case this gland 
 becomes infected much earlier than is generally believed, 
 and it is no uncommon thing to find pus formation at 
 the end of the first week of the attack. This being so, 
 it becomes necessary to know at what stage to examine 
 in routine treatment, and also what signs, developing 
 subsequently, should lead to further investigation of the 
 condition of the prostate. 
 
 Routine Examination is best done after the patient 
 has been under treatment for a week or ten days, except 
 in cases of acute prostatitis, which require to be dealt 
 with as described later. At this stage the patient has 
 little discharge, and the early tenderness and irritability 
 of the whole lower urinary tract are wearing off, thus 
 facilitating the examination and minimising the attend- 
 ant discomfort. The practice of examining every case 
 
 23 
 
24 TREATMENT OF GONORRHCEA 
 
 when first seen is not good, for, besides occasioning 
 anxiety and introspection in the patient, a wrong con- 
 clusion may frequently be drawn. Thus, with a recently 
 infected patient coming under observation early, 
 examination of the prostate may reveal nothing, or 
 but slight enlargement and tenderness, whereas a week 
 later there are definite signs of inflammation and sup- 
 puration. Such a case, being found normal at first, 
 might be treated for a considerable time before symp- 
 toms or signs pointing to prostatic involvement 
 would be sufficiently marked to lead to another 
 examination. 
 
 Indications for examination. (Apart from the 
 routine examination.) 
 
 Urine. — This may give indications of prostatic trouble 
 in three ways ; 
 
 (i) The presence of characteristic filaments in the 
 urine. 
 
 (2) Persistent cloudiness of both glasses in the 2- 
 glass test, with an almost complete absence of discharge 
 from the urethra. 
 
 (3) Rapid reappearance of cloudiness in both test 
 glasses when all treatment has been stopped. (This 
 is frequently, but by no means invariably, due to the 
 prostate.) 
 
 The absence of the characteristic filaments is no 
 criterion for assuming that the prostate is normal, but 
 the positive observations mentioned in (2) and (3) are 
 much more reliable. 
 
 Other indications are : 
 
 (1) Frequency of micturition, usually worse at night 
 than in the daytime. 
 
 (2) Pain referred to the bladder, rectum, or tip of the 
 penis, 
 
EXAMINATION OF THE PROSTATE 25 
 
 (3) Appearance of a discharge at the meatus after the 
 bowels have acted. 
 
 (4) Difficulty in commencing the act of micturition, 
 or intense desire to micturate with inability to pass 
 more than a few drops of urine at intervals of a few 
 minutes, or retention. 
 
 (5) Obstinate constipation. 
 
 Individually these are not pathognomonic, but when 
 several are present the prostate will usually be found 
 to be affected. These signs are well marked in Acute 
 Prostatitis, as would be expected, and most, if not all, 
 are then present. 
 
 Method of Examination. — The most satisfactory 
 position for the patient is kneeling on a moderately low 
 couch and resting on one hand, whilst the other hand 
 holds the test-glass beneath the penis. It is approxi- 
 mately the " Knee-elbow " position of gynaecology. The 
 use of a suppository containing atropine before the 
 examination is a safe-guard against the subsequent de- 
 velopment of epididymitis, and, in addition to diminish- 
 ing the discomfort, relaxes the anal sphincter. 
 
 Systematic investigation of the following points should 
 be carried out : 
 
 (1) Size (of the organ). 
 
 (2) Consistence. 
 
 (3) Tenderness on pressure. 
 
 (4) Secretion of the gland. 
 
 The size of the organ varies in different individuals, 
 but with experience the examining finger can readily 
 recognize pathological enlargement. It may be uniform, 
 confined to one or other lobe, or several loculi may be 
 distinguished. 
 
 The consistence of a slightly inflamed prostate is 
 
26 TREATMENT OF GONORRHOEA 
 
 firm and resistant, but as suppuration develops the 
 gland becomes softer and the finger readily sinks into it 
 on pressure, giving a tactile impression similar to that 
 obtained in " pitting " of the tissues in the oedema of 
 renal disease. If abscess formation occur, an area of 
 the gland may be found involving the rectum, into which 
 the abscess occasionally bursts spontaneously. Exami- 
 nation of such a case reveals a large swelling projecting 
 backwards into the anterior rectal wall, one portion of 
 which feels exceedingly thin and fragile and fluctuates 
 on the slightest pressure. It may burst into the rectum 
 when touched, however carefully the examination be 
 made, giving exit to a considerable quantity of pus. 
 
 The first examination often gives rise to a feeling of 
 faintness, especially if suppuration be present, and this 
 should always be watched for, both during and just after 
 treatment, since it is not confined entirely to the nervous 
 patient. 
 
 A small amount of tenderness is usually present on 
 massage of a normal prostate, and this increases rapidly 
 as inflammation develops ; but, being a subjective 
 sensation, its value is minimised. 
 
 The character of the secretion is most important. 
 During the examination a conical test-glass, containing 
 a little water, should be held beneath the penis, and any 
 secretion expressed allowed to fall into it. Normal 
 prostatic secretion is opalescent, and imparts this charac- 
 teristic to the water in the test-glass, but as inflamma- 
 tion develops its character changes. From being opales- 
 cent it becomes milky and increased in quantity, gradu- 
 ally, as the inflammation progresses, getting thicker, so 
 that two layers can be distinguished in the test-glass on 
 standing: (i) A white layer of muco-pus which sinks 
 to the bottom. (2) An opaque milky layer above. 
 
EXAMINATION OF THE PROSTATE 27 
 
 Later, abscess formation occurs and thick yellow pus can 
 be expressed. 
 
 Acute Prostatitis 
 
 This complication is described here because of its 
 intimate relationship to the subject matter of the 
 chapter and the various signs enumerated as indications 
 of prostatic involvement. For descriptive purposes 
 three forms are recognizable : Acute, Sub-acute, and 
 Chronic; but it must be realized that clinically they merge 
 one into the other without any very definite lines of 
 demarcation. Thus, a case of acute prostatis may under 
 suitable treatment rapidly become sub-acute, and then, 
 if treatment be neglected or stopped too early, reach the 
 chronic stage. 
 
 It usually develops about the seventh to twenty- first 
 day of discharge, its onset being rapid. Pain is often 
 the first warning, dull and dragging in character, referred 
 to the rectum, the bladder, or the tip of the penis. There 
 may be the history of the passage of a little blood at 
 the end of micturition during the preceding twenty- four 
 hours ; but this is often absent. The pain increases in 
 intensity and, side by side with this, difficulty in mic- 
 turition, with frequency, develops, until, when the acute 
 stage is at its height, there may be retention. Distressing 
 spasms of the prostate keep the patient restless, and the 
 associated inflammation at the neck of the bladder leads 
 to repeated attempts to pass water, though it contains 
 but a few drops. The temperature soon rises, and may 
 reach 102 or 103 , the patient is flushed and wears an 
 anxious expression, his attitude being very similar to 
 that assumed by abdominal cases — lying on the back, 
 the knees drawn up on the abdomen, and afraid almost 
 to move. The discharge diminishes to a negligible 
 
28 TREATMENT OF GONORRHCEA 
 
 quantity, especially if the temperature be moderately 
 high, and there is obstinate constipation, made worse 
 by reflex inhibition from the inflamed gland whenever 
 there is any pressure on the anterior rectal wall. In this 
 state a condition of exhaustion rapidly develops, and the 
 patient can neither sit nor lie down with any degree of 
 comfort. 
 
 Diagnosis. — A patient seen at this stage might well, 
 at first sight, be mistaken for an acute abdominal case ; 
 but, if already under treatment, the condition is readily 
 understood. A history of urethral discharge makes 
 diagnosis simple, but this is seldom volunteered without 
 special inquiry, and may even be denied. The diag- 
 nostic points are : 
 
 (i) Urethral discharge. A film shows the gonococcus. 
 It is rare, in such cases, for there to be insufficient dis- 
 charge for this. 
 
 (2) Tenderness is much more marked on pressure 
 over the perineum than over the lower abdomen. 
 
 (3) There is frequency of micturition, or retention. 
 
 (4) Rectal examination reveals an enlarged and 
 acutely tender prostate. The presence of epididymitis 
 concurrently may complicate matters, but even then 
 the tenderness is most marked in the groin, and enlarge- 
 ment of the testicle is obvious. 
 
 Treatment. — A rectal examination should be made 
 to discover the exact condition of the gland, but massage 
 should not be carried out at this stage. Having con- 
 firmed the diagnosis, treatment falls under three head- 
 ings : 1. Relief of pain. 2. Relief of frequency or reten- 
 tion. 3. Sleeping-draughts. 
 
 A hot hip-bath should be given at once and the patient 
 allowed to sit in it for a quarter of an hour, hot water 
 being continually added so as to maintain the tempera- 
 
EXAMINATION OF THE PROSTATE 29 
 
 ture as high as can be comfortably borne. It is in- 
 advisable to continue this beyond a quarter of an hour, 
 for there is a tendency for faintness to supervene. 
 Following on the bath a suppository containing y^th of 
 a grain of atropine should be given, and hot fomenta- 
 tions or an india-rubber hot water bottle applied to the 
 perineum. An almost immediate sense of relief is felt 
 and the patient can lie comfortably in bed. The atro- 
 pine suppository assists in diminishing the frequency of 
 micturition, as well as in relieving pain, and its action 
 should be continued by giving the following mixture 
 everv four hours : 
 
 ^. 
 
 Potass. Citratis. 
 Tinct. Hyoscyami. 
 Tinct. Belladonn. 
 Glycerin!. . 
 Syr. Zingiber. 
 
 grs. xx. 
 
 m. xx. 
 
 m. v. 
 
 m. xxx. 
 
 m. xxx. 
 
 Aqua ad 1 ounce. 
 
 When administering this drug its action on the glands 
 and pupil must not be forgotten, since after two or three 
 days' treatment the patient may complain of difficulty 
 in reading or seeing near objects, dryness of the mouth, 
 and thirst. The pupils are found to be dilated, and the 
 cause of the condition is clear. 
 
 If retention develops a soft rubber catheter (or gum- 
 elastic) should be passed, with aseptic precautions and 
 the urine drawn off. This will need to be repeated 
 during the acute stage, but after forty-eight hours' 
 suitable treatment the patient is usually able to pass 
 water fairly freely. The pain and febrile condition 
 prevent sleep, and this is best secured by using a bromide 
 mixture towards evening, two doses of x. or xv. grains 
 being given with an interval of three or four hours between 
 
3 o TREATMENT OF GONORRHOEA 
 
 them. It has the additional advantage of a sedative 
 action on the genital tract which is not shared by 
 trional or aspirin, though otherwise they are equally 
 good. 
 
 No irrigation should be allowed until the pain has 
 moderated considerably and the patient can pass water 
 freely. A weak solution of permanganate of potash 
 (i in 8,000) should then be given twice daily, the hip- 
 baths and suppository being continued. The use of 
 vaccine is a most valuable adjunct, and will be referred 
 to in another chapter. When the sub-acute stage has 
 been reached routine massage should be commenced, 
 twice a week being sufficiently often for the majority 
 of cases. In carrying this out the gland should be 
 firmly and evenly stroked from above downwards, the 
 finger sweeping over the surface in small curves directed 
 toward the centre of the gland, so as to include the out- 
 lying, as well as the central portions. The secretion 
 expressed is collected, as previously described, in a test- 
 glass containing a little water. Regular massage should 
 be continued until pus does not re-form and normal 
 secretion alone is expressed. Hip-baths should still 
 be given, and the irrigations twice daily, the strength 
 of the solution being increased to 1 in 6,000. 
 
 Some of the cases do not clear up, but pass into the 
 chronic stage, and for weeks or months pus or muco- 
 pus can be expressed from the prostate, with, perhaps, 
 a little blood. The administration of a gonococcal 
 vaccine has been found very effective in such, and should 
 always be tried along with routine treatment. In others 
 the openings of the prostatic ducts into the posterior 
 urethra may be enlarged through the urethroscope, but 
 this needs special instruments and technique and should 
 be left to the specialist. 
 
EXAMINATION OF THE PROSTATE 31 
 
 Chronic Prostatitis 
 
 In a very large number of gonorrhoea cases the infec- 
 tion spreads to the prostate, and some writers put the 
 figure as high as 80 per cent. ; but it must be explained 
 that symptoms of acute prostatitis such as have just 
 been described develop only in a very much smaller 
 number, and even this number can be reduced by the 
 proper use of vaccines in the early acute stage. In some 
 cases many of the signs already enumerated are obvious, 
 such as frequency of micturition, characteristic filaments 
 in the urine, the appearance of a discharge at the meatus 
 after an action of the bowels, or dragging pain when 
 walking about. Many show no signs at all of the exten- 
 sion of infection to the prostate, and it is only during 
 routine examination that the condition of the gland is 
 discovered. The two-glass urine test is often quite 
 valueless as a guide in these cases, for the second glass 
 may be perfectly clear and free from filaments when pus 
 or muco-pus can be expressed from the prostate on 
 massage. This fact is responsible for many relapses, 
 since examination of the gland is often neglected. The 
 patient stops treatment and goes about as usual with 
 no discharge, and then, as the result possibly of a chill, 
 over-exertion, or even constipation, there is a discharge 
 from the prostate, the urethra becomes re-infected, and 
 a relapse results. Such relapses can be avoided, in many 
 instances, by proper treatment of the prostate, and in 
 every case of gonorrhoea it should be the aim of the 
 surgeon to ensure that normal secretion only is present 
 in the gland when treatment is to be discontinued. The 
 method of examination has been described previously, 
 together with the characters of normal secretion. The 
 point of chief importance in chronic prostatitis is the 
 
32 TREATMENT OF GONORRHOEA 
 
 nature of the secretion expressed. The gland is usually 
 found to be moderately enlarged, and but slightly tender, 
 whilst the seminal vesicles may be involved as well. 
 There is slight discomfort on massage, but nothing 
 approaching the severe pain of the acute stage. The 
 consistence of the gland varies considerably, in many 
 patients being firm and resistant, very much like the 
 normal, but in a certain number fibrosis occurs leading 
 to a hard and, often, nodular condition. During massage 
 of these latter cases it requires considerable pressure to 
 express any secretion, and it may be that there is an 
 associated constriction or occlusion of some of the 
 ducts. 
 
 Treatment. — It takes a considerable time thoroughly to 
 clear up some of these cases of chronic prostatitis and, 
 owing to this fact, there is a tendency for the patient 
 to become despondent and worried about himself. The 
 nature of the treatment encourages introspection, and, 
 if care be not taken, an unhealthy state of mind is soon 
 developed. For this reason attention should be paid to 
 the general health and mode of living. Tonics are 
 prescribed if needed, food restriction and dieting done 
 away with as far as possible, and the patient encouraged 
 to take plenty of exercise in the open air, avoiding riding 
 and cycling. In one series of cases treated with vac- 
 cines it was found that the cases complicated by pros- 
 tatitis (including acute as well as chronic) took, on 
 an average, three weeks longer than those with epidi- 
 dymitis. The actual figures were : 
 
 Epididymitis : 101 cases. Average number of days, 
 
 38. 
 
 Prostatitis : 94 cases. Average number of days, 60. 
 No doubt the period of treatment for these cases 
 might have been shortened by a few days at the risk 
 
EXAMINATION OF THE PROSTATE 33 
 
 of relapses occurring, but it is more satisfactory to treat 
 the condition thoroughly. In the cases quoted no 
 relapses had occurred at a period six months after 
 completion of treatment. The lines of treatment are 
 four : 
 
 (a) Baths, combined with irrigation. 
 
 (b) Regular massage of the prostate. 
 
 (c) Vaccine treatment. 
 
 (d) Instrumental treatment. (Bougies and di- 
 
 lators). 
 
 Medicinal treatment has little or no effect upon the 
 prostate, as far as is known, and there is no particular 
 drug of value. Sandal-wood oil or a mixture of uro- 
 tropine and buchu is suitable. 
 
 Hip-baths are very useful in the chronic, as well as in 
 the acute, stage. The patient should take the bath 
 daily, as hot as can be comfortably borne, the tem- 
 perature being maintained by the addition of hot water, 
 as already described for acute prostatitis. Irrigation 
 of the whole urethra should be carried out daily, after the 
 bath, in order to wash away any secretion exuding 
 from the prostate. Zinc permanganate is a very useful 
 solution for this purpose, and may be used in a strength 
 of 1 in 4,000. 
 
 Massage of the prostate should be carried out regularly 
 in the manner already described, a suppository con- 
 taining atropine being given on the evening before the 
 examination and again one hour before it is actually 
 carried out. This diminishes the likelihood of Epidi- 
 dymitis resulting, but with all precautions its occurrence 
 cannot always be prevented. Special attention should 
 be paid to each part of the gland, and care taken not 
 to overlook a focus in the lateral areas. In the chronic 
 
 3 
 
34 TREATMENT OF GONORRHOEA 
 
 stage there is, frequently, loculation and, consequently, 
 should the examination lack thoroughness, an infected 
 area may remain untouched after repeated massage, 
 and nothing but normal secretion be expressed each 
 time, a fact which would be liable to mislead. 
 
 In certain cases the prostate is found to be hard and 
 its contents difficult to express. Under these condi- 
 tions it sometimes improves matters to carry out the 
 massage with a curved metal sound in position in the 
 posterior urethra. This diminishes the mobility of the 
 gland and allows its different areas to be compressed 
 against the metal shaft. The frequency with which 
 this examination needs to be carried out is determined 
 by the condition of the gland and the character of the 
 secretion, but should never be more than twice a week. 
 If there be only a small amount of pus or muco-pus 
 expressed at each massage the interval can be extended 
 to a week, and this is the common rule. 
 
 Instrumental treatment is required in some obstinate 
 cases where massage and irrigation do not suffice to clear 
 up the condition. Urethroscopy has shown that in 
 many of these there is a focus of infection in the posterior 
 urethra, often in the region of the prostatic sinus, 
 responsible for keeping up the discharge. The best 
 instruments for this purpose are large curved bougies 
 with a short beak, the pattern known as Clutton's 
 being, perhaps, the best. After thorough irrigation of 
 the urethra and bladder an injection of 2 per cent, 
 alypin is given into the posterior urethra, by means of 
 an Ultzmann's syringe, and the sound passed with full 
 aseptic precautions. Two instruments, or possibly three, 
 may be passed at each visit, but never more. 
 
 They need not be left in position, being simply in- 
 serted and withdrawn gently. Irrigation is then carried 
 
EXAMINATION OF THE PROSTATE 35 
 
 out once more. An interval of a week should be allowed 
 to elapse between each treatment. 
 
 Kollmann's posterior urethral dilator may be used in 
 certain cases, e.g. when the instruments of Glutton's 
 pattern have not been sufficient to produce the necessary 
 dilatation of the posterior urethra, as shown by the 
 urethroscope. It is an instrument which is but seldom 
 required, and should be used only for a definite purpose, 
 and always controlled by urethroscopic examination. 
 The instrument is of the four-bladed type, the irrigating 
 pattern being preferable, so that a solution of protargol 
 or silver nitrate may be run through during dilatation. 
 Suitable strengths for this purpose are 1 in 4,000 pro- 
 targol and 1 in 10,000 to 1 in 5,000 silver nitrate. The 
 introduction and subsequent expansion of the blades 
 should be carried out with the greatest care, since the 
 posterior urethra is not nearly so elastic and distensible 
 as the anterior portion. The method is similar in all 
 essential details to that previously described for Koll- 
 mann's straight dilator, and need not be repeated here. 
 An interval of a week should always be allowed between 
 these dilatations and the effect of each preceding one 
 estimated by means of the urethroscope before repeating 
 the operation. By this means satisfactory results can 
 be obtained and the risk of serious damage minimised. 
 
 Vaccines are of the greatest value in cases of chronic 
 prostatitis, especially where pus or muco-pus continues 
 to re-form rapidly in spite of repeated massage. In 
 many such cases the only sign is the appearance of a 
 little white secretion at the meatus after an action of 
 the bowels, while the urine in both glasses of a two-glass 
 test is perfectly clear. Such patients get very worried 
 over this morning discharge, even when gonococci can- 
 not be found in a smear from it, and it is essential to clear 
 
36 TREATMENT OF GONORRHCEA 
 
 it up as rapidly as possible. The prostate gets into a 
 catarrhal condition, and massage alone does not seem to 
 have much influence ; but when combined with vaccines 
 a steady improvement can be observed. A dose of 
 ioo million gonococci and 300 million staphylococci 
 should be given twice weekly, and massage carried out 
 once a week, followed by an irrigation of iin 6,000 perman- 
 ganate of potash. If the urine be clear and contain no 
 filaments, irrigation is unnecessary, except directly after 
 the massage. One case may be quoted as an example. 
 The patient had an attack of gonorrhoea, with acute 
 inflammation of the prostate. This subsided after six 
 weeks' treatment, and the urine was perfectly clear. The 
 prostate, however, remained somewhat enlarged and 
 continued in a catarrhal condition. Much muco-pus 
 could always be expressed on massage, though no dis- 
 charge was ever seen except after an action of the bowels, 
 and there was no discomfort. The patient was sent 
 away for a month and a complete rest from all treatment 
 allowed. At the end of that time a smear of the prostatic 
 secretion was examined. Gonococci were found to be 
 present. A course was commenced on the lines already 
 described, with vaccine at regular intervals and weekly 
 massage of the prostate, no irrigation being allowed 
 except once after each examination. At the end of six 
 weeks the prostate was of normal size and consistence, 
 its secretion having gradually changed from muco-pus 
 to the characteristic opalescent fluid. A second smear 
 was then taken. No gonococci could be found. All 
 treatment was stopped, and the patient seen again three 
 months later. The prostate remained normal, as also 
 its secretion, and no gonococci could be found after 
 examination of two slides taken at a few days' interval. 
 No sign of discharge had been present at any time and 
 
EXAMINATION OF THE PROSTATE 37 
 
 the cure was complete. An experience of many similar 
 cases treated by other methods has led the writer to 
 attribute a definite action to the vaccine which is 
 extremely valuable, and is, fortunately, most useful in 
 those cases which would otherwise require very pro- 
 tracted treatment, although the manifestations are so 
 aggravatingly slight. 
 
CHAPTER V 
 
 ROUTINE TREATMENT OF ACUTE GONORRHOEA 
 
 During the acute stage of the disease rest in bed and 
 a light diet are the first essentials. Apart from any 
 treatment this results in a speedy diminution of the dis- 
 charge, and it is a safe plan to keep a patient in bed until 
 there is little more than a yellow bead of pus visible 
 at the meatus in the morning. If the system of early 
 vaccine treatment, as described later, be adopted, this 
 usually happens after four or five days. Other treatment 
 can be conveniently described under three headings: 
 
 (i) General. 
 
 (2) Local. 
 
 (3) Special. 
 
 General treatment includes medicines — (a) urinary 
 antiseptics ; (b) aperients ; (c) sedatives ; together 
 with the nature of the diet. 
 
 Local treatment includes irrigations and instrumental 
 procedure. 
 
 Special treatment includes vaccines, mercury com- 
 pounds, electro- chemical methods. 
 
 Diet. — -This should be light in the acute stage, as 
 already mentioned, and include plenty of fluid. Milk 
 and barley-water are both suitable, and two to four pints 
 of the latter should be taken daily. It is a perfectly 
 bland fluid, and, with the addition of lemon, makes quite 
 
 38 
 
ROUTINE TREATMENT 39 
 
 a palatable drink. A little tea or coffee may be allowed, 
 but no alcohol of any description. This regime con- 
 tinues until the fourth or fifth day, when the patient 
 gets up and may be permitted an ordinary diet. Spices, 
 highly seasoned foods, sauces, and pickles should be 
 avoided and alcohol still forbidden ; but a moderate 
 amount of meat may safely be taken. 
 
 Exercise. — On being allowed up the patient should 
 begin to take exercise each day, the amount being 
 gradually increased as the acute stage passes off. There 
 is a mistaken idea amongst many sufferers from the disease 
 that it is a wise practice to abstain from meat and take 
 no exercise for some weeks after its development ; but 
 experience shows this to be wrong. By the tenth day 
 an uncomplicated case of gonorrhoea should be eating 
 a full diet, with the exceptions mentioned, going about 
 as usual, and, in fact, leading an ordinary life. By 
 following this course, too, the mind is turned away from 
 the disease, and it ceases to be the nightmare which it 
 frequently becomes on prolonged semi-starvation and 
 confinement to bed. 
 
 Medicines. — Urotropine is a useful drug in the acute 
 stage, being a urinary antiseptic. It should be given 
 with acid sodium phosph., mixed just before taking, 
 so as to secure its full effect. A useful prescription is 
 the following : 
 
 Urotropine 
 Aq. ad. 
 B. Ac. Sod. Phosph. 
 Potass. Citrat. . 
 Syr. Aurant. 
 Inf. Buchu ad 1 ounce t.d.s. 
 
 grs. x. 
 1 ounce 
 grs. xx. 
 grs. x. 
 3is. 
 
 Dose. — 1 ounce of each "mixed just before taking. 
 
40 TREATMENT OF GONORRHOEA 
 
 Some patients are intolerant of this drug, and com- 
 plain of an increased irritability of the bladder and 
 urethra, with considerable frequency, quite apart from 
 any prostatic complication. It should not be given 
 when there is acute posterior urethritis, with bleeding 
 at the end of micturition. Sandal- wood oil and 
 copaiba seem to have little effect on the course of the 
 disease at this stage. Aperients are usually required 
 to keep the bowels acting regularly, and this point should 
 always receive attention. Magnesium salts are the most 
 suitable for the purpose, and the dose can be readily 
 regulated by the patient to suit his own needs. 
 
 Sedatives are called for in the case of the painful 
 erections which are a common symptom. Potassium 
 bromide in grs. x. doses, given towards evening and 
 again on retiring, is quite effective. 
 
 Local Treatment. — Irrigation should be commenced 
 as soon as the condition has been diagnosed, and every 
 attempt made to get the irrigating fluid into the bladder 
 at the earliest possible moment. 
 
 Two conditions alone contra-indicate this : 
 
 (i) The presence of an acute epididymitis. 
 
 (ii) A hyper-acute urethritis, such as is occasionally 
 seen, in which blood and pus ooze constantly from the 
 urethra. 
 
 In these cases other measures have to be adopted 
 for a time before irrigation can be commenced, but in all 
 others no delay should take place in washing out the 
 whole urethra. 
 
 The most generally useful solution is i in 8,000 per- 
 manganate of potash, and two or three pints should be 
 used for each irrigation, the temperature being between 
 ioo° and 105 F. in the can. If colder than this it does 
 not enter the bladder so readily. 
 
ROUTINE TREATMENT 41 
 
 The apparatus consists of a can of two or three pints 
 capacity, to which is connected a piece of rubber tubing 
 about 4 feet in length. A blunt-ended glass nozzle is 
 attached to the free end of the tubing, and the flow of 
 fluid controlled by a ratchet-clip. The can is filled with 
 the permanganate solution (1 in 8,000) at the proper 
 temperature and suspended about 6 to 7 feet above the 
 ground. The patient wears a waterproof apron and 
 either sits or stands with a bucket at his feet to catch 
 the waste fluid. The clip is released and all air expelled 
 from the tubing, the flow of fluid being controlled 
 by the pressure of the fingers. The prepuce is re- 
 tracted and the meatus washed free from any accu- 
 mulated discharge by a gentle flow of the solution. The 
 nozzle is then pressed firmly against the meatus and the 
 fluid allowed to run freely. It can be felt to run up a 
 short wa3? and then stop. The nozzle is then withdrawn 
 and a jet of the solution runs away. This is repeated 
 four or five times and the nozzle reapplied more firmly, 
 so that nothing escapes at the meatus. The muscles are 
 relaxed in exactly the same way as during micturition 
 and the fluid allowed to run freely. The bladder can then 
 be felt to fill up gradually, and a desire to pass water 
 supervenes. The clip is closed, the nozzle withdrawn, 
 and the patient empties his bladder. This, too, should 
 be repeated two or three times. Some patients find a 
 difficulty in relaxing the muscles to allow free passage 
 to the fluid, but in these a change from the standing 
 to the sitting position during irrigation will often over- 
 come the difficulty, or vice versa. A certain proportion 
 of cases have some malformation of the penis, such as 
 hypospadias of various degrees. For these a special 
 nozzle with a long thin neck to insert well inside the 
 meatus is necessary. 
 
42 TREATMENT OF GONORRHOEA 
 
 Irrigation. — This should be done twice a day, in the 
 morning and again towards evening, the whole content 
 of the can being utilised each time. After a few days 
 the discharge diminishes considerably, and as soon as 
 the patient can irrigate successfully the strength should 
 be increased to i in 6,000 permanganate, beyond which 
 it is not necessary to go in the ordinary acute case. 
 Such a solution has comparatively little germicidal 
 effect during its short stay in the urethra, and the object 
 of irrigation is, almost entirely, that of flushing out the 
 inflamed lower urinary tract ; consequently the volume 
 of solution, not the strength, is of first importance. 
 Patients are very apt to imagine that, by using a very 
 strong solution which causes them more discomfort, 
 they are benefiting themselves and cutting short the 
 duration of the attack. This is a fallacy, and, although 
 a certain number of cases require a stronger solution, 
 it is unusual, and 1 in 6,000 permanganate is sufficient 
 for the vast majority. Since irrigation has to be 
 continued for three or four weeks in the most favourable 
 cases it is sound reasoning that the solution which does 
 least damage to the epithelium is the best. Irrigation 
 with 1 in 4,000 permanganate for two or three days de- 
 termines, in many instances, the onset of slight bleeding 
 at the end of micturition, arising from injury to the 
 delicate mucous membrane of the posterior urethra. 
 This rarely occurs with 1 in 6,000 permanganate which 
 is the most suitable strength for regular daily use in the 
 acute stage. Many other solutions have been advocated 
 as superior substitutes for permanganate of potash, 
 chiefly for use in the chronic stage, most of them being- 
 compounds of zinc or mercury, e.g. zinc permanganate, 
 zinc sulphate, mercury oxycyanide, zinc sulphocar- 
 bolate. Experience shows that potass, permanganate 
 
ROUTINE TREATMENT 43 
 
 is by far the best in the acute stage, and although no 
 specific action can be definitely asserted, its effects are 
 not approached by any of the other solutions. The merits 
 of each are referred to under the treatment of chronic 
 gonorrhoea. Zinc permanganate and zinc sulphate are 
 often of value towards the end of treatment in an acute 
 case when the urine is practically clear and there is 
 an almost complete absence of discharge, or just a little 
 adhesion of the lips of the meatus in the morning ; 1 in 
 6,000 zinc permg. and 1 in 1,000 zinc sulphate are suitable 
 strengths, and the change seems to have a stimulating 
 effect on the urethral mucosa, possibly due to the 
 astringent nature of the solution, resulting in the speedy 
 disappearance of all signs of dampness and of the small 
 flakes from the urine. 
 
 Bougies. — A straight pattern bougie should be passed 
 about the end of the second week of treatment, not for 
 the purpose of dilatation but as a means of investigating 
 the condition of Littre's glands and discovering the com- 
 mencement of soft strictures. A sound of a size which 
 passes readily is introduced, and gentle traction in an 
 upward direction made on the penis with one hand whilst 
 the thumb and index-finger of the other hand palpate the 
 urethra from the bulb towards the meatus. Small glan- 
 dular abscesses are in this way readily discovered and 
 massaged against the sound to express their contents. 
 Dilatation should not be attempted at this stage, but the 
 number of the sound used should be recorded for future 
 reference. 
 
CHAPTER VI 
 
 SPECIAL TREATMENT 
 
 Foremost amongst these is vaccine as an aid, not only 
 in preventing complications, but in materially assisting 
 a cure. An experience of some thousands of cases* treated 
 from the earliest stages on this plan has confirmed the 
 view that vaccines are equally of value in the acute, as 
 well as in the chronic, stage. A mixed stock vaccine 
 gives the most satisfactory results, and in the method to 
 be described later one of the following composition was 
 adopted : 
 
 Staphylococci . . 150 millions per c.c. 
 
 Gonococci 50 „ „ 
 
 The cultures were made from many different cases 
 and the resulting strains introduced. In treating gonor- 
 rhoea the difficulty always encountered is that of de- 
 stroying in situ or removing the gonococci lying below 
 the surface of the mucous lining of the urethra and its 
 many tiny glands. At a very early stage in the disease 
 the organisms penetrate between the cells and also enter 
 the gland ducts, and this condition is almost invariably 
 established forty-eight hours after the appearance of a 
 discharge. Once this has occurred it is quite clear that 
 irrigation alone will not cure the patient, for the effect 
 is merely that of washing away the accumulation of 
 * Vide British Medical Journal, Oct. 6, 191 7 
 44 
 
SPECIAL TREATMENT 45 
 
 pus and removing organisms lying on the surface. What- 
 ever the nature or strength of the solution it cannot 
 touch those organisms embedded deep down in the 
 various glands, and the only satisfactory way of attacking 
 them is via the blood-stream. A vaccine is the most 
 suitable medium for this purpose, since it acts by increas- 
 ing the power of the blood to destroy the particular class 
 of organism injected. Following on an injection there is 
 a negative phase, lasting from twenty-four to forty-eight 
 hours according to the dose and toxicity of the vaccine 
 employed, during which the power of the blood seems to 
 be diminished, followed by a rise in its hostility to the 
 organisms, known as the positive phase, lasting longer 
 than the negative phase. It is well known that in the 
 case of certain organisms one positive phase can be 
 superimposed upon another by giving injections at 
 suitable intervals and regulating the dose carefully. The 
 gonococcus is one of these, and in the method of vaccine 
 administration described below it is believed that this 
 is actually the case. 
 
 The dosage and intervals vary slightly according to 
 the vaccine in use and the particular cultures from which 
 it is made, but this can readily be determined by experi- 
 ment. That theory is borne out by practice and that 
 the gonococci lying below the surface are attacked by 
 injecting vaccine is readily shown. Take an acute case 
 after two or three weeks' treatment, when the urine is 
 clear and free from filaments, though the treatment is 
 not complete. Inject a dose of vaccine and examine 
 the urine twenty-four hours later. It will probably be 
 found cloudy and the patient may possibly see a slight 
 amount of discharge. This is a very useful test of cure, 
 and a moderate dose should be given three or four days 
 after all treatment has ceased, when, if there be no return 
 
46 TREATMENT OF GONORRHOEA 
 
 of discharge and the urine remain clear forty-eight hours 
 later, there is little likelihood of a relapse. Vaccine, 
 then, in the acute stage serves three useful purposes : 
 
 (i) To increase the power of the blood in antagonising 
 the gonococcus and so incidentally to diminish the 
 possibility of complications. 
 
 (ii) To assist cure by reaching the organisms lying 
 beneath the mucous membrane and causing their de- 
 struction or migration to the surface. 
 
 (iii) As a test of cure on the completion of treatment. 
 
 The routine method adopted will be fully described, 
 and all details of diet and medicinal treatment included, 
 since it is the most satisfactory method of treatment at 
 present known. 
 
 When first seen the patient is examined as already 
 described, and the diagnosis confirmed. In the morning 
 he passes a sample of urine, which has been held for six 
 or eight hours if possible, into two conical test-glasses, 
 the first four or five ounces into the first glass, and the 
 last few ounces into the second glass. In the acute stage 
 both are usually cloudy if there has been a discharge for 
 two or three days. The patient remains in bed and is 
 given a mixture of urotropine (prescription previously 
 given) three times a day, being allowed plenty of milk 
 and barley-water. Irrigation is commenced at once 
 with i in 8,000 permanganate of potash twice a da}/ and 
 every effort made to ensure its entry into the bladder. 
 Two or three pints of solution are used at a temperature 
 of about ioo° F. in the irrigating-can, the pressure 
 being roughly four feet. An initial dose of vaccine 
 is given (i c.c, containing 50,000,000 gonococci and 
 150,000,000 staphylococci) on the first day. The patient 
 stays in bed four days and continues the irrigation 
 medicine and milk diet during this period. On the third 
 
SPECIAL TREATMENT 47 
 
 day a dose of 2 c.c. (100,000,000 gonococci, 300,000,000 
 staph.) is given. The strength of the irrigation is 
 increased to 1 in 6,000 permanganate on the fifth day, 
 when the patient is allowed up, commences ordinary diet, 
 and takes gentle exercise. All alcohol and highly-seasoned 
 foods are forbidden, but meat and tea are allowed. The 
 discharge at this stage has almost invariably diminished 
 to a bead of pus in the morning and micturition gives 
 rise to little discomfort. On the sixth day another dose 
 of 2 c.c. vaccine is given and irrigation is continued with 
 the same solution. On the ninth day the vaccine is 
 repeated (2 c.c.) and the patient goes about just as usual, 
 taking no medicine and carrying out no treatment except 
 irrigation morning and afternoon. Towards the end of 
 the second week of treatment, when the discharge is but 
 slight, a straight bougie (metal) is passed, and the urethra 
 gently palpated. If any of the glands are found enlarged 
 they are massaged against the sound from below upwards 
 between the thumb and index-finger so as to express their 
 contents as far as possible. Should any constriction of 
 the lumen have commenced to develop the bougie reveals 
 it and its distance from the meatus is recorded, but no 
 attempt should be made to dilate the urethra at this 
 stage. On the twelfth day another dose of 2 c.c. of 
 vaccine is given, the irrigating solution remaining un- 
 altered, and again on the fifteenth day. It will be seen 
 that a course of six injections is thus given : 1 c.c. on the 
 first day, 2 c.c. on the third, sixth, ninth, twelfth, and 
 fifteenth days, the dose not being increased after the first 
 injection. 
 
 General reaction has been found to be almost negligible 
 after the initial dose and subsequent injections rarely 
 cause any headache ; but there is always a definite focal 
 reaction. Within twenty- four hours of the injection the 
 
48 TREATMENT OF GONORRHOEA 
 
 discharge from the urethra increases slightly and pre- 
 viously clear urine will probably be hazy on the following 
 morning when the gonococcus is still active. About the 
 fifteenth or sixteenth day a routine examination of the 
 prostate is made, and the secretion examined. If an 
 acute case in which treatment has been commenced early, 
 the normal secretion is usually present, but if treatment 
 has been delayed or neglected pus or muco-pus will 
 usually be found. Assuming the prostate to be normal, 
 by the sixteenth to twentieth day all discharge will have 
 disappeared, and there will be no bead in the morning, 
 nor after ordinary exercise, whilst a two-glass urine-test 
 will show both glasses clear with, perhaps, a little mucus 
 and one or two tiny flakes in the first. At this stage the 
 irrigation should be changed to i in 1,000 zinc sulphate 
 or i in 6,000 zinc permanganate for two or three days, 
 and then stopped completely. Exercise continues daily 
 as usual, and about three days after all treatment has 
 ceased a final dose of 2 c.c. vaccine is given, the urine 
 being examined on the following morning. There should 
 be no trace of discharge, and the urine should remain 
 perfectly clear. The patient is seen again after another 
 three or four days, when, if the samples are still satis- 
 factory, there is little likelihood of a relapse. 
 
 In many cases coming for treatment, however, a dis- 
 charge has been present for several days or weeks and on 
 massaging the prostate in the routine course pus or 
 muco-pus is expressed. If irrigation be discontinued in 
 these cases on the twentieth day and a vaccine given, a 
 copious discharge of pus results within twelve to twenty- 
 four hours, often described by the patient as worse than 
 when treatment was commenced. Irrigation must be 
 continued with 1 in 6,000 permanganate of potash and 
 routine massage of the prostate started, but not more 
 
SPECIAL TREATMENT 49 
 
 often than twice a week, unless there are special indications. 
 An irrigation should be carefully carried out after each 
 massage so as to remove any pus expressed into the 
 posterior urethra. 
 
 Note. — The tendency of some patients to faint during 
 this treatment has already been alluded to, and it is worth 
 while mentioning that a certain number also develop 
 malaise and moderate pyrexia during the succeeding 
 twenty-four to forty-eight hours. This is most often 
 the case when pus is present, and may be due to auto- 
 inoculation. 
 
 During this time a second and, if necessary, a third 
 course of vaccines may be given, the prostatic massage 
 and irrigations continuing until normal secretion only 
 is obtained from the prostate. After the sixth injection 
 no more vaccine is given until ten days have elapsed, 
 when a second course should be commenced if the dis- 
 charge persist. The initial dose in this course is the same 
 as the others, viz. 2 c.c, and should be given about the 
 t went}-- fifth day of treatment, an interval of two clear 
 days being allowed to elapse between subsequent injec- 
 tions. When both glasses in the urine-test are clear and 
 free from filaments, when the prostate yields normal 
 secretion on massage, and when no discharge has been 
 visible for three or four days in spite of vigorous exercise, 
 treatment may be stopped and the test-dose of vaccine 
 given, as referred to above in the case of uncomplicated 
 cases. It is believed that, by adhering to this dosage, 
 and particularly these intervals, a series of positive 
 phases is actually imposed successively one upon the 
 other, thus obtaining the maximum effect in the shortest 
 time. In practice it has been found that an increase in 
 the dose above 2 c.c. does not improve the results, and 
 longer intervals are less satisfactory. The dosage will 
 
 4 
 
50 TREATMENT OF GONORRHCEA 
 
 vary slightly with different brands of vaccines, but this 
 can readily be adjusted by experience, whereas the 
 interval will probably be found to be the optimum for 
 most gonococcal vaccines. It is of interest to note 
 that this method of administering vaccines in large doses 
 at comparatively short intervals has given excellent 
 results in cases of furunculosis and impetigo treated 
 with staphylococcal cultures, the lesions clearing up 
 with remarkable rapidity. This method of vaccine 
 treatment has three advantages : 
 
 (i) The speedy disappearance of discharge and pain 
 on micturition. 
 
 (2) Diminished liability to complications. 
 
 (3) A sound test of cure. (Freedom from active 
 signs.) 
 
 After four or five days' treatment the discharge in an 
 acute case is, almost invariably, reduced to a bead in 
 the mornings, and the patient suffers little discomfort 
 on passing water. He realises that he is getting better, 
 and it has a marked effect on the mental condition. 
 The treatment of even a few cases of gonorrhoea soon 
 reveals the fact that despondency on the part of the 
 patient is one of the symptoms with which it is hardest 
 to deal, and anything which tends to brighten his out- 
 look is of value. The disappearance of most of the dis- 
 charge after a week's treatment has a remarkably good 
 effect, and encourages the patient to persevere with what 
 is, at best, an irksome daily routine. Vaccine is of 
 undoubted value as a test of cure, and should entirely 
 supersede the " Stout Test." A patient on the com- 
 pletion of treatment is advised to take no alcohol for 
 some months, since it is often responsible for a relapse ; 
 and yet in some instances he is ordered several bottles 
 of stout as a " Test of Cure." It is only natural for him 
 
SPECIAL TREATMENT 51 
 
 to repeat the test at frequent intervals for his own satis- 
 faction and so increase the chance of a recurrence. 
 With vaccine this is avoided, whilst remaining just as 
 efficacious, and its use in several thousand cases has 
 proved it to be the most reliable, as well as the most 
 practical, test apart from microscopic examination. 
 
 Electro-chemical Treatment of Gonorrhoea 
 
 The electro-chemical treatment of gonorrhoea dates 
 back many years, and, from time to time, it is revived 
 with some slight modification in the method of ad- 
 ministration. There is a certain attractiveness about 
 it which seems to encourage not only the patient, but 
 the operator also. Just as with the X-rays, the bulk 
 of the apparatus as, for example, in the polystat creates 
 an impression, and the very word " Electricity " has a 
 magical effect. There is an almost complete absence 
 of pain during treatment, and the discomfort of irrigation 
 is avoided. Unfortunately the end-results of treatment 
 are not nearly so attractive as the method, and for this 
 reason it has been superseded. Various metals and 
 chemical solutions have been tried to get the maximum 
 destructive effect on the gonococci, those finding most 
 favour being salts of zinc or the iodides. In nearly all 
 recent work a perforated catheter has been used, the 
 solution being run through this, whilst a silver stylet 
 conducts the current. It has been pointed out pre- 
 viously that gonococci penetrate between the cells 
 and cannot be removed by irrigation alone. The object 
 aimed at in the electro-chemical method is to drive 
 active ions into the mucosa, and to reach these organisms. 
 It is known that ions can be made to penetrate the tissues 
 to considerable depths and there exert their charac- 
 teristic actions, but when the urethral mucosa becomes 
 
52 TREATMENT OF GONORRHCEA 
 
 the surface within which the active chemical agents 
 have to be liberated by the passage of the current, 
 certain factors come into play whose effects it is difficult 
 to estimate. Chief among these is the presence and 
 circulation of the lymph. No sooner have the liberated 
 ions penetrated the surface than they meet with this 
 fluid of definite chemical composition. What reaction 
 takes place cannot be stated, but it is reasonable to 
 suppose that the free ions are rapidly fixed by various 
 substances, and their nascent effects soon lost. In other 
 words, before the specific action of the ions can be 
 exerted upon the organisms secondary changes occur, 
 rendering them powerless. 
 
 Various methods have been advocated, but practically 
 all are modifications of the original apparatus consisting 
 of a perforated catheter, into which fluid can be poured, 
 and a metal stylet inserted to conduct the current. The 
 following method, used in a series of cases, was found 
 quite convenient and the apparatus easily manipulated. 
 The instrument consisted of a silver-plated perforated 
 catheter, about nine inches in length, enlarged at the 
 top into a cup-shape sufficiently wide to accommodate 
 an india-rubber cork, through which passed a hollow 
 silver stylet. The stylet reached to within a quarter 
 of an inch of the tip of the catheter, whilst the perfora- 
 tions extended about five inches upwards from the tip. 
 A small side-tube was let into the stem so that fluids 
 could be run in at will. A piece of india-rubber tubing, 
 about one inch in length, surrounding the metal stem 
 about six inches from the tip, secured a water-tight joint 
 at the meatus when the instrument was in position. 
 A glass container and four feet of rubber tubing served 
 to hold the chemical solution. By means of the con- 
 tainer a constant supply of fluid was assured, and, by 
 
SPECIAL TREATMENT 53 
 
 raising it, the pressure in the urethra was readily 
 increased, thus distending the folds and exposing a 
 larger surface to the action of the ions. The solution 
 used was potassium iodide, with a little dissolved iodine. 
 The catheter was sterilised by boiling, and passed in the 
 ordinary way after cleansing the lips of the meatus, 
 care being taken to adjust the ring of rubber so as to fit 
 within the lips of the meatus and prevent any leakage 
 of solution. A metal clip, adjustable to any angle; was 
 attached to the side of the table and maintained the 
 apparatus in the correct position after insertion, the 
 patient lying at full length. A large pad, consisting of 
 several layers of lint, was wrung out of saline solution 
 and placed beneath the buttock and perineum. To 
 this the negative pole was connected. The catheter 
 being in position, the solution of potassium iodide was 
 run in by opening the clip on the supply tube from the 
 container. The degree of pressure in each case was 
 regulated by the patient's sensation, the urethra being 
 kept comfortably distended by raising or lowering the 
 container. 
 
 The duration of the treatment on each occasion 
 was fifteen to twenty minutes, the positive pole being 
 connected up to the stylet within the catheter and a 
 current of 3-5 milliamperes passed. 
 
 No real pain was present on any occasion during 
 administration of the treatment. But it was frequently 
 found necessary to caution the patient about changing 
 his position, for the least alteration in pressure on the 
 pad caused a rapid variation in the current and, con- 
 sequently, a slight shock to the patient. The necessary 
 current was obtained from the main supply through a 
 polystat, and the strength readily controlled by a 
 graduated resistance. About five minutes was the time 
 
54 TREATMENT OF GONORRHOEA 
 
 usually required to reach 5 milliamperes without causing 
 discomfort. 
 
 The results were distinctly disappointing, for one case 
 only — a relapse — was cured by this treatment alone and 
 all the others, after reaching a muco-purulent stage, had 
 to be given vaccine treatment. Other solutions, such 
 as quinine, calcium lactate, etc., were used, but with 
 no more success. The impression formed on conclusion 
 of a full trial of this method was, that up to a certain 
 point the electrolysis had a beneficial effect on acute 
 urethritis, but was insufficient, of itself, to lead to a 
 cure. The discharge diminished after several applica- 
 tions, but, with the one exception mentioned, never dis- 
 appeared entirely. It would seem that this method 
 might be utilized to advantage in certain chronic cases 
 where irrigation has been continued for a long time 
 without leading to a cure. The value of a rest from 
 irrigation for some weeks is well known, and during this 
 period electro-chemical applications could be applied, 
 combined with regular injections of vaccine. There is 
 no doubt that a beneficial action results from each 
 application, but in the acute stage it is not powerful 
 enough, by itself, to prevent the multiplication of the 
 gonococci. In the chronic stage, however, the organisms 
 are fewer in number, and this form of treatment would be 
 likely to have more chance of success. 
 
 Mercury Compounds in the Treatment of 
 Gonorrhoea 
 
 From time to time various compounds of mercury 
 have been used with the idea of cutting short the dura- 
 tion of an attack of gonorrhoea. Intra-muscular in- 
 j ection has been found to be the most convenient method 
 of administration, since it allows a bigger dose to be given 
 
SPECIAL TREATMENT 55 
 
 than could be tolerated by the mouth and occasions the 
 least disturbance of the digestive system. Mercurial 
 cream, salicylate, and benzoate of mercury, enesol and 
 many other compounds have been tried, the usual dose 
 varying between 50 and 100 milligrammes, according to 
 the toxicity of the drug. The benzoate and salicylate 
 have found more favour than the others, since their toxic 
 effects, in moderate doses, are practically negligible. 
 
 The results of a large number of cases have been dis- 
 appointing, for although there is a speedy diminution 
 in discharge on first injecting the drug, subsequent 
 injections do not lead to its complete disappearance. 
 There are cases, too, as described later in connection 
 with gonorrhoea complicated by syphilis, where mercury 
 seems to be contra-indicated. 
 
 The usual methods of treatment are adopted as regards 
 medicine and irrigation, and an injection of mercury 
 given on the first day. On the fourth day the injection 
 is repeated and again on the seventh day, if there are 
 no signs of mercurialism. This constitutes a course, 
 and in the ordinary patient gives rise to no ill effects 
 beyond a little tenderness of the gums. In very sus- 
 ceptible patients it gives rise to diarrhoea with the 
 passage of mucus and blood ; but vomiting is not 
 common. After a rest of a week or ten days a second 
 similar course may be given, the dose remaining the 
 same, for no benefit seems to accrue from increasing it. 
 
 Clinically in an acute case the first injection is often 
 followed by a remarkable diminution of the discharge 
 within twenty-four hours, but the later results are not 
 so striking, the second and third injections being far less 
 potent. After treating some hundreds of cases on this 
 plan the conclusion arrived at was that in a small per- 
 centage a disappearance of all discharge was obtained 
 
56 TREATMENT OF GONORRHOEA 
 
 in about three weeks, the urine remaining clear ; but in 
 the majority no curtailment of the usual period of treat- 
 ment resulted. The very early acute cases seemed most 
 suitable, but it is just in these that vaccines give such 
 good results. The value of mercury is thereby minimized. 
 
 Certain disadvantages were also noticed, foremost 
 among which was the fact that, after a course of mercury 
 injections, a case that did not rapidly clear up often 
 became very intractable and the injection of vaccines 
 subsequently seemed to have much less effect than usual. 
 In the case of double infections, where the patient came 
 under observation with a discharge only and the sore had 
 not developed, the injection of mercury was apparently 
 responsible for a delay in the appearance of the chancre 
 in some instances for several weeks. Complications, 
 too, such as epididymitis and acute prostatitis appeared 
 not infrequently as late as the tenth or twelfth week 
 of treatment without apparent cause. These disad- 
 vantages were found to be common to all the mercurial 
 preparations employed, and not to one more than another, 
 whilst the results as regards duration and relapses com- 
 pare unfavourably with those obtained from vaccine 
 treatment. 
 
 It was hoped that the presence of mercury in the 
 circulation would lead to destruction of the gonococcus 
 in situ in the various glands connected with the urethra, 
 thus overcoming one of the chief delays in obtaining a 
 cure ; but these hopes have been sadly disappointed. 
 Exactly how far the action of the mercury extends can- 
 not be stated precisely, but it falls far short of the ideal. 
 Many cases have been seen in which a patient ceased 
 to have a discharge for several days, even when doing 
 hard work all the time, and then after about ten days 
 the urine became hazy and a discharge reappeared. 
 
SPECIAL TREATMENT 57 
 
 The conclusion arrived at after watching a large number 
 of cases throughout all stages of treatment and after 
 relapsing, which fits in most nearly with the facts 
 observed is, that mercury masks the disease by 
 temporarily diminishing the activity of the gonococcus 
 without destroying it. 
 
CHAPTER VII 
 
 COMPLICATIONS OF GONORRHOEA 
 
 Epididymitis. — This is a common complication of 
 gonorrhoea, and it is quite impossible to say exactly 
 what determines its development. The use of small 
 syringes and badly- given injections have been blamed 
 for a large number of cases in the past, but the propor- 
 tion seems just as large among those who have had no 
 treatment at all. A considerable number of cases 
 undoubtedly follows after energetic treatment of the 
 prostate, but epididymitis can also develop without the 
 presence of signs of active inflammation in this gland, 
 though it is unusual. It frequently develops about the 
 third or fourth week of the disease, but in many cases 
 as early as the tenth day. Its delayed appearance 
 (tenth to twelfth week) has been referred to under the 
 mercurial treatment of gonorrhoea. 
 Clinically four varieties may be seen : 
 
 (i) Hyper-acute epididymitis. 
 
 (2) Acute epididymitis. 
 
 (3) Sub-acute epididymitis. 
 
 (4) Chronic epididymitis. 
 
 Acute epididymitis is that most commonly seen, and 
 usually commences with pain in the testicle and groin 
 on the affected side and a slight rise in temperature. 
 At this stage a small and extremely tender area can be 
 
 58 
 
COMPLICATIONS OF GONORRHOEA 59 
 
 felt at the lower end of the epididymis, harder than 
 normal and but slightly enlarged. Following on this 
 rapid swelling takes place and often within twelve hours 
 there is a generalised enlargement of the epididymis and 
 a rise in temperature to 103 ° or higher, with severe pain 
 in the groin, described as running up to the kidney on 
 that side. The patient becomes unable to stand or walk 
 and takes to bed. It has been already mentioned that 
 in cases under observation and treatment the onset of 
 an acute epididymitis can often be recognized, shortly 
 before any swelling is perceptible, by examination of 
 the urine, there being a sudden change from hazy or 
 clear samples to cloudy ones which readily deposit 
 phosphates on standing. 
 
 The hyper-acute variety is not very common, but 
 develops rapidly and within twenty- four hours there is a 
 large tense swelling of the epididymis, frequently accom- 
 panied by some orchitis. It is intensely painful, the 
 skin of the scrotum being hot, red, and cedematous, 
 while the cord is tender on pressure. The patient 
 is flushed and may vomit at this stage. The bowels are 
 usually sluggish and the tongue coated, the temperature 
 varying between 102 to 104 . In this condition the 
 pain may be so intense that the patient loses all self- 
 control and needs watching carefully. Treatment 
 must be prompt and such as will give speedy relief. 
 
 The sub- acute and chronic stages follow after the 
 acute, and are but slightly painful. The temperature 
 soon falls, and is usually normal after three or four days' 
 treatment. The swelling at first varies very little from 
 day to day, but gradually softening commences, and the 
 testicle diminishes in size. More often than not the cord 
 is the most painful, part at this stage, and it can be felt 
 as a hard mass running up through the abdominal ring. 
 
60 TREATMENT OF GONORRHCEA 
 
 Under suitable treatment this soon subsides, and the 
 patient is able to walk comfortably, provided that a 
 suspensory bandage be worn. 
 
 In the hyper-acute variety one method is pre-emin- 
 ently successful, viz. puncture and aspiration of the 
 epididymis, and seldom fails when properly carried 
 out. All that is required is a sterile hypodermic syringe 
 of i or 2 c.c. capacity, with a fine needle (preferably 
 P. I.) fitting the glass barrel well, so as to make an air- 
 tight joint, and iodine for painting the skin. Prepare 
 everything before disturbing the patient, and have all 
 the materials within easy reach. Gently but firmly take 
 the affected testicle between the thumb and fingers 
 of the left hand, so that the lower end of the epididymis 
 lies between the thumb and index-finger, the bulk of the 
 testicle resting on the other fingers. Paint with iodine, 
 and, holding the needle firmly, push it steadily but rapidly 
 through the skin into the epididymis itself. Attach 
 the barrel of the syringe and draw out the piston. 
 Usually about i c.c. of blood or sero-sanguineous fluid 
 can be withdrawn. The needle is then removed and the 
 skin again painted with iodine. Should nothing be 
 withdrawn the negative pressure is maintained in the 
 syringe and the needle slowly drawn out, when, usually, 
 some fluid will be obtained. This is of little importance^ 
 however, for the relief obtained bears little or no rela- 
 tion to the quantity of fluid withdrawn. The use of a 
 larger needle gives much more pain and does not in any 
 way assist. After the puncture a hot fomentation with 
 glycerine and belladonna is applied and a morphia 
 suppository, gr. J, given. Relief follows almost immedi- 
 ately and within two or three hours the pain is reduced 
 to a dull ache. Further treatment is then the same as 
 described for acute epididymitis. 
 
COMPLICATIONS OF GONORRHOEA 61 
 
 In acute epididymitis the patient should remain in 
 bed, and if already irrigating this must be stopped. The 
 affected testicle should be painted every four hours with 
 glycerine and belladonna followed by a large hot fomen- 
 tation, one being kept on until the next is ready for 
 application. All dragging of the testicle on the cord 
 must be avoided, and for this purpose various forms of 
 support and bandages have been recommended. A 
 large pad of cotton- wool, if carefully adjusted, meets all 
 requirements and can be readily renewed when soiled. 
 An aperient is given at the onset, and nothing compares 
 with calomel for this purpose, followed some hours later 
 by a dose of white mixture. Towards evening a morphia 
 suppository, gr. J, is administered, and gives consider- 
 able relief, besides assuring some hours of sleep. The 
 use of sodium salicylate in the acute stage is often 
 advocated, but it is in no sense specific, and may give 
 rise to vomiting. When, however, the temperature con- 
 tinues high, or when arthritis is present in addition, it 
 is certainly indicated. Apart from this, a simple 
 mixture of magnesium salts, given two or three times 
 a day, keeps the bowels acting regularly and is just 
 as efficacious. 
 
 After four or five days, in favourable cases, the sub- 
 acute stage is reached, and usually considerable pain is 
 then complained of in the groin and cord. For this 
 ung. hydrarg. amnion., i in 4, is very useful, and 
 should be rubbed into the groin on the affected side 
 twice a day. This can be done quite well by the patient 
 himself, but should not be continued for more than three 
 or four days at a time, since the skin of the groin tends 
 to become irritated, and may break out in pustules. 
 This application speedily diminishes the pain and 
 hastens resolution. The patient is kept on milk diet for 
 
62 TREATMENT OF GONORRHOEA 
 
 three or four days, when, if the temperature be normal 
 and the pain subsiding, a full diet may be allowed. 
 Vaccines are of proved value in all the complications of 
 gonorrhoea, and particularly in epididymitis. They 
 should be given as described under " Vaccine Treat- 
 ment/' an injection when the condition is first diagnosed 
 and then repeated on the third, sixth, ninth and so on 
 days. The effect is especially seen in those cases which 
 are slow in resolving, and where the firm pressure of a 
 strapping does not seem sufficient to reduce the swelling 
 to normal size. The length of time during which a 
 patient is kept in bed depends entirely on the local 
 condition. In the greater number of cases, after about a 
 week or ten days, the swelling commences to go down, all 
 pain disappears, and there is but little tenderness of 
 the epididymis on pressure. A strapping with Scott's 
 dressing is then most efficacious, and after application 
 should remain on for three or four days. There is a 
 tendency for the skin of the scrotum to become inflamed 
 around the neck of the strapping, where there is bound 
 to be some constriction, and a watch should be kept on 
 this from day to day. It does not usually develop until 
 the strapping has been in position about three days. 
 When it has occurred the strapping should be removed 
 at once, and hot local baths substituted three times a 
 day. Another strapping can be then applied, if con- 
 sidered necessary, when healing has taken place. The 
 firm pressure obtained by this means leads to a speedy 
 return to normal size and consistence in most cases. 
 The patient may then be allowed up quite safely, but 
 should wear a suspensory bandage and walk about very 
 little for some days. 
 
 Once the strapping has worked loose, a hot local bath 
 should be commenced three times a day, the testicle being 
 
COMPLICATIONS OF GONORRHOEA 63 
 
 allowed to soak in water just as hot as can be borne 
 comfortably for ten or fifteen minutes, and irrigation 
 may then be commenced. 
 
 In a certain proportion of cases as one testicle subsides 
 the other swells and in these the fomentations must be 
 continued until both testicles are subsiding. In other 
 cases there is a recurrent epididymitis, the same testicle 
 swelling up two or three times. The treatment con- 
 tinues the same, but the possibility of a lesion in the 
 posterior urethra must be borne in mind. During the 
 onset of acute epididymitis all discharge frequently 
 ceases, only to return as the condition resolves. Many 
 patients worry about this return of discharge, which 
 they fondly imagine has gone for good, and wish to 
 irrigate at once. This must be forbidden, and the only 
 safe guide for recommencing is the entire absence of 
 pain. When the testicle seems to have reached a chronic 
 stage or is slow in resolving the use of potassium iodide, 
 grs. x. t.d.s., together with vaccines as described, has 
 proved of use. Finally, it must not be forgotten that in 
 a considerable number of epididymitis cases the prostate 
 is involved, and that this gland will need further treat- 
 ment. 
 
 Prostatitis has been dealt with separately. 
 
 Arthritis is a recognised complication of gonorrhoea 
 though not nearly so common as epididymitis. It usually 
 supervenes about the fourth or sixth week of discharge, 
 though occasionally earlier. As in the case of epididy- 
 mitis, it is impossible to explain what determines its 
 onset, and a history of recent injury is rarely volun- 
 teered by the patient as a cause for its development ; 
 but one fact is of importance, viz. that arthritis rarely 
 develops in an acute case which has undergone adequate 
 and sufficient treatment from the early stage of the 
 
64 TREATMENT OF GONORRHOEA 
 
 disease. It seems to occur most frequently in those 
 cases which have neglected treatment for three or four 
 weeks after the appearance of a discharge, or who have 
 been unfortunate in the treatment prescribed for them. 
 
 In a series of some thousands of acute cases coming 
 under observation within two or three weeks of the onset 
 not one developed this complication. The joints most 
 frequently affected are the knees, then the wrists, ankles, 
 elbows and hips. Not infrequently the meta-carpo- 
 phalangeal articulations are involved, while the meta- 
 tarso-phalangeal joints may be occasionally, but much 
 less frequently than the former. 
 
 Two types may be recognized : 
 
 (i) The inflammation of the joint is accompanied by 
 a considerable amount of effusion, with but little peri- 
 articular infiltration. 
 
 (2) The effusion is moderate, but there is much 
 infiltration of the peri- articular structures. 
 
 Any joint may be affected with either type, but the 
 first is more frequently seen in the case of the knee and 
 elbow, the second particularly in the ankle and wrist. 
 
 Clinically. — In the first variety the onset is rapid and 
 commences with aching in the affected joint, followed 
 within twenty-four hours by considerable swelling, 
 much pain on movement, and the development of a 
 perceptible effusion. The joint becomes hot, red, and 
 swollen, and the least movement causes pain, particu- 
 larly in the case of the knee, where walking becomes 
 impossible. Fluctuation is readily obtained, and the 
 rapid onset of the effusion leads to much distension of 
 the joint, one of the most important points to bear in 
 mind when considering treatment, upon the success of 
 which depends its subsequent usefulness. 
 
 The second type is usually less rapid in onset, the joint 
 
COMPLICATIONS OF GONORRHOEA 65 
 
 becoming slightly swollen and tender, with but little 
 effusion. Movement of the joint surfaces upon one 
 another causes intense pain, as also does the slightest 
 pressure on the joint itself. The swelling increases and 
 fluid can frequently be detected, but the surrounding 
 structures of the joint show the most marked signs, being 
 thickened and, at times, exhibiting pitting on pressure. 
 This is best seen in the ankle and wrist, where the extent 
 of the infiltration can readily be traced. Under suitable 
 treatment the inflammation subsides,the swelling gradu- 
 ally disappears and the fluid is absorbed. The end- 
 results of treatment depend upon whether the condi- 
 tion is seen in an early or late stage. An acute gonor- 
 rhceal arthritis seen within two or three days of its develop- 
 ment and properly treated usually results in the recovery 
 of full movement and power. When seen later the 
 prognosis is not so good, for there is the probability of the 
 formation of adhesions and over- stretching of the joint 
 structures. 
 
 Arthritis seems to develop, in those persons whose 
 resistance to the invading organism is below the average, 
 as is shown by the fact that many cases developing 
 arthritis are found to have a severe urethritis, prosta- 
 titis, with, frequently, epididymitis and vesiculitis. 
 With improvements in the methods of growing the 
 gonococcus it will, possibly, be found that this organism 
 can be recovered from the blood in most cases of this type. 
 
 Treatment. — In the acute stage the patient is kept in 
 bed, allowed milk diet with plenty of fluid, and given a 
 purge. Locally hot fomentations with glycerine and 
 belladonna are applied four-hourly to the joint, which 
 must be kept at rest. On no account should it be immo- 
 bilized on a splint except in the case of the wrist- joint, 
 for in all the others the most comfortable, as well as the 
 
 5 
 
66 TREATMENT OF GONORRHOEA 
 
 most suitable position is obtainable without such appli- 
 ances. For the elbow, a small soft pillow placed on the 
 affected side serves to support and steady the joint, 
 leaving it free for changing the dressing rapidly and 
 without pain. For the ankle, a large pad of wool and 
 two small sand-bags are quite sufficient to secure sup- 
 port and comfort, the foot resting on its outer side 
 against one bag, whilst the second supports the sole. The 
 slightly flexed position is best for the knee, and is readily 
 obtained by placing a small cylindrical pillow covered 
 with a thick layer of wool beneath the joint. The 
 weight of the limb rapidly moulds the wool into the 
 right shape, and an excellent support is obtained. For 
 both knee and ankle a cradle is essential to keep the 
 weight of the bed-clothes off the inflamed joint. For 
 the wrist, a straight splint extending to the tips of the 
 fingers is most useful. 
 
 Medicines. — Salicylates are valuable in the acute stage 
 and may be given in various ways. In mixture form 
 sodium salicylate, grs. x., combined with an equal 
 quantity of sodium bicarbonate, four-hourly. In tablet 
 form aspirin (grs. x. four-hourly) is very satisfactory in 
 relieving the inflammation and also in its analgesic 
 and soporific effects. Some patients, though not a large 
 proportion, exhibit an idiosyncrasy to this drug, and in 
 them it leads to nausea and vomiting. The best sub- 
 stitute in these cases is quinine, which is usually quite 
 well tolerated. 
 
 Aspiration becomes necessary at times during the 
 acute stage when the effusion is both rapid and plentiful. 
 It is a safe rule that a tightly distended joint should be 
 aspirated without delay if the effusion has not definitely 
 diminished after twenty-four hours' treatment. To 
 wait longer is to risk the subsequent usefulness of the 
 
COMPLICATIONS OF GONORRHOEA 67 
 
 articulation, especially in the case of the knee, where the 
 ligaments are easily liable to become overstretched, 
 resulting in permanent weakness. The greatest care 
 must be taken in maintaining asepsis in the perform- 
 ance of aspiration, for a joint is readily infected, and 
 preparation of the skin is necessary exactly as for opera- 
 tion. All the instruments must be carefully sterilised, 
 a 2 c.c. syringe being most useful, with preferably a 
 P.I. needle fitting the glass barrel accurately. It is 
 rarely the case that the fluid is too thick to pass through 
 a needle of this size. The needle is pushed rapidly 
 through the skin over the selected area, and then gradu- 
 ally made to penetrate the joint itself. Fluid usually 
 begins to flow at once, and the glass barrel may then be 
 attached, a syringeful at a time being removed. The 
 removal of the fluid should not be too rapid, since the 
 creation of a sudden negative-pressure in the interior 
 of the joint tends to bring any loose flakes towards the 
 site of the puncture, and thus the needle may become 
 obstructed. Another point sometimes recommended 
 is to leave a little fluid in the joint, and not to extract 
 the last few c.c.'s, but whether there is any advantage 
 to be gained is not yet settled. After the fluid has been 
 withdrawn a hot fomentation is applied to the joint and 
 changed every four hours. 
 
 Vaccines often have a remarkable effect in the acute 
 stage, and are of the greatest value in all cases. They 
 should be given as described under Vaccine Treatment, 
 the initial dose of 50,000,000 gonococci when the patient 
 is first seen, followed on the third day by 100,000,000, and 
 repeated on the eighth, ninth, twelfth, and fifteenth days. 
 There is usually a marked improvement after the second 
 injection, the effusion commencing to subside and the 
 pain diminishing considerably. 
 
68 TREATMENT OF GONORRHOEA 
 
 Sometimes after the first injection the joint seems to 
 become more swollen in the succeeding twenty-four hours. 
 Aspiration should be performed, and the ordinary dosage 
 continued. The effusion usually diminishes then after 
 the second injection and follows the normal course ; but 
 in a few cases aspiration may need to be performed 
 two or three times. 
 
 When the sub-acute stage has been reached and the 
 effusion is but slight the patient should be encouraged 
 to move the joint a little several times a day, and it is 
 here that the advantage of not immobilising it is appreci- 
 ated, for there is nothing to prevent movement in any 
 direction. The fomentations should be replaced by 
 Scott's dressing bandaged round the joint, and potas- 
 sium iodide, grs. x., or more, given three times a day 
 instead of the salicylate. Afterwards massage, hot 
 baths, and the rubbing in of a stimulating liniment, 
 such as lin. terebinth, are needed. The latter can be 
 done quite well by the patient several times daily, especi- 
 ally if there be any pain or stiffness after exercising the 
 joint. 
 
 Cowperitis. — This is not a common complication of 
 gonorrhoea, but sufficiently so to need description, since 
 it is of considerable interest from the point of view of 
 correct diagnosis and suitable treatment. Cowper's 
 glands, situated bi-laterally close to the anus, communi- 
 cate with the urethra by two separate ducts opening on 
 the floor of the bulbous portion. They are thus liable 
 to infection, and when this takes place the symptoms are 
 characteristic. The first is tenderness on pressure, 
 probably noticed most when sitting down or during an 
 action of the bowels, and frequently attributed by the 
 patient to piles or the prostate. Gradually the tender- 
 ness increases, and from being unilateral may become 
 
COMPLICATIONS OF GONORRHOEA 69 
 
 bilateral, though the former is the usual. It soon changes 
 to a constant aching, and acute pain is felt on sitting 
 down quickly. Examination in the early stage reveals 
 nothing beyond slight pain on pressure, but after forty- 
 eight hours a little swelling, with reddening of the skin 
 over the affected gland, becomes perceptible, and the line 
 of one or two lymphatics may be traced. Under these 
 conditions a rectal examination should be made at 
 once, and Cowper's glands palpated between the thumb 
 and index-finger, when one gland is usually found to be 
 small and insensitive, whilst the other is inflamed and 
 swollen, hot, and exquisitely tender on pressure. 
 
 Treatment. — An attempt may be made to express 
 the contents of the inflamed gland as follows. The 
 urethra is irrigated thoroughly with warm boric lotion 
 until the washings are clear and about four ounces of 
 solution are left in the bladder. The gland is then 
 massaged between the index-finger in the rectum and 
 the thumb on the perineum, the contents being expressed 
 through the duct into the urethra. The patient then 
 empties his bladder, the boric lotion washing out any 
 secretion that has been expressed and the presence of pus 
 thus readily detected. Unfortunately, however, the 
 duct in these cases usually becomes occluded, and nothing 
 can be expressed. The second method must then be 
 adopted and is invariably satisfactory. 
 
 Large hot fomentations are applied to the affected 
 area every four hours, and an atropine suppository given 
 at night to relieve the tension. The following day an 
 incision is made under local or general anaesthesia and 
 the gland laid open, scraped out with a Volkmann's 
 spoon, packed with iodoform gauze, and the fomenta- 
 tions repeated. Great relief follows at once, and the 
 same evening a morphia suppository, gr. J or h, should 
 
70 TREATMENT OF GONORRHOEA 
 
 be given to ensure comfort and sleep. Subsequently 
 healing takes place readily, and there is no further 
 trouble, but in some patients the organisms seem to lie 
 deep down in the ducts, and as soon as healing has taken 
 place light up a fresh inflammation at the same spot. 
 In these the wound should be reopened and enlarged, 
 the gland and most of the duct dissected out, the whole 
 cavity scraped out, packed with iodoform and allowed to 
 granulate up. 
 
 Vesiculitis. — This is dealt with under chronic gonor- 
 rhoea. 
 
 Peri-urethral Abscess. — This complication is the 
 result of inflammation of one or more of Littre's glands, 
 followed by occlusion of the gland ducts. Suppuration 
 goes on within the gland, and the inflammatory products 
 are unable to escape, an abscess forming in the ordinary 
 way. In the early stage a small tender nodule, about 
 the size of a pea, can be felt on palpating the urethra. 
 It gives rise to no pain apart from pressure. If untreated 
 it continues to enlarge and penetrates deeper into the 
 submucosa, causing a little pain and marked tenderness. 
 Finally, if still untreated, it continues to enlarge and 
 eventually reaches the surface, pointing beneath the skin 
 like an ordinary abscess. Occasionally the opposite 
 direction may be followed, and rupture into the urethra 
 occur spontaneously ; but it is unusual. 
 
 Diagnosis is quite simple, there being the presence of 
 a discharge or a history of a recent attack of gonorrhoea. 
 The swelling, when pointing beneath the skin, has all the 
 characteristics of an abscess, with tenderness, swelling, 
 and redness, whilst inflamed lymphatics can be traced 
 in severe cases, combined with oedema of the penis. 
 
 Treatment. — In describing the routine method of 
 treatment the value of the passage of a straight metal 
 
COMPLICATIONS OF GONORRHOEA 71 
 
 bougie about the end of the second week, and palpation 
 of the urethra, has been emphasized. By this means it 
 is possible to discover any nodules which might subse- 
 quently lead to abscess-formation and to express their 
 contents, for at this period of development they are 
 quite thin- walled and soft. 
 
 In the later stage, when a large nodule has formed, 
 the gland is best incised through the urethroscope by 
 means of a fine-pointed knife. The affected area is 
 brought into view and, whilst the penis is grasped firmly 
 on the outside, the knife is pushed through the mucosa 
 towards the centre of the abscess. Pus may issue at 
 once, but more often it requires compression of the 
 nodule to express the contents after the urethroscopic 
 tube has been withdrawn. The subsequent bleeding 
 is never serious. This method should be adopted in all 
 cases where the abscess is not actually involving the skin, 
 and very satisfactory results can be obtained. 
 
 When it is evident that extension has occurred, 
 and that the abscess is commencing to point on the 
 exterior, hot fomentations are applied every four hours. 
 Hot local baths, in which the penis is allowed to soak 
 for ten or fifteen minutes, are given in between the times 
 for the fomentations, until the abscess is ready for 
 incision. The incision should be made at the earliest 
 possible moment and the pus evacuated. The longer 
 the abscess is allowed to spread the greater is the risk 
 of a subsequent fistula ; but, if opened promptly, it is 
 unusual for this unpleasant complication to develop. 
 
 The commonest site for these abscesses which reach 
 the surface is either about two and a half inches from 
 the meatus, or in the region of the bulb. In the latter 
 position care is necessary, after incision, to avoid 
 secondary infection. After drainage these abscesses 
 
72 TREATMENT OF GONORRHOEA 
 
 usually heal readily, but treatment must not end there. 
 In every case of peri-urethral abscess there is the risk 
 of a stricture developing later, and for this reason, when 
 complete healing has taken place, a straight metal 
 bougie should be passed to locate any narrowing of the 
 canal. If present, regular dilatation will need to be 
 carried out. 
 
 Other complications are inflammation of the various 
 fascial structures, e.g. the plantar arch, keratosis, 
 endocarditis, etc., but they are not sufficiently common 
 to need description here. 
 
CHAPTER VIII 
 
 GONORRHEAL CONJUNCTIVITIS 
 
 This is a very serious condition, and its importance and 
 the need for thorough treatment are generally recog- 
 nized in the case of new-born infants, where Crede's 
 methods have done so much to improve matters ; but 
 in the case of adults it is not so widely realized. Once 
 diagnosed, a gonococcal conjunctivitis needs immediate 
 and continuous attention if the eye is to be saved or 
 remain of value afterwards, and it is just as important 
 and as urgent to know and apply the correct methods 
 as in dealing, for example, with post-partum haemor- 
 rhage. The latter are invariably well taught, the former, 
 unfortunately, but seldom, and, since perforation may 
 take place within thirty-six hours of onset, it is evident 
 that there is no room for delay. 
 
 Infection does not occur nearly as frequently as one 
 would expect, in spite of the uncleanly habits of many 
 gonorrhoea patients. The extension to the eyes is 
 usually brought about by direct spread from the fingers, 
 handkerchiefs, or towels in these cases. Others, without 
 a urethritis, may become infected by soiled articles of 
 a similar kind previously used by an infected person. 
 Whenever pus is present in an eye a film should be 
 made at once, and examined as soon as possible after- 
 wards. The presence or absence of a urethritis is no 
 
 73 
 
74 TREATMENT OF GONORRHOEA 
 
 criterion, though in the former case the probabilities 
 are in favour of the conjunctivitis being gonorrhceal. 
 
 The smear is made as follows : 
 
 A platinum loop is flamed and allowed to cool whilst 
 a glass slide is cleaned and dried. The patient sits down 
 in a good light, the head tilted slightly backwards. Two 
 small swabs of wool wrung out of perchloride of mercury 
 are placed over the lids, which can then be readily 
 separated by the index-finger and thumb of the left 
 hand. With the platinum loop a small flake of pus is 
 removed from the surface of the eye, transferred to 
 the slide, spread out in an even film, and then fixed by 
 passing a few times through the flame of a spirit-lamp. 
 It is stained by Gram's method and examined for Gram- 
 negative organisms. 
 
 Diagnosis of Smear. — -The typical film shows many 
 pus-cells, with numerous intra-cellular Gram-negative 
 diplococci, a noticeable feature being the almost com- 
 plete absence of other organisms. In cases simulating 
 gonorrhceal ophthalmia clinically the slide usually 
 shows large numbers of Gram-positive cocci and a few 
 Gram-negative cocci, frequently micrococcus catarr- 
 halis. The presence of a considerable number of 
 Gram-positive cocci is against the condition being one 
 of gonococcal conjunctivitis. 
 
 Clinical Features. — -The two striking points about 
 this condition are : 
 
 (i) The severity of the inflammation. 
 (2) The rapidity of its development. 
 
 Thus a patient may notice a small flake of pus in the 
 eye in the morning as the first indication and be unable 
 to open the eye six or eight hours later, on account of 
 the swelling. The first sign is often a little irritation 
 
GONORRHEAL CONJUNCTIVITIS 75 
 
 under the upper lid, gradually increasing to a burning 
 sensation, as if a small foreign body were lodged there. 
 Rubbing the lid only increases the discomfort, and on 
 examining his eye the patient notices a little yellow pus 
 in the corner. The irritation increases and tears are 
 freely secreted, so much so that the eye has to be kept 
 closed. Pus continues to collect, the lids swell up, the 
 eye can scarcely be opened, and photophobia develops. 
 Patients are seldom seen before this stage. 
 
 On examination the eye is found to be closed owing 
 to the swelling of the lids which are red and cedematous, 
 the upper one being affected more than the lower one. 
 Pus can frequently be seen exuding along the margin, 
 as well as at the inner canthus. On separating the lids 
 chemosis is found to be present, the palpebral con- 
 junctiva being tense and puffy with inflammatory 
 secretion. The whole of the sclera is uniformly injected 
 right up to the corneal margin, and numerous flakes of 
 pus are present. The iris is usually unaffected at this 
 stage, and the pupil reacts normally. 
 
 The other eye may or may not be affected, and treat- 
 ment must be modified accordingly. A smear is taken 
 for examination, as already described, and treatment 
 commenced at once. 
 
 Treatment. — Once the diagnosis is confirmed the 
 patient must be told of the risk of the loss of sight, 
 and warned to carry out the treatment in every detail. 
 The first point to decide is whether both eyes are 
 affected or one only. If the latter, every precaution 
 must be taken to prevent the extension of the disease 
 to the unaffected eye. 
 
 The Unaffected Eye. — The lids and cheek on that 
 side are carefully washed over with ether soap on a 
 gauze swab, followed by warm water, then dried and 
 
76 TREATMENT OF GONORRHOEA 
 
 finally wiped over with a little pure ether. If the 
 eye be kept firmly closed no smarting is caused by this. 
 A sterile watch-glass of suitable size is then fastened 
 over the eye and fixed in position by means of rubber 
 adhesive plaster, every care being taken to secure the 
 portion which is nearest the affected eye. 
 
 If there is the least doubt as to whether the eye is 
 infected it is wiser to leave it uncovered and treat 
 both eyes alike. 
 
 The Affected Eye. — After a smear has been taken the 
 eyelids are washed over with a weak antiseptic to remove 
 the discharge from their margins and the cheek. A 
 pint of warm boric lotion in an irrigating can to which 
 2 or 3 feet of india-rubber tubing and a clip are attached 
 is placed about 2 feet above the patient's head. The 
 patient sits in a chair with the head tilted slightly 
 backwards and holds a kidney-dish firmly in contact 
 with the face. The lids are separated with the index- 
 finger and thumb of one hand and a jet of the warm 
 lotion played between them. In a few seconds the 
 spasm of the lids passes off, and they can be fairly 
 widely separated. The jet should work repeatedly 
 inwards and outwards so as to reach every fold of the 
 conjunctiva, and, when all pus has been washed away, 
 two drops of i per cent, cocaine are placed in the eye. 
 A piece of wool is then wrapped round a small glass rod 
 with rounded ends, or, failing this, an olive-headed probe, 
 dipped in silver nitrate, grs. x. to the ounce, contained 
 in a watch-glass and applied to the lids in the following 
 manner : 
 
 The upper lid is first dealt with, being everted with 
 the thumb and index-finger, and the patient told to 
 look downwards. The whole of the palpebral conjunc- 
 tiva is painted so as to deal with every fold, special 
 
GONORRHEAL CONJUNCTIVITIS 77 
 
 attention being paid to the reflection on to the sclera 
 and the margin of the lid. The patient is then told to 
 look upwards, the upper lid replaced in the normal 
 position and the lower one drawn down. This, too, is 
 similarly painted with the silver nitrate. In spite of 
 the local anaesthetic this operation is usually somewhat 
 painful ; but a stronger solution of cocaine should not 
 be used owing to the risk of lowering still further the 
 resistance of the epithelium. Any excess of silver 
 solution is carefully removed, and none should be 
 allowed to come in contact with the eyeball. Two drops 
 of 20 per cent, argyrol are then placed in the eye. 
 After half an hour has elapsed the irrigation with warm 
 boric lotion should be repeated, all pus washed away, 
 and two more drops of argyrol instilled. A dose of 
 gonococcal vaccine is given at once, if available, or, 
 failing this, as soon as possible afterwards. The mixed 
 stock vaccine already referred to has given very good 
 results, with an initial dose of 50 million followed by a 
 dose of 100 millions on the third day. This concludes 
 the immediate treatment, but the subsequent measures 
 are just as important. 
 
 The patient must go to bed at once, and needs constant 
 attention. Whenever possible, someone specially trained 
 in the nursing of eye-cases should be obtained. The 
 affected eye is irrigated every hour with boric lotion, 
 the lids being cleansed each time with small pieces of 
 wool. Two drops of argyrol are put in every two hours, 
 I.e. after each alternate irrigation. Atropine is put in 
 every four hours until the pupil is well dilated, and no 
 covering is placed over the eye. This treatment is con- 
 tinued, the painting of the lids being repeated after 
 twelve hours and again after a similar period if con- 
 sidered necessary. The only indication for reducing the 
 
78 TREATMENT OF GONORRHCEA 
 
 frequency of the irrigations is a marked decrease in the 
 discharge. When no pus is present at the end of an 
 hour after irrigation and no flakes are washed away, the 
 number may be reduced to one every two hours, and 
 the argyrol put in every four hours. Atropine will then 
 be needed but once a day. Under favourable circum- 
 stances improvement speedily takes place, and the dis- 
 charge rapidly diminishes. The swelling of the lids 
 becomes less marked, chemosis decreases, and the injec- 
 tion is less intense. The cornea remains clear. Under 
 these conditions the irrigation may safely be reduced on 
 the third or fourth day to one every four hours and the 
 drops of argyrol instilled three times a day. The injec- 
 tion of the conjunctiva continues to diminish, and by 
 the end of the week the eye is normal again. 
 
 In later cases, in spite of energetic treatment, the 
 condition goes on to ulceration of the cornea. The other 
 signs remain the same, but the cornea becomes steamy 
 instead of remaining clear, and a beam of light thrown 
 on it by means of a convex lens shows an area where 
 the epithelium has been destroyed. At this stage the 
 eye can be saved with care and constant attention. 
 Exactly the same treatment is adopted, only owing to 
 the complications of corneal ulceration healing takes 
 longer. Atropine, with a drop of castor- oil, should be 
 instilled every day, and the vaccines continued regularly, 
 another dose of ioo millions being given on the sixth 
 day and again on the ninth, and so on. Once the dis- 
 charge has practically disappeared a change to i in 
 4,000 sulphate of zinc as an irrigation for a few days 
 is often beneficial, and hot fomentations should be 
 applied to the eye every four hours. Both eyes should 
 be kept at rest as much as possible, and no reading 
 permitted until healing is progressing satisfactorily. 
 
GONORRHEAL CONJUNCTIVITIS 79 
 
 By means of prompt treatment many of these cases can 
 be cured without much disability resulting, and the 
 methods may be summarized as follows : 
 
 Immediate Treatment. 
 
 (1) Take a smear for examination for gonococci. 
 
 (2) Cover the sound eye, if one only affected. 
 
 (3) Irrigate the affected eye with boric lotion. 
 
 (4) Paint the lids with silver nitrate, grs. x. ad. one 
 
 ounce. 
 
 (5) Instil argyrol (20 per cent.). 
 
 (6) Give a dose of gonococcal vaccine. 
 
 (7) Rest in bed, with continuous attendance. 
 
 Continued Treatment. 
 
 (8) Irrigate every hour with boric lotion. 
 
 (9) Instil argyrol every two hours. 
 (10) Repeat the atropine daily. 
 
 It is not proposed to deal here with the metastatic 
 conditions of the eye caused by gonococcal infection, 
 since they are not of the same urgency. 
 
CHAPTER IX 
 
 GONORRHOEA CASES COMPLICATED BY SYPHILIS 
 
 A certain proportion of cases of gonorrhoea coming 
 under treatment for a discharge are found to have 
 syphilis, and vice versa. In view of the fact that both 
 diseases have to be treated concurrently a modification 
 of the methods ordinarily adopted becomes necessar}', 
 and also certain eventualities need to be watched for. 
 The ordinary acute course of the disease is not altered 
 by the fact that syphilis is present, and complications 
 occur in just the same way. 
 
 Balanitis as a complication. — One of the most unfor- 
 tunate conditions is the development of balanitis at an 
 early stage, and neglect of treatment by the patient. 
 When advice is eventually sought it may be quite im- 
 possible to say at once whether or not gonorrhoea is 
 present. Another difficulty is that patients with but 
 little urethral discharge may attribute the latter to the 
 sore on the penis. This they try to treat for them- 
 selves, and so give the gonococcus a suitable opportunity 
 of settling down within the mucosa. 
 
 Diagnosis. — The following conditions may be met with, 
 and are divided into two groups, (a) and (b). 
 
 Under (a) there are cases where the prepuce can be 
 retracted. 
 
 Under (b) there are cases where the prepuce cannot be 
 retracted. 
 
 80 
 
COMPLICATED BY SYPHILIS 81 
 
 Group (a) includes : 
 
 (i) Balanitis from hard chancre (and possibly soft 
 sores), ? gonorrhoea. 
 
 (2) Soft or hard sores, with meatal chancre ; ? gonor- 
 rhoea. 
 
 Group (b) includes : 
 
 (1) Sores palpable beneath the prepuce ; ? gonorrhoea. 
 
 (2) Syphilitic abrasions with phimosis resulting ; 
 ? gonorrhoea. 
 
 In the first group (a) there is little difficulty in estab- 
 lishing the presence or absence of gonorrhoea, all that 
 is necessary being to thoroughly cleanse the glans and 
 prepuce, when on massaging the urethra a discharge is 
 at once seen, or by means of a two-glass urine test the 
 typical appearances are revealed. In doubtful cases, 
 when the amount of discharge is very small, a smear 
 from the meatus stained by Gram's method is con- 
 clusive. 
 
 In the second group (b), the delay in commencing 
 treatment is the troublesome feature. The following 
 preliminary treatment is necessary in (b) (1) : the penis 
 is bathed for ten or fifteen minutes in saline solution, 
 as hot as can be comfortably borne, every four hours, 
 attempts being made to retract the prepuce during the 
 process ; also the prepuce is syringed with the same 
 solution by means of a sterile glass syringe to remove 
 the accumulated discharge. In many instances this is 
 successful after forty-eight hours, but in others it may- 
 take several days. 
 
 In group (b) (2), syphilitic abrasions, this system of 
 bathing is not effective, for considerable induration and 
 contraction is present. In some of these cases it may 
 be possible to retract the prepuce sufficiently to introduce 
 an irrigating nozzle, when treatment can be commenced. 
 6 
 
82 TREATMENT OF GONORRHOEA 
 
 Failing this, circumcision becomes necessary, and should 
 be performed after the patient has had two or three 
 injections of salvarsan, the local baths and syringing 
 being utilised daily to remove all discharge until the 
 operation. Any one of the urinary antiseptics may be 
 given during this period, there being little to choose 
 between them. 
 
 Meatal Chancre. — This may complicate matters in 
 either of two ways : 
 
 (i) Irrigation may be found impossible until the 
 chancre has healed, owing to the tenderness on pressure 
 usually manifested by patients with these lesions. 
 
 (2) Owing to the resulting induration, instrumental 
 treatment may be impossible without a meatotomy or 
 prolonged dilatation. 
 
 Little difficulty usually arises in diagnosis in these 
 cases. 
 
 Assuming that irrigation can be commenced, a 
 solution of 1 in 8,000 permanganate of potassium is used 
 and vaccines given on the plan indicated. A difficulty 
 arises when the vaccine and salvarsan fall due on the 
 same day, but in this eventuality it is better to omit 
 the vaccine, or else give it on the day before the injec- 
 tion of salvarsan. The interval at which the vaccines 
 follow one another is a matter of considerable importance, 
 and for this reason, quite apart from any other advan- 
 tages, the plan of administering salvarsan at weekly 
 intervals by the intra-muscular or deep subcutaneous 
 method is preferable to the intravenous system, the 
 patient requiring fewer injections. In this way the 
 need of postponing the vaccines is avoided. As soon as 
 the irrigation is carried out successfully the strength is 
 increased to 1 to 6,000 permanganate. 
 
 The modern methods of syphilis treatment include a 
 
COMPLICATED BY SYPHILIS 83 
 
 series of mercury injections during the course of salvarsan 
 administration, and on this account the effects of mercury 
 on the progress of the urethritis must not be overlooked. 
 It has been mentioned, under the treatment of gonorrhoea 
 by mercury compounds, that certain undesirable effects 
 are often observed, such as the late appearance of com- 
 plications and the intractability of some of the cases 
 after the administration of mercury. By bearing these 
 facts in mind the difficulties can usually be avoided. The 
 conclusion arrived at after its prolonged trial was that 
 mercury tends to mask the disease by diminishing the 
 activity of the gonococcus. For this reason the treat- 
 ment of the urethritis must be energetic from the start. 
 The irrigation is increased from 1 in 6,000 to 1 in 4,000, 
 if the discharge does not speedily begin to clear up, and 
 vaccines are given from the time of admission onwards. 
 Mercury has a peculiar way of lighting up infection in 
 the prostate, as is well shown by a case quoted later, 
 and examination of this gland should be carried out 
 about the tenth day and its condition determined. The 
 passage of a straight bougie at the end of the second 
 week is also useful, and plenty of exercise should be 
 taken each day. Complications must be carefully 
 watched for and treated on the ordinary lines. 
 
 In spite of every precaution, some of these cases of 
 gonorrhoea continue a discharge after completion of the 
 course of salvarsan without developing any compli- 
 cations, and everything points to mercury as the cause. 
 It raises the point as to whether it would not be advisable 
 to withhold the injection of any mercury compound for, 
 possibly, the first two weeks, when the vaccine would 
 have had a very fair chance of overcoming the gonococcal 
 infection. At present there are no figures available to 
 show what detrimental effect this plan would have in 
 
84 TREATMENT OF GONORRHOEA 
 
 delaying the conversion of the Wassermarm Reaction 
 from positive to negative. 
 
 Cases with a Past History of Gonorrhcea 
 
 A certain number of cases of primary and secondary 
 syphilis coming for treatment are found to have had 
 gonorrhoea in the past, with or without complications, at 
 periods varying from a few months to many years. 
 Careful inquiry should be made as to the occurrence of 
 any complications or subsequent relapses, and the urine 
 tested for gonococci, or, in the absence of a discharge, 
 a smear made from the prostate. Many of these patients 
 show no signs of gonorrhcea and no gonococci can be 
 found, yet during the course of treatment with salvarsan 
 and mercury untoward symptoms are found to occur 
 in a certain number. When this fact is appreciated the 
 cases are found to be more numerous than is usually 
 believed, and correct treatment can be applied at once. 
 The following case is a type. A patient was admitted 
 with primary syphilis and commenced a course of intra- 
 venous injections of " 606," together with mercury 
 injections once a week. At the end of three weeks he 
 complained of pain in the " pit of the stomach " though 
 the bowels were quite regular and the tongue clean. 
 The temperature was 99 . The pain continued in spite 
 of rest in bed and later was referred to the right iliac 
 fossa, though no definite tenderness over McBurney's 
 point could be elicited. The temperature rose to 10 1°. 
 A history had been obtained, on admission, that the 
 patient had ah attack of gonorrhcea twelve months 
 previously without complications, but had seen no signs 
 of discharge ever since. A 2-glass urine-test, on admis- 
 sion, was entirely free from filaments, and there was no 
 
COMPLICATED BY SYPHILIS 85 
 
 discharge at any time. Owing to these facts a digital 
 examination of the prostate was made, acute prostatitis 
 diagnosed, and thick yellow pus expressed. Signs of 
 inflammation were also noticed over the site of the left 
 Cowper's gland. Fomentations were applied to the 
 perineum for two days, when pointing took place and 
 the abscess was drained after incision. A smear was 
 taken from the pus obtained and numerous gonococci 
 found. Arthritis of the left shoulder developed a week 
 later, but subsided under vaccine treatment and free 
 movement was subsequently recovered. 
 
 The possibility of a re- infection of gonorrhoea was 
 negatived by the fact that there was no discharge and 
 nothing in the urine at any time during the first three 
 weeks of treatment. The fact that pain was referred 
 to the stomach in this case tended to draw attention 
 away from the actual site of the trouble, but bearing 
 in mind the old history of gonorrhoea a correct diagnosis 
 was speedily arrived at. Another example with a 
 longer history illustrates the same point. A patient 
 was admitted with primary syphilis, and there were no 
 signs of gonorrhoea. The urine was normal on admis- 
 sion, but there was a history of an attack four years 
 previously without complications. Twenty-five days 
 after admission, when three injections of mercury had 
 been given, acute epididymitis developed without 
 apparent cause. Trauma of any description was not 
 accountable for it. The urine became hazy during the 
 acute stage, but speedily cleared up with ordinary treat- 
 ment after the epididymitis had subsided. The possi- 
 bility of a re-infection whilst under treatment could be 
 definitely excluded, and, in fact, the urethritis never 
 assumed an acute aspect. The duration of the epididy- 
 mitis was three weeks. Several other similar cases 
 
86 TREATMENT OF GONORRHCEA 
 
 have been noted, the commonest complications being 
 prostatitis and epididymitis. It is impossible to give 
 accurately the frequency, but 5 to 10 per cent, were met 
 with in one series of syphilis cases, with a past history 
 of gonorrhoea. In every syphilis case an inquiry 
 should be made as to the occurrence of an attack of 
 gonorrhoea in the past, the patient being advised that 
 it is to his advantage to admit it, and also any compli- 
 cations developed as a result thereof. 
 
 Treatment. — A two-glass urine test is made on ad- 
 mission and examined microscopically for signs of 
 gonorrhoea, the urethra also being inspected and inquiry 
 made as to the presence of a gleet on rising in the morn- 
 ing. The prostate is examined during the first week 
 and a smear made. If gonococci are found to be pre- 
 sent in this, irrigation should be commenced, even in 
 the absence of a discharge. By doing this the likeli- 
 hood of complications developing later is minimised. 
 If gonococci are not present no further treatment is 
 required. These two examinations are well worth 
 carrying out systematically, for the development of 
 prostatitis or epididymitis usually means a delay of some 
 weeks in continuing the administration of salvarsan, and 
 so defeats the object of the intensive course. 
 
CHAPTER X 
 
 CHRONIC GONORRHOEA 
 
 The transition from the acute to the chronic stage in 
 gonorrhoea is gradual, and there is, frequently, nothing 
 in the clinical phenomena beyond the persistence of a 
 discharge. It is thus a difficult matter to say at any 
 one period when a case should cease to be called acute, 
 and be classified as chronic This difficulty, however, 
 does not in any way affect the methods of treatment and 
 what follows may be assumed to apply to all cases of 
 three months' duration and over, whether following on 
 continuous treatment or relapsing at some period after 
 its completion. Cases of this nature are essentially 
 difficult and need much attention, and the most careful 
 and thorough examination, if the result is to be successful. 
 The usual history is that of a past attack of gonorrhoea 
 with the subsequent reappearance of a discharge some 
 weeks, months, or even years later, quite apart from 
 the risk of re- infection. Inquiry should be made on 
 the lines suggested earlier as to the date of the original 
 attack, the incubation period, and the duration and 
 nature of the treatment ; also as to the occurrence of 
 any complication. The next step is to make a complete 
 examination, beginning with the discharge obtained on 
 massaging the urethra, noting whether it is purulent, 
 muco-purulent, or transparent, and making a smear 
 
 8 7 
 
88 TREATMENT OF GONORRHOEA 
 
 from it. The following method should be adopted: 
 The prepuce is retracted, cleansed thoroughly with small 
 swabs of wool moistened in an antiseptic solution, the 
 lips of the meatus separated and freed from discharge. 
 The urethra is then compressed from the bulb forwards, 
 the lips of the meatus again separated and a small bead 
 of the discharge removed from the urethra on a platinum 
 loop. This is transferred to a slide, fixed and stained 
 by Gram's method. By this means the organisms of 
 balanitis are excluded together with any other con- 
 tamination which may be present. Assuming that 
 gonococci are found, it remains to discover the source of 
 the discharge, which can be done only by a process of 
 exclusion. 
 
 The patient is instructed to pass urine into four glasses 
 on first rising in the morning, if possible the urine of six 
 or eight hours. This test differentiates fairly accurately 
 between the anterior and posterior urethra as well as 
 indicating involvement of the prostate ; but it is better, 
 when the amount of discharge is small, to adopt the 
 following modification : 
 
 The patient, having passed no urine for several hours, 
 irrigates the anterior urethra thoroughly. Cold boric 
 lotion at a pressure of two feet is used, since this will 
 not penetrate beyond the triangular ligament. The 
 washings are collected in Glass I. A soft rubber ca- 
 theter is then passed, and the urine drawn off from 
 the bladder into Glass 2. The bladder is washed 
 out with boric lotion through the catheter until the 
 washings return quite clear and eight ounces of 
 lotion are left therein. The patient passes about two 
 to four ounces into Glass 3. The prostate is then 
 massaged, and the remainder of the boric lotion passed 
 into Glass 4. 
 
CHRONIC GONORRHOEA 89 
 
 Glass 1 represents : Anterior urethra. 
 
 ,, 2 ,, Bladder. 
 
 ,,3 ,, Posterior urethra. 
 
 4 ,, Prostate. 
 
 The types of filaments have already been described 
 under the heading of the urine test, such as the comma's 
 from Littre's glands or heavy muco-purulent flakes, and 
 with experience they are readily distinguished and a 
 correct opinion formed as to their origin. 
 
 Prostatic secretion and the changes it undergoes in 
 inflammation of the prostate have also been explained. 
 On a subsequent occasion the prostate should be mas- 
 saged following on thorough irrigation of the whole 
 urethra. The first few drops of secretion are allowed 
 to escape into a glass containing a little water, and 
 then the next drop is collected on a glass slide. This 
 is spread out in an even film dried over the flame of a 
 spirit-lamp, stained with Gram's stain and examined 
 for gonococci. 
 
 The methods of examination so far described give 
 very useful information, and from the results it becomes 
 possible to say whether gonococci are present, whether 
 the anterior or posterior urethra is involved, or possibly 
 both. The existence of a chronic lesion of the prostate 
 or infection of the bladder is revealed, as well as 
 involvement of the seminal vesicles. These tests, 
 however, are concerned chiefly with the location of the 
 trouble and do not, to any great extent, make clear the 
 nature of the existing lesions. To discover the true 
 condition of the urethra the urethroscope is essential, 
 and a urethroscope examination should invariably be 
 carried out before deciding finally on a course of treat- 
 ment. ' 
 
9 o TREATMENT OF GONORRHOEA 
 
 The urethroscope is simply a metal tube, illuminated 
 inside by a small electric lamp, by means of which 
 successive portions of the urethral surface may be 
 examined as the tube is withdrawn. Many different 
 patterns are now available, but Luy's is, perhaps, the 
 simplest to begin with. It consists of a metal handle 
 bearing a small lamp mounted on a fine metal stem 
 which is sufficiently long to reach to the end of the 
 urethroscopic tube without projecting. The examining 
 tube is cylindrical, and has a metal pilot for the purpose 
 of introduction. It is lubricated and passed in the 
 same way as an ordinary sound, the pilot withdrawn, 
 and the excess of lubricant absorbed with small swabs 
 of wool mounted on wooden or metal stems. The 
 handle is attached to the tube by means of a thumb- 
 screw and the light switched on. The circular area of 
 mucosa at the end of the tube, known as the " central 
 figure," is brightfy illuminated and pathological changes 
 can readily be seen. This pattern of instrument, whilst 
 illuminating the area to be examined very well, provides 
 no means of testing the condition of the urethra at any 
 particular point as regards infiltration, the presence and 
 location of which it is so important to recognize if treat- 
 ment is to be successful. Wyndham Powell's instru- 
 ment provides for this, an attachment being made so 
 that the urethra may be distended with air at will. It 
 differs from Luy's pattern in having an external source 
 of light, parallel rays being reflected down the tube by 
 a small mirror contained in the handle. When the tube 
 is in position in the urethra with the handle attached 
 its outer end is firmly closed by a closely- fitting glass 
 window. This permits a clear view of the central 
 figure and yet allows air-distension to be carried out at 
 the same time through a valve, controlled by a tap, to 
 
CHRONIC GONORRHOEA 91 
 
 which is attached an india-rubber hand-bellows. When 
 air is pumped in, the tap being open, the central figure 
 can be seen to roll back gradually as the pressure rises 
 until, when fully distended, it disappears altogether, 
 the urethra assuming the appearance of a long tunnel. 
 On closing the tap, and so shutting off the air-pressure, 
 the sides gradually collapse into the position of rest. 
 One of the most common changes in gonorrhceal ure- 
 thritis is the formation of local infiltrations with the 
 subsequent development of a stricture if not recognized 
 and suitably treated. By means of air-distension these 
 infiltrations can be readily detected, since any loss of 
 elasticity results in imperfect dilatation at that point 
 when the air-pressure is raised. This flexibility of the 
 urethra will be referred to again later in connection with 
 the different classes of case to be dealt with ; but the 
 striking difference in flexibility between a normal and 
 an infiltrated urethra under air distension has only to 
 be seen to be appreciated. More elaborate instru- 
 ments are made for the purpose of examining the pos- 
 terior urethra and neck of the bladder, but the two 
 mentioned give the greatest possible assistance in 
 diagnosing most lesions of chronic gonorrhoea. 
 
 Technique. — Before examining a patient with the 
 urethroscope two factors have to be considered : 
 
 (1) The amount of discharge present. 
 
 (2) The calibre and condition of the urethra. 
 
 In the acute stage it is always inadvisable to attempt 
 urethroscopy because of the inflamed state of the 
 mucous membrane and the risk of spreading infection 
 deeper down the urethra. In the chronic stage the dis- 
 charge is usually less abundant, but whenever the 
 amount is considerable it is wiser to defer the examina- 
 
92 TREATMENT OF GONORRHOEA 
 
 tion until this has been checked by a few days' irrigation. 
 
 It should be an invariable rule never to attempt to 
 pass a urethroscopic tube on a patient whose urethra 
 has not been previously investigated. Graduated metal 
 sounds should be passed at an earlier visit so as to dis- 
 cover the presence of any obstruction and also to deter- 
 mine what size of tube can be used for the actual 
 examination. The position of the patient is usually 
 semi-recumbent when a special table is used, the feet 
 resting on adjustable supports ; but, failing this, a table 
 on which the patient can lie full length answers the 
 purpose. The instruments being laid out ready for use, 
 the prepuce and glans are washed over with an anti- 
 septic solution, special attention being paid to the lips 
 of the meatus.' A suitable tube with its pilot is selected, 
 lubricated thoroughly with a sterile medium and intro- 
 duced gently into the urethra. The lips of the meatus 
 should be separated during this proceeding since they are 
 liable to become inverted by the descent of the tube 
 and obstruct its ready introduction, in addition to 
 causing unnecessary discomfort. The most convenient 
 size of tube for general use is No. 26, and will be found 
 suitable for the majority of cases. Should obstruction 
 occur just inside the meatus a preliminary dilatation 
 becomes necessary with graduated metal dilators of 
 Wyndham Powell's pattern, or a smaller tube may be 
 tried. The tube being in position, the pilot is gently 
 withdrawn, any excess of lubricant removed with small 
 mounted swabs and the handle bearing the lamp at- 
 tached. The examination is then commenced, the succes- 
 sive fields being brought into view and inspected as the 
 tube is slowly withdrawn. Two precautions are necessary. 
 
 (1) To maintain the tube in the long axis of the penis 
 during the examination so as to avoid distortion. 
 
CHRONIC GONORRHOEA 93 
 
 (2) To avoid pushing the tube down the urethra in 
 order to examine an area which has been passed since 
 the folds of the mucosa are thereby liable to serious 
 injury, even from tubes made with a round edge. When 
 properly carried out with care and dexterity the patient 
 should experience no pain from start to finish, except, 
 perhaps, a little discomfort during the introduction of 
 the tube. The preliminary investigation of the urethra 
 by sounds and attention to detail both aid in achieving 
 this end, and it is seldom necessary to use any local 
 anaesthetic. In certain cases, however, an anaesthetic 
 has to be given, it may be for a hyper-sensitive patient 
 or preceding some intra-urethral operation, such as 
 incision of a lacunar abscess. A choice has then to be 
 made between the various available preparations. 
 Cocaine was at one time much in vogue, but it has 
 disadvantages which are not shared by other more 
 modern preparations ; besides which, its action con- 
 siderably modifies the urethroscopic picture. i\lypin 
 in a strength of 2 per cent, is quite harmless and causes 
 no appreciable alteration in the appearance of the 
 mucosa, whilst producing complete anaesthesia. 
 
 Urethroscopic Appearances. — To appreciate the patho- 
 logical changes in a urethroscopic picture, a thorough 
 acquaintance with the normal appearance is essential. 
 A brief description is, therefore, given, but actual practice 
 is the only way of acquiring this knowledge. Seeing 
 that the examination is made during the gradual with- 
 drawal of the tube, it follows that the bulbous urethra 
 is first inspected, then the penile, finishing up at the 
 meatus. The normal mucosa is smooth, red, moist, 
 and glistening, the walls folding together beyond the 
 end of the tube to form a rosette with a central lumen 
 from which numerous folds together with fine blood- 
 
94 TREATMENT OF GONORRHCEA 
 
 vessels radiate towards the periphery, like the spokes 
 of a wheel, varying in number in the different parts of 
 the urethra. Normally striation is well marked, and 
 the colour is a fairly deep red in the bulb, a little lighter 
 in the penile part, and quite pale in the glandular portion, 
 the depth of colour depending on the vascularity of the 
 individual and the presence or absence of inflammation. 
 
 Opening on the surface of the urethra along the whole 
 length from the meatus to the membranous portion are 
 numerous glands, the glands of Littre, chiefly distri- 
 buted along the roof and sides of the penile part. The 
 mouths of their tiny ducts are barely visible in the 
 normal condition, but become evident when inflamed. 
 
 The lacunae of Morgagni also open along the roof of 
 the penile urethra, the openings being larger than 
 those of Littre's gland ducts and, consequently, more 
 readily seen in the normal state. One in particular, 
 situated about 2 cm. from the meatus, is practically 
 constant, its free margin being known as the valve of 
 Guerin. These lacunae are small pouches extending 
 at times to a depth of several millimetres, at the bottom 
 of which the openings of one or more of the ducts of 
 Littre's glands may be found. Their suitability for 
 harbouring gonococci is obvious, and once inflammatory 
 changes have developed it becomes harder than ever 
 to dislodge them. 
 
 The ducts of Cowper's glands open on the floor of the 
 bulbous urethra, but are not usually visible, except under 
 air-distension, owing to the numerous folds of the 
 mucosa at this part. At times this opening takes the 
 form of the letter V like a large lacuna, with the 
 point towards the bladder, and may then become a 
 source of infection, though this is unusual. 
 
 Pathological Changes. — In chronic gonorrhoea changes 
 
CHRONIC GONORRHOEA 95 
 
 may be found in any of the places described, viz. 
 Littre's glands, lacunas of Morgagni, or any portion 
 of the mucosa, all of which can be recognized by means 
 of the urethroscope. 
 
 The mucosa gradually becomes infiltrated during 
 prolonged inflammation, and may appear in places. 
 
 (1) Dull and hyperaemic, the surface having lost its 
 glistening appearance and the characteristic striation 
 being replaced by a uniformly red and inflamed central 
 figure. The numerous folds of the normal state no 
 longer exist, and three or four coarse ones compose the 
 central figure. Under air-distension the lack of elas- 
 ticity is at once seen. 
 
 (2) Paler than normal, with small white areas here 
 and there in the wall, showing the development of 
 fibrous tissue, and early stricture formation. The 
 folds of mucosa are few, and there is a marked loss of 
 elasticity. 
 
 (3) Where definite stricture- formation is in progress, 
 the walls infiltrated more or less all round, the lumen 
 narrowed, an entire absence of folds and an anaemic 
 mucosa from the absence of blood-vessels in the fibrous 
 tissues. Under air-distension the part of the urethra 
 anterior to the stricture dilates up, leaving the narrowed 
 lumen in full view, unaffected by this degree of air- 
 pressure. 
 
 All stages may be experienced between (2) and (3), 
 depending on how far the infiltration and fibrosis have 
 progressed, and various classifications defining soft and 
 hard infiltrations have been made by Oberlander and 
 others ; but it is beyond the limits of this work to deal 
 with them. 
 
 Littre's glands, when infected, show different changes 
 according to whether the duct remains patent or becomes 
 
g6 TREATMENT OF GONORRHOEA 
 
 occluded. In the former case the appearance is as 
 follows : — 
 
 The opening of the inflamed duct resembles a tiny 
 papilla standing out slightly above the general level 
 and usually surrounded by a small ring of hyperlink 
 mucous membrane. A drop of pus may be present 
 in the mouth of the duct, or be expressed by gentle 
 pressure with the end of the tube. If the duct become 
 occluded one of two things may happen ; either the 
 gland atrophies or a small cyst is formed. In the 
 latter event the small cyst is visible through the 
 urethroscope as a tiny yellow circular projection of the 
 size of a pin's head, though frequently larger. 
 
 Lacunae of Morgagni are very liable to infection, 
 like the glands of Littre. They become red and in- 
 jected, and their openings usually appear as small V- 
 shaped areas with the broad ends towards the meatus. 
 The adjacent mucosa is frequently inflamed for a dis- 
 tance of two or three millimetres. 
 
 These changes have been described with regard to the 
 individual structures of the urethra, but it must not be 
 imagined that one particular group is affected in one 
 case and another group in another; a pure Littritis, 
 for example, without any affection of the lacunar is 
 uncommon, as also infiltration of the mucosa without 
 involvement of some of the glands of Littre. One of 
 the commonest lesions found in chronic gonorrhoea is 
 a soft infiltration, where the folds of the mucosa are 
 coarse and diminished in number, the elasticity much 
 less than normal, and the surface dull and hyperemia 
 In such cases it is quite common to find a group of 
 inflamed Littre's glands close to the infiltrated area. 
 
 So far the urethroscopic examination has concerned 
 only the anterior urethra as far as the bulb, which can 
 
CHRONIC GONORRHOEA 97 
 
 be inspected by means of the ordinary straight tube. 
 With longer tubes it is possible to examine the posterior 
 urethra and neck of the bladder. Usually these tubes 
 are made with a short beak so as to facilitate their 
 introduction, an oval opening being left at the convexity 
 for observation. By their means the verumontanum 
 and openings of the prostatic ducts can be seen, and 
 also the presence of abnormalities, such as polypi in 
 this region. More complicated instruments with a 
 lens-system, of a pattern similar to the cystoscope, are 
 made and permit of various operative procedures. Most 
 of them employ water instead of air for distending the 
 urethra. 
 
 Only the commoner changes, such as are most fre- 
 quently seen, have been referred to here, and those 
 which are of most importance from the point of view of 
 treatment. For more detailed information on urethro- 
 scopic work one of the larger text-books should be 
 consulted. 
 
 There is one method of examination in connection 
 with the urethroscope which is chiefly of value when the 
 clinical evidence is very slight. It consists in giving a 
 moderate dose (50 to 100 millions) of a gonococcal 
 vaccine. The patient is examined twenty-four hours 
 to forty-eight hours later, when, if the disease be still 
 active, the signs are much more marked. 
 
 The methods of examination described may be sum- 
 marized under five headings : 
 
 (1) Microscopic. 
 
 (2) Four-glass urine test. 
 
 (3) Massage of the prostate. 
 
 (4) Urethroscope examination. 
 
 (5) Vaccine test. 
 
9 8 TREATMENT OF GONORRHCEA 
 
 With the information gained by these several exam- 
 inations it becomes possible to assign a case to one or 
 more of the following categories : 
 
 (a) Anterior urethritis, including infiltrations soft 
 and hard, inflammation of Littre's glands and the 
 lacunae of Morgagni. 
 
 (b) Posterior urethritis, including prostatitis, vesi- 
 culitis, Cowperitis. Clinically a large number of cases 
 are found to come under the first group, the only signs 
 being a little irritability of the urethra on micturition, 
 with a small drop of transparent, glycerine-like dis- 
 charge at the meatus in the morning. After a hard 
 day's work or a long walk this may appear opaque or 
 yellow and slightly increased in amount. This often 
 brings the patient to seek advice. Following the plan 
 laid down, the discharge should be examined for gono- 
 cocci, a urine-test made, the prostate massaged, and 
 then urethroscopic examination carried out, the patient 
 having passed no urine for some hours previously. On 
 passing the tube resistance is frequently met with at 
 some point, and, subsequently, an infiltration is found 
 to be the cause, the folds of the mucosa being dimin- 
 ished in number, the lumen narrowed, and infected 
 Littre's glands present at several points. In these 
 cases particularly a dose of vaccine twenty-four hours 
 before examination with the urethroscope makes the 
 lesions very much more obvious. To cure these cases 
 is a matter of time and patience, the one essential being 
 regular attendance on the part of the patient and con- 
 scientious carrying out of instructions. 
 
 The chief part of the treatment of this class of case 
 consists of regular dilatation by means of Kollmann's 
 dilator, or a modification of the four-branched pattern. 
 These instruments are made in several shapes so as to 
 
CHRONIC GONORRHOEA 99 
 
 dilate the anterior urethra as far as the bulb, the 
 posterior urethra alone, or anterior and posterior com- 
 bined. The latest models have four metal blades 
 attached to a central stem in such a way that they can 
 be expanded by means of a thumb-screw at the top 
 of the handle, the degree of expansion being registered 
 by a pointer on a circular scale. The position and 
 mounting of the blades are such that the folds of mucous 
 membrane cannot become caught between them, and 
 there is no risk of damaging the surface. When closed 
 for introduction the stem corresponds to a No. 21 or 
 22 Wyndham -Powell straight metal dilator. 
 
 Two models are made : (1) Irrigating ; (2) Non- 
 irrigating. 
 
 In the irrigating pattern there is an inlet and outlet 
 whereby solutions can be run through the urethra during 
 the process of dilatation, whereas with the non-irrigating 
 model there is no provision for this and it dilates only. 
 The irrigating models are unobtainable at the present 
 time, though preferable in many ways. 
 
 Technique of Dilatation. — Three points need bearing 
 in mind when dilatation is to be carried out : 
 
 (1) The patient should irrigate thoroughly before and 
 after the dilatation. 
 
 (2) No local anesthetic should be given. 
 
 (3) Dilatation should be gradual. 
 
 The urethra is washed clear shortly beforehand, a 
 suitable solution being protargol (1 in 4,000). For this 
 purpose the permanganates of potassium and zinc are 
 best avoided, since their astringent properties render 
 the surface dry and tenacious, making the introduction 
 of the instrument, even when well lubricated, somewhat 
 painful. After dilatation this objection does not hold. 
 
 The reason for giving no local anaesthetic is that the 
 
ioo TREATMENT OF GONORRHOEA 
 
 operator depends, to a considerable extent, upon the 
 patient's sensation to guide him as to the degree of 
 dilatation permissible at each sitting. When the 
 urethra is tightly stretched a feeling of discomfort is 
 present which speedily gives place to acute pain if any 
 damage be caused to the surface. To give a local anaes- 
 thetic is to abolish this safeguard. 
 
 The rationale of dilatation is to overcome, by repeated 
 stretching, the tendency of the fibrous tissue formed 
 during the inflammation to contract and lead to stricture 
 formation. The need for gradual dilatation is obvious 
 since any solution of continuity causes new fibrous 
 tissue-formation at that point and defeats the object 
 of the treatment. Besides its effect on infiltrations the 
 branched-dilator favourably influences lesions of Littre's 
 glands and the lacunae. Considerable tension is set up 
 in the walls by the tight stretching of the mucous mem- 
 brane during dilatation, and this tends to compress and 
 empty the contents of such glands or lacunae as are not 
 obstructed. In those with occluded gland ducts where 
 cyst-formation has taken place regular and gradual 
 dilatation leads to their rupture and resolution. 
 
 The patient lies comfortably on a couch during the 
 operation. All aseptic precautions must be taken, the 
 meatus and glans being cleansed with an antiseptic 
 and the dilator itself boiled. The instrument is placed 
 in sterile water until ready for use, then dipped in a 
 sterile lubricant, such as liquid paraffin, and passed 
 into the urethra. Two points need attention at this 
 point : 
 
 (i) See that the blades are completely closed before 
 attempting introduction. 
 
 (2) Support the instrument, once it is introduced, so 
 that the weight of the handle does not press the point 
 
CHRONIC GONORRHOEA 101 
 
 into the urethral wall, and maintain its long axis accu- 
 rately in the axis of the urethra, allowing no rotation. 
 
 Patients, more often than not, are extremely nervous 
 when any instrumental treatment has to be carried out, 
 and the least shock will upset them. To carry out 
 dilatation successfully, the patient's confidence has to be 
 won, and to cause unnecessary pain at the first attempt 
 is to minimize one's chance of success. He has to be 
 convinced that no real pain is involved, and every 
 detail, therefore, needs attention from the start. Once 
 the instrument is in position, the expansion must be 
 very gradual, the first turn of the handle needing 
 especial care, since the numerous folds of the urethra 
 have to adapt themselves to the four metal blades. The 
 tension is then increased slowly, the patient's sensation 
 being the best guide at the first dilatation. When the 
 walls are getting somewhat stretched tenderness is 
 usually complained of at one or more places, frequently 
 the site of a soft infiltration, and from this point onwards 
 the turning of the handle must be very slow and careful, 
 not exceeding one division on the scale. The instru- 
 ment is allowed to remain in position for about ten 
 minutes when this stage is reached, then unscrewed and 
 withdrawn. No bleeding should occur after this 
 operation, and it is far better to err on the side of too 
 little, rather than too much, dilatation. The leverage 
 obtainable by the milled-screw is considerable, and by 
 careless handling a great deal of permanent damage 
 may be caused ; but with experience the degree of 
 stretching attained can be readily recognized by the 
 resistance of the blades. The operation needs to be 
 repeated at regular intervals, and it is rarely advisable 
 to perform it more often than once in six or seven days, 
 so as to allow the mucous membrane a chance of settling 
 
102 TREATMENT OF GONORRHOEA 
 
 down. The object aimed at is to increase the amount 
 of dilatation at each operation by, roughly, one division. 
 Thus, if 34 were reached at the first sitting, 35 would 
 be the aim of the next one, and 36 at the third. 
 In many cases this can be carried out, but not in all. 
 Thus, for example, if in the case quoted above 35 were 
 reached at the second sitting, and a little bleeding 
 were produced by over-stretching, it would be found 
 that at the third sitting pain would probably com- 
 mence at 34, or even 33, and 36 could not be reached. 
 For a day or two following the dilatation a little dis- 
 charge is to be expected so long as lesions are present. 
 When the irrigating pattern instrument is used, pro- 
 targol (1 in 4,000) or silver nitrate (1 in 10,000 to 
 1 in 5,000) are suitable solutions to run through during 
 the dilatation. After three or four sittings the urethra 
 should be examined again with the urethroscope to 
 see what progress has been made. The appearance 
 of the glands and any infiltrations should be noted 
 and recorded for reference. 
 
 Other instrumental treatment is frequently valuable 
 in cases of chronic gonorrhoea where extensive involve- 
 ment of Littre's glands has taken place, and numerous 
 small nodules can be felt on palpating the urethra with 
 a metal sound in position. The branched dilator makes 
 little impression on these nodules, and the following 
 procedure is often efficacious. 
 
 Inject a few c.cs. of 2 per cent, alypin into the 
 urethra by means of a sterile glass syringe, and allow 
 this to be retained for about five minutes. Introduce 
 a No. 22 Wyndham- Powell straight metal bougie, 
 noting if it is " gripped " at any particular part of the 
 urethra. If it pass readily, a No. 23 is tried, until the 
 sise is found which just fits tightly without causing any 
 
CHRONIC GONORRHGEA 103 
 
 tension. The urethra is then massaged against this 
 sound, beginning at the bulb and working forwards. 
 The mucous membrane is rolled between the thumb 
 and index-finger of the right hand, the sound allowing 
 the necessary pressure to be made, whilst the left hand 
 steadies the end of the instrument and keeps it in 
 position. When the peno-scrotal junction is reached, 
 the index-finger and middle finger support the penis, 
 whilst the thumb compresses the urethral wall against 
 the bougie, expressing the contents of many of the 
 glands. Since the glands are chiefly situated near the 
 roof, the thumb should work round as far as possible 
 towards the middle line. On completion of one side 
 the position is reversed, and the other side similarly 
 "stripped." After successful manipulation many of 
 the nodules are found to have disappeared and, in fact, 
 they can frequently be felt to disperse under the pressure. 
 A little bleeding is usually caused, but stops after irri- 
 gation with weak permanganate of potash, 1 in 8,000. 
 Dilatation with the branched dilator, if needed, can 
 usually be commenced after a week's rest. 
 
 Irrigating Solutions in Chronic Gonorrhoea.— In 
 prescribing an irrigation for any special condition the 
 personal factor must be taken into account, for the 
 same solution will prove satisfactory in some cases and 
 unsatisfactory in others, even though the lesions be 
 identical. The majority of patients tolerate the usual 
 strengths of permanganate of potash, for example, quite 
 readily, and it gives excellent results ; yet in a small 
 minority the patients cannot use it, even in a strength 
 of 1 in 8,000, since it leads to acute pain soon afterwards, 
 lasting for several hours, considerable pain on micturi- 
 tion, and even a little haemorrhage, quite apart from 
 acute posterior urethritis, This idiosyncrasy cannot be 
 
104 TREATMENT OF GONORRHOEA 
 
 detected beforehand, and is discovered only after a few 
 days' use of the solution , when the patient complains 
 of some or all of the symptoms mentioned, and an 
 examination of the urine shows that the discharge is 
 not diminishing appreciably and that there is an excess 
 of mucus present. For this reason a patient should 
 always be seen a few days after commencing a course 
 of irrigation, and if any idiosyncrasy be shown it is 
 advisable to try another solution rather than to persist 
 with the same one, since there are several to choose 
 from, and but little difference in their therapeutic value. 
 The three solutions which have proved of real value 
 after prolonged tests in several thousand cases, both 
 acute and chronic, are : 
 
 (i) Permanganate of potash. 
 
 (2) Permanganate of zinc. 
 
 (3) Protargol. 
 
 No doubt there are many others, and in recent years 
 there has been a considerable addition to the lists, 
 especially of silver compounds, but those mentioned 
 meet the requirements of most cases and have the 
 advantage of being readily obtainable. Once a case of 
 chronic gonorrhoea has been investigated on the lines 
 suggested, the gonococcus found, and the site of the 
 lesions determined, an irrigation of permanganate of 
 potash (1 in 8,000) should be prescribed. 
 
 Whether the anterior or posterior urethra be involved 
 is no matter, for it should be the aim of the patient to 
 fill up the bladder three or four times at each irrigation, 
 and so flush out the whole of the lower urinary tract. 
 Where idiosyncrasy is shown it is advisable to change 
 to zinc permanganate (1 in 8,000) which is usually well 
 tolerated. Once the patient has got into the way of 
 
CHRONIC GONORRHOEA 105 
 
 irrigating properly and successfully gets the solution 
 into the bladder, the strength may be increased to 
 1 in 6,000, at which it should remain unless there is a 
 definite indication for a change. In lesions of the 
 posterior urethra and prostate the solution has been 
 found the most useful. 
 
 Zinc Permanganate is particularly valuable in chronic 
 cases in which the glands of Littre are affected and 
 where soft infiltrations are present. The urine in 
 these cases contains many filaments and under its 
 influence seems to clear up quicker than with the per- 
 manganate of potash. A strength of 1 in 6,000 should 
 be given at first and increased, after a few days, to 
 1 in 4,000 if well tolerated. Patients often find it 
 easier to irrigate with this solution than with the 
 potassium salt, and will succeed in getting it into the 
 bladder when they have repeatedly failed with the 
 latter. In such cases it is advisable to continue its use 
 until proficiency is attained, and then to change back 
 to the potassium salt, if necessary, at a later date. 
 
 Protargol does not come up to the other two prepara- 
 tions for general usefulness, one drawback being that 
 distilled water is needed for making the solution. After 
 energetic instrumental treatment it is useful to prescribe 
 since it has no astringent effect, whereas the perman- 
 ganates may cause irritation and discomfort at this 
 stage. Its use before dilatation with the branched 
 dilators has been referred to earlier, and also its suita- 
 bility as a solution for running through the irrigating 
 patterns of these instruments. Its prolonged use is 
 not recommended since it is not sufficiently stimulating, 
 and allows the mucosa to get into a condition of stasis, 
 where there is no purulent discharge secreted, but always 
 a glairy mucus. 
 
io6 TREATMENT OF GONORRHOEA 
 
 Vesiculitis. — This proves, at times, a very trouble- 
 some complication of chronic gonorrhoea, for, once 
 infection has reached the seminal vesicle, it is only with 
 difficulty that it can be eradicated. The symptoms are 
 but slight, and, in many instances, it is the persistence 
 of a discharge which leads to an examination and dis- 
 covery of the condition. The following method should 
 be adopted. About eight ounces of boric lotion are 
 injected into the bladder after thorough irrigation of 
 the whole urethra, and the position already described 
 for prostatic massage is assumed by the patient. The 
 index-finger is passed into the rectum until it dominates 
 the prostate and is then gently swept from above down- 
 wards and inwards over the seminal vesicle on each 
 side. When inflamed, the vesicle can be readily felt as 
 a small tender mass lying on each lateral lobe of the 
 prostate. When normal, it is difficult to distinguish 
 from the surrounding tissue. 
 
 The secretion is of a greyish colour and quite viscid, 
 but when affected by gonococcal infection it becomes 
 thick and, frequently, purulent. Massage of the 
 vesicle is a delicate operation and should be carried out 
 in an extremely gentle manner, for unpleasant sequelae 
 may arise from too vigorous treatment. One symptom 
 needs mention, viz. the presence of blood mixed with 
 the seminal fluid on emission. It is found in cases of 
 vesiculitis, and, when present, is diagnostic. Its chief 
 importance lies in the fact that it occasions the patient 
 so much anxiety about himself. Other symptoms are 
 frequency of micturition, pains in the rectum and down 
 the thighs, nocturnal emissions, often associated with a 
 condition of mental depression, the concomitant of 
 prolonged treatment. One other symptom, which must 
 be quite rare, has been described by certain writers, 
 
CHRONIC GONORRHOEA 107 
 
 and consists of pain along the course of both ureters, 
 attributed to an effect of the diseased vesicles on the 
 ureters where they approach the bladder wall. In cer- 
 tain cases obstruction of the ejaculatory ducts develops 
 as a result of vesiculitis, leading to painful ejaculation. 
 On massage of the vesicles no secretion can be expressed, 
 and the condition shows no signs of improvement under 
 irrigation. It is a very troublesome complication, and 
 is best left for the specialist to deal with. Posterior 
 urethroscopy needs to be carried out to determine 
 the changes in the verumontanum and utriculus, since 
 these form a valuable guide as to the state of affairs in 
 the vesicles themselves. 
 
 Catheterization of the ejaculatory ducts or cauteriza- 
 tion of their orifices may be necessary, followed by 
 subsequent massage and irrigation ; but it is unneces- 
 sary to describe here the technique of this somewhat 
 complicated procedure. 
 
 Urethroscope Treatment. — Under the heading of 
 " Dilatation " mention has been made of the use of the 
 urethroscope in controlling the amount of stretching at 
 each operation and revealing the progress of healing. 
 In some of these cases, even after prolonged dilatation, 
 certain resistant areas remain practically unaffected, 
 and the urethroscope is a valuable means of applying 
 local treatment directly under the control of the eye. 
 It is especially useful in cases of chronic anterior urethritis, 
 where the soft infiltrations have been successfully cured 
 by means of repeated dilatation, but in which a certain 
 number of Littre's glands, or some of the lacunae, 
 remain unaffected. Their mouths are inflamed and 
 readily visible, with or without the presence of a tiny 
 bead of discharge. Such glands can be brought into 
 the field and dealt with in one or more ways : 
 
108 TREATMENT OF GONORRHOEA 
 
 (a) By painting with silver nitrate (2 per cent, or 
 stronger) by means of small mounted swabs. 
 
 (b) By means of silver nitrate fused on to the end of 
 a platinum-ended probe and inserted into the gland 
 orifice. 
 
 (c) B3' the actual cautery. 
 
 Of these three probably the second one is the best, 
 applied through the Wyndam- Powell urethroscope, but 
 has not given complete satisfaction. A method whicli 
 has given very successful results has recently been 
 devised by the writer. For the purpose a fine platinum- 
 ended cannula is needed, about 7 inches long, to which 
 a small glass syringe can be attached. The end of the 
 cannula is of the same bore as a fine hypodermic needle, 
 but it is cut off square. The urethroscopic tube is 
 passed and the affected gland brought into view. The 
 cannula is passed down the tube and its point gently, 
 but firmly, inserted into the gland mouth. The syringe 
 contains a solution of iodine in chloroform of a strength 
 of 1 in 30, and a drop of this fluid is expressed into the 
 gland. The cannula is at once withdrawn, and any 
 excess of solution removed with small mounted swabs. 
 Each gland is dealt with in turn until all have been 
 injected. When properly carried out no pain results. 
 On the following morning it is usual to find a bead of 
 very thick yellowish-brown discharge and slight tender- 
 ness mav be noticed in one or two indefinite areas. 
 But no further symptoms occur. On examination a 
 week later it is almost impossible to identify these glands 
 from the normal. It should be made quite clear that 
 treatment through the urethroscope is required only 
 when all the routine methods have been carried out 
 beforehand. There is one exception to this, which is 
 dealt with in the chapter on the complications of gonor- 
 
CHRONIC GONORRHOEA 109 
 
 rhcea, viz. the incision of an abscess in a gland or lacuna 
 during the early stage of its development to avoid 
 the formation of a peri-urethral abscess. The advan- 
 tage of the air-inflation urethroscope over the ordinary 
 pattern, such' as Luy's, is ver}' marked in this particular 
 branch. The glands and lacunae are made perfectly 
 obvious, and it is quite a simple operation to insert a 
 probe, pointed with silver nitrate, into the mouth under 
 air-distension. In the ordinary pattern the numerous 
 folds of the mucosa tend to conceal the openings of the 
 ducts. 
 
CHAPTER XI 
 
 THE GONORRHCEA PATIENT 
 
 There are certain features about gonorrhoea, as a 
 disease, which considerably modify the patient's aspect 
 of it. Thus, in the case of married men attempts have 
 frequently to be made to conceal the attack, and in the 
 unmarried man, at any rate of the better class, every 
 effort has to be made to remain at work and to keep 
 the nature of the complaint a secret. Such difficulties 
 as this, and the numerous predicaments in which the 
 patient finds himself from time to time, all tend to prey 
 on his mind, encouraging an unsettled and unstable 
 condition. He visits his doctor when there is no 
 alternative but to do so, and trusts that, by the mercy 
 of Providence, he has got only a mild attack. His first 
 inquiries are not as to the danger of the disease, but the 
 duration ; not as to precautions to be taken, but the 
 time it will take to cure ; not as to the risk of serious 
 after-effects, but as to how long he will remain infectious. 
 All these concern the inconvenience he may be caused, 
 and the actual treatment he will need to carry out takes 
 a distinctly second place. It is important not to over- 
 look these facts, for otherwise serious mistakes in the 
 method of dealing with such cases will occur. Thus, 
 for example, a patient inquiring at his first visit as to 
 how long he will require treatment need not be told of 
 the risk of all the complications which undoubtedly may 
 
 no 
 
THE GONORRHOEA PATIENT in 
 
 occur. Without in the least minimizing the need for 
 regular and efficient treatment, a very hopeful prognosis 
 can safely be given in the ordinary acute case. 
 
 It is essential to keep the patient's outlook in view 
 at all times and to avoid any expression of opinion 
 which could possibly tend to discourage him. Even- 
 tually, of course, the truth about the duration of 
 infectivity has to be explained, but when the patient is 
 practically cured the impression created will then have 
 a far less depressing effect than would be the case at 
 the onset of the attack. The surgeon, on his side, 
 starts with a handicap, for he cannot, as in the case of 
 syphilis, tell the patient almost to a day how long he 
 will need to be under treatment. At present, there is 
 no remedy comparable with salvarsan for the treatment 
 of gonorrhoea, and the probable duration of an attack 
 can be estimated only after careful observation of the 
 progress made on the methods adopted. This uncer- 
 tainty, however, is the concern of the surgeon alone, 
 and since he cannot, except in a few instances, foretell 
 the cases in which complications will occur, the best 
 plan is to inform the patient of the usual duration of an 
 uncomplicated case, warning him of the risk run by 
 neglect of treatment or indulgence in alcohol of any 
 description. It must be remembered, too, that when 
 the patient first seeks treatment he is, more often than 
 not, suffering from the initial malaise, pyrexia, and 
 discomfort of the acute onset. He feels irritable and 
 run down, and often has an intense dread of having 
 contracted syphilis in addition to gonorrhoea. 
 
 To do all in one's power to set his mind at rest and 
 smooth out difficulties as they arise is just as important 
 a part of the treatment as the irrigations and injections. 
 The necessary rest in bed for a few days often causes a 
 
H2 TREATMENT OF GONORRHOEA 
 
 difficulty, but this can usually be overcome, and it is 
 well worth while to enforce it because the likelihood of 
 complications developing is thereby considerably dimin- 
 ished. During the course of treatment the same care 
 must be exercised, for introspection soon develops, 
 and the patient will begin examining his urine for threads 
 and other signs of disease, and even haunt the public 
 library for medical works on the subject. These cases 
 represent the extreme type, but it must be remembered 
 that the majority are easily disheartened and constantly 
 need encouragement. 
 
 In the past quack remedies have had a considerable 
 vogue, the patient supplementing his treatment with 
 one or more ; but with new legislation in progress this 
 practice is likely to be short-lived. 
 
 An excellent instance of the mental condition into 
 which a patient can lapse is afforded by the following 
 case : 
 
 The patient had an attack of gonorrhoea following 
 on which a gleet developed. Though but very slight, it 
 had occasioned him so much anxiety that, on the advice 
 of a friend, he injected some pure carbolic acid into the 
 urethra with the object of stopping the discharge. The 
 result no doubt exceeded his expectation, for extensive 
 sloughing ensued. 
 
 Certain warnings need to be given at the outset : for 
 example, the danger of infection of the eyes. It is 
 best to explain that this will not occur if ordinary care 
 and cleanliness be exercised. Probably the commonest 
 cause of infection is the use of handkerchiefs to prevent 
 soiling of the clothes. This practice should always be 
 forbidden, and a small linen or cotton sac substituted, 
 containing cotton- wool which can be changed frequently 
 and burnt. Towels, in the same way, should be kept 
 
THE GONORRHOEA PATIENT 113 
 
 free from contact with the discharge. After irrigation 
 the patient should invariably wash his hands and wipe 
 them on a towel kept for this purpose alone. As an 
 example of the slight risk of infection where ordinary 
 care is taken, it may be mentioned that, out of 3,000 cases 
 of gonorrhoea, not one developed conjunctivitis after 
 beginning treatment. 
 
 Another warning is required with reference to over- 
 exertion in the acute stage. Once the patient has got 
 up and finds that the discharge has almost disappeared, 
 he is apt to imagine that he can go about as usual with- 
 out risk. In many instances no harm will result, but 
 in a certain number it leads to complications, especially 
 epididymitis. A moderate amount of exercise is bene- 
 ficial at this stage, but fatigue must be avoided. 
 
 Cases developing epididymitis should be advised to 
 wear a suspensory bandage for a month or six weeks 
 after the swelling has subsided. 
 
 Patients will often ask whether it is advisable to wear 
 a bandage during an attack of gonorrhoea when no 
 complication is present. It should be explained that, 
 in uncomplicated cases, the bandage is of doubtful value, 
 but can do no harm, the decision being left to the 
 individual. A constant watch should be kept in every 
 acute case for the development of syphilis. Owing to 
 the longer incubation-period of this disease, a patient 
 contracting a double infection may have been under- 
 going gonorrhoea treatment for two or three weeks before 
 the primary syphilitic sore develops. A small sore 
 may easily be overlooked or considered too trivial to 
 need treatment. The frequent use of permanganate 
 irrigations, too, makes the slighter lesions much less 
 obvious and tends to promote rapid healing. It is quite 
 unnecessary to tell the patient of this risk, unless he 
 8 
 
ii4 TREATMENT OF GONORRHOEA 
 
 should inquire about it, so long as he can be kept under 
 observation, it being usually sufficient to inspect the 
 glans, the prepuce, and coronal sulcus periodically and 
 to palpate the inguinal glands at the same time. The 
 method of irrigation has been dealt with under " Routine 
 Treatment," and any difficulties connected with it are 
 best overcome by demonstration. The use of a glass 
 syringe in place of the irrigating-can and nozzle should 
 not be allowed, since it is inferior in every way, and leads 
 to complications if carelessly handled. 
 
 The remaining question — the test of cure — is dealt 
 with separately, since it involves a consideration of 
 various details and methods described later. 
 
 Test of Cure 
 
 The Complement-fixation test which is so valuable in 
 syphilis has not 3^et reached a practicable stage in the 
 case of gonorrhoea, and, consequently, it is not so simple 
 a matter to pronounce a patient to be cured. In the 
 past and, in many instances, at present even the " Stout 
 Test " is considered sufficient. The patient drinks 
 several bottles of stout and his urine is examined for 
 signs of a discharge. Failing an obvious relapse, he is 
 sent away after a further short period of observation. 
 Under vaccine treatment this test has been denounced 
 because it defeats the aim of treatment, the patient taking 
 alcohol although its effects are known to be detrimental. 
 On completion of a course of treatment the value of 
 vaccines as a test of cure has already been sufficiently 
 emphasized. Assuming that the patient shows no sign 
 of relapse, he should be advised to have an examination 
 made again in three months' time. This should include : 
 
 (i) Examination of a two-glass urine test, the urine 
 
THE GONORRHOEA PATIENT 115 
 
 to be a 6 or 8 hours' specimen, passed twenty- four 
 hours after receiving a dose of gonococcal vaccine (100 
 million gonococci). 
 
 (2) Massage of the prostate, a smear being taken for 
 microscopic examination. 
 
 (3) Urethroscopic examination. 
 
 The urine may contain a few threads. If this be the 
 case, they should be taken up with a fine glass pipette 
 and transferred to a slide, teased out, stained by Gram's 
 method, and examined for gonococci. 
 
 The character of the prostatic secretion will reveal 
 gross lesions of the prostate and microscopic examina- 
 tion of the slide supplements this. 
 
 Urethroscopic examination is the most important of 
 all, and without its aid no final pronouncement of cure 
 is justifiable, even though the microscopic examination 
 reveal no gonococci. Certain points need particular 
 attention in these cases. Briefly they are : 
 
 (1) The colour and brilliance of the mucosa. The 
 mucosa should be of uniform colour throughout, corre- 
 sponding, of course, with each particular region, showing 
 no hypersemic areas, and combined with a glistening 
 appearance which readily reflects light from every point. 
 In other words, a normal central figure. 
 
 (2) Folds. — These should be numerous and well 
 formed, not thick and coarse, responding freely to air- 
 dilatation with the urethroscope. 
 
 (3) The vascular striation should be visible as in a 
 normal urethra, but this condition cannot always be 
 fulfilled. 
 
 (4) Glands of Littre and Lacunae. — These should show 
 no sign of inflammation round the gland mouths. The 
 openings of the gland ducts should be barely visible, 
 and of the same depth of colour as the surrounding 
 
ii6 TREATMENT OF GONORRHCEA 
 
 mucosa. No cysts should be present. This examina- 
 tion is a complete one, and, if it give negative results in 
 all three sections, the patient is probably cured, though 
 a second examination after a further interval (two to 
 three months) is preferable before giving the final pro- 
 nouncement. After another three months, i.e. six months 
 after completion of treatment, the examination should 
 be repeated in entirety, when, if all three methods again 
 prove negative, the patient can be considered cured 
 
INDEX 
 
 Abscess, peri-urethral, 70 
 
 Of prostate, 26 
 Adenitis of groins, 8 
 Anaesthetic, local for urethra, 102 
 Appearance of urethra with 
 
 urethroscope, 93 
 Arthritis, gonorrhoeal, 63 
 Aspiration of joints in arthritis, 66 
 Atropine suppository, preceding 
 
 prostatic massage, 33 
 
 Balanitis complicating gonor- 
 rhoea, 81 
 Baths in prostatitis, 28, 33 
 Bougies in anterior urethritis, 43 
 Prostatitis, 34 
 Clutton's, 34 
 
 Case-recording, method of, 5 
 Chancre, meatal, 82 
 Conjunctivitis, treatment of 75 
 
 Diagnosis of, 74 
 
 Appearance of smear in, 74 
 Cowperitis, 68 
 Cure, test of, 114 
 
 Depression in chronic gonor- 
 rhoea, 106, 112 
 
 Diet in acute stage, 38 
 
 Dilatation, method of, 99 
 Irrigating solutions in, 102 
 Precautions necessary, 101 
 
 Dilator, Kallmann's anterior, 99 
 Posterior, 35 
 
 Electro-chemical treatment, 51 
 Enlargement of glands in groin, 8 
 Epididymis, puncture of, 60 
 Epididymitis, 58 
 Examination of Cowper's glands, 
 
 69 
 Of urine, 15 
 Patient, method, 7 
 Prostate, 25 
 Urethroscopic, 91 
 Vesicles, 106 
 Exercise in acute stage, 39 
 
 Fainting after examination of 
 
 prostate, 26 
 Folliculitis, peri-urethral, 70 
 
 Gonorrhoea, complications of, 58 
 History, diagnosis, etc., 5 
 Routine treatment of, 38 
 
 Gonorrhoeal arthritis, 63 
 Conjunctivitis, 
 Epididymitis, 58 
 Prostatitis, 23 
 
 Groin, enlarged glands in, 8 
 
 Haemorrhagic Urethritis, 4 
 Hip-baths in prostatitis, 28, 33 
 Hypospadias, special nozzle for 
 irrigation, 41 
 
 Incision of peri-uretbral abscess, 
 
 71 
 Indications for examination of 
 prostate, 24 
 
 117 
 
n8 
 
 INDEX 
 
 Infiltration of urethra, 91, 95 
 Ionisation of urethra, 51 
 Irrigation, method of, 41 
 Solutions for, 104 
 
 Janet's system of irrigation, 41 
 
 Kollmann's Dilator, method of 
 use, 99 
 Straight Dilator, 99 
 Posterior Dilator, 35 
 
 Lacuna? of Morgagni, 96 
 Littritis, 95 
 
 Local anaesthetic, for bougies, 102 
 Baths in epididymitis, 62 
 
 Massage of Littre's glands, 43, 103 
 
 Prostate, 25, 33 
 Meatal chancre, 82 
 Medicines in acute stage, 39 
 
 Arthritis, 66 
 Mercury compounds, use of, 54 
 
 Normal appearance of urethra, 93 
 
 Operation for peri-urethral ab- 
 scess, urethroscopic, 71 
 
 Palpation of Littre's glands, 43, 
 
 103 
 Peri-urethral abscess, 70 
 Permanganate of potassium, as 
 an irrigating-solution, 104 
 Of zinc, as an irrigating-solu- 
 tion, 105 
 Prostate, massage of, 25, 33 
 Prostatitis, Acute, diagnosis of, 28 
 Use of bougies in, 34 
 Chronic, 31 
 
 Protargol for irrigations, 105 
 Puncture of epididymis, 60 
 Pyrexia after massage of prostate 
 49 
 
 Recording cases, 5 
 Urine-test, 19, 21 
 
 Secretion in prostatitis, 26 
 Smear from eye, 74 
 Prostatic, 13 
 Urethral, 12 
 Solutions for ionisation, 51, 54 
 
 Irrigating, 104 
 Sounds, metal, in anterior ure- 
 thritis, 43 
 Prostatitis, 34 
 Suppository, preceding massage 
 
 of prostate, 33 
 Symptoms of prostatitis, 24, 27, 
 
 3i 
 Syphilis complicating gonorrhoea, 
 80 
 
 Temperature of irrigating solu- 
 tions, 40 
 Test of cure, 114 
 "Test" Vaccine, 50 
 Threads in urine, 19, 20 
 Treatment, electro-chemical, 51 
 
 Mercury, 54 
 
 Urethroscopic, 107 
 
 Vaccine, 44 
 
 Urethral chancre, 7 
 Urethroscope, Luy's, 90 
 
 In peri-urethral abscess, 71 
 
 Use of, 91 
 
 Wyndham- Powell's, 91 
 Urethroscopic appearances, 93 
 Urine, examination of, 15 
 
 Filaments in, 19 
 
 For gonococci, 13 
 
 Recording, 19, 21 
 
INDEX 
 
 119 
 
 Vaccine test, 50 
 
 Vaccines, in acute stage, 44 
 
 Arthritis, 67 
 
 Chronic prostatitis, 35 
 
 Dosage of, 46 
 
 Epididymitis, 62 
 
 Positive phase,* 45 
 
 Vesiculitis, treatment and symp- 
 toms, 106 
 
 Wyndham- Powell's bougies, 43, 
 102 
 
 Zinc, permanganate, 
 gating, 104 
 
 for irri- 
 
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