•R C gQI Ti2>/g CoUege of ^fjpgicians! anb ^urgeong Hilirarp t PRE SBNTED IN MEMORY' OF ,WILLL\MHENRYDRAPER 1830-1901-P .^T) S.-1855 AND HIS SON WILLIAM KINMCUTT DRAPER 1863-1926-P.AND S-1888 \hafiM>^ri ne rencontre aucune indication precise de la syphilis proprement dite dans les tnedecins de la Grrece et de Rome et eela jette le doubte siir ce point d'Jdstoire medicale." And, further, Lancereaux's contention still holds good. He says : " (Test en vain quon cherche dans antiquite line expo- sition dogmatique de la syphilis., elle ne s'y rencontre pas." The first authentic account of syphilis is given by medical writers about the end of the fifteenth and the beginning of the sixteenth cen- tury. These w^riters, who were familiar with the chancroidal ulcer, describe syphilis as the morbus Gallicus and the morbus novus et inaudi- tus. They recognized the initial lesion and described its physical qual- ities, particularly its hardness. Its venereal origin was soon definitely settled, and the fact that it was the forerunner of constitutional syphilis is clearly brought out in their detailed and graphic descriptions of the evolution of the disease.^ The virulence of this terrible disease caused horror and amazement, for in this famous epidemic none seemed to be spared. Men, women, and children of high and low degree were ' Jacobus Cutaneus, in his Traetatus de Morbo Galileo, 1504, ■writes: "Anno Viro;inei partus millesinio quadragentisimo nonagesimo quarto, invadente Carolo Octavo, Fran- corum Rege, Regnum Parthenopppura, Alexandro Vero, Sexto ea tempestate summum pontificatuni gerente, exortus est in Italia monstrosus morbus, nullis ante seculis visus totoque in orbe terraruin." For the history of the origin of syphilis in the Middle Ages the reader is referred to Geigel, Geaehlelite, PatJiolnr/ie, mid Thernpie der Sypli 1 1 isf, Vi'uvzhurg, 1867; Auspitz, Die Lehrenvom Syphllitlxehen contagium, Wien, 1866; and Proksch, i>ie Geschichte des Vener- ischen Krankheiten, Bonn, 1895. 20 VENEREAL DISEASES. attacked. The disease, in the language of a poet of that period, is said to have "neither spared the crown nor the cross." The epidemic of syphilis which stands out so boldly in medical his- tory occurred about the time (the latter part of the year 1494) when Charles VIII., king of France, Avith a large army invaded Italy Avith the intent of taking possession of the kingdom of Naples, which he claimed by right of inheritance. Charles left Rome on his way to Naples January 28, and reached the latter city February 21, 1495. After a time the Neapolitans revolted against the authority of Charles, and, aided by a Spanish army under the command of Gonsalvo of Cor- dova, they endeavored to drive the French out of Italy. There were then three armies encamped near Naples, and about this time the fear- ful epidemic broke out. It is not definitely established that the disease first appeared among the troops, but they certainly were attacked, and were one of the means of conveying the disease into other countries. There is ample evidence to prove that within a few years the disease had spread over the greater part of Europe. Thus we find that syphilis was by the Neapolitans called the morbus Gallicus, by the French mal de Naples, and was also called the Polish, Spanish, Turkish, and Christian disease. It was also named after some saints, and was called the disease of the holy man Job, of St. Leonard, St. Clement, St. Mevius, and St. Roche. It was not known as the American disease until twenty years after the return of Columbus from his first trip (1493). A writer named Oviedo, long after the death of that great navigator, by means of far-fetched arguments and distortions of facts tried to prove that his sailors became infected Avith syphilis from the Indians in America, and that they carried the disease to Europe. Oviedo and his statements and claims are really unworthy of historical chronicle. It seems strange — and it is certainly unparalleled — that such a strikingly well-marked disease as syphilis should thus break forth in epidemic form Avithin a quite restricted area of territory, and that its nature and origin should be wholly unknoAvn to all observers and Avriters (and very many of them AA'ere learned and experienced men) of that period. Yet the fact remains that it Avas unknoAvn in Europe prior to the last decade of the fifteenth century. Those physicians who had been familiar Avith the chancroid and gonorrhoea prior to the year 1494 had very clear ideas as to their nature, and they kncAv perfectly well that they Avere not in any Avay related to the new disease. Consequently, early in the sixteenth cen- tury there Avas no confusion as to the nature of any of these diseases. As time went on, however, the men who witnessed the famous epidemic died, and in a few years Avhat is knoAvn as the "age of confusion " in venereal diseases appeared. Then syphilis, chancroid, and gonorrhoea came to be regarded as one disease, having one origin, and Avas knoAvn as the venereal disease — lues Venerea. The above-mentioned confusion, Avith the resulting indiscriminate mode of treating these diseases, existed unabated until toAvard the close of the last century, and did not Avholly cease until the first half of the present century had been passed. The identity of gonorrhoea Avith syphilis Avas, hoAvever, denied even INTE OD UCTION. 21 in the last century by Astruc/ Balfour,^ and Benjamin Bell.^ It was believed in by Hunter, but met with further opponents in Swediaur/ Hernandez,^ and especially Ricord,'' who by the use of the speculum in venereal diseases, by means of experimental inoculations, and his discovery of the chancre larve, refuted the chief arguments which had been adduced in its favor, and established the non-identity of the two diseases beyond dispute for ever. This was the first great step out of darkness into light. The idea that all venereal sores are due to a single virus, the virus of syphilis, had been the prevailing one for nearly three centuries prior to the year 1852. At the same time, it had not escaped the notice of many observers that the results of infection were by no means identical — that in some cases the persons infected showed no symptoms after the healing of their ulcers, while others developed a train of symp- toms lasting through years, and even transmissible to their children. In the year 1852, Bassereau^ claimed a distinct cause or origin for each of these two classes of cases. He founded his claim, first, on the history of venereal sores, which we have already referred to, and which shows that although contagious ulcers of the genital organs, communicated in sexual intercourse, had been well known to the an- cients, yet that the constitutional disease which we call syphilis made its appearance in Europe in the latter part of the fifteenth century. Bassereau's second argument Avas based upon the " confrontation " of persons affected with venereal diseases, and he and others were able to prove in several hundred cases that when the disease was local in the giver it was also local in the recipient, and that when it was con- stitutional in the giver it was always constitutional in the recipient ; in other words, that the broad line of distinction separating a local disease on the one hand from a constitutional disease on the other was constant in successive generations without limit. It will be observed that this proof does not involve any diff'erences, real or supposed, in venereal ulcers themselves ; it may be said to rise above such consideration in that it ascends to the source and origin of such sores. Though to Bassereau is certainly due the credit (which was even conceded by Ricord) of sharply distinguishing the non-identity of syphilis with chancroid, yet it is evident in the writings of the latter^ that he Avas convinced that the hard and the soft sores were entirely different in nature and in origin. Ricord comes so near in some passages, particularly in his nineteenth letter, saying what Bassereau afterward proclaimed as a doctrine, that it is surprising that the whole truth did not flash through his mind, for he says that syphilis is abso- lutely inseparable from the indurated ulcer. Undoubtedly, the master gave his disciple the clue which he worked out so successfully and ^ De morhis venereif^, Paris, 1740. ^ Dissert, de (jonorrhma virulenta, Edinburgh, 1767. ^ Treatise on Gon. Virulenta and Lues Venerea, Edinburgh, 1793. * Traite complet des Maladies veneriennes, Paris, 1801. * Essai analytique sur la Non-identite des ViniJi fjonorrheique et syphilitique, Toulon, 1812. ^ Traite pratique des Maladies veneriennes, Paris, 18.38. ^ Traite des Affections de la Peau symptomatiques de la Syphilis, Paris, 1852. ^ " Lettres sur la Syphilis," L' Union niedicale, 1850-51, and Paris, 1852. 22 VENEREAL DISEASES. clearly. Ricord was fully convinced that antecedent constitutional conditions, temperament, bad food, alcoholics, bad hygiene, and inter- current diseases had not, as was claimed, any influence in causing a hard chancre in one man and a soft one in another. He saw, though he does not specifically say so, that the two lesions were due to two distinct causes. Bassereau's lucid separation of the chancroid from syphilis was the second step in the era of light. Unfortunately for medical science, this doctrine, so modestly put forward by Bassereau, Avas not allowed to rest in its clearness and sim- plicity. Clerc, also a disciple of Ricord, while he recognized the clinical distinctions between the initial lesion of syphilis and the chancroid, put forward the claim that in essence they Avere related. Clerc's thesis ^ was that the simple non-infective chancre is the result of the inoculation of the secretion of an infecting chancre upon a subject who has or who has had syphilis, and that it is the analogue of varioloid or false vaccinia; hence, that the term "chancroid" should be given to it. This much may be said, that while Clerc's theory has not been accepted, his name — chancroid — for the soft non-infecting sore is the best that we have. Lntil the time of Bassereau's essay the doctrine of unicism held sway in venereal diseases : that is, that syphilis and the soft sore were alike in nature and origin. To the minds of many Bassereau's modest statement of facts was not radical enough ; so Rollet ^ of Lyons and others set themselves to the task of proving that the chancroid was the expression of a distinct, special virus, and as a result they put forward the doctrine of dualism in syphilis, the essence of which was that syphilis originated in its OAvn virus, and that the chancroid was also the expres- sion of a distinct virus. The stability of this doctrine depended upon the sharpness and precision in distinguishing these two poisons and their results. It was very easy to present clearly-cut lines of diflfer- ential diagnosis between the two kinds of sores, but Avhen the advocates of dualism made the claim that the chancroid was peculiar in the fact that the tissues of the head were immune to it, and advanced the tenet (which was vital to their theory) that the secretion of syphilitic lesions could not be (as were those of the chancroid) inoculated with success upon the person bearing them or any syphilitic individual, they exposed themselves to attacks which have since demolished their main theory. There were, therefore, four principal contentions and many minor ones now unnecessary to consider in the doctrine of dualism : 1st, that the chancroid, like syphilis, was due to a specific, special virus ; 2d, that this virus never originated de novo, but was handed down in generations, each sore propagating only its own kind ; 3d, that syphilitic secretions produced hard chancres about the head and face, Avhich parts were iln- aff"ected by chancroidal pus ; and 4th, that the pus of chancroids was also inoculable, while the secretions of syphilitic sores were not. These tenets were very soon vigorously attacked. The claim that the tissues of the head and face possessed an immunity against the action of chan- ^ "Du Chancroi'de syphilitique," Extrait du. Moniteur des Hopitaia, 1854. ^"De la Pliiralite des Maladies veneriennes," Gaz.med.de Lyon, 'So. 3, 1860; J?€- cherches cliniques. et experimentales aur la Siiphili.% le Chancre simple, et la Blennorrhagie, 1861 ; and Traite des Maladies venenennes, Paris, 1865. INTRODUCTION. 23 croidal pus, while they readily reacted under the influence of syphilitic secretions, was soon demolished by the publication of cases in w^hich true chancroids were found upon these parts. The main points of attack of the antagonists of dualism were — first, that each sore, hard and soft, propagated only its own kind; second, that the soft sore always originates in one of its oAvn species. The first blow delivered by the antagonists of this doctrine was the fact brought out by the experi- ments of Clerc, Melchoir Robert,^ and others, who succeeded in inocu- lating the secretion of syphilitic sores on their bearers, with the result of producing ulcers without an incubation period which presented all the characteristics of the chancroid and were inoculable in successive generations. Then, following up this line of attack, Henry Lee,^ Kob- ner,^ and Pick^ clearly proved that the secretion of a true chancre could become purulent and auto-inoculable when irritated by any agent or means (powdered savin, tartar emetic, setons, etc.). This fact was also proved by Boeck, Bidenkap, and Gjor in their experiments in syphilization. These early observers had at their command only clin- ical observation and experimental inoculations. They made no use of the microscope, and in those days it would have profited them nothing. To-day we know that the syphilitic chancre, when kept clean and un- irritated, gives issue only to serum or sero-mucus. If it is irritated, as it usually is by the deposition of dirt of many kinds, it gives issue to pus which contains pyogenic microbes, which pus will produce chan- croidal ulcers on its bearer and on the non-infected. If the early disputants on the doctrines of unicism and dualism had only known that pus-producing micro-organisms were at the bottom of all the changes in the irritated ha]:d chancre, and that their presence in either is accidental or the result of their own blundering manipula- tions, their controversy would have been short-lived. The unicists at once claimed that the results of these various experiments, above men- tioned, confirmed their doctrine and demolished that of the dualists. The experiments in reality proved that the chancroid might originate de novo. They certainly do not prove a common origin for the hard and the soft sore. To defend itself, the dualistic school then took refuge in the doc- trine of the "mixed chancre," a sore combining both the syphilitic and chancroidal poisons, which, it was asserted, would satisfactorily explain all these cases and still leave the tenets of dualism, as at that time understood, intact. This explanation was for a while regarded as satis- factory, but it could no longer be upheld when such experiments had been multiplied indefinitely ; when their number was so great that the chance of the commingling of two kinds of specific virus in their simul- taneous inoculation was reduced to an absurdity ; when an indurated syphilitic primary lesion could be taken at random, and, after due irri- tation, its secretion could be successfully inoculated, with the eifect of ^ Nouveau Traite des Maladies veneriennes, Paris, 1853 and 1861, pp.306 et seq. '^ Brit, and Fm-eir/n Med.-Chir. Review, vol. xxiii., April, 1859, pp. 496 et seq., and Lancet, 1856, 1869, 1860, and 1861. ^ Klin, und Experiment. 3Iittheiiungen aus der Deiinatologie und Syphilidolo(/ie,EiTla.ngen, 1864, pp. 70 et seq. * Auspitz, op. cit., pp. 335 et seq. 24 VENEREAL DISEASES. producing pustules and ulcers bearing every characteristic of the chan- croid ; and when the same result could even be obtained at will by the inoculation of the secretion from a purely secondary lesion, as, for in- stance, a syphilitic mucous patch. If the chancroid was dependent upon a distinct specific virus, its presence in all these cases was simply impos- sible, and yet not a single shade of difference could be pointed out between the result produced and that from the most emblematic chan- croid ever met with in practice. Dualism was indeed henceforth dead, if by "dualism" be meant that each of the two kinds of venereal sore has a distinct, specific virus of its own. A mixed chancre is simply an accident, and is by no means a uni- form pathological process. Any hard chancre may be attacked by pus- microbes and its general appearances much changed. There is, then, the same aggregated mass of specific syphilitic cells which has become the seat of ulcerative action. But the last word had not been spoken in favor of a distinct origin of the chancroid from that of syphilis, nor the last experiment made and recorded which would decide this question. Let us examine more carefully the experiments just referred to. What w^as the matter so suc- cessfully inoculated ? The pure, unmixed virus of syphilis ? By no means. It was a compound product, taken, to be sure, from a syphilitic lesion, but a lesion irritated commonly to suppuration by artificial means, containing possibly the germ, of syphilis, but containing also, and in fact chiefly composed of, jjus, which we know to-day contains pyogenic micro-organisms. Which of these two factors was responsible for the effect produced ? The syphilitic virus ? In that case this virus should have preserved its poAver of infecting the constitution, and matter taken from these ulcers and inoculated upon healthy individuals should have invariably produced syphilis, which has been shown not to be true. More- over, if it could be proved that pus alone, free- from all suspicion of syphilitic mixture, Avas capable of producing the same result, then pus was the pathogenic factor. This idea opened up a new line of attack, led mainly by Pick, Reder, and Kraus. In 1865, Pick, at the suggestion of Zeissl,^ inoculated simple, non- venereal pus of inflammatory origin upon syphilitic subjects. Taking the secretion of pemphigus, acne, scabies, ecthyma, and lupus, he in- oculated it upon persons affected with syphilis and produced pustules not preceded by incubation, and the matter of which was further inocu- lable through several generations. Counter-inoculations upon the per- sons free from syphilis who were the bearers of these affections were without effect. The same result was attained by Kraus and Reder ^ with the pus of scabies, and by Henry Lee ^ with pus from a non-syphilitic child. The late Mr. Morgan * of Dublin also succeeded in producing pustules and ulcers identical in appearance Avith the chancroid, and capable of reinoculation through a number of generations by inoculat- ing syphilitic women with their vaginal secretions. It is unnecessary to further amplify this subject, for to-day there is no fact more clearly proved in medicine than that pus applied to the ^ Lehrbuch cler Syphilis, Stuttgart, od ed., 1875, pp. 180 et seq. ^Pathologic und Therapie der Veiierischen Kmnkheilcn, Wien, 1868, pp. 25 et seq. ^ Op. cit. * Practical Lessons in Contagious Diseases, London, 1872. INTB OD UCTION. 25 skin, particularly of those actively attacked by syphilis, will produce suppurative dermatitis. The evidence oflFered by cases of ecthyma and impetigo contagiosa proves very conclusively that these diseases are due to pus-implantation. What is thus far in our study proved by scientific investigations is, that the secretions of irritated syphilitic lesions, primary and secondary, when inoculated on persons suffering more or less from active syphilis produce pustules and ulcers absolutely like chancroids in all their cha- racteristics and attributes. The fact that the skin and the mucous membranes in early — and sometimes in late — syphilis are peculiarly sus- ceptible to irritation and inflammation is undoubtedly the underlying factor in this pyogenic process. Thus far, it will be seen that the inoculations had only been made upon syphilitic subjects, and the burning question which then arose was : What effect had this pus, experimentally produced on a syphilitic, when inoculated upon a non-syphilitic subject? To prove that this same in- oculation was possible on non-syphilitics without the transmission of syphilitic infection to them was then the crucial point in the controversy. Strange as it may seem, the necessary evidence presented itself by mere chance in the experience of men who were not working in this direction. The following observations by Boeck, Danielssen, Bidenkap, and Gjor paved the way to a correct understanding of this obscure point : Boeck ^ in 1856 treated a non-syphilitic woman suffering from chronic eczema rebellious to all forms of treatment by means of repeated inocula- tions with the irritated secretion of hard chancres. The woman was bene- fited, and was not rendered syphilitic. Five years afterward this treatment was again employed on the same woman at the hands of Dr. Bidenkap, who took matter from a typical hard chancre which had been irritated. The result was the production of pustules, but syphilis was not trans- mitted. Danielssen's ^ observation is still more striking : A man thirty years old, free from syphilis, was inoculated three hundred and ninety-three times with pus derived from irritated hard chancres, and Avas not ren- dered syphilitic. Later on he was inoculated directly with the natural secretion of a hard chancre, and became the victim of syphilis. Bidenkap's * case is also very convincing. It was that of a non- syphilitic woman suffering from gonorrhoea, who inoculated herself with the pus derived through several generations from an initial syphilitic lesion, with the result of producing a sore identical with a chancroid, the secretion of which was accidentally auto- inoculated with success. At this time the woman was not infected with syphilis, but a year and a half later she became infected. Gjor's cases, communicated in writing to Dr. Bumstead, offer import- ant cumulative evidence. Gjor was practising the now obsolete method of treating syphilis by syphilization, which consisted in the continuous inoculation of the patient with virus derived from irritated early syphi- '^ Recherches sur la Syphilis, Christiania, 1862, p. 686. Tliis is the case usually attrib- uted to Bidenkap, who experimented on it under Boeck's direction. '^ Die Syphilisation in ihre Aruvenduny yeyen Syphilis unci Spedalskecl, 1858. This case was also reported by Dr. Gjor, Deutsche klinik, 1858, 33. ^ Om del syphilitiske Vii-us, Christiania, 1863, and Wien. med. Wochemchrift, 1865, No. 34. 26 VENEREAL DISEASES. litic lesions. The cases now detailed became inoculated with pus derived from irritated mucous patches. The first case was that of a girl twenty- five years old, free from syphilis and under treatment for some simple afi"ection. She stealthily procured some of the pus and inoculated her- self, with the result of producing chancroid-like pustules. She has never presented any symptoms of syphilis. The second case was that of a girl aged nineteen, free from syphilis, who inoculated herself in a similar manner with a similar result. For several months after this experience she was kept under observation, but showed no signs of syphilis. A year and a half later she contracted a true chancre in sexual intercourse, which was followed by secondary manifestations. The third case was that of a girl eighteen years old, who followed the examples of the two preceding girls and produced chancroids, but was not infected with syphilis. These observations and experiments warrant the following conclu- sions : 1. That irritation of syphilitic lesions, particularly the early ones, gives rise to an actively destructive form of pus which by auto-inocula- tion produces ulcers identical in all characteristics and attributes with chancroids. 2. That this pus inoculated upon subjects virgin to syphilis produces ulcers unmistakably chancroidal and inoculable in generations like chan- croids. 3. That this form of pus, though very irritating and destructive, does not contain the germ of syphilis. Clear and convincing as this evidence is, it can be urged against it that it is experimental and not clinical. It was my good fortune early in 1870 to observe an undoubted and incontrovertible case in which chancroids were contracted by a non-syphilitic woman from irritated lesions resembling chancroids in her syphilitic husband. This man, syphilitic in 1869, came in March, 1870, with a papular syphilide and acute gonorrhoea. A few days later he came with a group of unruptured herpetic vesicles on the under surface of the prepuce near the fr^enum. He had not had coitus in three weeks. During the Aveek following his gonorrhoea remained active, and at the end of that time I found that the herpetic vesicles presented the appearance of oval, absolutely typical chancroids. A few days later his gonorrhoea, being on the decline, while intoxicated he had connection with his wife, who ten days later came to me with five or six large typical chancroids on the fourchette and inner aspect of the labia minora. The wife also was careless, and her chancroids became large and deep and gave rise to a typical bubo. The husband also had a chancroidal bubo. Two years later the woman contracted syphilis from a lover. Here, then, is a case of a man suffer- ing from active syphilis who had undoubted herpetic vesicles, which, owing to contamination Avith pus-microbes, become converted into true chancroids, which chancroids gave rise to similar lesions in his wife. This clinical observation, very carefully made and duly noted, confirms in every particular the results of experimental inoculation. During the past twenty years I have seen several cases of chancroids in men which have been traced to purulent and muco-purulent genital discharges in women in the secondary stage of syphilis. It can be safely asserted that INTR OD UCTION. 27 any observer may obtain similar results if he will take the pains to fol- low up to their origin a series of cases of chancroid in the male. I have also seen chancroids in the female which had been contracted from men whose hard chancres in their period of decline had become irritated, and then resembled chancroids. Thus far we have seen that the chancroid may become developed de novo from the secretion of irritated syphilitic lesions both in syphi- litic and virgin subjects. It has also been shown that pus taken from healthy persons and inoculated upon syphilitic subjects has produced pustules and ulcers in all particulars like chancroids. Thus far, how- ever, although it has been shown that the chancroid may originate de novo, the inoculations have been upon syphilitic subjects by means of their own irritated secretions, or these secretions have been inocu- lated upon healthy persons. The case, therefore, cannot be considered complete, and the doctrine of dualism effectually destroyed, until we have cut adrift wholly from syphilis, and have proved that pus from non-syphilitic subjects may be inoculated on its bearers or other healthy subjects, and that from such inoculations ulcerations similar to chan- croids have been produced. Though the inoculability of many forms of pus is well known and generally conceded, it is best to give here the evidence as it has thus far been presented in its bearings upon the doctrine of dualism. The first experiments are those of Dr. E. Wigglesworth ^ of Boston, made in 1867-68 upon himself. He, being free from all disease and only a little run down from over-study, took pus from an acne-pustule upon himself and inoculated his arm. The result Avas the development of well-marked pustules which were successfully inoculated in three gen- erations. On the removal of the crusts perceptible ulceration of the skin was seen. Wigglesworth then made the claim, which has since been substantiated, that the products of simple inflammation if properly introduced into the skin will cause local ulcers resembling chancroids. Next in importance are the results obtained by VidaP in 1846 and again in 1852, which, while they amply proved (at a time when this subject was enveloped in doubt and obscurity) that simple non-specific pus was auto-inoculable upon its bearer, had much influence upon the trend of thought in this direction. Vidal inoculated ecthymatous pus upon its bearers, who also suffered with typhoid fever : the result was the development of pustules identical with those from whence they were derived. Kaposi's^ testimony has also had much weight in determining the exact nature of the chancroid. He says : " My own experiments have taught me that non-specific pus, such as that from acne and scabies pustules, when inoculated upon the bearers, as well as upon other non- syphilitic persons, will produce pustules whose pus proves to be con- tinuously inoculable in generations." Further evidence is given by Tanturri,^ who by inoculations of pus ^ Written communication to Dr. Burastead. '^ " Inoculabilite des Pustules d'Ecthyma," Annates de Deiitiat. et de Syphiligraph., 1872 and 1873, vol. iv. pp. 350 et seq. ^ Die Sijpkilis der Haul und der ungrenzenden Schleimhdute, p. 47, Wien, 1873. * " Suir eterogenia dell' ulcera non-sifilitica," Giornale ltd. delle Malat. Vemr. e della Pelle, vol. ix. 1874, pp. 257 et seq. 28 VENEREAL DISEASES. from various sources succeeded in producing characteristic ulcers. These experiments of AVigglesworth, Kaposi, and Tanturri, taken in connection with those previously detailed, are of the greatest value, and they certainly warrant the conclusion that ulcers similar to the chan- croid may be produced by the products of simple inflammation. Some- thing more, however, was needed to clinch the matter, and this has been supplied by the very convincing experiments of Finger.^ This observer took for his subject a woman suffering from leucorrhoea and eczema. These affections were cured ; the uterine and vaginal secretions Avere then demonstrated to be innocuous, and it was established beyond doubt that the woman was not suffering from chancroids. Further than this, there had not been a case of chancroid in the hospital for several weeks. Every care was exercised that no contamination of the woman from without could occur. Finger then with the curette irritated the poste- rior vulvar commissure, and Avithout cleansino; or bandagincr the parts he put the woman to bed. Inoculations with the scant secretion of this erosion were unsuccessful. Then Finger smeared the lesion over with powdered savin. On the following day there was an abundance of true pus, from which a series of successful inoculations were made upon the patient's thighs, which were further followed by an inflammatory bubo in the groin. A man was successfully inoculated with the pus from the woman's thighs. Four more cases were experimented upon in like manner, with similar results. The teachings of these cases are particularly striking in the fact that the suppurative process was developed upon the genitals, and that with the pus thus obtained ulcers in all respects like chancroids were pro- duced. These observations are sujiported by facts observed by Tom- masoli^ in clinical practice. Tommasoli had under his care a man who did not contract chancroids in coitus, and was not exposed to any infection. He simply suffered from severe balanitis, which was further complicated by the development of vegetations in the coronal sulcus. As a result of these combined inflammatory conditions a purulent dis- charcre was established which gave rise to ulcers identical with chan- croids, from Avhich inoculable pus was obtained. In the section on the etiology of chancroid as presented in clinical practice many cases corroborative of Tommasoli will be found. At this late day it may seem almost unnecessary to follow the fore- going series of cases in their full detail, since they only prove what is so generally known and conceded, that pus rich in pyogenic microbes is promptly and freely inoculable and auto-inoculable. But even now there are physicians (usually those who have failed to acquaint them- selves with all the facts involved in the battle between the unicists and the dualists) Avho have vague ideas as to the nature of the chancroid, and Avho prefer to look upon it as an occult and mysterious ulcer rather ^ "Ueber die Natur des Weichen Schaiikers" (Vierteljahr.fur Derm, und Syph., 1885, pp. 670 et seq.) and "Zur Frage iiber die Xatur des Weichen Schankers und die Infectiositiit tertiarer syphilisprodukte " {AUc/. Wien. Med. Zeituny, 1887, Xos. 9, 10, 11, 13, 14, and 15). ^ " Beitrag zur Kenntniss des Weichen Schankers," Allg. Wien. Med. Zeitung, 1886, vol. xxxi. p. 351. INTR on UCTION. 29 than as one whose origin is clearly known, and which at best is a hybrid affair, an ordinary septic ulcer of the genitals. Carefully reviewing and weighing all the foregoing facts, we are warranted in stating that ivhile the chancroid may he — and very com- monly is — derived from a jyrevious chancroid, a chancroidal bubo, or chan- croidal lymphangitis, it may also 07'iginate in the pus derived from irritated lesions of syphilis and from irritated simple lesions in syphilitic subjects, and also in simjjle pus, particularly when originating in active or intensely irritated lesions. "With this disposal of the question of the essential virulence of chan- croid, the assertion which is loudly proclaimed by some, that " if all the patients in the world with chancroid would avoid contact with others until their malady got well, the disease would cease from off the face of the earth," is at least amusing. Experimental studies in pus-inoculation show that the intensity of the destructive action of the secretion depends largely on the degree of irritation to which the producing lesion is subjected, and that its unknown quality, which has wrongly been called " a special specific virus," is really due to that. Pathology further teaches that the activity of the pus resides in the vast number of microbes proliferated and in the toxines Avhich they give rise to. A common-sense view of the course of these destructive ulcers of the genitals does away with the necessity of assuming a subtle virulent action as being possessed by them. Of all parts of the human frame, the genital organs are those most prone to irritation. In them the circulation in capillaries and sinuses is very abundant. They are the seat of frequently-recurring congestions with or without coitus, and are largely under the control of the mental emotions. Their conformation is such that unless kept continually and scrupulously clean inflammations are sure to occur. What wonder, then, that ulceration is severe upon these exuberant regions ! Syphilis is a virulent disease ; chancroid is a hybrid, heterogeneous lesion, a septic ulcer, and in many cases an active form of wound-infec- tion. The unicists would have been right if they had claimed a special virus for syphilis only, but they erred in attributing a similar origin to the chancroid. The dualists were warranted in asserting that there is a specific syphilitic virus, but the reader can judge from what has been presented in the foregoing pages how much importance he shall attach to their claim that there is a special specific virus for the chancroid. It may be mentioned, as a matter of history, that gonorrhoea was relegated to the plane of a catarrhal process by Ricord when he demon- strated its non-identity and non-relationship to syphilis. It is no longer necessary to burden the mind with the points brought out by the advo- cates of the catarrhal origin of gonorrhoea against the claim of the virulists that it was a virulent process, since to-day it is clearly proved that the contention of the latter is correct. PART I. GONORRHCEA AND ITS COMPLICATIONS. CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE PENIS, THE UEETHRA, THE BLADDER, THE PROSTATE, AND ACCESSORY PARTS. For a thorough knowledge of gonorrhoea and its complications and sequelae a clear general understanding of the anatomy and physiology of the genito-urinary tract is necessary. The penis is a pendulous organ consisting of root, body, and glans, and through it three-fourths of the urethra runs. It is the organ of copulation and of urination, and is composed of two parallel cylindrical bodies called the corpora cavernosa, which, lying side by side, have a groove on their under surface in which is situated the corpus spongio- sum. These cylindrical bodies, with connective tissues, vessels, nerves, and lymphatics, together with the tegumentary investment-sheath, form the penis. Each corpus cavernosum has a dense, quite thick, but very elastic fibrous investment, from which thin processes or trabeculge pass inwardly and form cavities which are filled with erectile tissue. The inner sur- face of each cavernous body is thick and complete in the proximal part of the penis ; consequently, there is at that part a distinct septum formed by the fusion of these two inner surfaces. More anteriorly or distally there are only a number of vertical bands of fibrous tissue arranged like the teeth of a comb, and hence called the septum jjeetiniforme. It is important to bear in mind the structure and relations of the cavernous bodies, as well as of the spongy body, in operations on the penile ure- thra. The corpus spongiosum also consists of a firm, fibrous sheath, from which trabecular processes pass inward and form meshes which contain erectile tissue. In the outer coat of the corpus spongiosum is a thin layer of circular muscular fibres continuous with those of the bladder. A second layer of longitudinal muscular fibres is situated between the inner surface of the corpus spongiosum and the mucous membrane of the urethra. The corpora cavernosa constitute the chief bulk of the penis, and each one begins in a tapering portion, the crus penis, which is attached along a groove in the rami of the ischium and os pubis. They are fur- ther attached to the symphysis pubis by a strong elastic suspensory ligament, the base of which is fused in their fibrous tissue and the apex is inserted into the symphysis. Converging together at once at the root 31 32 GONORBHCEA AND ITS COMPLICATIONS. of the penis, these cylindrical bodies run parallel side by side, and each ends in a bluntly-rounded extremity Avhich fits in a depression in the base of the glans penis. The corpus spongiosum surrounds the urethra from the triangular ligament to the meatus urinarius. It begins in the centre of the peri- neum in an expanded form called the bulb, which rests directly on the anterior surface of the triangular ligament. It then runs under the corpora cavernosa in the groove left for it, like a ramrod under a double-barrelled gun, and ends in an expanded extremity, the glans penis, the apex of which corresponds to the meatus. The glans penis is therefore the expanded distal portion of the cor- pus spongiosum, Avhile the bulb is its proximal expanded portion. The glans is an obtusely-conical, acorn-shaped body, somewhat flattened on its upper surface, and ending in a rounded, expanded portion called the corona, which rounds off abruptly and projects like a collar beyond the body of the penis proper, and behind it is seen when the prepuce is retracted a nearly circular groove called the coronal sulcus, the balano- preputial furrow, and the cervix. A little below the centre of the apex is the vertical slit-like opening of the urethra, called the meatus. The under surface of the glans is flat and triangular in shape, the apex of which usually ends at the inferior commissure of the meatus, and into it the fraenum of the prepuce is inserted. The integument of the penis forms an investing sheath w^hich retains its tubular form in the normal condition up to a little beyond the extremity of the glans penis. Then it is reflected or folds on itself, backward, in the form of a mucous mem- brane, and is inserted by gradual merging into the whole length of the coronal sulcus. It is then reflected forward over the glans, to which it is firmly adherent, and ends at or a little wathin the orifice of the meatus, with the mucous membrane of which it is continuous. Thus it is that for a short distance (one-quarter to one inch or more) the mucous mem- brane of the urethra consists of squamous or pavement epithelium. The fact of the firm adherence of the mucous membrane to the glans and of the absence of loose connective tissue explains why hard chan- cres of this part are not much indurated, and Avhy chancroids are slow in their destructive action. That portion of the under surface of the prepuce which is in the median line becomes transformed into a fibrous band which is called the frgenum preputii, and which, as we have seen, is inserted just under the lower part of the meatus urinarius. The prepuce, therefore, consists of two layers — the outer one integumentary and continuous with the skin of the penis, and the inner or reflected one formed of mucous membrane, w^hich is covered with stratified pave- ment epithelium, which extends, as already stated, into the meatus for a varying distance. The integument of the penis is very thin and extensible, and very readily movable over the cavernous and spongy bodies by means of a very delicate, loose, and abundant connective tissue destitute of fat-cells. The integument of the penis is plentifully supplied with sebaceous and hair-follicles, which frequently become the seat of inflammatory processes and of new growths (milia and wens). In the normal condition the prepuce, or foreskin, forms a tube of quite uniform calibre, which is loose and roomy and readily admits of ANATOMY AND PHYSIOLOGY OF THE PENIS, ETC. 33 its retraction and replacement over the glans penis. Usually it ends at or just beyond the meatus. In some cases, however, it is redundant and extends more or less beyond the end of the penis. Then, again, it may be short, so as only to cover a portion of the glans, and in quite exceptional cases in the adult there is no prepuce at all. In this event it has happened that as the penis developed the integumentary layer did not correspondingly increase. Sometimes the preputial orifice is very small, so that it will Avith difficulty allow the glans to emerge through it. Then, again, this con- traction may be so great that only a pin-sized aperture is seen, in which event retraction is impossible and very little of the glans or meatus can be seen. In some cases the calibre of the prepuce is decidedly too small for its easy retraction, and it then may exert injurious pressure upon the glans. In other cases the frgenum is too short (and it is then usually a rather thick cord), and by the contraction which it exerts upon the prepuce some deformity results. These conditions are shown in the chapter on Phimosis. The penis is cylindrical when flaccid, triangular in shape when tur- gid, and therefore has three sides with corresponding rounded margins. The dorsal flat surface is broader than the lateral surfaces. It is widely stated that the mucous layer of the prepuce normally contains minute sebaceous glands called by old writers glanduloe Tysonii odoriferce. This, however, is erroneous. Whenever present, Tyson's glands are situated externally on the penis, and are distributed along the corona glandis in the sulcus and on the reflection of the prepuce and near the frgenum. In young children these glands are fairly numer- Showing a section through one of Tyson's glands in the prepuce of a young child. ous, but in adults they are much more difficult to find, as they seem to become atrophied to a large extent. Tyson's glands are identical in every respect in structure to the sebaceous glands of the skin or scalp. 3 34 GONOBRHCEA AND ITS COMPLICATIONS. They consist of two or more bag-like acini lying just beneath the epi- dermis, which open into a common duct, and the whole cellular lining of the duct and the gland is continuous with the epithelium of the skin. (See Fig. 1.) Von Diiring ^ has made an exhaustive study of the microscopical anatomy of the preputial mucosa, and he claims that it contains no glandular structures whatever, but that there are minute inversions or invaginations of the mucous membrane in the form of diverticula, and longer and narrower ones found near the frsenum, which he calls cys- ternse frsenuli. The so-called glands are therefore simply reduplicatures or invaginations of the membrane in the form of minute shallow or deep crypts. Von Diiring's conclusions have been confirmed by investigations made for me by Dr. Van Gieson. Certain clinical and pathological observations, however, seem to show that occasionally one or more Tyson's glands persist in later life. (See p. 193.) • Preputial smegma, that whitish coating of cheesy odor, is therefore simply effete epithelium, perhaps formed in the crypts or on the mucous membrane itself. The meatus is normally a constricted part of the urethra. In struc- ture it varies more or less in diiferent individuals. In some its vertical lips are thin and coapt with each other like the leaves of a book, form- ing a not prominent vertical slit. In other cases the lips are more or less rounded and the meatus has a rather expanded, pouting appearance. Then, again, owing to the fact that the mucous membrane is rather redundant and loose, its lips sometimes have an uneven, somewhat mam- millated appearance. In some very rare cases the mucous membrane forms a cylinder of a line, or even a third of an inch, in length beyond the apex of the glans, constituting a membranous extension of the urethra to which my friend Dr. Otis ^ applies the term " fusiform meatus." In somewhat rare cases a thin septum is seen to extend hori- zontally across from one lip to the other, seemingly dividing the meatus into two parts. Separation of the lips, however, shows that this septum simply forms a blind pocket which may be shallow or rather deep. In this condition the narrowing of the meatus is at its superior portion, and therefore the surgical indication here is to relieve the trouble by cutting toward the roof of the urethra, while in almost all other cases the rule is to cut toward its floor. In somewhat exceptional cases the meatus is very small, even of pin- head size. In this case it will generally be found, by passing the tip of a probe inward and downward, that the abnormal smallness of the cali- bre is due to the fusion of the mucous membrane at the lower commissure. While a full consideration of the malformations of the meatus and glans (which belong to the domain of general surgery) is not germane to this w^ork, it is well to mention, in a general way, that there may be more or less absence of the floor of the urethra in its glandular portion, in which case the urethral orifice is a small, round, or a transverse, slit- like hole. This condition is called hypospadias. ■* "Beitrage zur Anatomie des Penis," Monatshefte fur Prakt. Dermalologie, vol. vii. pp. 1117 et seq., 18S8. 2 The Male Urethra, p. 10, Detroit, 1888. ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 35 Fig. 2. The seat of the urethral orifice or meatus is sometimes found higher up on the dorsum of the glans, and in one case I found that the urethra at the base of the glans turned upward quite abruptly and ended in a well-marked slit seated in the middle line of the coronal eminence. Absence of the distal part of the upper wall of the urethra is called epispadias. The male urethra is a slit-like canal, regarded by some as a closed valve, which extends from the bladder to the meatus urinarius. It is the vent-pipe for the urine and gives issue to the seminal fluid. It there- fore has two functions, which must be kept in mind in order that its diseases may be clearly understood. It is in direct relation with the kid- neys, the ureters, and the bladder, and may be the means of trans- mitting disease to these organs of the urinary system, or it, in turn, may become diseased by the exten- sion of pathological processes from these organs and structures. Then, again, pathological processes attack- ing the urethra may extend to all or to certain portions of the geni- tal system — namely, the testicles, the vasa deferentia, the seminal vesicles, and the prostate and its crypts and follicles. In its turn the urethra may be involved by the extension of disease from either of these structures and appendages, with which it is in direct anatomi- cal relation. If the function of the urethra were simply that of trans- mitting the urine, a length of about two inches would be sufficient, as it is in the female, but, being also a part of the genital apparatus, its length is necessarily much increased for purposes of intromission and fec- undation of the female. This in- crease in length, as Ave have seen, is due to the existence of the cav- ernous and spongy bodies. The urethra is composed of three layers — a mucous layer, a submucous connective-tissue layer, and a muscular layer. Its walls are always in contact, except during the passage of urine and semen, a period of three or four minutes during the day. The average length of the urethra is from seven to Showing the normal urethra opened longitudi- nally on its upper surface. 36 GONORRHCEA AND ITS C03IPLICATI0NS. eight and a half inches, but it may be shorter or longer. It is increased in length during erection and in hypertrophy of the prostate. When the urethra is split longitudinally in its whole extent on its upper surface, its course, with its varying expansions, comes into view. (See Fig. 2.) At the meatus urinarius we find a normal narrowing of the canal, w^hich then expands into a spindle-shaped portion which is called the fossa navicularis ; hence this is called the navicular portion of the urethra. As this part emerges into the spongy or penile por- tion a slight constriction occurs. The canal then expands, and we find it of somewhat uniform calibre in its course through the corpus spon- giosum for a distance of four or five inches. It then expands again, in conformity with the bulbous expansion of the corpus spongi- osum, and a spindle-shaped canal is formed, which is from an inch to an inch and a half in length, and which is called the sinus of the bulb or the bulbous portion of the urethra. Again becoming contracted at the anterior layer of the triangular ligament, it has a uniform calibre for a distance of about three-quarters of an inch, when, at the posterior layer of this ligament, it emerges to expand again into the prostatic urethra. In its course through the triangular ligament it is simply a membranous canal seated about an inch beneath the summit of the pubic arch and surrounded by the compressor urethr?e muscle. The prostatic urethra is the direct continuation of the membranous urethra. It also has a spindle shape, and is about an inch and a quarter in length. (See Fig. 2.) Thus, anatomically, there is a navicular, a spongy, a bulbous, a membranous, and a prostatic portion of the ure- thra, making five divisions in all. The term "penile," or pendulous, urethra is also applied to that portion which extends from the glans to the peno-scrotal angle. Clinically, in a general Avay, we speak of the anterior and posterior urethra, the former ex- tending to the anterior layer of the triangular ligament, and the latter including the portion beyond. The mucous membrane of the urethra is smooth and shining and of a yellowish-pink color, which is deeper at the first inch and at the bulbous portion. For a short distance — one- fourth to one inch w^ithin the meatus — the mem- brane is covered with flat pavement epithelium ^ beyond that part it is of the columnar variety as far as the vesical orifice. With the naked eye we observe, particularly on its upper wall, certain valve- or pocket-like reduplications of the mucous membrane, which are called lacunae. Generally there is but one large one, which is seated on the upper wall of the navicular por- tion of the urethra, one-half to three-quarters of an inch from the meatus. This structure is called the lacuna magna, and is well shown There may be, exceptionally, several of these valve-like struc- FlG Sectirn f tht urethia slit up on Its lower wall, show ing the lacuna magna and a deeper, valve-like pocket and the orifice of numerous mucous glands. in Fig. 3. ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 37 tures, which, however, are not, as a rule, found deeper than three inches from the meatus. In Fig. 3 a second lacuna is portrayed, about an inch and a half beyond the lacuna magna. With the naked eye — or, better, with the aid of a pocket-lens — a num- ber, sometimes large, of minute pits or openings may be seen, particularly on the upper wall of the urethra, for a distance of three or more inches. These are the orifices of the mucous follicles or glands of the urethra. Though they are generally found on the upper, they are sometimes seen on the lower, wall, as shown in Fig. 2, which was drawn from nature. These glands are usually not very closely grouped together, being sepa- rated from each other by about three or four millimetres, and the excre- tory duct appears as a tiny pit about one-half millimetre in diameter. If a flap of urethral mucous membrane is dissected up, these follicles can be seen in the submucous connective tissue in the shape of very minute yellowish masses. The mucous glands of the urethra are said to be the follicles or glands of Littre and the lacunce or crypts of Morgagni, but there is a general lack of directness of statement on the subject, and our know- ledge is therefore not precise. The truth is, that the crypts of Morgagni are nothing but the glands or follicles of Littre, which have an unusually tortuous or wide-mouthed duct, and structurally they are simply mucous glands which are a trifle larger or more prominent macroscopically than the remainder of the glands. Fig 4 One of the mucous glands, or glands of Littre, opening into the lumen of the urethra : x, y, lateral branches of the main duet with their more supurflcially-situated acini; z,z, continuation of the main duct witli deeply-situated acini ; s, s, sinuses of the cavernous tissue ; tv, w, tunica albuginea. In structure these glands or follicles follow the type of the compound racemose gland (Fig. 4). The duct divides into one or more branches 38 GONORRHCEA AND ITS COMPLICATIONS. Fig. 5. which pass directly into a cluster of two or three or more acini lined with cylindrical epithelium like that lining the ordinary mucous glands, as of the trachea or duodenum. As a rule, the main duct divides into one or more secondary branches. In Fig. 4, for example, there are in the particular plane of the section three branches of the main duct, each becoming continuous with a cluster of a rather limited number of terminal acini. The epithelium of the urethra passes over into the mouths of the ducts and lines them almost down to the junction with the acini. While the branches of the main duct pass oif laterally and more or less parallel to the surface of the urethra, the main duct passes down more vertically, deep into the cavernous tissue of the urethra; consequently some of the gland-acini, as those of the branches x, y in Fig. 4, are quite superficially situated, while the acini belonging to the main duct lie very deep, sometimes almost reach- ing down to the tunica albuginea (Fig. 4, z). The lacuna magna is a large, tortuous mucous gland which opens into the apex of the valve- like reduplication of the urethral mucous mem- brane just at the posterior limit of the fossa navi- cularis. In structure all these valve-like pock- ets are the same. The ducts of the follicles or glands pursue a more or less oblique course, di- rected forward toward the meatus. This condition is well shown in Fig. 5. When the urethra is col- lapsed the mouths of the ducts generally open into the bottom of the folds or creases into which the urethral lumen is thrown. If the urethra is dis- tended or stretched out flat (as was the case in Fig. 4), the relation of the ducts of the glands to the surface of the urethra becomes much plainer. One point of practical importance in reference to these mucous glands, as Avill be shown later on, is the considerable involvement of their mouths and deeply-situated ducts by the extension of the inflammation in acute, and especially in chronic, gonorrhoea. Another important point to be remem- bered is, that in passing large and particularly small instruments through the urethra it is neces- sary to hug the lower wall in order that the point of the instrument may not be caught in the vari- ous pockets and follicular orifices. A glance at Fig. 5 will make these points very evident to the mind. This figure shows the upper wall of the urethra, in which are very many quite patulous ducts of mucous glands into which bristles have been passed. It will be seen that the course of the duct outlet is obliquely outward toward the meatus. The male urethra is best studied by tracing its course from the bladder toward the meatus. The relations between the urethra, the n /I Section of the urethra on its lower wall, showing the upper wall, with bristles passed into the ducts of mucous glands. ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 39 bladdei', and the prostate are so intimate that a kno'wledge of these organs is essential. The bladder is the musculo-membranous reservoir for the urine, and is seated in the pehds behind the pubes and in front of the rectum. When empty and contracted it is a small triangular sac deeply seated in the pel- vis. When distended it assumes a rounded form, partly fills the pelvis, and rises into the abdominal cavity. In many cases of retention of urine it is so distended that its apex reaches the umbilicus. Its vertical is greater than its lateral diameter, and its long axis is obliquely downward and back- ward, owing to the fact that it curves slightly toward the abdominal wall. The apex of the bladder is rounded and connected to the umbil- icus by the urachus. The front of the body of the bladder is not cov- ered with peritoneum, and is in relation with the triangular ligament, the symphysis pubis, and the internal obturator muscles. The peritoneum is reflected from the anterior surface of the rectum to the lower and back part of the bladder about an inch distant from the base of the prostate and just behind the points where the ureters pass into the bladder. It, however, in some cases comes down as low as the base of the prostate. It then passes to the summit, and from there is reflected upon the abdominal wall. As a result of this arrange- ment the peritoneum sags down behind the pubes when the bladder is empty. As the viscus becomes distended its base extends toward the perineum and its summit comes in contact Avith the abdominal walls. As it rises in the abdomen the prevesical peritoneal covering of the bladder gradually forms a pouch which, when the organ is much dis- tended, and particularly when the base of the bladder is elevated by a distended rubber bag in the rectum, becomes more and more elevated above the pubes, and leaves a space of two or three inches of the ante- rior wall of the bladder free from peritoneum. This arrangement of the anterior bladder-wall and of the peritoneum must be borne in mind in the operations of aspiration and of suprapubic cystotomy. It is also necessary to be familiar with the space between the pubes and the anterior wall of the bladder, called the prevesical space or the cavity of Retzius. This cavity is pyramidal in shape, and is formed by the oblique position of the bladder as it tilts forward toward the abdom- inal wall. The prevesical space is formed by the transversalis fascia, which divides into two layers just above the pubes, the anterior layer passing down behind the pubes and there becoming merged, while the posterior one passes over and behind the bladder, merging with the pelvic fascia. Thus there is a triangular space formed, the apex of which corresponds with the line of the fusion of the fascia above the pubes, while the base of it is behind the pubes. In this space more or less fatty tissue and blood-vessels are found, and it is through it that the incision is carried in the suprapubic operation. The mucous membrane of the bladder is of a pale yellowish-red or pale rose color, and is covered by flat polyhedral epithelium, under- neath which are club-shaped and spindle-shaped cells. It has a few fol- licles, and some small racemose glands lined with columnar epithelium near its neck, which are seated in the submucous connective-tissue coat. When the bladder is opened on its anterior surface, togetber with the upper wall of the prostate, it is seen to be thrown into folds or rugae, 40 QONORRHCEA AND ITS COMPLICATIONS. which for the most part pass horizontally around the viscus. Other rugge run longitudinally and obliquely, and as a result the membrane is divided up into more or less square and irregular flat eminences. This queer appearance is due to the contraction of the muscular fibres acting upon the mucous membrane and its submucous coat. It gradually dis- appears when the bladder becomes distended. When in health the bladder is examined by means of the cystoscope, the membrane is seen to be smooth and of light pink, sometimes with a yellowish tinge. It follows from what has been said that the mucous coat of the bladder is loosely attached to the muscular coats. This is the case in its whole extent except at its base. At this part we find the trigone or trian- gular space, which is bounded on each side by a slight but well-marked ridge which corresponds with the position of the muscles of the ureters. These ridges begin and form the apex of the trigone near the vesical orifice and uvula vesicae, and run outward and backward about two inches. At its base the trigone is about two inches wide, and at each angle of it the orifice of a ureter opens into the bladder. From apex to base the trigone is about one and a half inches in length. The mu- cous membrane of the trigone is of pale color, smooth, never wrinkled, and firmly attached to the parts beneath. (See Fig. 2.) That portion of the bladder situated just behind the trigone is called the post-trigonal space, and is of great surgical interest in the matter of pouches, stones, and tumors. The prostate gland is situated at the neck of the bladder, and is a firm body having the shape of a horse-chestnut or truncated cone, its base corresponding with the vesical orifice and its apex being continuous with the membranous urethra and deep perineal fascia. The prostate gland encloses the first part of the urethra. Its upper surface is about three-quarters of an inch below the pubic arch and about an inch behind it. Its base is about two and a half inches from the anus, while its apex is about one inch and a half from that orifice. It is formed of glandular tissue which consists of an aggregation of mu- cous follicles similar to those of the anterior urethra, Avhich form about one-third of the whole structure. In addition to this there is a com- pact mass of unstriped muscular fibres arranged in varying directions, transverse, longitudinal, and oblique, which, together with connective tissue, elastic fibres, vessels, lymphatics, and nerves, form the body of the gland. The prostate therefore is a musculo-glandular body capable of much dilatability. It is covered by two sheaths or capsules, the ex- ternal one, of firm fibrous structure, being a reflection of the recto- vesical fascia, which merges into the deep perineal fascia at the apex of the gland. The inner or true capsule is a thin but firm structure com- posed of muscular and connective tissues and elastic fibres, which are continuous with those of the parenchyma of the gland. A plexus of veins is found between the capsules of the prostate. There are two lobes of the prostate which are always present, and these are called the lateral lobes. They are of equal size, and in many cases can be clearly made out by the tip of the finger in the rectum, which usually discovers a more or less superficial or deep groove or notch between them. In the healthy adult the width of the prostate as felt in the rectum is about an inch and a half, while its length is ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 41 about an inch or an inch and a half. In hypertrophy these measure- ments become greatly increased. As the two lobes merge behind, a pyramidal-shaped space is left on their upper surface, which is filled up by what is called the middle or third portion (wrongly called lobe) of the prostate. This part of the organ is particularly rich in glands, muscular tissue, and blood-vessels, and is the one most prone to hyper- trophy after middle age. This middle portion lies behind the veru- montanum, and is tunnelled by the two ejaculatory ducts. When this portion becomes of such size and extent as to constitute a true lobe, it is then a pathological growth and a decided obstruction to urination. It may form a well-marked bar at the entrance of the bladder, and it may be formed in the shape of a small round ball, Avhich on urination is pushed over the urethral orifice like a valve, producing more or less complete obstruction to urination. Dr. Measor'^ claims that in subjects over sixty years of age the middle lobe is enlarged in 20 per cent. In old age enlargement of the lateral lobes is sufficiently common. This enlargement may be concentric, in which case the calibre of the urethra is more or less lessened, or it may be in a longitudinal direction, in which event the length of the prostatic urethra is more or less increased. We are now in a position to study the posterior urethra. The posterior urethra includes the membranous and prostatic por- tions, and extends from the vesical orifice to the anterior layer of the triangular ligament. The prostatic portion of the urethra extends from the apex to the base of the prostate, and is situated about one-third nearer the upper than the lower surface of the gland. (See Fig. 11.) In exceptional cases prostatic tissue is absent for a short distance on the roof of the urethra. This is compensated for by fibrous and elastic tissues which are merged with the sphincter. It is an inch and a quarter in length, but it may become much longer in cases of hypertrophy. The pros- tatic urethra, also called the neck of the bladder, is spindle-shaped and has a diameter of 30 F. at the apex, 45 in its middle portion, and 33 at its vesical end. This portion of the urethra contains some very im- portant structures. On the floor is a narrow longitudinal ridge, the verumontanum, also called the caput gallinaginis, crista galliTe, or collic- ulus seminalis. This structure is composed of erectile tissue and mus- cular fibres, w^hich during erection become turgid and prevent the passage of semen back into the bladder. It likewise temporarily prevents the passage of the urine. The verumontanum is continuous with the uvula vesicae, and is eight or nine lines long and one and a half lines in height. In the verumontanum and in the neighborhood of the prostatic ori- fices the tissues are richly supplied with nerves of peculiar sensibility, and it is here that the seat of the sense of pleasure in the sexual act is centred. It is here that inflammatory processes give rise to disturb- ances of the sexual function and to various painful sensations which may extend to parts beyond. When the seminal fluid is poured into the urethral canal mixed with the secretion of the seminal vesicles and with the prostatic fluid, it is prevented from passing backward by the verumontanum and uvula vesicae ; then the muscles of the gland power- fully contract and discharge it. ^ Med.-Chir. Trans. London, vol. xliii., quoted by Holden in Manual of Dissection. 42 GONORBHCEA AND ITS COMPLICATIONS. When one considers the complexity of structure of the posterior urethra with its multitude of crypts and follicles and its great vascular- ity, it can readily be seen why the gonorrhoeal process becomes so firmly seated there. On the summit of the verumontanum, sometimes at its fore part and sometimes about its middle, is a slit-like depression which leads to a cul-de-sac, or flask-shaped cavity, of about one to three-quarters of an inch in length, directed upward and backward. This is called the sinus pocularis, vesicula prostatica, and uterus masculinus from its homology with the female uterus. In its lips or vertical Avails, and sometimes just on each side of it, are openings of the ejaculatory ducts. (See Fig. 2.) In some cases both of these ducts open into the sinus pocu- laris itself; in other cases only one duct is thus placed. On each side of the verumontanum is a slight depression which is called the prostatic sinus, and into these sinuses the twenty or thirty orifices of the pros- tatic ducts of the lateral lobes open. The ducts of the middle portion open behind the verumontanum. On section the prostatic urethra is like an inverted y? thus — /^. When the bladder is empty its walls, contracted into a rounded or triangular mass, are in coaptation. At this time the lumen of the prostatic urethra is effaced by the contraction of the muscular fibres. The vesical end of the prostate is then in the form of a well-defined but not very resistant sphincter, which divides the urethra sharply from the bladder. As the viscus gradually fills the pressure of the accumulating water overcomes the tonicity of the inter- nal sphincter. Dilatation of the prostatic urethra then begins, and as this progresses it gradually loses its spindle shape and becomes de- cidedly funnel-shaped and directly continuous with the bladder. Thus, when the bladder is empty the prostatic urethra is essentially its neck, but when it is quite fully distended the neck-like arrangement becomes lost and the bladder and prostatic urethra arc continuous without any barrier between them. It follows from what has been said that the urethra proper is longer when the bladder is only slightly full than it is when it is quite fully distended. When the bladder is nearly empty it Avill be found that it is necessary to introduce the catheter nearly an inch farther than it is necessary to introduce it when it is full. The reason of this is obvious : with the bladder only slightly distended the internal sphincter is still contracted and the eye of the instrument must pass that part before urine is reached. Later on, when the sphincter is much dilated and the prostatic urethra is transformed into a funnel- shaped cavity continuous with the bladder, it is only necessary for the eye of the catheter to pass behind the external sphincter, when it en- counters urine. Finger is certainly right in his claims on this subject. In this connection it is necessary to more fully call attention to the two sphincters of the prostate. The internal prostatic sphincter is situated at the point of the junction of the' prostate with the bladder, and is merged with the substance of the former. It is composed of smooth muscular tissue and elastic fibres arranged in the form of a ring, into the meshes of which muscular and elastic fibres from the bladder enter at right angles. The internal prostatic sphincter there- fore contains no voluntary muscular fibres. The external prostatic or vesical sphincter is situated at the apex of the prostate, and is composed ANATOMY AND PHYSIOLOGY OF THE PENIS, ETC. 43 of smooth muscular fibres, together with a greater quantity of voluntary muscular fibres. The involuntary fibres are arranged in the form of a ring. The voluntary fibres at first (that is, in the portion toward the apex of the prostate) form a transverse band across the upper portion of the urethra, stretching from lobe to lobe. At the apex, however, they are quite numerous and form a distinct ring, which with the ring of involuntary fibres constitutes a very strong sphincter. It is this sphincter, when the bladder is full and the internal sphincter is much dilated and lost in the bladder-tissue, Avhich remains firm, occludes the canal, and prevents the passage of the urine. The relation of the pros- tatic urethra and the sphincter to the bladder when empty and full is well shown in Figs. 6 and 7, which are modified from Finger's pictures. Fig. 6. Fig. 7. Showing a partially-filled bladder sepa- rated from the prostatic urethra. Bladder much distended and fused with the prostatic urethra, which is funnel-shaped. In Fig. 6 the bladder is only partly full, and the well-defined vesical orifice is still intact by reason of the tonus of the internal sphincter. In Fig. 7 the bladder is much distended and the prostatic urethra is obliterated, of a funnel-shape, and merges directly with the bladder- cavity. In this case the external vesical or prostatic sphincter exerts its tonus and retains the urine. The direction of the prostatic urethra, Avhich is in a fixed position, is downward and forward until it reaches the posterior layer of the triangular ligament, when it becomes the membranous urethra, which pursues nearly the same direction with a slightly upw^ard tendency. The membranous urethra is from three-quarters to an inch in length and of a calibre of 27 F., and, owing to the fact that this segment of the canal forms a part of the subpubic curve of the urethra, its superior wall is somewhat shorter than the inferior wall. It is peculiar in the fact that it is composed wholly of mucous membrane with a submucous connective-tissue coat and some unstriped muscular fibres. It is the 44 GONOBRHCEA AND ITS COMPLICATIONS. least vascular part of the urethral canal, and has very few mucous glands and crypts. By reason of its anatomical structure it is not so severely affected by the gonorrhoeal process as the other portions are ; consequently it is rarely, if ever, the seat of true stricture. When strictures are found in this region they are usually the result of trau- matism. Indeed, traumatic strictures are usually found in the mem- branous and bulbous portions of the urethra, resulting from wounds and contusions of the perineum against the pubic arch. The membranous urethra is situated and held in a fixed position between the two layers of the triangular ligament, a knowledge of which is essential. The triangular ligament, which is a portion of deep perineal fascia, consists of two layers, an anterior and a posterior layer, between which is the compressor urethrje muscle. In Fig. 8 the anterior layer is shown as a dense fibrous membrane, stretching from the posterior lip of the OS pubis and ischium, from which the crura of the penis have been dissected off. This anterior layer is about an inch and a half in length, and in accord with the direction of the pubic bone its base is directed backward. About an inch below the symphysis pubis is the urethral orifice, the external termination of the membranous urethra. Around this orifice, as shown in Fig. 8, the fibrous membrane is seen, Fig. 8. Showing the anterior layer of the triangular ligament and Henle's deep transverse ligament of the pelvis, with openings for vessels and nerves. which is continued forward over the bulbous portion of the urethra. The triangular ligament extends upward toward the symphysis to a dis- tance just above the hole for the urethra, and is shown in Fig. 8 as a curved line. Above that is the dense fibrous tissue called '• Henle's deep transverse ligament of the pelvis," which is pierced by the open- ANATOMY AND PHYSIOLOGY OF THE PENIS, ETC. 45 ings for the vessels and nerves. The triangular ligament and Henle's ligament therefore close this part of the pelvic outlet. The posterior layer of the triangular ligament is derived from the obturator fascia, and from it a prolongation passes backward and forms the outer capsule of the prostate. Its upper portion, called Henle's ligament, is pierced by the opening for the plexus venosus ijuhicus impm\ which consists of veins returning from the penis and of the dorsal arteries. The triangular ligament proper is pierced by the mem- branous urethra, as shown in Fig. 9, which also shows the apex of the Fig. 9. Showing the posterior layer of the triangular ligament. prostate and the external prostatic sphincter blending with the mem- branous urethra. When the anterior layer of the triangular ligament is dissected off, •the compressor urethrse muscle is exposed in the form of a firm, flat muscular band, rather more than an inch wide, stretched between the pubic rami, but not wholly covering the pelvic outlet at its apex. (See Fig. 10.) This muscle, also called the constrictor urethra, the cut-off muscle, is composed of transverse fibres of the striped variety, some of which pass directly over and some under the urethra, while others pass around and encircle it. This muscle is very powerful, and, being under the control of the Avill, it can at any time suddenly stop the flow of urine. Though the external prostatic sphincter consists of rings of un- striped muscular fibres at the apex of the prostate, the greater part of the true sphincteric action is performed by the compressor muscle. In the course of acute and chronic gonorrhoea, and during irritative pro- cesses in the prostate, seminal vesicles, and bladder, tliis muscle may undergo spasm and produce what is wrongly termed "spasmodic stric- ture." Under the influence of rough manipulation by instruments in 46 GONOBRHCEA AND ITS COMPLICATIONS. the urethra, of cold, and of very strong and irritating urethral injec- tions, spasm may also be produced. Then, again, as a result of opera- tions about the rectum, abdomen, lower limbs, etc., this muscle may be thrown into spasm and retention of urine may result. Some authors Fig. 10. Showing the compressor urethrse or cut-off muscle. claim that this muscle is always in a state of rigid contraction or tonus, so that the lumen of the urethra is of the fineness of a hair, and that this contraction tends to prevent the extension of the gonorrhoeal pro- cess from the anterior into the posterior urethra, and also acts as a dam, preventing secretions in the prostatic and membranous urethra escaping into the anterior urethra. This is far too sweeping a statement. When the bladder is more or less full the compressor or constrictor urethrge closes up the membranous urethra and prevents the escape of urine; but when the bladder is not full, even in cases of subacute inflamma- tion in any part of the urethra, bulbous or prostatic, there is not in the majority of cases any unusual tonus or spasm of this muscle. This fact can be readily demonstrated, as I have done hundreds of times, by the gentle passage into the bladder of a soft catheter or bougie of a calibre of 12 or 14 French. This instrument, causing no irritation or nervous shock, glides easily first into the membranous urethra, then along the prostatic urethra into the bladder. The excessive tonus claimed to be peculiar to this muscle in general occurs when rigid instruments, par- ticularly of large size and when not skilfully passed, are used, or Avhen injections have been forcibly made. Then the nerves of the urethra are disturbed, and prompt reflex spasm of the muscle occurs. In the major- ity of persons the compressor muscle and the external prostatic sphinc- ter keep the urethral canal mildly compressed. Tliat is, its tonicity is such that the lumen of the canal is obliterated by the coaptation of the ANATOMY AND PHYSIOLOGY OF THE PENIS, ETC. 47 folds of membrane, but there is no spasm. Consequently, it occurs, as a rule, that the secretions of the prostatic urethra are kept from escap- ing into the anterior urethra. Though this may be stated as the law, it has exceptions in some cases of acute posterior urethritis, in some of prostatorrhoea, and in some of suppuration of the seminal vesicles. Though Finger and some other authors deny this occurrence, I am posi- tive that it sometimes occurs. When the bladder is only slightly full the internal prostatic sphincter is sufficiently competent to occlude the vesical orifice, and thus prevent the escape of urine into the prostatic urethra. As the fluid accumu- lates, however, such expansive pressure is exerted that the vesical sphincter gradually yields and allows the escape of urine into the pros- tatic urethra. For a time the external prostatic sphincter, which is stronger than the internal, is strong enough to keep the urine back, but when the bladder becomes very full the sphincteric action is per- formed by an effort of the will through the compressor urethras muscle. On each side of the membranous urethra, quite near to it and seated in the substance of the compressor muscle, are Cowper's glands. These glands are of pea size and of the compound racemose variety. From each one a duct three-quarters of an inch in length passes through the anterior layer of the triangular ligament and opens obliquely into the floor of the bulbous portion of the urethra near the median line. These glands secrete a mucous fluid during sexual excitement and coitus. They are interesting clinically as being sometimes the seat of gonor- rhoeal inflammation. (See Fig. 11.) Fig. 11. Showing the normal contractions and expansions of the urethra from the meatus to the bladder, with Cowper's gland opening by its duct into the bulbous urethra. Lying just upcn the anterior layer of the triangular ligament is the bulb of the corpus spongiosum, containing the bulbous expansion of the urethra. Here the membranous urethra ends, and the part is called the bulbo-membranous junction. The urethra enters the bulbous ex- pansion nearer its upper than its lower half; consequently the pouch- like dilatation of the urethra is greater on its lower surface. It is this condition which sometimes causes trouble in the passage of sounds and 48 GONOBBHCEA AND ITS COMPLICATIONS. catheters, to obviate which it is necessary here to keep the point of the instrument toward the roof of the urethra, and to put the penis on stretch in order to eiface the pouchy pocket as much as possible. As age advances the bulb frequently becomes more roomy and lax, and thus it often presents in old men greater obstacles to the passage of the catheter. The bulbous portion of the urethra or the sinus of the bulb is unusually vascular, and its tissues are soft and succulent. Conse- quently, the gonorrhoeal process is often very acute and severe at this part, and the disease shows a tendency here to remain in a chronic condition. As a result we find the larger number of true strictures in this region. The direction of the bulbous urethra is forward and upward, and its calibre is from 33 to 36 French. The downward and forward direction of the prostatic urethra and the slightly upward direction of the mem- branous urethra, with the decidedly upward direction of the bulbous urethra, form what is called the subpubic curve. Continuous out- wardly with the bulbous portion of the urethra is the spongy penile or pendulous urethra. It, like the bulbous portion, is contained in the corpus spongiosum. It is from six to six and a half inches (sometimes more) in length, and is surrounded by erectile tissue. The mucous- membrane crypts and follicles of this portion of the urethra have already been described. The calibre of the penile or pendulous urethra is usually from 27 to 30 French, but it is often found to be greater than this measurement. The penile urethra is susceptible of considerable dilatability, but it must be remembered that the word "calibre" repre- sents normal distention, such as is found by the moderately easy passage ♦of instruments or by the stream of urine, while "dilatability" means a calibre produced by unusual or excessive distention of the canal by instruments. The distal portion of the urethra seated in the glans penis is called the fossa navicularis, or the navicular portion of the urethra. It is of spindle shape, and at its middle portion its calibre is 30 to 33 F. At its point of junction with the penile urethra the calibre is from about 28 to 30 F. The calibre of the meatus, the terminal point of the ure- thra externally, is from 21 to 28 F. ; exceptionally, however, it is greater. A schematic representation of the urethra with its normal contractions and expansions is given in Fig. 12. To recapitulate : ^ The calibre of the urethra is not uniform, there being, as already shown, physiological contractions and dilatations. As a general average the following figures will be found to be correct : Meatus, 7 to 9 m. m 21 to 28 F. Fossa navicularis, 10 to 11 in. ra 30 to 33 F. Middle of pendulous portion, 9 to 10 m. m 27 to 30 F. Bulb, 11 to Tim. m 38 to 36 F. Membranous urethra, 9 m. m ;..■... 27 F. At apex of prostate, 10 m.m 30 F. Middle of prostate, 15 m.m 45 F. Vesical end of prostate, 11 m. m 33 F. 1 Dr. Otis (Practical Clinical Lectures, etc., 1883, pp. 441-442) states that there is a constant relation between the circumferential measurement of the flaccid jienis and tiie calibre of the urethra in the healthy condition. He says: "When the circumference is 3 inches the urethra has a normal calibre of at least 30 F. ; if 3|, it will be 32 F. ; if 3.} = 34 F. : if 32- = 36 F. ; if 4 inches = 38 F. ; and if 4.V = 40 or more. ANATOMY AND PHYSIOLOGY OF THE PENIS, ETC. 49 The degree of mobility of different portions of the urethra is chiefly influenced by the attachments of the neighboring fascia. The anterior part of the penis is free, and capable, in a flaccid condition, of assuming almost any position ; in its posterior third, however, this organ is con- nected with the symphysis by means of the suspensory ligament, with the ischiatic and pubic rami by the crura of the corpora cavernosa, and with the anterior layer of the triangular ligament by means of the bulb ; the spongy urethra may therefore be said to be fixed in pro- portion as it approaches the membranous region. The membranous region is the least movable of all, owing to its firm connection w^ith the pelvis by means of the tw^o layers of the triangular ligament. The prostatic urethra is susceptible of some slight change of position, de- pendent upon the action of the anterior fibres of the levator ani, the amount of urine in the bladder, and the passage of sounds or catheters. In a flaccid condition of the penis the urethra has two curves — the first confined to the anterior, the second to the deepest, portion of the canal. The former is simply due to the dependent position of the ante- rior part of the organ, and is efilaced in a state of erection or when the penis is elevated to an angle of about 60° with the body. The latter is called the subpubic curve, from its position beneath the symphysis. Unless some degree of force be used to straighten the canal this curve is permanent, and a knowledge of its direction is essential -in deter- mining the proper form of instruments and the manner of their intro- duction. The subpubic curve commences an inch and a half anterior to the bulb in the penile urethra, attains its lowest point when the body is Fig. 12. Fig. 13. Fig. 14. Section through the pre- puce and glans. Just behind the meatus. Through prepuce at base of glans. Fig. 15. Fig. 16. Fig. 17. Through prepuce and corona glandi.s. Sections just behind the corona ghmdis, spongj- and cavernous bodies well shown. 60 GONOBBHCEA AND ITS COMPLICATIONS. Fig. 18. Fig. 19. Fig. 20. Fig. 21. Fig, 22. Fig. 23. Figs. 18 to 23 show sections from before backward through the penile urethra. The pectiniform septum is complete except in Fig. 19, where corpora cavernosa are continuous with one another. Fig. 24. Fig. 25. Fig. 26. Through bulbo-membranous Through apex of prostate. Through middle of prostate, junction, urethra sur- capsule of prostate well rounded by some anterior shown, fibres of the compressor. Fig. 27, Fig. 28. Through the bladder and prostate, behind Just behind the prostate, through the bladder the urethra. and seminal vesicles. ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 51 in the upright position nearly opposite the anterior layer of the tri- angular ligament, and finally ascends through the membranous and pro- static regions. According to the observations of Mr. Thompson and Mr. Briggs, it " forms an arc of a circle three inches and a quarter in diameter, the chord of the arc being two inches and three-quarters, or rather less than one-third of the circumference." Mr. Thompson states that he has often found it more acute in spare men, and in the corpu- lent more obtuse — that traction of the abdominal muscles exercised through the suspensory ligament may also render it more abrupt, whence the advantage of raising the shoulders when performing catheterization upon patients in the recumbent posture. The elevation of the bladder above the pubes in children, and the enlargement of the prostate so common in old men, also effect a change in the direction of the sub- pubic curve from its usual adult standard, and require, therefore, a corresponding variation in the form of instruments. Swellings and abscesses about the lower extremity of the rectum, large hemorrhoidal tumors, and various other conditions may also operate in a greater or less degree to cause some change in the direction of this curve. The urethra is far from uniform as regards its shape and conforma- tion in its various positions. This is well shown in Figs. 12 to 26, taken from sections of the frozen penis between the end of the glans and the bladder. The canal is seen to be a vertical slit in Figs. 12 to 17. This vertical condition exists as far as the junction of the navicular with the penile urethra. In the penile urethra proper the canal be- comes transverse, and so remains in its Avhole extent as shown in Figs. 18 to 23. At the bulb it becomes round, and so remains at the bulbo-membraneous junction and in its membranous portion. At the apex of the prostate it is somewhat changed, as shown in Fig. 25. In the middle of the prostate the urethra looks like an inverted Y — thus, A (see Fig. 26) — between the arms of which is the verumontanum containing the utriculus masculinus. At the bladder the urethro-vesi- cal orifice is nearly round, the circle being impinged upon by the uvula vesicse at its lower segment. In Fig. 27 the very beginning of the urethra is shown in the depression in the centre of the base of the bladder. This is the posterior surface of the urethral orifice, its ante- rior surface, formed by the prostate, not being shown in the section. The two dots near the under surface of the prostate indicate the ejacu- latory ducts, which run side by side. Fig. 28 shows a section behind the prostate, through the bladder and the seminal vesicles. The seminal vesicles are two membranous pouches situated at the base of the bladder, between it and the rectum. They are loosely yet firmly attached to the bladder on their upper surface, and between them and the rectum is a layer of the vesico-rectal fascia. Each vesicle is some- what pyramidal in form, measures two and a half inches in length, about half an inch in breadth, and a quarter to a third of an inch in thickness. The anterior or pointed extremities of the seminal vesicle are situated within a finger's breadth of each other on each side of the median line, just at the base of the prostate. They then diverge from each other so as to form the letter V when the bladder is full. The trigone is the space in the bladder which corresponds with the V-shaped space at its base. Just near the prostatic end of each vesicle, on their inner side, they are 62 GONOBRHCEA AND ITS COMPLICATIONS. Fig. 29. joined by the corresponding vas deferens, and they fuse together and form the common ejaculatory ducts, which tunnel the prostate side by side and open on the lip of the utriculus masculinus or into its cavity. At the prostatic end of the seminal vesicles and the vasa deferentia these structures lie together so closely in juxtaposition that it is difficult, if not im- possible, in health to define their contours by the finger-tip in the rectum, and even more difficult in diseased conditions. This difficulty is much increased when the am- pullation of the vasa deferentia, which is frequently found here, is very pronounced. (See Fig. 29.) The seminal vesicles have been described as tubes convoluted like little sacculated bladders and as racemose glands. Such opinions are erroneous. The seminal ves- Showiug the relations of the seminal icles are really blind-ended tubes with di- vesicles, vasa deferentia, ureters, . , ^ "^ . . mi • • i i prostate, and urethra. vcrticula 01 vanous sizes. Inis IS Clearly shown in Fig. 30. On the right-hand side the vesicle is seen with its tubes rendered distinct, but in natural coapta- tion, by the removal of the connective tissue. On the left hand, however, the tubes are shown, three in number, after being dissected apart. The inner tube is seen to have a decided distal enlargement ; the middle tube is seen to join the third tube at right angles. These two tubes bear the same relation to each other that the blade of a jack-knife does to its handle. The outer enlarged tube, of dog's-ear shape, is called the handle of the jack-knife and the middle tube its blade. ■ When placed in natural coaptation the knife-blade fits snugly in the concavity existing in the handle. It is necessary to understand the form of arrangement of the tubes of the seminal vesicles for reasons stated in the chapter on the dis- eases of these structures. The seminal vesicles have three coats — a fibrous, a muscular, and a mucous coat, the latter covered with columnar epithelium and studded by various small tubular glands. The seminal vesicles serve as reservoirs for the semen ; they also secrete a mucous fluid which becomes mixed with the semen, It is well to remember that the apex of the prostate is about half an inch or more from the anus, and that its base is fully an inch and a half farther back and upward ; consequently, the finger-tip must cer- tainly be within the rectum for at least an inch and a half before the vesicles are reached. In some thin subjects this is accomplished quite readily, but the examination is more difficult and the results are more unsatisfactory in proportion as the subject is fat and compactly built. Near the base of the seminal vesicles the peritoneum is reflected from the anterior surface of the rectum upon the bladder. The space betAveen the base of the bladder, with the attached prostate and seminal vesicles, and the rectum is filled with a quite dense connective tissue, the recto- vesical fascia, which is very dense and firm at the prostate. It is through this space, by means of a semicircular incision anterior to the anus, that ANAT03IY AND PHYSIOLOGY OF THE PENIS, ETC. 53 the seminal vesicles are reached in cases of abscess pointing toward the rectum, and in tuberculosis of these organs. The testicles are two oval glands suspended in the scrotum by the spermatic cords. These glands are flattened on their sides and hang obliquely, the upper portion being directed forward and outward, the lower border backward and inward. Around the superior and posterior surface of each testis is a crescentic-shaped body called the epididymis, Fig. 30. Showing the bladder and ureters, the ampuUated end of the vas deferens, seminal vesicles, prostate, and membranous urethra : a, bladder ; 6, 6, ureters ; c, c, vasa deferentia ; d, d, seminal vesicle ; e, prostate ; /, membranous urethra ; g, corpora cavernosa, corpus spongiosum, and bulbous portion of the urethra. which consists of three segments, the upper and larger one being the head, also called the globus major, the middle portion the body, and the inferior portion or globus minor. The glandular structure of the testis is shown in Fig. 31 in the form of conical-shaped lobules with bases at the circumference of the organ and apices ending in the mediastinum testis. These lobules are enclosed in fibrous tissue which extends between the mediastinum and the tunica albu- ginea, or proper fibrous tissue of the testes. These lobules are made up of convoluted seminiferous tubes, of which there are more than eight hun- 64 GONOBBHCEA AND ITS COMPLICATIONS. Fig. 31. Tunica Vaginalis. Tunica Albugii dred, each one of which when dissected out and unravelled measures two and a half feet. These lobules contain seminal cells and spermatoblasts. In the connective-tissue meshwork which surrounds the lobules are fine capillary vessels and nerves. At the me- diastinum the tubules bend at right an- gles, and these form thevasa recta (twenty or thirty in number), which pass verti- cally upward and perforate the tunica vaginalis. x-Vs these minute tubes pass through the upper part of the tunica vaginalis they become larger and less numerous (fifteen or twenty), and are called the vasa efi"erentia. They then become much enlarged and convoluted, and form cone-shaped masses, called the coni vasculosi, which, together with ves- sels, nerves, and connective tissue, con- stitute the globus major of the epididy- mis. The tubes of the coni vasculosi end at the lower part of the globus major in one tube, which becomes intricately convoluted, and thus forms the body of the epididymis and the globus minor. This convoluted tube is fully twenty feet in length, and it increases in cali- bre until it merges in the vas deferens. The tunica vaginalis is a serous pouch which covers the testes and epididymis, the attached portion being called the visceral layer (tunica vaginalis propria), and its reflection upon the scrotal wall the parietal layer (tunica vaginalis reflexa). Inflammation of the gland-substance and oedematous hyperplasia of the globus major may produce dropsy of this serous pouch, which is called hydrocele. The vas deferens, or seminal duct, begins at the lower part of the globus minor and runs upward along the inner and posterior border of the testes. It is here accompanied by the spermatic artery, the artery of the vas deferens, and the cremasteric artery. Besides these vessels are the spermatic veins, coming from the back of the testes, which become convoluted and form the pampiniform plexus. All these vessels, together with a rich nervous supply, form what is called the spermatic cord, which is surrounded by a distinct fibrous sheath. At the internal abdominal rings the vessels join their several trunks, while each vas deferens descends into the pelvis, crosses the external iliac artery, curves around the bladder on the outer side of the epigastric artery and inner side of the ureter, backward and downward to its base ; there it usually becomes ampullated and joins the duct of the seminal vesicles, forming the common ejacula- tory duct. Each vas deferens is from eighteen to twenty -four inches long. The testes are covered by the scrotum, a musculo-cutaneous pouch which is divided into two parts by a fibrous septum. This cutaneous envelope and its dartos muscle, together with the external spermatic fas- cia, cremaster muscle, infundibuliform (internal spermatic) fascia, and the tunica vaginalis, constitute the coverings of the testis. Vertical section of the testis and epi- didymis (after Gray). GONOBBHCEA IN THE MALE. 55 CHAPTEE II. GONOKRHQEA IN THE MALE. GoNORRHCEA, the most frequent of all venereal diseases, and the one essentially of sexual origin, is a virulent process, attended by much sup- puration, which attacks chiefly the mucous membrane of the urethra, male and female, and the parts in immediate and more remote anatomical relation. The mucous membrane of the eye is also particularly suscept- ible to its action. There is no doubt that the rectal and anal mucous membrane may be attacked by this process, but there is much doubt about the existence of gonorrhoea of the mouth and nose. The term "gonorrhoea," which signifies a flow of sperm (from yovrj, sperm, and peu)^ to flow), although etymologically incorrect, is so old, has so long been employed, and carries with it so much clearness and precision of meaning to the medical and lay mind, that it is well to retain it in our nosology. It is also called urethritis, blenorrhagia, blenorrhoea ; chaude pisse by the French ; tripper by the Germans ; and plain clap by Eng- lish-speaking nations. In this work the terms gonorrhoea and urethritis will be used interchangeably. It is claimed by Ricord that 80 out of every 100 men living in large cities suffer from gonorrhoea at some period of their lives. Gonorrhoea is found much more frequently in the male than the female. The first attack is usually more acute and severe than are sub- sequent ones, which are very often subacute in form and chronic in course. When many years have elapsed between two infections, the second may be equally as severe as the first. Gonorrhoea is mostly found in young men, but instances of children^ and even infants, being thus affected are far from uncommon. Toward puberty it is very often found in the male, w hile between the twentieth and thirtieth years its frequency of occurrence is greatest. From the thirtieth year onward its occurrence grows progressively less frequent, but it is seen in a goodly number of cases of middle-aged, and even of old, men. Isaacs^ reports the case of a man one hundred and three years old who applied for treatment of a florid gonorrhoea. This par- ticularly virile individual had suffered from chancroids when he was one hundred years old. The male sex derives it by infection from the female, and vice versd. In the vast majority of cases gonorrhoea is communicated by direct infection in coitus, but it is possible that it may be contracted by medi- ate infection, particularly in women. The pus from the infected geni- tals of a girl or woman may be deposited on those of a healthy person by means of the fingers, or it may be transported upon towels and syr- inges or in baths. The time-worn explanation of the origin of the trouble by contact with a foul privy or urinal may be looked upon as a euphemism to be used in the case of some clerical, venerable, or mar- ried transgressor. In very many cases of men who have had an initial 1 Med. Record, April 14, 1894, p. 462. 56 GONOBBHCEA AND ITS COMPLICATIONS. attack of gonorrhoea acute urethral suppuration may be solely due to sexual and alcoholic excesses, which have changed a chronic and dor- mant localized inflammation of the urethra into a more or less acute condition. Gonorrhoea is one of the most persistent diseases which attack mu- cous membranes. It invades the tissues deeply, and as a consequence it is very often difficult to cure. After a more or less prolonged chronic stage it often settles down into a latent and dormant condition in a local- ized form, and may thus cause no symptoms for years. Then, again, this condition of latency may be frequently varied by acute attacks of the disorder. When all the features, complications, and sequelae of gonorrhoea are taken into consideration, it will be seen that it is a disease of no insig- nificant character. In many cases it passes away and leaves no bad effects. In others it leads to the development in the male of such painful complications as swelled testicle and abscess in connection with the urethra. In the female it may lead to cystitis, inflammation of the OS uteri, the tubes, the ovaries, and even to peritonitis. Its long dura- tion in the male urethra frequently leads to stricture, with its distressing and often fatal results from bladder, prostatic, and kidney complications. By the action of the toxines which the gonorrhoeal process gives forth, and also from the absorption of its virulent microbes from the urethra into the circulation, violent and painful inflammations of joint-structures, joints, tendinous sheaths, burs^, fasciae, and fibrous tissues are pro- duced. In many of these inflammations gonorrhoea seems to produce a true septicaemia through the action of its own virulent microbe. In many cases it is very probable that the morbid action of the gonococcus prepares the tissue for the invasion of pyogenic microbes. By these combined or mixed forms of infection the whole organism may be in- volved, and severe illness, structural impairment of parts, invalidism, and even death, may be produced. By reason of this action of the gonococcus alone or aided by that of other pyogenic microbes the eyes, the heart and its membranes, the coverings of the spinal cord (and, it is also claimed, those of the brain) may be attacked, and serious, even fatal, results may follow. When we consider the vast range of pathological conditions which gonorrhoea may cause or lead to, we are certainly warranted in assert- ing that it is, taken as a whole, one of the most formidable and far- reaching infections by which the human race is attacked. The demonstration of the fact that the gonococcus and other pyo- genic microbes are the cause of urethral suppuration has clearly proved that gonorrhoea is an essentially virulent process. THE GONOCOCCUS. 67 CHAPTER III. THE GONOCOCCUS. The gonococcus is reliably revealed to the eye by means of staining processes ^ and by the microscope Avith a high power and oil-immersion, using at least a ^l^'^^^h lens. It is a relatively large micrococcus, nearly always appearing as a diplococcus. It measures 0.8 to 1.6 micro- millimetres in length and 0.6 to 0.8 micromillimetres in breadth. The gonococci are usually found in pairs. Fig. 32. each half of the diplococcus being of kidney shape, m m, g^ f% (Mi and the two thus resemble a cofiFee-bean or a French 'S' 'S' ^ fl f| roll. Occurring thus in pairs, they lie close together, ,. >, ^ ^■^■^, . o ,i.'.Y fe^' Morphology of the gono- their liattened surfaces being m close coaptation and coccus (after Bumm). their outer margins convex. Between each coccus is a very narrow split which shows as a bright line. In these particulars the gonococcus resembles other diplococci. In its multiplication this diplococcus divides by a transverse cleavage or at right angles to the median fissure. By this means of fission each pair of the diplococcus is converted into four diplococci, which are grouped in fours. The mode of division is schematically pictured in Fig. 32. Beginning at the left hand of the figure, the line of cleavage is shown to be more and more distinct until the full development is reached, as pictured in the right-hand figure. In this way these micro-organisms increase and multiply. Other diplococci, however, develop in a similar manner. From this method of transverse fission and growth originates the pecu- liar grouping of the gonococcus into twos and fours and their multiple derivatives. It must be remembered, however, that, owing to their rapidity of growth, we sometimes see these cocci of varying sizes, and not infrequently the halves are not quite symmetrical in size. In the acute stage of gonorrhoea these diplococci are found in greater or less number encapsulated in masses within the pus-cell. When numer- ous and thus seated they have been said to present the appearance of a swarm of bees. Under rather low powers they look like little particles of gunpowder. They may be so numerous within a pus-cell as to rup- ture its Avail. Then we find the cocci lying free in the serum, scattered in a disordered manner betAveen the pus-cells, but even then presenting the four and multiple-of-four arrangement. Early in the infection gono- cocci are seen seated upon epithelial cells. Under microscopical examination gonococci are readily found and recognized in the pus of acute gonorrhoea. Then the clinical features of the infection and the microscopical picture of the discharge and its pus, epithelium, if present, and diplococci, taken together, are so striking and unvarying that a mistake can scarcely occur. But in later stages of true gonorrhoea, and in many more or less subacute cases of urethral ^ In unstained preparations the gonococcus looks like a minute roundish body, which may be distinguished from the surrounding cells and their nuclei by a peculiar clear pearl-like sheen and its quick rotatory motion. 58 GONOBBHCEA AND ITS COMPLICATIONS. suppuration, it is very often most difficult, and sometimes impossible, to say whether the microbe is the gonococcus or some other form of diplo- coccus. In many cases the crucial test rests in cultivations and inocu- lations. While, however, there is no single individual sign or mode of distinc- tion of the gonococcus, there are a number of signs which, when taken together, offer strong presumptive evidence that the microbe in question is the one just named. These, as given by Neisser and others, are — 1. The shape, which is, as we have seen, roundly oval, with its median fissure and its roll-like or coffee-bean appearance, and its lengthwise fissure. Still, as Bumm says, many pathogenic and non-pathogenic dip- lococci resemble the gonococcus very closely, even to the very fine point only made out by high powers — namely, a slight indentation which is sometimes seen in the contiguous surfaces of both hemispheres. 2. The size : they are large diplococci, and in their development are variable and resemble other diplococci. 3. The grouping, as a result of their mode of division, is in single pairs, in fours, eights, sixteens, etc. They never occur in chains. 4. Their intracellular position : the gonococci are found in heaps within the protoplasm of the pus-cells, and also scattered between the cells in varying numbers. Other diplococci, however, are also found within the pus-cell. Steinschneider ^ emphasizes the fact that this dispo- sition in heaps of other diplococci is so irregular and different from that assumed by the gonococcus that a mistake is impossible. 5. Their staining properties : gonococci are readily stained by aniline colors, and they readily lose their staining by Gram-Roux's^ method. This quality is very characteristic of the gonococcus, but it is also pos- sessed by certain other diplococci, by streptococci, and by staphylococci. Neisser ^ himself concedes this point, and says the intracellular disposition of diplococci is nearly an exclusive property of the gonococcus. In this connection it must be remembered that Legrain, Bockhart, Zeissl, Eraud, and Hugounenq and Hogge have found diplococci in masses within the cells in specimens of urethral secretions. Consequently, the student must be cautious in drawing conclusions. The intracellular grouping of micro-organisms in other than urethral pus has been found by many observers. The truth of the matter is this : that while in the secretion of florid gonorrhoea it is easy to recognize the gonococcus, it is very difficult in chronic and subacute cases even for skilled and experienced persons to say that a given coccus is the gonococcus from microscopic study alone. In such cases, to be absolutely positive, cultures must be made. It follows from this that we should not accept most of the statements made of the discovery of the gonococcus in chronic urethral affections. Methods of Staining-. — For general purposes a solution of methyl blue is all that is needed for staining gonococci, but fuchsine, methyl violet, gentian violet, and victoria blue may be used. The technique is as follows : Spread by means of a platinum-wire loop some of the pus, threads, or secretion ^ on a cover-glass in a very thin film, or place a drop ^ Vide infra. ^ Vide infra. ^ Vide infra. * Neisser and Finger recommend, when the secretion is very scanty, that an injection of sublimate, 1 : 10,000, or of nitrate of silver, 1 : 2000, shall be made in order to produce THE GONOCOCCUS. 59 of the secretion in the centre of a cover-glass, and then place another cover-glass over this. Then separate the two by sliding them over each other, not by pulling them apart. In this way two evenly-spread speci- mens are obtained. It is always necessary to thoroughly wash the glans penis and the meatus before taking the secretion, since many microbes are seated on these parts. In taking secretions from the female genitals scru- pulous care should be exercised, so that no extraneous or accidental micro- organisms are gathered up. In dispensary work the secretion from the male urethra may be allowed to drop upon a glass slide, and it is then to be spread out over its surface by drawing the edge of a similar slide over it. The specimen may be allowed to dry in the air or it may be passed two or three times (the right side up) through an alcohol or gas flame. The dried secretion is then lightly smeared with the staining fluid by means of a glass rod. The simplest and most expeditious method of staining these specimens is to put a drop of a dilute watery solution of methyl blue upon the cover- glass, allow it to remain two or three minutes, wash off with water, and then examine in water. This may be allowed to dry, and then it may be mounted in Canada balsam. By this method, however, the gonococci are not shoAvn so clearly as by others to be mentioned. One of the most satisfactory and rapid methods of examination is that recommended by Schiitz.^ This is founded on the resistance of the gono- coccus to acetic acid after being stained with methyl blue. After the cover-glass is covered with a thin film of the suspected material it is passed three times through the flame. It is then brought in contact with a saturated solution of methyl blue in 5 per cent, carbolic-acid water for five or ten minutes. It is then washed with water and placed, for a time long enough to count one, two, three slowly, in a solution of five drops of acetic acid in twenty cubic centimetres of distilled water, and immediately washed again in pure water. Everything is then decolorized except the gonococci, which remain distinctly blue. The specimen may be then examined and preserved, or at this stage it may be double stained with a very dilute aqueous solution of safranine. This second staining should be very slight, the cover-glass being washed at once in pure water. By this process the gonococci will be found of a deep-blue color, the epithelial cells of the same color, while the pus-cells and their nuclei will be salmon- colored. Lanz ^ proposes the following method of staining, which makes the detection of the gonococcus very easy : The cover-glass smeared with the gonorrhoeal pus is dipped for half a minute in a 20 per cent, solution of trichloracetic acid, then washed, and dried by means of filtering-paper, then gently heated in an alcohol flame. It is then dipped in a solution of methyl blue for from two to five minutes, dried, and mounted in Canada balsam. Double coloration may be obtained by eosin staining. The gonococci are stained a deep blue, in marked contrast with the pale-blue a decided discharge. This procedure may be practicable in hospitals, but it should not be employed in private practice, unless with the full understanding and consent of the patient. ^ " Ein Beitrag zum Nachweise der Gonococcen," Miinchen mecl. Wochenschrift, xxxvi., No. 14, 1889. 2 Beut. med. Wochenschrift, 1894, No. 20, p. 200. 60 GONOBRHCEA AND ITS COMPLICATIONS. color of the rest of the celL The acid renders the cell and its nuclei transparent, and by this procedure the microbes may be seen in the sub- stance of the nuclei. Frankel's ^ method may also be used. This consists in treating the cover-glass preparation for a few minutes with a concentrated alcoholic solution of eosin (by heating the staining fluid). The surplus of the dye is absorbed with blotting-paper ; the specimen is at once placed in a con- centrated alcoholic methyl-blue solution (for fifteen seconds at most), and then it is to be washed in water. The cocci will appear blue on a red ground. The cellular elements of the blood and pus have absorbed the eosin, while the nuclei and micro-organisms are colored blue. All these specimens when dried may be preserved in Canada balsam. Much study has been, and is being, expended upon the perfection of such means of coloring gonococci that their distinctions shall be clearly and absolutely made out. Many observers, particularly those of the Neisser school, place great, almost implicit, confidence in the process known as the Gram-Roux ^ method. The procedure is as follows ; Having dried the specimen, it is stained with methyl blue or gentian violet; then it is submitted for two or three minutes to the action of Gram's solution (iodine 1 part, iodide of potassium 2 parts, water 100 parts), which possesses the property of fixing the aniline colors exclusively on the microbes, and not on the anatomical elements. Then the specimen is decolorized in absolute alcohol, washed in distilled water, and then recolored with eosin. The micro-organisms then stand out again clearly in blue or in violet, while the epithelial cells or leucocytes offer a rose- colored background. Roux says that he learned by experiments that Gram's liquid does not sufiiciently and firmly fix the basic aniline colors in gonococci, but that as soon as the specimen is treated with absolute alcohol these cocci and the anatomical elements become very difiicult to recognize with the microscope. This negative fact therefore constitutes an element of diagnosis, since other micro-organisms do not thus become decolorized. He claims, therefore, that when the presence of gonococci is shown by aniline dyes and upon the addition of Gram's liquid and alcohol they disappear, it is certain that Neisser's coccus is present. On the other hand, if the micro-organisms remain stained, it is in all prob- ability not the gonococcus. This method, however, when put to the crucial test, has been shown to be in a measure fallible. Lustgarten and Mannaberg, as we shall see, claim that one or several species of diplococci are found in the nor- mal urethra which completely resemble the gonococcus in shape and tinctorial qualities, especially in being decolorized by Gram's method. Steinschneider,^ Neisser's disciple, admits that Roux's method gives absolute results in about 95 per cent, of cases. In the remaining 5 per 1 Text-hook of Bacteriology, p. 330, New York, 1891. '^ "Precede technique de Diagnose des Gonococcus," Annales des Maladies des Org. Gen.-urin., 1887, p. 56. * It is well to emphasize the fact, brought out by Hogge {vide infra), that out of the 86 cases examined by Steinschneider only 28 were those of chronic gonorrha?a, and it is in these that mixed and saprophytic infections are most commonly foimd. The reader is referred to Hogge's paper for some sensible critical remarks as to the possibility of errors in the various modifications used in the Gram-Koux method. If his suggestions are followed, the results will certainlv be more accurate. THE GONOCOCCUS. 61 cent., however, the diplococci resembling gonococci have, he claims, such a markedly different arrangement and distribution that their recognition is easy. Steinschneider says that in doubtful cases after the decolorizing process he stains the specimens with Bismarck brown. Then " at once we got the remarkable results that in all cases in which there was no acute or chronic gonorrhoea present there were among the brown-stained ana- tomical elements only few bacteria, few diplococci, especially, which were distinguished by the dark-brown staining. If gonorrhoea was present, there Avere found clusters or individual pairs of gonococci which had the same color as the cells. Never did these diplococci which did not lose Gram's staining show the well-known disposition of gonococci. If they lay in heaps, which was rare, their disposition was so irregular and so different from that of the gonococci that confusion was impossible." It will be seen from the foregoing that, after all, the staining process as a means of diagnosticating the gonococcus is liable to lead to error in a goodly proportion of cases. No trouble will be experienced in studying the secretion of acute gonorrhoea even when some weeks old. But the doubt comes in in subacute and chronic cases, just the ones in which we are anxious to determine whether the long-drawn-out inflammation is really kept up by the gonococcus, and whether this micro-organism has, as it is claimed it has, an indefinite life as a morbific agent in the male urethra. It will be readily seen that these bacteriological studies of urethral secretions are very dif&cult, intricate, and attended at every step Avith liability to doubt, confusion, and error ; consequently, skepticism and conservatism are warranted, indeed are essential, even in the presence of statements made by experienced and skilled observers. The consensus of opinion of the most eminent investigators of this subject is that from cultures alone can we get absolutely correct know- ledge of the character and identity of micro-organisms. In this way the gonococcus can be demonstrated without any trouble, and confirmation of its existence may be obtained (if a consenting case can be found) in experimental inoculations on the male or female urethra. It must be borne in mind that the mucous membranes of most animals are immune to the virulent action of the gonococcus, but the urethra of the dog can be infected with cultures made in an acid medium. This micro-organism outside of the human body has little vitality. Its culture media are blood-serum, and blood-serum and agar-agar, and urine and urea, in acid solution. As we shall see, Bumm had much trouble in cultivating the gonococcus, but Wertheim has lately simplified the matter by using human blood-serum with agar-agar on plates. Further than this, Ghon and Schlagenhaufer ^ have simplified the method by spreading a drop of human blood over the surface of the agar plate. My advice to any one desiring to familiarize himself with the biology and morphological characters and nature of the gonococcus, and of other micro-organisms of the male and female genitals, is to study the subject practically in a pathological laboratory. The other micro-organisms which can, under favorable circumstances, produce urethral suppuration are some varieties of the staphylococci and streptococci, as claimed by Bockhart. ^ Wiener klin. Wochenschrift, No. 39, Aug. 24, 1893. 62 GONOBBHCEA AND ITS C03IPLICATI0NS. Our knowledge of the morphological character, life-history, habitat, and pathogenic influence of these micro-organisms is, as yet, very slight indeed. It will require much time, skill, and patience on the part of many investigators to place this subject on a satisfactory and scientific basis. CHAPTER IV. THE PATHOGENIC ACTION OF THE GONOCOCCUS. The experimental inoculations upon the human urethra by Bumm, Wertheim, Aufuso, and Finger with the cultures of the gonococcus have clearly demonstrated the virulent action of that diplococcus. Let us now study clinically this microbic invasion of the urethra and systematically examine the secretion in the earliest days of the infection. As is shown in another chapter (p. 107), gonorrhoea, like all virulent processes, has a period of incubation of varying length, its shortest being two days and its longest fourteen days, though even longer periods are claimed. In the light of clinical study alone it was difiicult to understand why one man's gonorrhoea began two days after coitus, while that of others' came on three, five, and on intervening days up to the fourteenth. It is very probable that certain unknown conditions inherent to the tissues of the penis pre- dispose a patient to gonorrhoeal infection, just as we see some persons prone to tonsillar, pharyngeal, bronchial, and pulmonary inflammations and to infectious processes of the skin. Then, again, the structure and conformation of the organ may present conditions of predisposition. (See chapter on Predisposing Conditions, etc.) Microscopical study, how- ever, further shows that the number of the gonococci seems to be an ele- ment in their virulence, and that acuteness of invasion may depend on the quantitative rather than the qualitative element of the gonococcus. It is possible, however, that at certain times and under unknown con- ditions the virulence of the micro-organism is more or less active. The duration of exposure to the infecting secretion in prolonged coitus, with much alcoholic indulgence, has undoubtedly much to do in many cases with the acuteness and severity of the attack. When in coitus the gonococci are deposited in the urethra or on the lips of the meatus, they immediately begin to proliferate, and in due time give rise to a scant serous secretion. Clinical and microscopical study shows that diff"erent individuals are afi"ected in different ways. In some the attack, as shown by the discharge, comes on briskly and promptly, while in others the morbid process develops slowly and insidiously, and often with much halting. In the very earliest period of gonorrhoea much can be learned as to the mode of invasion of the disease, and as to the pathological conditions in a given case, by the microscopic examination THE PATHOGENIC ACTION OF THE GONOCOCCUS. 63 of the secretion. This scientific examination should be made in every case, since from its results indications of a practical nature may be derived. Not only in the very earliest stage does the microscope give much aid and broad enlightenment in pathology and treatment, but throughout the whole course of gonorrhoea its teachings are invaluable. As will be shown farther on, the number of gonococci in the serous discharge of the first day or two shows very great differences in individual cases. In some periods, the earlier as a rule, there are enormous numbers of gonococci in the discharge, while during the latter stages of the attack there are frequently so few of them that but one or two pus-cells can be found in the entire field containing gonococci. So a drop of discharge at one stage of the attack may contain, estimating it roughly, but two or three or several hundred gonococci, while at another time the drop holds enormous quantities of the cocci — a million or more. A glance at Figs. 35 and 36 will illustrate this numerical difference of the cocci in two dif- ferent specimens of gonorrhceal discharge. Thus when gonorrhoea is contracted, as a result either of the duration of the exposure to the infecting pus or according to the stage of develop- ment of discharge in the donor, the number of gonococci received may vary within very wide limits. This numerical variability, then, in the gonococci seems in a measure to determine the period of incubation and the character of the onset of the discharge. The vulnerability of the tissues and the conditions favorable to inflammation also have much to do with the promptitude of the onset of the inflammation. In some cases, where a very few gonococci embodied in the pus-cells are received, the discharge does not become visible for some days, although during this time there is an exudation, but it is so scanty and colorless that it escapes attention. In such a case as this it would seem that so few gonococci entered the urethra that some days are requisite for them to proliferate extensively enough to produce a widespread chemotaxis or attraction of the leucocytes from the blood-vessels of the urethral mucosa, or that the tissues were not particularly vulnerable. After the gonococci have proliferated and become more extensively distributed over the ure- thra, a widely-spread and severe exudative inflammation of the urethra takes place more or less suddenly. An attack of gonorrhoea would be liable to begin in this slow, mild way if the infection originated from a- similar discharge, such as fairly old gleet or declining gonorrhoea, in which it takes considerable searching with the microscope to find a pus-cell here and there containing gonococci. In other cases a severe discharge, muco-purulent from the beginning, occurs suddenly within forty-eight or seventy-two hours after the exposure. In such a case as this we may suppose that a very large number of gono- cocci enter the urethra and proliferate extensively. The initial cocci are not localized, but become rapidly distributed — perhaps at the exposure — over a large surface of the urethra, and exert chemotaxis, or, in other words, produce inflammation simultaneously at many points over a large segment of the urethra. A glance at Fig. 37 will show how the great numbers of gonococci swimming about free in the serum would be dis- tributed almost immediately over a large tract of the urethra in virtue of its capillary attraction, from before backward, if a portion of such a discharge entered the meatus. 64 GONOBBHCEA AND ITS COMPLICATIONS. Between these two extreme types of acute and mild invasion there are all sorts of intermediate grades of the incubation. Sloiv Invasioji. — In the cases of long incubation — where there seem to be but few gonococci received at the infection, and that these remain localized for a few days before proliferating extensively enough to spread over a considerable part of the urethra, an exudation really exists during the whole period of the incubation. This exudation in the beginning is almost a microscopic element ; it is exceedingly limited and serous, and so generally escapes attention that there is seldom an opportunity to exam- ine it microscopically. After two or three or several days this scanty serous exudation, becoming gradually more copious, suddenly changes and becomes a purulent discharge. This sudden change indicates the period when the gonococci have proliferated and become extensively enough dis- tributed to excite general chemotaxis. (Compare the increase of the gonococci in Figs. 33 and 34.) In the very beginning of the prodromal or exudation stage ante- cedent to the onset of the purulent discharge in these cases of slow incu- bation there is simply a thin or sticky moisture of the walls of the urethra. In a day or two more the exudation grows more material and a trans- parent drop the size of two or three pin-heads may be forced out of the meatus by gentle pressure. The exudation may in exceptional cases stay this way for a week. Although this exudation is not seen during the day, it appears in the first part of the urine as scanty lump-like masses. The discharge is best seen in the morning, and it then looks very much like glycerin, except that suspended in the drop are some minute trans- lucent and whitish flocculi, like tiny particles of rice-seeds or suet. A Fig. 33. Gonorrhceal discharge in the early da%s of infection in a ease of long incubation, showing pave- ment epithelial clIK on -which a few gonococci are seated, and a few pus-cells which as yet contain no gonococci little later the drop becomes more copious, appears during the day, and is streaked with whitish-yellow streaks ; then, perhaps in a few hours or within a day, the drop may change suddenly and radically, when it be- comes entirely yellow and creamy, thick and copious, and takes on the characteristics of the ordinary purulent discharge. The structural features of the discharge in this early stage of its development in these cases of long incubation are as follows : The exuda- THE PATHOGENIC ACTION OF THE GONOCOCCUS. 65 tion consists largely of fluid or serum containing some desquamated epi- thelial cells, and later on only a scattered pus-cell here and there. In the early stages the desquamated epithelial cells predominate, and as the Fig. 34. Showing the features of the discharge a few days later than are shown in Fig. 33. The epithelial cells are covered by an increased number of gouococci, but these microbes are not as yet con- tained in the substance of the pus-cells, which are rather more numerous. exudation progresses the pus-cells become more numerous. (Compare Figs. 33 and 34.) ' It is the desquamated clusters of the cells lining the urethra that produce the appearance of the rice-like or suet-like granules in the clear drop. Finally, when the drop suddenly becomes yellow, the epithelial cells disappear almost entirely or are overshadowed by the enormous num- bers of pus-cells. ^ The case which furnished Figs. 33, 34, and 35 is extremely interesting and merits a brief recital : Four days after a short and incomplete coitus the patient noticed a slight moisture, with some translucent particles, at the meatus. This condition continued un- changed for seven days (the eleventh day after exposure), Avhen the secretion amounted to a small drop in the morning, and was perfectly clear and contained rice-like particles. A specimen taken at this time presented under the microscope the appearances shoAvn in Fig. 33. There we see a few cocci at the edge of an epithelial cell, but none in the few pus-cells present. Eight days after this (the nineteenth of the exposure) a slide taken presented the appearances shown in Fig. 34. It will be seen that tlie gonococci are much more numerous, and that they are seated on the epithelial cells and at their edges. They are not contained in the pus-cells. Eight days later the gonococci were found in the pus- cells and the epitlieliura liad disappeared. In Fig. 33 tliere were only eiglit gonococci, and they were floating free in the serum. In Fig. 34, taken eight days later, they were more numerous, and in Fig. 35, taken eight days later, we see a cliaracteristic picture of confirmed acute gonorrhoea. In this case, therefore, the incubation period was four days and tlie duration of the prodromal stage, or stage of microbic colonization, was twenty -seven days — a most unusual occurrence. In all probability the small number of the micro- organisms received in coitus was the factor in the slow evolution of the disease. Perhaps the existence of pavement epithelium in the fossa navicularis offered a barrier to the inva- sion of the cocci. This patient had recovered from gonorrhoea seven months before the present infection. 66 GONOBBHCEA AND ITS COMPLICATIONS. The gonococci in this stage of scanty exudation, before the regular discharge, may not be found at all by the ordinary cover-glass staining Fig. 35. Shows the features of the discharge in confirmed acute gonorrhoea, the initial and preparatory- conditions of the case being shown in Figs. 33 and 34. The epithelium has wholly disappeared, and only pus-cells containing many gonococci now appear in the field. tests. If the incubation is very slow, they may be found at first in very limited numbers, entirely free in the serous fluid, later on about the edges Fig. 36. Gonorrhceal discharge obtained a few hours after onset of disease, containing cylindrical epithe- lium, pus-cells, and gonococci. or on the surface of the epithelial cells, and finally exclusively in the pus-cells. It is very interesting to study the spreading of the gonococci over the surface of the cell. At first the micro-organisms may be seen only on the edges of the cell ; then they gradually extend until they cover its whole surface, perhaps in several hours or perhaps in a day or two. (See Figs. 33 and 34.) It is important to remember that when the discharge consists only of serum, epithelial cells, and gonococci, the latter are seated on the cells and they also float free in the serum. This condition also may be observed where a few pus-corpuscles have become mixed in the discharge. At this time, therefore, the micro-organisms may be present only in small numbers in the pus-cells, or they may not be thus placed at all. Later on, when the discharge becomes decidedly purulent, the majority of the gonococci THE PATHOGENIC ACTION OF THE GONOCOCCUS. 67 will be found in the pus-cells, and very few will be free and scattered through the serous fluid. The behavior of gonococci in a case of long incubation seems to be somewhat as follows : The gonococci received at infection are too few to be generally distributed over the urethra, and hence the chemotaxis they Fig. 37. Showing enormous quantities of gonococci in pus-cells and floating free. arouse is too limited to appear as any appreciable exudation. The cocci seem at first to lie free on the surface of the epithelium, and then they work their way down between the surface cells to the deepest layer of urethral lining cells. As the gonococci thus approach the capillaries beneath the epithelium, chemotaxis comes into play. There is at first a slight determination of leucocytes from the blood-vessels, accompanied by some serum Avhich passes out into the urethra, and synchronously with this there is a desquamation of the epithelium lining the urethra. As the gonococci become more and more numerous and are distributed to the deeper parts of the urethra in virtue of its capillary attraction, there comes a time when these microbes attract the leucocytes from a consider- able territory of the canal simultaneously, and this corresponds to the time when the discharge suddenly becomes purulent and abundant, with the gonococci enclosed in the pus-cell. (See Fig. 35.) The gonococci are found in the pus-cells, not because the cocci them- selves actively penetrate the protoplasm, as has been erroneously stated, but because the leucocytes act as phagocytes. The leucocytes enclose the cocci by virtue of their amoeboid properties, and carry them out of the urethra in the purulent discharge. It is the pus-cell, in all probability, which carries the infecting cocci from one person to another, and probably very few individuals are infected by gonococci floating about free in a discharge. Acute Invasion. — The character and onset of the cases of acute inva- sion may now be considered. In these cases the number of the gonococci received at the exposure is so large, their proliferation is so rapid, or they become so soon distributed — very likely at the exposure — over a large surface of the urethra, that the discharge may be sero-purulent or purulent from the beginning, and in that case the preliminary scanty serous exu- 68 GONOBBHCEA AND ITS COMPLICATIONS. dation previously described is very evanescent or almost entirely absent. It happens very seldom indeed that in these cases there is an opportunity to examine microscopically the evanescent serous stage of such a dis- charge, but still there is a stage of desquamation of the urethral epithe- lium in advance of the purulent discharge. This is well shown in Fig. 36.^ The desquamated epithelium appears as tiny rice-colored grains in a clear exudation, but this stage of desquamation is very short in these acute cases, lasting only a few hours, and then the discharge becomes purulent. A further illustration of very acute invasion with myriads of gonococci is typified in Fig. 37.^ ^ The case from which Fig. 36 was taken illustrates a very early stage of the discharge in an attack of acute invasion. This patient had a sero-purulent discharge from the beginning apparently (incubation four days), and came under observation a few hours (six or eight) after hrst noticing discharge. The case (see Fig. 36) illustrates especially well how even in acute cases there is a desquamation of epithelium from the urethra, although it is so transient in these acute cases that it is seldom observed. In this case the urethra appears to have been in the perfectly normal or virgin condition, for the sur- face epithelial cells have their proper cylindrical shape. There are very many gonococci in this specimen, a considerable number of the pus-cells being loaded with them. A very few scattered gonococci were found free in the serum in groups of twos and fours. In this case the urethra was probably invaded by a great number of gonococci at the infection — either the man having exposed himself generously — or there were many cocci in the discharge of the donor, or perliaps both conditions were combined. The initial extensive number and distribution of the cocci provoked a rapid acute onset. ^ Fig. 37 shows a very unusual feature in the large numbers of free gonococci sus- pended in the liquid portion of the discharge. This figure was not selected with a view to exaggerate this feature, but is taken at random from the slide, which shows quite uni- formly the conditions thus pictured. The case was that of a man who had had gonorrhoea seven years before. The incubation period of the present infection was five days. Two of the pus-cells contain forty-eight gonococci, one of them eighteen, and the other forty- eight gonococci, while ninety-eight gonococci were counted lying free in the serous fluid of the same field (Leitz, oil-immersion, -^^ ocular, 4-tube, length 15.5 mm.). Estimat- ing that one drop of this fairly thin discharge could be spread in a thin film over ten cover-glasses 18 mm. square, such a droji would contain, counting roughly, 1,038,260 free gonococci and 524,120 gonococci enclosed in pus-cells ; and this, if anything, is a very low rather than a high estimate. This gives a tangible idea of the number of gonococci occurring sometimes in a discharge. A drop of exudation, as in this case, entering a man's urethra would carr}^ a little short of two millions of gonococci. Apparently in this case the gonococci are proliferating in enormous numbers over the surface of the urethra, and are being distributed over the whole surface of the anterior, if not very soon into the posterior, part of the canal. The specimen was taken from the second day of the discharge, and chemotaxis, or the attraction of the leucocyte by the gonococci, has taken place fairly voluminously, but the proliferation of the bacteria has been more rapid than that of the white blood-cells, which takes an appreciable amount of time. Thus the leucocytes have not yet appeared in sufficient numtjers at this particular stage of the discharge to embody the cocci, so that they are free to pass to new portions of the urethra. In reflecting over this latter behavior of the gonococcus, proliferating faster than the white cells can embody them, and passing to all parts of tlie urethra, we have some sort of rational basis to explain the different grades of severity so well marked in gonorrhoea. It is very seldom that just such a picture as this, showing so many free cocci, is ob- tained. Most likely these enormous numbers of gonococci are rather a transient feature of a discharge, for a very extensive observation of gonorrhoeal discharge, studied in tlie light of the doctrine of chemotaxis, shows that the supjjly of white blood-cells is so exces- sive in response to the chemotactic demand of the gonococci that they are quite generally engulfed in the body of the leucocyte. Probably in this particular case a few hours would have sufficed to bring out such an increase of leucocytes that a large majority of the free gonococci would be enclosed in the protoplasm of the pus-cells. Another interesting feature of this case is the way such a discharge would act in infect- ing another urethra. If a urethra were infected with such a discliarge, the resulting attack would certainly be acute and severe, from the large numlier of free gonococci. The urethra being endowed with a species of capillary attraction from before backward, THE PATHOGENIC ACTION OF THE GONOCOCCUS. 69 As a general rule, the long incubation of gonorrhoea is best marked in cases where the urethra has been the seat of, or damaged by, previous attacks, while the very acute invasion often is best exhibited in the virgin or normal urethra. In previous protracted or multiple gonorrhoeas there is a tendency toward a distinct change in the structure of the urethral epithelium. The urethral lining in places becomes thicker and the sur- face cells become flattened. Pavement epithelium then replaces the cylindrical variety. To what extent this change in the urethral epithe- lium determines the long incubation often seen in patients who have had many previous gonorrhoeas is a rather difficult question to decide. Having thus far studied the nature of the discharge in the very earliest stages of both the slow and acute invasions, the later and final stages may now be described. The Purulent Stage of the Discharge. — When the discharge has once commenced and becomes tangible and yellow, so that the patient notices it, its structural characters are very uniform. It consists almost entirely of pus-cells and serum. The pus-cells of gonorrhoea are larger than those of any other form of suppuration. Under the microscope with a moderate power the pus-cells can be seen scattered all over the field, with no tendency whatever to agglomeration or aggregation. Occasion- FiG. 38. Showing gonococci in the pus-cells of acute gonorrhoea ; much magnified. ally in the beginning of the purulent stage a number of red blood-cells appear, and finer and coarser bands or sheets of fibrin. Occasionally also a stray rounded or oval epithelial cell may be found here and there. A these free gonococci would lie distributed at once over a largo surface, lighting ny) inflam- mation at many points simultaneously. Tlie older idea, tliat gonorrlui'a starts in at the meatus, lingers in the fossa navicularis, and then trails slowly backward, certainly does not explain very well a large number of cases, which seem rather to show a simultaneous invasion of several portions of the urethra. 70 OONOBBHCEA AND ITS COMPLICATIONS. certain proportion of tlie pus-cells — say, one to twenty or one to fifty — contains from two to fifty or eighty gonococci enclosed in their cell-bodies. There are seldom any free gonococci except in the earlier stages of the purulent period. This uniform structure of the purulent stage per- sists right along until the declining stage, and a good idea of the micro- scopic picture in this stage is shown in Fig. 35, and under a higher power in Fig. 38. As the purulent stage declines the secretion becomes more whitish from the admixture of mucus, and less liquid. Then it gradually grows less in quantity and more inspissated, so that toward the end of the acute stage it is not seen as a secretion, but as little yellowish-white clumps or threads in the urine. Examination of the secretion of this stage shows masses of pus-cells held together somewhat in thread form by mucus. This condition is the first step in the formation of the gonorrhoeal threads, or tripper faden. The Declining Stage. — Gleet. — Gonorrhoeal Threads. — In the de- clining period, or after the discharge has persisted as a gleet for some days or weeks, it still consists of pus-cells, less thickly aggregated, how- ever, than in Fig. 35, entangled in sheets of fibrin or mucus, with a vari- able number of rounded epithelial cells. In this stage healing of the mucous membrane usually begins. The hyperemia gradually grows less, the morbid surface becomes contracted, lessened in area, and a tendency is observed to render the surface of the mucous membrane normal. In this process exulcerations and eroded spots, caused by the gonorrhoea, become more or less completely covered by an epithelial coating. As this salutary epithelial proliferation goes on there is much desquama- tion, as well as the escape of serum and leucocytes from the membrane. It thus happens that a larger or smaller number of epithelial cells are found in a gleety discharge. With the appearance' of epithelial scales the reparative process may be said to really begin, and as the case progresses the pus-cells become less and less numerous, while the epithelial cells in- crease in number. Then, if all goes well, these cells gradually grow less numerous, and a cure results. It follows, therefore, when in a declining!; gonorrhoea pus-cells persist in great numbers, while epithelial cells are scanty, that there is slow progress toAvard cure. Then, on the other hand, when frequent examinations show that the pus-cells are disappearing and that the epithelial cells preponderate, it is evident that the moi'bid process is ceasing. As in the early stages, so in the later ones, the microscope gives us great aid in determining the character and extent of the inflam- matory process. In these later stages the discharge is commonly so scanty that it does not escape from the meatus, but it is carried from the canal by the stream of urine. This discharge is then seen to be in the form of clumps rounded, irregular, or crab-like, in the form of flakes of various size and irregular shapes, and in the form of threads which may be long and very thin or thick or short and stumpy. The threads from either the anterior or posterior portion of the urethra have the same mi- croscopical structure as the gleety drop ; they are composed quite con- siderably of pus-cells entangled in a thick fluid exudation containing fibrin or mucus and generally a variable number of epithelial cells. The Question of the Presence of the Gonocoecus in Gleet and Threads. — This is an exceedingly important subject, since it introduces the ques- THE PATHOGENIC ACTION OF THE GONOCOCCUS. 71 tion of late and remote infection. Many clinicians since the discovery of the gonococcus seem inclined to believe that this micro-organism stays somewhere hidden or quiescent in the urethra as long as the gleet or threads remain, and that it is the direct cause of the gleet or threads. Others go still further and make it appear that the gonococcus may per- sist in a latent way for a long time after the chronic discharge or gleet has utterly ceased, and that under appropriate irritation it may become active and aggressive again. These observers — who have, moreover, quite a large number of followers in' their way of thinking — have appar- ently come to their conclusions about the lengthy or indefinite persistence of the gonococcus by calling any diplococci which they see about the size of the gonococcus in the secretion of old gleets, gonococci. As we have already seen, there are many species of diplococci very much like the gonococcus in form and staining qualities ; consequently, morphological identification of the gonococcus without cultures is apt to be fallacious. I think that this vieAv of the extreme persistence of the gonococcus in the urethra has been much overdrawn, and those who hold it seem to over- look the fact that there is abundant damage done to the urethra by the gonococcus, which produces an exudative inflammation which remains long after that micro-organism has disappeared. On the other hand, I do not state positively that the gonococci promptly disappear in the declining stages — they may persist for some time in the gleety discharge — but after a gleet has lasted for two or three or six months the gonococci are in all probability in most cases absent.^ To decide precisely when the gonococci ^ The most elaborate study of the frequency of occurrence of gonococci in chronic urethritis is that of Prof. Goll {Correspondenzblaitfilr Schweitzer Aerste, 1891, vol. xxi. pp. 25 et seq. ), but, unfortunately, his results were all obtained from the microscope, wliich we have shown to be fallible in many cases, (ioll's studies were carefully made, the secretion in each case being examined from three to fourteen different times. The following table will show the dates at which gonococci were found in 1046 cases : Duration since infection. Number of cases. Gonococci found. Negative result. Percentage of occur- rence of gonococci. 4-5 weeks 6 " 7 " ...... 2 months 3 " 4 " 5 " 6 " 7, 8, 9 months . . 1 year li years ... . . 3 "'.'.'.'.'.. 4 " 5 " 6 and more years . . . 85 54 35 75 76 62 43 55 103 83 76 135 80 37 20 22 40 21 11 15 13 13 8 8 21 12 7 7 2 45 33 24 60 63 49 35 47 87 71 69 128 78 37 20 22 ■ 47 per cent. 38 " 31 20 " 17 21 18 14 " 19 14 9 " 5 " 2^ " Cases examined . . 1046 178 868 In these studies Goll convinced himself that in some young healthy men the gonococ- cus disappeared for good in three weeks, wliich nuist be regarded as an exceptional occurrence. A perusal of the tal)le shows that, unless mistakes were made by which other diplo- cocci were regarded as the gonococcus, the latter organism may be found very counnonly 72 GONORBHCEA AND ITS COJIPLICATIOXS. disappear is impossible by the microscope alone. In the female there seems at present to be some evidence — in exceptional cases, however — in favor of the long persistence and dormant condition of gonococci in the uterus and tubes. As a o;eneral rule, the o:onococcus crraduallv ceases in the srleetv morn- ing drop and in the urine threads. It becomes extinct and disappears out of the urethra, yet the gleet and threads still persist, but this is because of certain structural changes in the urethra left behind by the severe exudative inflammation caused by the gonococcus. All sorts of bacteria may be found in the urine threads and often in old gleets, and among them several diplococci which resemble or look almost exactly like the gonococcus. also long and thin and short and thick bacilli. In fact, by the microscope alone it is almost impossible to positively identify the gonococcus in old gleet or threads ; consequently, it is well to be skeptical and perhaps incredulous as to statements of authors that they have found this microbe under these conditions. Unless the author is known as a conservative and skilled observer, or there is inherent evidence of abso- lute thoroughness, carrying conviction in his essay, his conclusions are not entitled to stand as scientific evidence.-' The discharge persists after the extinction of the gonococcus because of the ulcers, erosions, small round-cell residues, and thickening beneath the epithelium or other sequelae incident to the intense exudative inflam- mation aroused by the gonococcus. An ulcer or exulceration, especially in a long, narrow, closed sinus like the urethra, will continue to exude indefinitely without any assistance of the gonococcus. Chronic Relapsing Gonorrhcea. Patients with these superficial ulcers or other sequeh'e, such as a smouldering inflammatory condition of the vessels and cells of the part, left behind after the extinction of the gonococcus. may become the sub- jects of chronic relapsing urethritis or "latent" gonorrhoea — termed latent apparently because the gonococcus is supposed to hibernate some- where in the urethra, and then become active again with appropriate stimulation. The real explanation seems to be this : The gonococcus is not responsible for these intermittent attacks continuing long after the primary attack, but the erosions, ulcers, epithelial deficiencies, or small round-cell residues (corresponding to the granular condition of the mucous membrane), which have never been perfectly healed, light up afresh after debauchery or sexual stimulation. Yet the purulent discharge started up up to the ninth month of infection ; that during the second year it occurs in a goodly proportion of cases, and in the third year in a small percentage ; and that it is not found after the third year. The truth of the matter is, that our studies in this direction have hardly commenced, and they should be prosecuted by many observers on many patients in the light of our newly-acquired and yet-to-be-acquired knowledge of the gonococcus and its biology. It will be a long time before dogmatic statements can be made which will stand scientilic scrutiny. ' In the light of this position it is interesting to know that Sahli { Correspoiulensblaft fiir Schweitzer Aerzte, 1887, p. 495) says that he had not once failed to find the gonococcus in the numerous male patients he had examined even after a long duration of the disease. Even Fiirbinger, who is a careful and scientific man (Die inneren Krankheiten, 2d ed., p. 438), speaks of the disappearance and reappearance of gonococci after mechanical and chemical irritations of the urethra. THE PATHOGENIC ACTION OF THE CWNOCOCCUS. 73 in this way contains no gonococci, although at times diplococci of one kind or another may be found looking very much like the gonococcus or quite identical "with it, so far as form and staining reactions are concerned. As to the determination of the gonococcus in all these stages of gon- orrhoea by the microscope alone without culture methods, it should be said that it is sometimes exceedingly difficult to identify the coccus in the earliest and, as we have said before, particularly in the later gleety, stages of the discharge. In the active purulent stage, however, as we have seen, the identification of the gonococcus is quite reliable, especially when the clinical history and physical signs are dovetailed in with the micro- scopical examination. We now come to the study of the pathological products of urethral inflammation, early and late. Gonorrhoeal threads, urethral filaments, also called trijyjJer faden, may be divided into four quite distinct varieties. First, there is the pus- Fig. 39. thread which has already been alluded to, and is pictured in Fig. 39. It is a thread only in the sense of pus-cells being aggluti- nated with each other or strung together by means of mucin as a basement-substance. It may be in the form of threads, clumps, and irregular masses. This prod- uct is observed just before the appearance of epithelia in the threads. The second is the gelat- inous thread. The third is a firm thread, consisting of pus, mucus, round and epithelial cells, and indicative of a well-developed chronic exudative process. The fourth form of thread consists chiefly of epithelium, Avith very little pus, and some basement mucin to hold the cell-elements together. This product is essentially a desquamation. The gelatinous threads are seen most commonly toward the end of the acute stage, when mucin comes to be secreted and acts as a cement sub- stance for the cellular exudation. These gelatinous threads are also not uncommonly seen late in the course of gonorrhoea when the exudative process still lingers in the submucous connective tissue and the overlying membrane is in a catarrhal condition. These gelatinous threads ai'e some- times finer than the finest hair, and are of intermediate sizes until the dimensions of a knitting-needle are reached. They are often very long (three, four, and more inches), and float about in the urine in graceful curves. Then, again, they are thicker, less lengthy, and perhaps of irregular calibre. They are usually very elusive, and are with difficulty captured by the pipette or the forceps, and when caught they collapse into a little gelatinous mass. In this form of thread we find entangled in the cement substance pus-cells, round-cells, and perhaps some large flat epi- Showing a thread-like agglomeration of pus-cells held together by mucin, being the first stage in the formation of the thread. 74 GONOBRHCEA AND ITS COMPLICATIONS. tlielial cells. This form of thread is usually seen to follow the pus-thread already pictured in Fig. 39, in which no epithelium is yet present, and Fig. 40. Mucin, pus, and epithelium. Fig. 41. Showing gelatinous thread with pus-cells, round hyaline (iodophilous) cells, epithelial cells held together by mucin : declining stage of acute gonorrhoea. which is symptomatic of the turning-point in the- acute stage of the dis- ease. With these gelatinous threads there is frequently such an amount -p , A^ of mucus as to render the urine cloudy, though not opaque, and very often to look like mucilage diluted with Avater, or new cider. The microscopical appearances are shown in Figs. 40 and 41. The third form of urethral fila- ments consists of whitish-gray and brownish-white threads, varying in length from a third of an inch to an inch and more in length. They may be thread-like, thin, and deli- cate or thick and stumpy. Some have a distinct head, and resemble a comma, and are said to come from the posterior urethra. Then, again, they present branched forms, and some resemble crabs in shape. Indeed, words fail to describe all the shapes assumed by these urethral filaments. Examined under the microscope, these pathological products Showing secretion of late declining anterior gonorrhoea. THE PATHOGENIC ACTION OF THE GONOCOCCUS. 75 Fig. 43. Showing secretion of piosterior urethritis in chronic stage. are found to consist of round cells, hyaline cells readily colored with iodine (iodophilous), pus-cells, epithelial cells, oval, polygonal, irregulat, fusiform, and caudate. All these elements are held together in the most complete disorder as to arrangement by the basement substance. In Fig. 42 is well portrayed the appearance of the discharge in chronic gon- orrhoea of the bulb, and its study Avill give a clear idea of the mi- croscopical picture. Attempts have been made with- out success to establish sharply- marked differences in the micro- scopical pictures of the discharge in anterior and posterior gonor- rhoea. The truth is, that in the main there are the same cellular elements to be seen in the dis- charg-e from the anterior urethra as are found in that of the poste- rior urethra in chronic gonorrhoea. Consequently, in many cases the microscope affords little help in determining exactly where a dis- charge comes from, but it generally gives a good idea of the condition of the process. In some cases, however, we find dead spermatozoa inex- tricably mixed up among the cell-groups, and thus we have presumptive evidence that the morbid focus is in the posterior urethra. But even in this event a positive conclusion cannot be reached until it has been proven that the seminal vesicles are not affected, since the same micro- scopical picture may be presented in seminal vesiculitis. In Fig. 43 the appearances of the dis- charge from the posterior urethra are Avell shown. There is much resemblance to the picture pre- sented by the discharge from the anterior urethra already shown. (See Fig. 42.) But it will be seen that there are many sperma- tozoa scattered and in clumps, and that the round-cells are pres- ent in rather greater numbers. These appearances of the mor- bid cellular elements in anterior and posterior gonorrhoea may be seen months, and even years, after the onset of the infection. In other words, in chronic cases the morbid pro- cess gives rise quite uniformly to the same orders of pathological products. Fig. 44. Showing epithelinm and pus from a localized morbid area. 76 GONORBHCEA AND ITS COMPLICATIONS. The scaly threads or flakes which form the fourth variety are less common than the threads just described. They may be seen in the form of a coarse powder, in threads, in lumps, and flakes of whitish-gray color. They are firm in structure, and readily sink to the bottom of the glass. Examined with the microscope, these flakes show a quite uniform field of flat epithelium in various shapes, which shows stability of structure. Many of these cells are nucleated, and not infrequently they are the seat of fatty degeneration. There are usually some pus-cells intermixed in the field. This form of thread or flake (well shown in Fig. 44) is usually the prod- uct of a localized inflammatory process in the anterior urethra as far down as the bulb. It is usually indicative of an erosion or ulcer in which the reparative process is abortive, and, although new epithelium is formed, the integrity of the mucous membrane is not re-established. On finding such a microscopical picture one is warranted in making an endoscopic exami- nation with a view of localizing the morbid area. In stricture of the urethra the third and fourth varieties of threads are usually found, together with more or less pus and mucus. CHAPTER V. INVASION OF THE TISSUES BY THE GONOCOCCUS. We have already studied the pathogenic action of the gonococcus in the light of clinical observation, aided by the microscopical study of the gonorrhoeal secretions. The further process of the invasion of the tissues by the gonococcus may now be considered. Owing to the great difiiculty, and at times impossibility, of obtaining a urethra the seat of active gonococci-invasion, Bumm studied the subject upon the conjunctiva of infants inoculated with gonococci-containing pus. As the mucous membrane of the eye resembles that of the urethra, and as the two mucous membranes react similarly to gonorrhoeal infection, it is fair to assume that the morbid processes and appearances are similar in each instance. It is this want of pathological material on my own part which forces me here to make use of Bumm's observations and results. Having gained a foothold on the superficial epithelial layers, and there having greatly increased in numbers, the gonococci penetrate between the epithelial cells, which have become swollen and succulent, into the soft protoplasm substance. It is interesting to note that in the infective pro- cess the cocci themselves are the active agents in advancing and attack, and that they are not enclosed in pus-cells. Indeed, active participation of the pus-cell is not observed. The spreading of the micro-organisms onward is thought by Bumm to be due to their grooving more actively on one side — a condition caused by the diff'erence in soil and probably by an increased supply of oxygen. In all cases the road traversed by the gono- cocci is through the cement-substance between the cells. Sometimes they PLATE 1. ^- '•.--- ^'"♦S •sg 't, <-~«^" .? — > *" '^t^ **^«» *^i- INVASION OF THE TISSUES BY THE GONOCOCCUS. INVASION OF THE TISSUES BY THE GONOCOCCUS. 77 squeeze and penetrate by their files ; then again they advance in a larger body, and, when the tissues will admit, they form a roundish colony, and from that stage make further incursions into the tissues. When they have got well down toward the subepithelial connective-tissue layer, reaction on the part of the tissues occurs.^ Then great numbers of Avhite blood- cells escape from the dilated capillaries, together with much serum. This stream of pus, pouring out, breaks through the epithelium or even carries it away in small or large plates, The removal of the epithelium then permits further invasion of the gonococci even to the papillary layer, but there it stops. Pus-cells filled with the gonococci may now be seen, but free gonococci are much more numerous. Coincidently with this cocci- invasion and multiplication the inflammatory process increases in inten- sity, and a dense round-cell infiltration is formed beneath the surface of the mucous membrane. This is the transition to the purulent stage of gonorrhoea. In some cases as early as the fourth day regeneration of the epithelium begins and rapidly progresses, and then the further invasion of the micro-organism may be stopped. During this reparative process the pus-cells escape unhindered, and rows and clusters of gonococci may be harbored between the cells of the uppermost layer of the epithelial strata. Under some circumstances there may then be a new invasion by the gonococci. An outpouring of pus destroys more or less of the epi- thelial layer, and this opens a way for the second invasion. This condi- tion is what occurs in relapses of acute and tolerably acute gonorrhoea. The cocci may develop between the superficial connective tissue and the tunica propria, but they do not luxuriate. It seems probable that they do not find in the deep parts of the mucous membrane the conditions necessary for development, or that they are unable to withstand the influ- ence exercised by the tissue-elements.^ They are most at home in the superficial layers of the connective tissue and between the epithelial cells. In this infective process, therefore, we see a violent invasion of a mucous membrane by large masses of gonococci which penetrate between the cells. There is always to be observed a connection between the multiplication and activity of the micro-organism and the intensity of the inflammatory process. The reaction on the part of the tissues corresponds to the intensity of the irritation excited in the soft and sensitive epithe- lium. So long as there is secretion present on a mucous membrane, the gonococci may remain in it and multiply, for it oifers a favorable culture- soil. The great mass of gonococci in the uppermost strata of tissues perishes there from simple dissolution. Final healing is caused not so much through the elimination of the micro-organism as by the develop- ment of a protective covering of squamous epithelium in several strata which closes up all gaps, cracks, and inlets to further invasion. The infective process is, therefore, brought to an end by the energetic devel- opment of epithelium, which forms a barrier which the gonococci cannot break throug-h. The foregoing description will be rendered much clearer and more striking by a study of the figures representing microscopic sections of the conjunctiva (Plate I.) : ^ Chemotaxis. * Bumm states that gonoiTho?al pus injected into tlie subcutaneous connective tissue produces no reaction, and that the gonococci soon disappear. 78 OONOBBHCEA AND ITS COMPLICATIONS. In Fig. a is shown a section through the conjunctival fold of the lower lid. The epithelial layer is covered with an exudation which consists of fibrin and pus-cells, and contains free gonococci and others enclosed in pus-cells. In Fig. h the invasion of the conjunctival epithelium by colonies of gonococci is shown. Fig. c shows a perpendicular section through one of the furrows of the fornix conjunctivae of the lower lid. The conjunctival epithelium is invaded by gonococci. It is desquamating, and is infiltrated with the products of exudative inflammation — serum, fibrin, red blood-cells, and pus-cells. Fig. d shows the ingrowths of large superficial colonies of gonococci in the epithelial layer. In Fig. e is shown a vertical section through the conjunctiva of the lower lid. The epithelium has been completely desquamated, and some of the earliest colonies of gonococci are seen penetrating the conjunctival connective tissue. In Fig. / is shown two colonies of gonococci penetrating still deeper into the subconjunctival connective tissue. In Fig. g is shown the gonococci invading the superficial portions of a papilla. In Fig. h is shown proliferation of gonococci in the superficial (ede- matous part of an intrapapillary portion of the conjunctival epithelium. Fig. i shows the character of the newly-formed epithelium (after the cessation of the gonococci-invasion), Avhich is somewhat changed and has more the type of squamous epithelium. On the surfiice there is a small cluster of gonococci. In Fig. j is shown a recurrent invasion of newly- formed epithelium by gonococci. It is very probable that when gonorrhoea is caused by the staphylo- coccus and the streptococcus the pathological processes and changes are similar to those produced by the gonococcus. CHAPTER VL THE PATHOLOGY OF CHEONIC GONORRHCEA AND OF STRICTURE OF THE URETHRA.^ As we have already seen, gonorrhoea does not produce a mere catarrhal inflammation of the urethra, from which the membrane might readily return to the normal condition, but in addition a severe exudative inflam- ^ For a more technical exposition of these subjects the reader is referred to Wasser- mann and Hall^, " C Contribution a I'Anatomie patholowique des Eetrecissements de rUr^thre," Annales des Mai. des Organ. Ge'n.-urin, vol. ix., 1891, pp. 143, 242, 295 et seq. ; also Finger, "Beitrilge zur Pathologischen Anatomic der Blennorrh(Te der Miinn- lichen Sexualorgane (1, C'hronisclie Uretlu-al-blennorrhfi') " Ergiinzungsheft zur Archiv fur Derm, und Syphilid, 1891, pp. 1 et seq.; and same (2, Chronisclie Urethritis posterior und die Chronische prostatitis), ibid., Ergiinzungsheft fiir 1893, pp. 27 et seq. PATHOLOGY OF CHRONIC GONOBRHCEA. 79 Fig. 45, /^.^y 'A, 1 1 V i*^ '^^;hm: ^ Showing a transverse section through the entire urethral canal and tunica albuginea, with round-cell infiltration around urethra and mucous follicles. mation in the submucous connective tissue results, Avhich has a tendency, if the process persists for a long time, to damage the urethra permanently. We have, therefore, a catarrhal and an exudative process combined. Such Fig. 46. lowing a segment of roof of urethra, with round-cell infiltration of the mucosa and tubular ducts of follicles ; higher magnifying power than in Fig. -15. 80 GONOBBHCEA AND ITS COMPLICATIONS. an exudative inflammation induced by the gonococcus is attended first with a desquamation of the urethral epithelium, and Avhen this epithelium is restored it is liable to be more or less thickened and to have a different character from the normal epithelium of the urethra. In other words, the normal cylindrical epithelium of the urethra becomes destroyed by the gonorrhoeal process, and is on healing replaced by flat pavement epithe- lium. These epithelial proliferations are seen by the endoscope to appear like granular and warty patches, and even polypoid growths. When old they may present a whitish, opaque appearance resembling cicatrices. Then, again, the exudative inflammation attending gonorrhoea may pro- duce ulcers or erosions, and frequently induces a formation of connective tissue in the walls of the urethra. The mucous glands may also be con- siderably changed. Figs. 45 and 46 show the character of the gonorrhoeal inflammation, and Figs. 47, 48, and 49 illustrate some of the more import- ant sequelae of chronic gonorrhoea — namely, stricture-formations. Figs. 45 and 46 were taken from sections of the urethra of a subject at Charity Hospital who had had chronic gonorrhoea for some months. In Fig. 45 the topographical distribution of the inflammation is shown in a Fig. 47. Showing an exulceration of the urethra, with round-cell infiltration-bed and absence of epithe- lium ; newly-formed capillaries in red. section through the entire thickness of the urethral canal, including the tunica albuginea. The whole folded lumen of the urethra is surrounded by a deep ring of small round-cells (2, z\ Avhich seem mainly to have come from the superficial vessels of the mucosa, Avhile a part of them may be proliferated connective-tissue cells. The epithelial lining of the urethra is desquamated, and is entirely absent in places {x, x\ while in other places {y, y) it is still in proper position, although infiltrated with pus- cells. In the roof of the urethra, in this section, the ducts of the mucous glands at various depths are also surrounded by a heavy infiltration of PATHOLOGY OF CHRONIC GONORBHCEA. 81 small round-cells, which indicates an extension of the inflammation along the mouths of the glands from the surface of the urethra {to, w). Fig. 46 shows the invasion of the urethra by the gonorrhoeal process still more plainly. The drawing includes the whole thickness of a segment Fig. 48. Showing a section through a superflcially-seated stricture, with moderately dense, newly-formed connective tissue. from the roof of the urethra, corresponding to the rectangular area indi- cated by p q in Fig. 45. With this higher magnifying power in Fig. 46 the infiltration of the mucosa and tissue surrounding the tubular ducts of the mucous glands is shown in detail. With the exception of the patches Fig. 49. , / i' Showing a section through a firm inodular stricture, the connective tissue being so dense as to resemble cicatricial tissue. denoted by x and y, the epithelial lining of the urethra is absent, so that there are extensive areas of erosion of the infiltrated mucosa. Lying free in the urethral lumen near the denuded surface is a flake of the gonorrhoeal exudation {z, z, Fig. 46). This flake is quite identical in structure with the ordinary gonorrhoeal discharge as seen on a cover- 6 82 GONOBBHCEA AND ITS COMPLICATIONS. glass, and consists mainly of pus-cells lying in a fluid or granular matrix. The mucosa just beneath what is left of the epithelial lining is very densely crowded with small round-cells to the extent shown in the figure at V, V. In the same way the ducts of the mucous glands u, w, and r, and in places the gland acini themselves (t), are similarly infiltrated with the small round-cells. The ducts w and r have their lumina partially filled with desquamated cells and granular material. These figures (45 and 46), then, serve to show that when gonorrhoea has become chronic it must necessarily take a long time for the disease to heal, since in the affected regions of the urethra all this desquamated epithelium must be restored, and the infiltration of small round-cells be disposed of before the urethra can become healthy again. Among the most important sequelae of gonorrhoea are ulcers or erosions of the urethra, which are, as a rule, small and sharply localized. Fig. 47 shows a longitudinally situated narrow linear ulcer from the middle of the penile urethra. The section was cut transversely through the urethra. As far as the structure of this ulcer is concerned, it needs but little description, for it does not differ essentially from minute ulcers elsewhere — in the skin or mucous membranes approaching the skin in structure. At the site of the ulcer the epithelium is deficient ; there is a fairly circumscribed collection of small round-cells, interspersed with newly-formed capillaries, which tend to pass up vertically toward the sur- face. In a word, the ulcer has a bed of granulation tissue. The practical importance of such a condition of the urethra is that it tends to persist almost indefinitely, and keep up a discharge which appears as a scanty gleet or a discouragingly prolonged appearance of gonorrhceal threads. We now come to the study of more advanced conditions of urethral inflammation and coarctation. Further, then, the exudative inflammation is of great surgical importance, for the reason that it almost inevitably tends, if not properly treated, to the development of stricture of the urethra, with all its dangerous sequelae. Early in chronic urethritis the newly-formed submucous-tissue infiltration is still soft and succulent, and when it produces very decided diminution of the calibre of the urethral canal, it may be then called "soft stricture." As the morbid tissue grows older, and connective-tissue cells take the place of the small round-cells, it becomes more condensed, and then the stricture can no longer be called soft, and the term "semi-fibrous" may be applied to it. Thus in the domain of chronic anterior urethritis we recognize in clinical practice, as ulterior results, the soft and the semi-fibrous strictures. Figs. 48 and 49 illustrate two forms of stricture of the urethra. In Fig. 48 is shown one of the forms of large-calibred stricture, Avhile Fig. 49 is from a section of a more extensive tight stricture, contracting the urethra to a considerable degree. These figures serve not only as a text for the exposition of the detailed minute anatomy of urethral stricture, but also as a practical demonstration of the topographical distribution and general structure of two extreme forms of strictures. Both of these strictures were evident to gross inspection. In Fig. 48 is a section of the stricture shown grossly in Fig. 117. (See chapter on Stricture of the Urethra.) This stricture was situated in about the middle PATHOLOGY OF CHRONIC GONORRHCEA. 83 of the anterior urethra ; it lay a little to one side of the roof of the ure- thra, and looked like a bit of coarse cotton thread stretching across the surface of the membrane for a very limited distance — only three to four millimetres. The urethra was perfectly normal both above and below the tiny constricting band or thread. A vertical section of the urethra pass- ing transversely through this little band presents the appearance shown in Fig. 48. This stricture is very superficial ; in fact, most of it is raised up above the surface of -the urethra, although a slight amount of connective tissue stretches out in the mucosa on either side of the centrally-elevated nodule which corresponded to the thread-like band shown. In Fig. 48 the stric- ture is composed of fairly dense newly-formed connective tissue, which, however, lies very superficially : the wall of the urethra itself is but very little invaded by the stricture. This is a good illustration of the least- developed form of stricture. This band or ring form of stricture is not common, and may be said to be in reality rare. In this case but one imperfect band was present, but in very exceptional instances several bands may be found, which may exist separately, the tissue between them being healthy. As a general rule, when bands of stricture exist, the whole expanse of mucous membrane on which they appear is the seat of morbid change. Those authors who lay great stress upon strictures of large calibre teach that these contractions consist of separate and distinct bands. This statement is pure assumption, and is not based on studies in pathological anatomy. Therefore it is, in consequence, incorrect, the truth of the matter being as just now stated. Fig. 49 shows a much more extensively developed form of stricture. In this instance the lumen of the urethra was considerably narrowed — approximately to about the calibre of a No. 9 or 10 sound (French). This stricture formed an annular ridge extending transversely about one- quarter way round the urethra at the junction of the membranous with the bulbous portions. In the vertical section (Fig. 49) of the urethra passing through the stricture it will be seen that the stricture is due to the development of a conical lump of newly-formed connective tissue which extends deeply into the wall of the urethra, so as to involve the membrane very extensively, almost down to the albuginea. This mass of connective tissue is very dense, and forms a fairly rigid body, and altogether it has the structure resembling cicatricial tissue. The inter- lacing strands of dense fibrillated fibres composing the mass pass in several directions : many of them pass circularly about the urethra, while others run up and down the canal for a short distance. Over the centre of the stricture the urethral surface is elevated in a conical point, while on either side the epithelium is somewhat thickened. At the right-hand side of the drawing the mucosa is thickened, and some newly-formed vessels pass up vertically toward the surface, as is generally the case in the skin. This latter stricture is in striking contrast to the previous one in its lack of elasticity, extensive involvement of the urethral wall, and corre- spondingly greater degree of narrowing of the urethral canal. It is merely necessary to say that in this case only a limited portion of the lumen of the urethra was involved, and it is here portrayed and described in order that the pathological condition can be placed in contrast with 84 GONORRHOEA AND ITS COMPLICATIONS. the healthy tissues around it. In cases in which the process is deeper and denser the same pathological conditions are presented. As the stric- ture increases in extent and depth the same cicatricial tissue is formed, going down as far as the tunica albuginea, and even involving it and sur- rounding the whole lumen of the urethra. This form of stricture is known in clinical practice as the inodular stricture, which, when fully developed, involves a greater or less segment of the urethral canal in its totality. True stricture of the urethra, then, is the outcome of gonorrhoeal in- flammation, which results in a cirrhotic periurethritis and cavernitis. The morbid process in chronic posterior urethritis is essentially the same as that which affects the anterior urethra — namely, a small-cell exudative inflammation into the submucous connective tissue. This small-cell infiltration may be superficial and only involve the connective- tissue layer, or it may extend deeper into the structural parts of the prostatic urethra. In the superficial form of infiltration the lesion only involves the upper layers of the subepithelial connective tissue, and does not result in much condensation of the membrane. In the deeper form the whole subepithelial stratum is involved, and the caput gallinaginis, the sinus pocularis, the openings of the ejaculatory ducts, and the glands of the posterior urethra may also be more or less implicated in the cell- infiltration, and their structure and function more or less damaged and impaired. All these structures may be invaded in precisely the same manner as the racemose mucous glands of the anterior urethra are. These pathological changes must be remembered in cases of spermat- orrhoea, prostatorrhoea, and in functional disturbances of the general sexual apparatus. Where this cell-infiltration is very extensive and deep the prostatic urethra becomes more or less callous and dense. The pic- ture seen by the naked eye of chronic posterior urethritis is sometimes a granular condition due to epithelial thickening, and perhaps a slightly warty condition due to the presence of minute new vessels covered with thickened epithelium. In later stages the caput gallinaginis is seen to be enlarged and covered by callosities formed by the heaping up of patho- logical epithelial layers. As a result of these lesions we find evidences of a persistent desquamative catarrh. Owing to these changes the dila- tability of the prostatic urethra is somewhat impaired, and its lumen is perhaps slightly impinged upon by the epithelial thickening and by the increased size of the caput gallinaginis; but there is no such condition (though the parts may have even become cirrhotic) of stricture, such as we find in the anterior urethra. In the posterior urethra there seems to be a tendency to the condensation of the tissues, without much decrease in the lumen of the canal. THE ETIOLOGY OF GONOBRHCEA. 85 CHAPTER VIL THE ETIOLOGY OF GONOERHCEA. The cause and origin of gonorrhoea constitute a question which has almost constantly occupied the medical mind for more than a hundred years, and which has given rise to many animated and acrimonious argu- ments and disquisitions. In a scientific point of view it is most essential that there should be a clear and full understanding of this vitally import- ant subject, which is commonly treated of in a biassed way or disposed of too briefly and magisterially. No subject in medicine is more worthy of careful, unprejudiced study, and for that reason I make no apologies for this exhaustive presentation. So often in practice the etiology of gonorrhoea becomes a question which involves social, marital, and domestic relations, and so often upon its correct understanding depend the happiness, harmony, honor, and well-being of families, that a clear knowledge of it is absolutely neces- sary. The question of the fidelity and loyalty of wife and husband, lover and mistress, so frequently occurs, resulting from some purulent discharge from the genitals of the male and the female, that it is one of the funda- mental subjects in medicine concerning which the physician should have clear, practical views. There is no longer any ground for claiming that gonorrhoea is simply a catarrhal inflammation. It has been clearly and fully demonstrated that it is a typically virulent process, and that its essential virus resides in the action of one microbe, the gonococcus, and that other micro-organ- isms also act as virulent agents and causes. Though these facts have been proven beyond doubt or cavil, there are yet many gaps in our know- ledge as to how gonorrhoea originates in many cases. There is to-day an easy-going, self-satisfied assertiveness on the part of the more radical of virulists to the eff"ect that the question is settled and the case closed. But we shall see in the progress of this chapter that, though much has been learned, and though a flood of light has been thrown on the subjects of the origin and nature of gonorrhoea, there still remains much to puzzle us, much yet to be solved, and much to be reconciled by patient clinical observation, supplemented by broad studies in bacteriology over a very wide field. It will be seen farther along that, although the virulent nature of gonorrhoea has been demonstrated, there are many strong and vital points in the doctrines of the non-virulists which have been passed over, ignored, and belittled by the ultra-virulists. I shall endeavor to present our knowledge on this subject in an impartial and unbiassed manner, and shall only draw such conclusions as are clearly warranted in the general survey. To this end a statement and analysis of the researches and views of the various observers who have contributed to this subject are neces- sary. By a scientific and an historical study we may put ourselves in possession of much knowledge which has until now not been collated or formulated. For many years the opinion was held by the advocates of its virulent 86 GONOBBHOEA AND ITS COMPLICATIONS. origin, though it lacked demonstration, that gonorrhoea was caused by a virus animatum or formed ferment. In 1837, Donne ^ claimed that an infusorium called by him the trichomonas vaginalis was found in vaginal pus, and that it was the cause of infection in coitus. This micro-organism is a habitat of the normal vagina, and has no pathogenic influence. Jousseaume^ in 1862 claimed that the alga genitalia, discovered by him, was the cause of gonorrhoea. In a similar strain, Salisbury^ in 1868 claimed that his own discovery, the fungus which he called crypta gon- orrhoica, was the origin of the disease. In the same year Hallier claimed that a fungus discovered by him, and called the coniothecium, was the true materies morhi. As a matter of history only, it may be mentioned that Thiry put forward the claim that gonorrhoea was due to a granular virus. This theory was largely based on the observation of granulations on the urethral and ocular mucous membranes as a result of gonorrhoea. It is shown elsewhere that these granulations are pathological results of the gonorrhoeal process. Thus it will be seen that no real pathogenic micro-organisms had been found, but that accidental infusoria and inert cocci had been seen, and were by some looked upon as pathogenic. In 1879, Neisser ^ published a short and modest paper which marks an epoch in the history of gonorrhoea. In this paper he claimed that by means of Koch's staining methods, and the microscope, using a lens of high power and oil-immersion, he had found in the gonorrhoeal pus of thirty-five cases of from three days' to thirteen weeks' duration a micro- organism which he called the gonococcus. He claimed that in each case this organism was found, and no others, and that it was not found in the pus derived from other sources nor in the simple leucorrhoeal secretion. He found it also in the vaginal discharge of two young girls who had been assaulted by a man suffering from gonorrhoea, in the pus of seven cases of ophthalmia neonatorum of from one to six weeks' duration, and in two cases of gonorrhoeal ophthalmia in adults. Neisser's claims were soon verified and supported by a large number of observers, notably Weiss,^ Bokai,® Welander,^ and Bumm,^ who found the gonococcus in gonorrhoeal pus of the urethra. In like manner, Haab,^ Krause,^" Kroner," Leopold and Wessels,^^and Zweifel,^^and others endorsed ^ Becherches microscopiques sur la Nature des Mucus, Paris, 1837. ^ "Des V^getaux parasites de 1' Homme," These de Paris, 1862. ^ " Description of Two New Algoid Vegetations, one of which appears to he the specific cause of Syphilis, and the other of Gonorrhoea," Am. Journ. Med. Sciences, Jan., 1868, p. 17. * " Ueber eine der Gonorrhoe eigenthiimliche Micrococcusform," Centralblatt fur die med. Wissenschciften, No. 28, 1879. 5 "Le Microbe de Pus blennorliagique," Thhe de Nancy, 1880. ^ "Ueber das Contagium der acuten Blennorrhbe," Allgem. med. Cevtraheitung, No. 74, 1880. ''"Quelque K^cherches sur les Microbes pathog^nes de la Blennorrhagie," Gazette medicate de Paris, 1884, pp. 267 et seq. 8 Der Micro-organi^mus der Gonnorrhoischen Schleimhaut Erkranhungen, " Gonococcus Neisser," AViesbaden, 1887. 9 " Der iSIicrococcus der Blennorrhcea Neonatorum," FeMschriff, Wiesbaden, 1881. 1" "Die Micrococcen der Blennorrhcea Neonatorum," Centralblatt fiir praet. AugenheU- kunde, 1882, pp. 134 et seq. " "Zur Aetiologie der Ophthalm.oblennorrha?a Neonatorum," Archiv fiir Gynecologic, XXV., 1884, pp. 109 et seq. ^2 "Beitragzur Aetiologie und Prophylaxe der Ophthalmoblennorrhoea Neonat./' ibid., vol. xxiv. pp. 92 et seq. 13 " Zur Aetiologie der Ophthalmoblennorrhoea Neonator.," ibid., vol. xxvi. pp. 318etseq. THE ETIOLOGY OF GONOBRHCEA. 87 Neisser's claim that the gonococcus was the materies morhi in gonorrhoeal ophthalmia, and demonstrated by numerous observations and confronta- tions that the eye-infection of the many children reported was caused by gonococci-containing pus Avhich was present in the genital tract of the mothers. Since the publication of Neisser's original essay a multitude of papers have appeared relating to the gonococcus. Many of these papers are by able men, and are of value as cumulative evidence only ; but still more of them are the lucubrations of inexperienced and unskilful physicians. It is well, therefore, to ignore much that has been written, and to consider only the essays which we may term magisterial. Neisser's earlier observations were wholly microscopical, but in a sec- ond paper, published in 1882, he speaks of attempts which were not suc- cessful to cultivate the gonococcus. Claims were made by Bokai (1880) and Bockhart (1883) that they had cultivated the gonococcus and had inoculated it with success. Bokai claimed that with the product of his cultures he inoculated the urethrse of three medical students, who were thereby infected with gonorrhoea. Bockhart inoculated a fourth culture on gelatin into the urethra of a paralytic, in Avhom he produced urethritis, cystitis, and pyelitis. The man died ten days after of pneumonia. It has within a few years been clearly shown that the gonococcus can only be cultivated upon human blood, blood-serum alone, or in combination with peptone-agar ; consequently, it is fair to assume that the micro-organisms cultivated by Bokai and Bockhart were not gonococci at all, but some form of pus-producing cocci. These observations, however, have much clinical importance in the fact that quite early in the history of the bac- teriology of urethral discharges they showed that other organisms than the gonococcus can produce suppuration in the urethra. It is therefore necessary to emphasize the statement that no reliance whatever can be placed on cultures obtained with any other media than those just men- tioned^namely, human blood or blood-serum alone or in combination with agar-agar or peptone-agar. Where other culture-media have been used some other organism than the gonococcus has been cultivated. FrankeP very tersely says : " The gonococcus belongs to the most incar- nate parasites inhabiting the human body, and the conditions of its exist- ence outside of the latter are at any rate very restricted." Up to the year 1885 the recognition of the gonococcus had been only made by means of the microscope. The efforts of many observers to cultivate the micro-organism had failed or had led to false results, as we have seen, for the reason that the proper cultivating medium had not been used. Neisser himself fell into error when he claimed that he had cultivated a coccus on flesh-peptone gelatin, which was the gonococcus, but which was in all probability a non-pathogenic diplococcus. The first reliable experiment of inoculating the human subject with the cultivated gonococcus was made by Bumm, who introduced a second culture into the urethra of a female previously healthy as to her genitals. On the third day a burning pain was felt on passing water, and gonococci were found in the epithelium of the urethra. A characteristic gonorrhoea followed, the acute stage of which lasted three weeks. Daily examination of the discharge showed the presence of gonococci. Though this experiment ^ Text-book of Bacteriology, New York, 1891, pp. 330 et seq. 88 GONOBBHCEA AND ITS COMPLICATIONS. seemed striking in result, it was not convincing, for the reason that only a second culture had been used. Fliigge^ expressed himself as follows regarding this experiment: "In this instance, notwithstanding the fact that no pus-cells were found in the culture on microscopical examination, we cannot entirely put aside the objection that perhaps the cocci in the urethral discharge were simply carried over, especially as the first transference upon the artificial culture- medium was made with relatively large masses." To settle all doubt, Bumm made a second experiment, and in it used the twentieth culture of the gonococcus on human blood-serum, which he had impregnated with the pus of gonorrhoeal ophthalmia. The patient was also a woman, healthy as to her genitals. The infecting culture was placed in her urethra, care having been taken that no other infection could occur. In about two days the urethral mucous membrane was seen to be red, and from it a small quantity of cloudy serous fluid exuded, which under the microscope was seen to contain gonococci and epithelial and pus-cells. A typical gonorrhoea was produced. This, then, is the first satisfactory and unimpeachable experiment by culture, which proved the gonococcus to be the pathogenic agent in gonorrhoeal infection. Owing to the great care and skill necessary, and the great difficulty experienced in cultivating the gonococcus, many observers have failed in their efforts to thus isolate it. Aufuso^ sterilized and coagulated the fluid taken from an inflamed knee-joint and inoculated it with active gonorrhoeal pus. Cultures were successfully made, and from the tenth generation he inoculated the urethra of a healthy man, using a portion the size of a pinhead. In two days a muco-purulent discharge appeared, which was the forerunner of acute gonorrhoea. In the secretion characteristic diplococci (gonococci) were found. Cultures on gelatin remained sterile. Wertheim,^ however, has lately added much to the question of the pathogenic nature of the gonococcus and has made some very important advances in its prompt and ready cultivation, which have been accepted by Bumm as reliable and confirmed by Gebhard.^ Taking the pus of gonor- rhoeal salpingitis, this observer has cultivated it according to his method, and with the product has by inoculation into the human urethra produced gonorrhoea in five cases. Thus we have ample proof of the virulence of the gonococcus when produced by cultures. It will, therefore, be seen that the gonococcus thrives with equal luxuriance and acts with equal virulence in the conjunctival and urethral mucous membranes. The observations of the ophthalmological investigators already mentioned have clearly shown that gonococci-containing pus from the mother's genitals causes, under favorable circumstances, virulent ophthalmia in the eyes of their new-born children. In clinical practice Welander^ studied twenty-five cases of men suf- fering from gonorrhoea in confrontation with the women from whom they derived the infection, and in each instance found the gonococcus in the ^ Die Mikro-organismen, 2d ed. , p. 1 58. ^ Riforma Medka, 1891, anno vii., vol. i. pp. 328 et seq. ^ "Die Ascendirende Gonorrhoea beim Weibe, etc.," Archiv filr GynakoL, 1892, vol. xlii. pp. 1-86, and ' ' Zur Lehre von der Gonorrlioe," Verhandl. chr Deutsch. Gesselsch. fur Gynaek., Leipzig, 1892, iv. pp. 340 et seq. * " Der Gonococcus Neisser auf der Platte und Reinculture," Berl. klin. Wochenschrift, 1892, No. 11. 5 Op. cit. THE ETIOLOGY OF GONOBBHCEA. 89 secretions of both sexes. Such uniformity of result, however, it must be admitted, is little less than marvellous. This observer also introduced gonococci-containing pus into the urethrse of three men. The result was gonorrhoea in its typical form in two days, in the secretion of which gonococci were found. Bumm also speaks of a case in Rinecker's clinic in which gonococci-containing pus Avas introduced into the human urethra, with the effect of promptly producing typical gonorrhoea. The foregoing evidence is further supported by innumerable observa- tions made by very many observers, Avho constantly found gonococci in the pus of true acute gonorrhoea. There is further certain negative evidence which demands our atten- tion, since it is both interesting and important. Thus, Kroner and Zwei- fel, who by clinical observation and inoculation had demonstrated that pus and lochia containing gonococci always produced typical gonorrhoeal ophthalmia, invariably observed negative results when they inoculated the conjunctiva with vaginal secretions free from gonococci.^ The expe- rience of Welander, Leopold and Wessels, and Bumm confirmed that of Kroner and Zweifel. Bumm in a series of experiments {a) with the cer- vical secretion free from gonococci after the subsidence of gonorrhoea, (&) with the secretion free from gonococci of chronic gonorrhoea, and (c) with gonorrhoeal secretion in which the gonococci had perished, also obtained negative results by inoculating the eye. Neisser^ in his latest essay, reaffirming his belief in the virulence of the gonococcus and its causative relation to the gonorrhoeal process, lays stress upon the negative facts brought out by Sternberg,^ Lundstrom,* Chameron and Constantino Paul,^ and others. These observers, without any preconceived prejudices and with the object of producing gonorrhoea, inoculated into the human urethra in a number of cases non-specific cocci which they had cultivated upon media upon which the gonococcus Avill ^ This absolute uniformity of negative result is so striking that it is apt to beget doubt in one's mind. This is particularly the case when we consider the results obtained by my colleague, Dr. J. A. Andrews, whom I know to be an accurate and skilled observer. Andrews says (art. "Gonorrhoeal Ophthalmia," A System of GenUo-urinary Diseases, etc., vol. i. p. 224) : "The writer has examined the secretion from the vagina of the mothers of eighty-eight infants in which ophthalmia developed from fifty to seventy-two hours after birth. The gonococcus was found in two only of tliese cases in the mother and child, the one infant being infected at birth, and the other six days after birth through careless- ness of the mother. The typical clinical picture of gonorrhoeal conjimctivitis was absent in eighty-six cases ; nevertheless, one eye was lost in five infants and both eyes in one infant, the disease being non -gonorrhoeal." Andrews further on says that his microscop- ical studies have convinced him that in the majority of cases ophtlialmia neonatorum is not of a gonorrhoeal nature. Thus we see that the result of clinical observation is not in accord with the result of experimentation in this matter. Therefore in this particular instance, and in all essays at experimentation on the subject of urethral suppuration, we must not be too much carried away with the results claimed for experiments, the majority of whicli have been made by men who are champions and zealots of the gonococcus doc- trine. We shall see farther on that scientific clinical observation, aided by unimpeach- able microscopic skill, leads to conclusions which are more or less, and in some cases wholly, at variance with some of the claims of the gonococcus champions. ^ "Ueber die Bedeutung des Gonococcen fiir Diagnose und Therapie," Verhandlungen der Deuischen Dermatoiogischen Gesellschaff, Vienna, 1889, pp. 133 et seq. 3 "The Micrococcus of Gonorrhoeal" Pus, etc.," Med. News, .Jan. 20, 1883, pp. 67 et seq., and "Further Experiments with the Micrococcus of Gonorrhceal Pus, etc.," ibid., Oct. 18, 1884, pp. 426 et seq. * "Studier ofver Gonococcus," Inaug. Dissert., Helsingfors, 1885. ^ " Du Traitement de la Blennorrhagie consider^e comme Affection parasitaire," These de Paris, 1884. 90 GONORRBCEA AND ITS COMPLICATIONS. not thrive. The experiments were made as early as 1884, when it was not known that the gonococci could only be cultivated on human blood- serum. Consequently, the culture-products they obtained were not gono- cocci at all, but some harmless microbe. Though these cultures of sup- posed gonococci were introduced freely into the urethra, no result whatever was produced in any case. Neisser further makes the important statement that he has studied the action of various cocci cultivated from gonorrhoeal pus upon the human urethra, and that he has obtained absolutely negative results. Welander's experiments also presented some striking results. He introduced into the urethra of five men the fetid pus of balanitis which contained indifferent microbes, also leucorrhoeal secretion containing a multitude of different micro-organisms, yet in no instance was any patho- logical reaction induced. He took the vaginal secretion of a fourteen- year-old virgin containing epithelial cells, spherical and bacilliform microbes, and introduced it into the urethrse of three men, without indu- cing any reaction whatever. Again, he introduced fetid purulent vaginal discharge, containing large quantities of microbes, into the urethrae of three other men, with an absolutely negative result. From three women whose urethral secretion contained gonococci, but whose vaginal secretions were free from these organisms, he took a considerable quantity of this vaginal secretion and introduced it into the urethrse of three healthy men, without any effect whatever. From the urethra of one of these women, who was menstruating at the time, he took a small quantity of the secre- tion and introduced it into the urethra of a healthy man. The result was the rapid induction of a true gonorrhoea, as shown by the symptoms and the presence of gonococci in the pus. A small quantity of the urethral secretion of three women, in which gonococci were present, was introduced into the urethrae of two of the men who had previously been unsuccessfully experimented upon with the pus not containing gonococci, with the result of producing gonorrhoea promptly. Summing up the knowledge thus far presented, which may be called the creed of the gonococci-advocates, it is claimed that the following propo- sitions are worthy of acceptance : 1. The demonstration of the gonococcus by the microscope in gonor- rhoeal pus. 2. Its cultivation and its production by means of experimental inocu- lation of gonorrhoea in the human urethra. 3. The development of gonorrhoea experimentally in the human subject by the introduction into the urethra of gonococci-containing pus from males and females. 4. Certain negative evidence which seems to, and it is claimed does, prove that secretions not containing gonococci will not produce gonorrhoea. 5. A number of indifferent microbes obtained by cultivation and falsely regarded as gonococci produced no pathological result. 6. Various purulent secretions taken from men and Avomen not con- taining gonococci did not, when experimented with, produce gonorrhoea. 7. It must not be forgotten that certain microbes, supposed to have been, but which certainly were not, gonococci, in the hands of Bokai and Bockhart produced violent suppuration resembling true gonorrhoea in experiments on the human subjects. This last point has been almost THE ETIOLOGY OF GONORRHOEA. 91 ignored, but certainly passed over, by Neisser and his followers ; but it will require our attention and further elaboration again a little farther on. Bumm, as a result of his studies (and his views are accepted in full by Neisser and many others), thinks that in the present state of medical science he is warranted in presenting the following postulates : 1. When no disinfecting treatment has been used gonococci are to be found in the secretion of every gonorrhoeal mucous-membrane inflamma- tion. 2. Secretions free from gonococci behave as non-infectious toward mucous membranes. 3. A secretion containing gonococci causes gonorrhoeal inflammation in susceptible mucous membranes with absolute certainty even when used in small quantity. He further claims that the presence of Neisser' s gono- cocci in a secretion proves, under all circumstances and m all certainty, both the infectious origin of the disease of the mucous membrane and of the secretion poured forth, and that, conversely, a secretion free of gono- ■cocci, whatever he its origin, has no virulent properties. The foregoing gives a full and impartial statement of the position of Neisser and his followers. It will be seen that their claims are far-reaching, and that they are made with an absolutism which is peculiar to most new departures which break into an era of doubt and uncertainty. Until 1879 we had groped in the dark, unaided even by a ray of truly scientific light, as to the essential nature of the gonorrhoeal process. Having found the gonococcus, Neisser and his followers proceeded in the most magisterial manner to claim that it, and it alone, was the pathogenic agent in the causation of gonorrhoea, and that in it resided its virulence. It was the same tendency of the human mind which actuated Ricord when, more than forty years previously, he had claimed with vehemence, in season and out of season, that gonorrhoea was a simple catarrhal process absolutely with- out virulence or specificity. Gonorrhoea had so long been confounded with syphilis — which is, of course, a virulent disease — that when Ricord established the non-identity and non-interdependence of the two diseases, he very promptly and truculently proceeded to deny for gonorrhoea any virulent principle whatever, and to relegate it to the group of simple catarrhs. In like manner, but in an opposite direction, Neisser and his followers, as soon as the gonococcus was revealed to them, put up the claim, which has been stated, that in the gonococcus alone resided the virulence of true gonorrhoea. But absolute statements, particularly on subjects as yet not long and broadly discussed, luckily always incite in the minds of some doubt, skepticism, and conservatism, which lead to further study and examination, and in the end to broader views and posi- tions nearer the truth. This, naturally, is what has occurred in the matter of the gonococcus question. Neisser's far-reaching claims and assumptions have led to a broad investigation of the Avhole subject of the etiology of gonorrhoeal discharges by many observers. As a result, it will be seen that while Neisser's main proposition as to the relation of the gonococcus to acute gonorrhoea is true in a large majority of cases, it may have its exceptions. It has also been further very clearly shown that other micro-organisms may be the pathogenic agents in urethral suppura- tions. It is well, therefore, not to be led by the writings of Neisser, Bumm, and others into a feeling that the question is fully and finally 92 GONOBBHCEA AND ITS COMPLICATIONS. settled, but to examine into and ponder over the facts which have been brought out by those who deny, in part or in whole, the absolute specificity of the gonococcus. The question of the etiology of gonorrhoea is to-day, as we have said before, far from being on an absolutely definite and set- tled basis, and very much careful and extended study is yet needed to broaden our knowledge, to clear away doubt and confusion, to reconcile inconsistencies, and to fill very many important gaps. The bolt which struck in the camp of the gonococcus-adherents, and did the most damage, was the paper of Lustgarten and Mannaberg,^ which may be said to have produced consternation. These observers show that in the normal urethra a variety of micro-organisms grow. Most of these microbes are harmless parasites or saprophytes. There are three, how- ever, which, the authors think, deserve especial attention. They are — 1, a pyogenic coccus, the staphylococcus aureus ; 2, a bacillus resembling the tubercle bacillus, and probably identical with the smegma bacillus ; and 3, one or several species of diplococci, which resemble completely Neisser's gonococcus in shape and tinctorial qualities, especially in being decolorized by (jrram's method. The establishment of the fact that in healthy urethras micro-organisms known to have a pathogenetic power lurk and lie dormant is of great importance in further perfecting our knowledge and in removing obscuri- ties from many seemingly queer or anomalous cases. Besides these pyo- genic bacteria there are several, if not many, others which are thought to be innocuous, but which may, perhaps, under favorable circumstances, become harmful. Lustgarten and Mannaberg's observations led to the study of this question by several other observers, who have, in the main, confirmed their statements. Thus, Steinschneider,^ a pupil of Neisser, made an exhaustive study of the bacteriology of the urethra in a normal state, and also in subjects suffering from acute and chronic gonorrhoea. Fig. 50. tf^ Showing on the left half some groups of gonococci obtained, by culture, and on the right half some groups of a so-called pseudo-gonococcus cultivated from a specimen derived from a normal urethra virgin to gonorrhoea (cultures by Dr. Henry Heiman in the pathological laboratory of the College of Physicians and Surgeons,"N. Y.j. As a result, he found virulent and inert organisms in healthy urethras, and also, like Bumm, various other organisms in gonorrhoeal pus besides the gonococci. He concedes that a diplococcus, or, as it may be termed, ^ "Ueber die Mikro-organismen der Normalen Mannlichen Urethra, etc.," Viertel- jahresschrift filr Derm, unci Syph His, 1 887, pp. 90o et seq. ^ " Ueber Seine in Verbindung mit Dr. Galewsky vorgenommenen Untersucliungen liber Gonococcen und Diplococcen in der Harnrohre," Verhandlungen der Deutsch. Der- matol. GeseUschafi zu Prague, 1889, pp. 159 et seq. THE ETIOLOGY OF GONORRHOEA. 93 pseuclo-gonococcus, which in a measure resembles the gonococcus, is found, and may lead to a possibility of doubt and error in about 5 per cent, of cases. This statement, coming direct from Neisser's laboratory, is cer- tainly very significant. In this connection Fig. 50 is worthy of attentive study. On the left- hand side of the figure the true gonococcus is seen, while on the right- hand side a larger, but very similar, diplococcus, arranged in groups of twos and fours, is portrayed. A comparison of these two orders of diplo- cocci shoAvs no visible difi'erence except in size. It can be readily seen, therefore, that unless a person is thoroughly skilled in bacteriology he may easily fall into error in the identification of these micro-organisms. There is still further evidence, however, in the same direction and strain.^ A number of capable men have separately studied this question, and have shown conclusively that many micro-organisms are found in the healthy urethra, most of which are non-pathogenetic. There is consider- able unanimity of statement that microbes very closely resembling the gonococcus, and very difficult to distinguish from it, are quite constantly found. Then, again, it is very clearly proved that such micro-organisms as the staphylococci and streptococci, whose virulence under favorable conditions is well known, have been frequently found in the normal urethra. The net results of the studies thus far made into the bacteriol- ogy of the normal and diseased urethra go to show that the gonococcus is the most constant and potent morbific agent in the production of urethral inflammations, but that other micro-organisms also play an active role in this direction. We have knowledge enough concerning some of these pyogenic microbes to warrant the statement that they can, and do under favorable conditions, produce urethral suppuration. In the course of time it may be proved that certain micro-organisms found in the urethra, which are now regarded as harmless saprophytes, may also, under certain conditions, be capable of producing inflammatory changes. At present precise statements as to the pathogenic agent or agents in other than gonococci-produced urethral suppurations cannot be made. It will require much patient and accurate study by many observers to place this subject upon a clear scientific basis. All that we can do now is to place on record the experience thus far developed and the views derived from such experience. To Aubert^ is certainly due the credit of having first definitely called attention to the fact that urethral discharges are caused by other micro- organisms than the gonococcus. He made a series of observations which ^ This may be found in the following essays : Giovannrni : " Die Microparasiten der mannlichen Ham rohren trippers," Centralbl.f. d. med. Wissenschaft, 1886, No. 48 ; Legrain : " Les Associations microbiennes de 1' Ur^thre," Annates des Maladies des Organes Genito- urinaires, 1889, pp. 141 et seq. ; Petit et Wassermann : " Micro-organismes de 1' Urethra de I'Homme," same journal, 1891, pp. 378 et seq. ; Eovsing : " Die Blasenentzundungen ihre Aetiologie, etc., Berlin, 1890, pp. 60 et seq.; Hall^, "De I'lnfection urinaire," Ann. des Mai. des Org. G^n.-urin., Feb., 1892; Keymond : "Cystites survenues chez des Malades n'ayant jamais ete Sondes," ibid., Oct., 1893, pp. 734 et seq. Several observers found many micro-organisms quite uniformly ; some differ from others as to the nature and character of certain microbes, but all are fairly well in accord with the statement given in the text. (Vide supra.) The fact is, that we have only just begun tlie study of the bacteriology of the healthy and diseased urethra, and that no absolute statements or any generalization whatever can yet be made. ^ "De 1' Urethrites bact^riennes," Lyon Medical, 1884, xlvi. pp. 337 et seq. 94 GONOBBHCEA AND ITS COMPLICATIONS. convinced him that besides ordinary gonorrhoea there are certain urethral discharges characterized by the presence of bacteria which differ markedly from the gonococcus, and which may be complicated by epididymitis and cystitis. He speaks of having found in three cases a small oval and elongated coccus and bacillus. He is not certain whether this form of gonorrhoea is a type or an accidental condition due to what we now call mixed infection. The value of Aubert's work resides in the broad possi- bilities which it suggests, rather than in the definiteness of its statement. Further light is thrown on the subject by a lengthy paper by Bock- hart/ in which he describes and pictures certain micro-organisms which he found in urethral pus and by cultivation during the study of fifteen cases. Bockhart concludes that there is a benign acute pseudo-gonor- rhoeal urethritis which results from infection by bacteria of the vagina, among which most prominent are a small staphylococcus and an ovoid streptococcus. In its clinical course this form of gonorrhoea resembles that which is elsewhere described as simple urethritis. Zeissl,^ in an extended study of this question, examined the pus of seven cases of urethral suppuration, non-gonorrhoeal in origin, and found diplococci resembling gonococci and other micro-organisms. Zeissl's paper is interesting and valuable in the fact that the various microscopic pictures are clearly reproduced. Further evidence as to the origin of urethral suppurations in pus free from gonococci, and as to the existence of diplococci resembling gonococci, is furnished by a number of observers. Thus, Rauzier^ details three cases of so-called gonorrhoea in the secretion of which no gonococci were found, but a larger diplococcus was present, which resembled the former. Legrain * reports the case of a medical student who had urethritis, in the pus of which the presence of the micrococcus cereus albus of Passet was found. The woman with whom the man had cohabited was consid- ered healthy, but she had previously suffered from retro-uterine phlegmon. In this case the supposition is warranted that perhaps infection was caused by urethral inflammation which developed the pathogenic power of a saprophyte. Legrain ^ further details the case of a man free from venereal disease or vegetations who, while convalescing from typhoid fever, was attacked by urethral suppuration, at one time slightly sanguinolent, which involved the posterior urethra. In the pus of this case the micrococcus pyogenes aureus and several other micrococci were found. Castex ^ reports the case of a perfectly healthy boy who, having reten- tion of urine following an operation on the knee, was catheterized, per- haps carelessly. A slight sluggish purulent urethritis was produced, in ^"Ueber die pseudo-gonorrhoische Entziindung der Harnrohi-e und des Xeben- hodens," 3Ionatshefte fiir Prakt. Dermatohgie, 1886, pp. 134 et seq. '' " Ueber die Diplococcus Neisser's und seine Beziehung zum Tripperprozess," Wiener klinik, Nov. and Decern., 1886. * "Le Gonocoque et la Duality des Urethrites," Gazette med. de Montpelier, Nos. 7 and 8, 1888. * "Contribution a la Diagnose du Gonococcus," Annales des Maladies des Organ. Gen.- urin., 1888, pp. 523 et seq., and "Contribution a 1' Etude de I'Etiologie des Urethrites non-blennorrhagiques," ibid., 1889, pp. 337 et seq. ^ "Urethrite survenue chez un Convalescent de Fi^vre typhoide," ibid., 1889, pp. 291 et seq. * "Urethrite sans Gonocoque," Gaz. hebd. de Med. et de Chir., 2d Series, vol. xxiv. p. 358, 1887. THE ETIOLOGY OF GONORRHCEA. 95 the secretion of which a staphylococcus was found and further cultivated. Somewhat similar in nature is the case reported by De Amicis.^ This observer injected ammonia into the male urethra (being a repetition of the classic experiment of Swediaur), which produced suppuration, in the pus of which diplococci resembling gonococci were found. These diplo- cocci were larger than gonococci, and were not found in the pus-cells. De Amicis further claims that he took pus from a child suffering from vulvo-vaginitis which was not due to gonorrhoeal infection and inoculated with it the male urethra. The result was typical gonorrhoea, in the pus of which micrococci resembling gonococci were found. The experiment of Martin^ is corroborative of the result obtained by De Amicis. Martin took the secretion of a child which was suffering from declining vulvo- vaginitis. Though when first observed the pus contained gonococci, it was free from the microbe at the time of the experiment. Some of the secretion was placed three-quarters of an inch deep into the urethra of a consenting hospital patient. In four days the prodromal symptoms of gonorrhoea were noted, and on the sixth day there was a profuse purulent and bloody discharge. Examination of this secretion on the tenth day showed large numbers of gonococci. Later on the man suffered from pos- terior urethritis. Eraud ^ has for some years studied the question of the specificity of the gonococcus. As a result, he seeks to prove that the gonococcus is probably an inoffensive guest of the normal urethra. He thinks that the specificity of the gonococcus is not yet proven — that it may be a harmless saprophyte of the normal urethra capable of transformation under condi- tions not yet made clear. His researches have been carried on with secretions of patients suffering from gonorrhoea, prostatitis, and orchitis, and on secretions from the healthy urethrse of infants six days old, from young children, and adolescents virgin to gonorrhoea. He concludes — 1. There exists in the urethrse of healthy men a staphylococcus which is capable of producing orchitis ; 2. This microbe is found in children and infants; 3. This saprophyte presents the same characters as the microbe of orchitis and gonorrhoeal prostatitis ; 4. There is reason for supposing, if not for concluding, that all these microbes are one and the same para- sites living as saprophytes in the normal urethra, and capable under unknown conditions of giving rise to the gonorrhoeal process. These observations have been further put to the test and studied by Prof. Hugounenq,* who endorses Eraucl's conclusions. In this connection it is well to consider the statement of Prof Straus,^ whose knowledge and skill in bacteriology are well known. Straus reports the case of a boy sixteen years old who never had coitus, but who was a confirmed masturbator. This boy was attacked with urethritis showing ^ "De la Nature parasitaire de la Blennorrhagie," Lyon Medical, Aug. 2, 1884, pp. 1075 et seq. ^ "Vulvo-vaginitis in Children," Joui'nal of Cutaneous and Gen.-urin. Disea,^es, Nov., 1892, pp. 415 et seq. ^ "l)es Kaisons qui semblent militer en faveur de la non-specificit^ du Gonocoque, etc.," Bulletin de la Societe fran^aise de Derm, et de Syph., vol. ii., 1891, pp. 231 et seq. * "Sur un Microbe pathog^ne de I'Orchite blennorrhagique," Annates des Maladies des Organes Ginito-urinaires, Juin, 1893, p. 465. * "Presence du Gonococcus de Neisser dans un Ecoulement urethral survenu sans rapports sexuels," Archiv. de Med. exper. et d'Anatomie path., 1889, i. pp. 326 et seq. 96 GONORBHCEA AND ITS COMPLICATIONS. acute symptoms. On four occasions, at intervals of time, Straus found in the urethral pus gonococci in the pus-corpuscles and on the epithelial cells. He thinks this case is important as regards the view held by many, that gonorrhoea may be contracted without sexual exposure or contagion as a result of great irritation of the urethra. Straus advances the propo- sition that perhaps the gonococcus is a normal and inoffensive guest of the urethral canal, and that under the influence of irritation it becomes patho- genic. He thinks there may be a similarity in the action of the gonococ- cus to that of the pneumococcus of Frankel, which usually remains dor- mant in the mouth and air-passages until some favoring causes call into play its virulent action. I have myself studied the bacteriology of urethral pus very extensively, and I am thoroughly convinced that urethral suppuration is produced by other microbes than the gonococcus. I have seen cases of mild gonorrhoea in the secretion of Avhich I have found the staphylococcus and a small streptococcus. In many of these cases the clinical picture of simple or mild urethritis was present, but I have seen three instances in which the suppuration and subjective symptoms were such that a diagnosis of viru- lent gonorrhoea was warranted. These cases, moreover, ran a rebellious course, and one case was complicated by severe typical posterior urethritis and epididymitis. Careful examination of the pus showed an absence of the gonococcus and the presence of a streptococcus. A patient attending at my college clinic presented the typical symptoms, objective and sub- jective, of acute gonorrhoea. In the pus taken from this man's urethra Dr. Van Gieson found by the microscope the streptococcus pyogenes, which he was able to cultivate on human serum-agar and on glycerin- agar. No experimental inoculations were made, for the reason that the cultures died so quickly. Other observers, Bockhart, De Amicis, and Aubert, have also noted the occurrence of seemingly virulent gonorrhoea in the pus of which no gonococci could be found, but, on the contrary, a streptococcus or a staphylococcus. We have already seen that the injec- tion of ammonia (De Amicis) may cause urethral suppuration in the pus of which a microbe C9,n be found, and the same result sometimes follows the passage of a sound. In the pus of a case seen by me of a urethral discharge induced by intemperate endoscopy at the hands of one of its enthusiasts (an anterior and posterior urethritis of severe type, but of short duration, having been produced). Prof. Prudden found by the micro- scope and by cultivation micrococcus urese in large quantities. Few men aifected with true gonorrhoea suffered more than this patient did, who had had no urethral inflammation for many years previously. I have in many other cases of traumatic urethritis found cocci other than the gonococci.^ ^ In these cases it is most probable that the trauma of the urethra produces a hyper- emia and succulence of the cells which are favorable to the morbid activity of its sapro- phytic microbes and guests. An organism which was harmless becomes potential and pathogenic, and a suppurative inflammation is indiiced. It is not unreasonable also to suppose that morbific microbes may be introduced into the urethra upon unclean instru- ments. Legrain ("Des Urethrites non-blennorrhagiques," Annales des Maladies des Org. Genito-urinaires, 1889, pp. 337 et seq. ) states that he carefully introduced a bougie smeared with the second culture of the micrococcus pyogenes aureus into the bladder and produced no result. A week later he repeated the same experiment, using slight violence, and as a result a mild and ephemeral form of suppuration was produced in thirty-six liours. He failed in a similar manreuvre when he used tlie micrococcus pyogenes albus. Legrain recalls the fact that Voillemier introduced into the urethra of two patients a bougie THE ETIOLOGY OF GONORRHCEA. 97 As further bearing on this subject it is well to give the results of some very careful observations made by Hogge ^ under Guy on' s auspices in the Necker Hospital laboratory. Hogge in two cases very clearly shows the difficulties and drawbacks experienced in examining chronic urethral dis- charges and pus from the bladder and in distinguishing the microbes there found from the gonococcus. The first case was that of a man aged sixty- five who never had had gonorrhoea, but who had a purulent secretion follow- ing the introduction of a sound. This pus contained a diplococcus found in the cell-substance and scattered over the field, which resembled in its various features the gonococcus. It was also decolorized by Gram's method. It could be cultivated on gelatin, agar-agar, and in bouillon. The second case Avas one of cystitis following operation for a bladder neo- plasm in a patient who had gonorrhoea tAventy years before. In the urin- ary sediment a similar microbe was found, which could be cultivated on the media just mentioned. The author shows that in chronic discharges there are microbes which by their form, size, intracellular position, their mode of grouping, their number, their mode of coloration and decolora- tion, resemble the gonococcus. These microbes can be cultivated on gel- atin, agar-agar, and bouillon, whereas the gonococcus Avill not grow on these media. Consequently, in such chronic cases we cannot affirm that a certain microbe is the gonococcus, and can only ascertain its real nature by cultivation. In this connection it is well to remember that in the nor- mal urethra Lustgarten and Mannaberg found a coccus resembling the gonococcus. As a result of the accumulated knowledge upon this Avhole subject up to 1889, Neisser^ has had to concede that it is possible, under certain circumstances, that other micro-organisms than the gonococcus may cause purulent urethritis. But he strenuously contends that these forms of urethritis are all clinically absolutely different from true gonorrhoea. He states in this paper (1889) that since 1879 every case of urethritis in his private, polyclinic, and clinical practice has been examined for the gono- coccus, and that only two cases of purulent urethritis, appearing in an acute form and caused, as it seemed, by infection, have been observed Avhich did not positively show the gonococcus. In these cases, moreover, no pseudo-gonococci were found. In his latest paper, however, Neisser^ concedes that it is often exceed- ingly difficult to establish the diff"erence betAveen gonococci and similar diplococci. Then he details the case of a man who several years before his marriage had gonorrhoea and double epididymitis, and who, after frequent coitus with his Avife, had a profuse acute purulent discharge. Yet on examination of the pus no microbes of any kind could be found. He further cites the case of a man Avho for nine years had cohabited only smeared with the pus of an abscess of the tliigh and of a cold abscess of the glands of the neck, and that no reaction followed in either case, though the bougie remained in situ two hours. In these cases it seems to me very probable that an old pus, poor in microbes or whose microbes were in a state of decadence, was used, and that mechanical violence was not produced. 1 " Gonocoques et Pseudo-gonocoques," Annales des Mulad. des Org. G^nito-urin., April, 1893, pp. 281 et seq. ^ "Ueberdie Bedentung der Gonococcen fiir Diagnose und Therapie," Verhandl. der Devt. Dermat. Gemlhchaft Gehalten znr Prag, Vienna, 1889, pp. 133 et seq. ^ "Welchen Werth hat die Mikroscopische Gonococcenuntersuchung ?" Deui. med. Wochenschrift, Nos. 29 and 30, 1893. 98 OONOBBHCEA AND ITS COMPLICATIONS. with his wife, yet who came to him with a urethritis which from its symp- toms he would have been led to pronounce gonorrhoeal. He could find no gonococci in the secretion, but, on the contrary, numerous small diplo- cocci. This attack was cured, but five or six days after each intercourse with his wife the patient was similarly attacked. The foregoing very clearly proves that Neisser to-day does not consider his first position as firm as he in earlier years thought it to be. The results obtained by Neisser (and his followers are equally as rad- ical in their statements) are certainly startling, and from their uniformity of success as to the gonococcus they beget a spirit of skepticism in con- servative minds. Seeing that a number of disinterested observers — and myself included — in much shorter periods of research than ten years have found in numerous cases other micro-organisms than gonococci in acute gonorrhoea, the suspicion is warranted that a rigorous differentiation was not practised by Neisser and others.' When such dogmatic statements are made as emanate from the ardent advocates of the gonococcus, par- ticularly the one that this microbe is the sole and essential morbific agent in acute gonorrhoea, there should be ample evidence offered that full and sufficient care has been taken in establishing the presence of the gono- coccus in the vast number of cases claimed, and also that the presence of other pathogenic microbes has been looked for and not found. Thus far, this certainly has not been done, and it is safe to say that the question can never be settled by microscopic examination alone. Cultures of urethral pus in very many cases and by many men Avorking separately are absolutely necessary toward a solution of this question. Then, again, much experimental inoculation will be required to confirm the knowledge gained by the study of the cultures. Reviewing, therefore, the question of the pathogenesis of gonorrhoea and of miscellaneous urethral discharges in the light of our present know- ledge and in a judicial spirit, we are warranted in drawing certain con- clusions and of stating certain assumptions which may fairly be drawn from facts and statements now in our possession : ,1. In a large proportion — perhaps in a large majority — of cases of acute purulent gonorrhoea or urethritis the pathogenic agent is the gono- coccus. (Bumm, it will be remembered (vide supra), claims that in every case it is found.) 2. In a small proportion of cases of acute purulent gonorrhoea or urethritis the infecting agent or agents seem to be, in the absence of the gonococcus, one or more of the pyogenic microbes, the staphylococcus and the streptococcus, and perhaps others whose virulency is not yet demonstrated. (Bumm claims that secretions free from gonococci are non-infectious.) 3. In many cases of mild urethritis in virgin subjects, and in those who have had true gonorrhoea some time before, these micro-organisms ^ I have several times been struck by the looseness of statement of the ultra-ardent advocates of the gonococcus, and by their easy-going, routine methods of microscopical examination. They rarely ever fail to see this microbe in any specimen which they examine, even when taken at haphazard. With great celerity they dry and stain the secretion, place it under the lens, and in an instant claim that they see the gonococcus. The case is then settled for them. Thus tliey continue in case after case. I suspect that if the truth were really kno^vn regarding statements and liistories of cases, in fully 80 per cent, the gonococcus was not really found, although it was claimed to be clearly seen. THE ETIOLOGY OF GONORRHCEA, 99 and others more or less well known to us are in all probability the causes of urethral suppuration, the tissues being rendered by coitus favorable to their pathogenic action. 4. Some cases of mild or more severe relapsing gonorrhoea, with abun- dant purulent secretion, may be due to the renewed activity of gonococci, which may have remained latent and dormant in the urethra, but which, under favoring circumstances, had again taken on their virulent action. In some of these cases the symptoms are much less severe than in the first attack. The inference, then, is that the tissues are less susceptible or that the virulence of the gonococcus has become attenuated. 5. Many cases of more or less severe relapse after true gonorrhoea are not due to the gonococcus, but to the other less virulent microbes. Then, again, the hypersemia left after an attack of gonorrhoea may increase to an active purulent inflammation as a result of stimulation or sexual ex- cesses, microbic action being entirely absent. This is probably the con- dition in most cases of acute or mild urethritis in which neither gonococci nor other micro-organisms are to be found. 6. It is clearly proved by clinical observation and experimental inocu- lation that pus or any secretion {e. g. the lochia) containing gonococci may, and does, produce a virulent suppuration in susceptible mucous membranes, most commonly of the urethra and of the eyes. 7. The observations of Lustgarten and Mannaberg, of Steinschneider and Galewsky, and of others already mentioned, go to show that patho- genic and non-pathogenic micro-organisms are found as inoffensive inhab- itants of the normal urethra. There is sufficient evidence in our posses- sion to-day to warratit the belief that under the favoring conditions of sexual excitement and excess these micro-organisms become hostile and virulent and give rise to urethral suppurations of both mild and severe types. 8. The statement is further warranted that these saprophytic agents may cause a purulent inflammation in a urethra congested, ulcerated, or infiltrated as a result of a previous gonococcus inflammation. There is no doubt whatever that many cases of relapse of gonorrhoea are not caused by a renewed gonococcus-infection nor by the relighting into activity of latent hibernating gonococci, but that they are due to the morbid action of the less virulent microbes, denizens of both healthy and damaged urethrge. 9. The advocates of the gonococcus theory go too far when they claim that this micro-organism so frequently remains dormant and hiding in the urethra after the cessation of a true gonorrhoea. The gonococcus is essentially a virulent agent and a disturber of the peace, and for reasons and from facts to be given later it is fair to assume that it disappears from the urethra upon the final cure of true gonorrhoea. It is the excep- tion, rather than the rule, that it should remain dormant in the urethra for a long time. 10. Most of the cases of gonorrhoea or urethritis which are the result of chemical or mechanical irritation or violence are in all probability due to the morbific action of a number of micro-organisms so constantly found in normal and chronically and very subacutely inflamed urethrae. This statement is very clearly proved by the evidence of Legrain, De Amicis, Castex, myself, and others. In some cases these chemical and mechanical 100 GONORRHCEA AND ITS COMPLICATIONS. irritants provoke an exacerbation of the virulence of the gonococcus. In these cases, however, it is probable that the virulent urethritis is not yet at an end or that the gonococcus had not yet thoroughly disappeared. 11. The studies of Eraud, Hugounenq, and D'Arlhac are worthy of thought and investigation, since they put the gonococcus question in a new light. They think that this micro-organism is a denizen of the normal and diseased urethra, and that under favorable conditions it takes on virulent action. It will be seen a little farther on that it is frequently very difficult, and in many cases impossible, to find gonococci in the secretions of a woman with whom a man suffering from true gonorrhoea has had coitus. Many cases seem to prove that the infection of the man (he even having a healthy urethra) is due to causes inherent in himself. Neisser and his followers in a magisterial manner claim that gonococcus- infection in the male urethra in a virgin subject always is derived from a secretion of the female consort containing gonococci. We shall see, later on, that this view is at variance in many cases with clinical facts, and that Eraud's proposition may in the end lead to a partial or full explana- tion of the subject. There are, however, very many cases (as we have seen) of gonorrhoea which were derived from a similar process in the female. 12. The term " pseudo-gonococci " does not apply to any particular micro-organism, but it is being applied rather loosely to any and all microbes capable of producing urethral suppuration. The net outcome of all this knowledge is, that gonorrhoea is a disease induced by micro-organisms, the condition of the affected mucous mem- branes being such as to favor their pathogenic action. It is therefore a virulent disease, its chief pathogenic agent being the 'gonococcus. Other micro-organisms also give rise to urethral suppuration, sometimes as violent and as much complicated as true gonorrhoea. In these rather unusual <3ases nothing but microscopical examination can determine that the morbid process is not caused by the gonococcus. The suppurations caused by a number of pus-producing microbes, some of which have been called pseudo-gonococci, are usually milder in character and shorter in duration than the gonococcus-infection. They are simply cases of a milder form of urethral infection. These views are less radical and sweeping than those of Neisser's school, which are well summed up in the following quotation from Finger,^ who says : " Blennorrhoea (gonorrhoea) is a virulent process whose virus is the gonococcus, and we therefore recognize only one condition as neces- sary to the production of blennorrhagic urethritis as of all blennorrhagic affections — namely, the conveyance of gonococci in any vehicle, which usually, but not always, consists of mucus or pus derived from another blennorrhagic affection. Blennorrhagic urethritis can only develop by inoculation with gonococci. Its chief source is the transmission of hlen- norrhagic pus from the female sexual organs, and therefore coitus with a woman suffering from blennorrhoea of the sexual organs is the main source of blennorrhagic urethritis in the male Blennorrhoea of the sexual organs in the female is therefore the most important source of blennoi'rhagic urethritis in the male, and coitus is the means of infec- tion." ^ Die Blennorrhoe der Sexualorgane und Hire Compllcationen, 2d ed., Leipzig und Wien, 1891, p. 37. THE ETIOLOGY OF GONORBHCEA. ' 101 The practical outcome of this doctrine is that whenever a man has a purulent discharge in which gonococci are to be found the conclusion is surely and logically warranted that he derived the infection from a woman similarly infected. In other words, this theory of the ultra-adherents of gonococci-virulism proclaims in its essence that gonorrhoea originates only in gonorrhoea.^ The general acceptance of this doctrine can only result, in very many cases, in suspicion, rude and violent recrimination, estrange- ment, unhappiness, dishonor, and even suits for divorce in families and in society between males and females, husbands and wives, lovers and mistresses, between whom there may not be any breach of fidelity or lack of loyalty whatever. Such a doctrine is brutal in the extreme, and is largely the outcome of too great reliance being placed upon the results furnished by the microscope. It is another instance of the absolutism of thought which so often pervades the human mind when light is suddenly thrown on a hitherto dark subject. To enthusiasts the subject then seems clear and settled ; any doubts, uncertainties, inconsistencies, and gaps in knowledge are by them ignored or passed over unconsidered. There can be no doubt that many men contract gonorrhoea from women suflFering from a specific gonococcus-infection of some part of their genital tract, and, on the other hand, women are infected by men similarly infected in their urethra. But there is met Avith, particularly in private practice even among nice people, a class of cases in which men contract gonorrhoea from women who claim to be and seem to be perfectly healthy. The latter state that they never had the classical symptoms of gonorrhoea, and prior to the infecting coitus and after it considered themselves perfectly healthy. On this subject we have some very strong evidence which to-day by the Neisser school is looked upon as false and obsolete. No one certainly studied this question more intelligently and for a longer time than Ricord, and yet to-day his vievrs Avith many go for naught. Let us look at these old views and see whether there is not at least some truth in them. Ricord^ says : " When we investigate with the greatest care the determining causes of the most characteristic gonorrhoea, we are forced to admit that the gon- orrhoea! virus is absent in the majority of cases. There is nothing more common than to find that women who have occasioned the most intense, the most persistent gonorrhoeas, accompanied with the most characteristic gonorrhceal complications, were only afi"ected with uterine catarrh, some- times hardly purulent. Quite often the menstrual flux appears to have been the sole cause of the disease. In a great number of cases we can discover nothing unless perhaps errors in diet, excess in sexual intercourse, the use of certain drinks or of certain articles of food. Hence the frequent belief of patients, which is often correct, that they have contracted their clap from a perfectly healthy woman. Upon this point I am assuredly familiar with all sources of error, and I have the pretension to say that no one is more guarded than myself against the various forms of deceit which beset the path of the observer ; yet I confidently maintain the following proposition : ivomen frequently give gonorrhoea ivitltout having it them- selves. When one studies gonorrhoea without prejudice, without precon- ' In his edition of 1888, Finger went so far as to say, "It is an evident condition sine qud non that the woman from wliom a man acquires blennorrhagic urethritis must herself suffer from blennorrhtea." He omits this sentence in the 1891 edition. ^ Lettres sur la Syphilis, 3d ed., 1863, pp. 46 and 47. 102 OONORBHCEA AND ITS COMPLICATIONS. ceived notions, he is forced to admit that it originates from causes that give rise to inflammation of other mucous membranes." ^ On this subject Fournier^ remarks: "With the purpose of elucidating this difficult question of the origin of gonorrhoea I have made during many years a great number of eonfro7itations of patients, to whom I believe I have given the most minute attention. More than sixty times I have examined women from whom true gonorrhoeas have been contracted under conditions which could scarcely leave any doubt as to the origin of the disease. Now, from this study I am convinced that the opinion of my master (Ricord) is the only true one, and the only one which conforms to the facts of daily observation, Ricord says frequently women give gonorrhoea without hav- ing it : in my opinion he should have said 7nost frequently. For one gon- orrhoea which results from contagion (in the precise sense of the word), there are three at least in which contagion plays no part. According to my observation, a man is more often responsible for his gonorrhoea than than the woman from whom he seems to have contracted it : he gives him- self gonorrhoea more frequently than he receives it."^ ^ It is never amiss to quote Kicord's remarks, for they always show a profound know- ledge of human nature and of medicine. His recipe for conti-acting gonorrhoea is graphic, comprehensive, and suggestive. He says : " Select some woman of a pale, lymphatic temperament — a blonde is better than a brunette — and the more whites she has the better. Take her out to dine ; order oysters first, and don't forget asparagus afterward. Drink often and freely : white wines, champagne, coffee, liqueurs, — they are all good. After dinner dance a while, and have your friend dance with you. Get well heated during the evening, and quench your thirst without stint with beer. At night play your part val- iantly : two or three times would not be too much, but more would be better. The next morning do not forget to take a prolonged hot bath ; moreover, do not omit an injection. This programme having been conscientiously followed out, if you don't have a clap, some good deity must have saved you." ^ Art. " Blennorrhagie," Nouveau Dictionnaire de Med. et de Chirurqie pratique, vol. v., 1866, pp. 152 et seq. ^ This statement merits even more emphasis than is given to it in the text, since the conditions underlying the question are to-day better understood. Now, we know posi- tively that in normal urethrse there are many and varied hibernating and harmless micro-organisms which under conditions of irritation of the tissues become active and pyogenic. We further know that very many men have chronically-damaged urethne, due to local ex ulcerations, thickening, and hyperemia, subacute inflammation of follicles and crypts, granular and papillomatous conditions, ulcers, warts, polypoid growths, and even stricture — conditions ever ready to fall into inflammation. Now, these may exist with no symptoms and little if any perceptible discharge. In these cases of damaged urethrse there is good evidence in hand that saprophytic microbes may also be present in innocent inactivity. Now, with these facts in mind it is easy to understand why the fol- lowing conditions, agents, stimulants, and excitants produce purulent discharges in men : 1, protracted and repeated coitus, with perhaps much alcoholic excess, masturbation, and priapism with much excitement ; 2, spicy food, alcoholics, beer and ale, cantharides, arsenic, the terebinthinates, asparagus, iodide and bromide of potassium (these act as irritants through the urine) ; 3, strong injections, chiefly ammonia, nitrate of silver, per- manganate of potassium, bichloride of mercury, etc ; 4, careless passage of sounds and catheters, horseback riding, bicycling, football, and all violent exercises, prolonged walk- ing, and games. Many authors, notably Guyon ("Sur les Urethrites blennorrhagiques," Annales des Maladies des Organ. G^n.-urin., vol. i., 1883, pp. 333 et seq.), lay great stress upon certain diatheses as being the (at least) underlying causes of gonorrliwa. These are gout, the plethoric condition, rheumatism, and tuberculosis. This, of course, is debatable ground. There are certainly some persons more prone to infections of various kinds than otliers : the tissues of these persons, we may say, offer fertile culture-grounds to micro-organisms. Therefore it is, I think, more correct to consider that the diatheses or morbid conditions are underlying and predisposing rather than exciting causes of gonorrhoeal infection or of urethral suppuration. There can be no reasonable doubt that in early syphilis the urethrse of men, and sometimes of women, are prone to become the seat of a suppurative THE ETIOLOGY OF GONORBH(EA. 103 In a like strain wrote my deceased colleague, Dr. Bumstead, who was ever an intelligent, painstaking, and alert observer. He says : " Of one thing I am ahsolutely certain : that gonorrhoea in the male may proceed from intercourse Avith a woman with whom coitus has for months, or even years, been practised with safety, and this, too, without any change in the condition of her genital organs perceptible to the most minute examina- tion with the speculum. I am continually meeting cases in Avhich one or more men have cohabited with impunity with a woman before and after the time Avhen she has occasioned gonorrhoea in another person, or, less frequently, in which the same man, after visiting a woman for a long period with safety, is attacked with gonorrhoea without any disease appear- ing in her, and after recovery resumes his intercourse with her and expe- riences no further trouble. The frequency of such cases leaves no doubt in my mind that gonorrhoea is often due to accidental causes, and not to direct contagion." These opinions,^ emanating from three of the most learned and expe- rienced men in the study of venereal diseases, are certainly worthy of attention, and I think that their correctness in the main will be found to be in consonance with the prevailing knowledge of gonorrhoeal infection. There can be no doubt whatever that in many cases men, even those pre- viously virgin to the disease, contract true gonorrhoea, presenting typical gonococci, from women Avho never had gonorrhoea and in whom the most careful and rigorous examination failed to reveal the gonococcus. I have had this experience many times, and I am fully alive to all sources of error and to all the tricks and deceitful practices of patients. Here are three instances : A gentleman virgin to gonorrhoea has had coitus with a girl aged eighteen for a year. He was the only man she had ever cohab- ited with, and she had never suffered from gonorrhoea or leucorrhoea. Tour days after a prolonged and exciting coitus, stimulated by much wine, he developed severe gonorrhoea with abundant typical gonococci. I examined the woman the day after the development of his trouble and the fifth after the coitus. By the speculum I saw that the vulva and process. The reason is very simple : the tissues of syphilitics (the infection being active) are very prone to be attacked by pyogenic micro-organisms if any traumatism or irrita- tion is inflicted upon them. Horteloup lays great stress {Legons sur I' Uretkrite chronique, 1892) upon herpetism as an underlying cause of chronic gonorrhoea. He defines herpe- tism as a vasomotor and trophic neurosis, but it is hard to understand what morbid entity he means. ^ In this connection it is well to consider the results of De Luca's experiments (" Con- tribuzione alia Patologia ed alia Clinica del Catarrho venereo nella Donna," Giornale Interned, delte Scienze Med., nuova serie, Naples, 1880) : 1. He injected the purulent ute- rine .secretion of a patient into her urethra, and produced typical gonorrhoea. 2. Later on, when less purulent, the same secretion was injected into the urethra of a prostitute, with no result. 3. Sero-epithelial secretion of uterine catarrh injected into the urethra of a prostitute ; no result. 4. The previous case of mild uterine catarrh was rendered purulent by introducing a sound dipped in ammonia into the cervix ; the resulting i)uru-. lent secretion, when injected into the urethra of a prostitute, produced typical gonorrlKva. 5. Purulent sputum, with vibratile epithelium, from a case of bronchitis and malaria was introduced into the urethra of a woman, and produced an active purulent inflammation. 6. Secretion from tliis artificial urethritis introduced into the urethra of another woman produced typical gonorrhcea. 7. Laudable pus from a small abscess of the eyebrow in a syphilitic subject wlien introduced into the female urethra produced a subacute urethritis. 8. Secretion from pervious subjects introduced into tlie la-ethra of another woman pro- duced a similar result. It is unfortunate that the bacteriology of these cases was not studied. It i.s, however, most probable that these urethral suppurations were caused by pyogenic microbes. 104 OONOBRHCEA AND ITS COMPLICATIONS. vagina were a little redder than usual, but free from pus (no injections or preparatory cleansing having been used), and that a little glairy whitish mucus escaped from the os. I examined many specimens of the secretions of all the genital parts, taken on a sterilized platinum-wire loop, and found many cocci and bacilli, but absolutely no gonococci.^ Nothing in the way of treatment was done for this girl, yet she is healthy to-day, having resumed coitus with her lover on his recovery from his ten-weeks' tribulation. I have in six other similar cases made similar examinations and arrived at the same results. Here is another case worthy of thought, for I can vouch for the cor- rectness of the statements concerning it : A man, whom I cured of gonor- rhoea twenty-five years before, came to me, having been perfectly well in the mean time, with a second typical attack, a year or so ago, in the dis- charge of which gonococci were abundant. He had had coitus only with his wife for many years, and she was confined to her bed as a result of self-produced miscarriage. Her symptoms were those of pelvic peritonitis. Microscopic examination of the secretions showed no gonococci whatever. In the vaginal secretion I found numerous varieties of microbes ; in the urethra nothing could be found, but in the pus which exuded from the os uteri both streptococci and staphylococci were abundant. It certainly cannot be claimed that gonococci remained latent in this man's urethra for twenty-five years, and it is clear that his infection was derived from his wife. She had many cocci in the vagina and os, but no gonococci, which her husband had. A similar instructive case is as follows : A gen- tleman had typical gonorrhoea in all particulars (his fii-st attack, which was followed by severe posterior urethritis). Gonococci were frequently found in his discharge. He had had intercourse with a lady who never had had any affection of the genital apparatus, but who had suffered from a retro-uterine phlegmon for some time, during which he had coitus with her. In her vaginal pus many microbes were present, but no gonococci. These and several other cases were carefully watched and studied, and in none of the women could gonococci be found, while all the men presented typical gonorrhoea with gonococci-containing pus. Cases like these make one at least skeptical at Finger's statement, " that direct transmission of of the gonococci-containing vehicle is necessary to infection." I claim that in the present state of our knowledge such magisterial statements as this (which is the tenet of the gonococcus school) are not warranted. There has not been sufficient study of the healthy and morbid vaginal secretions to warrant such a sweeping and specific statement. Since in these cases of healthy and diseased female genital apparatus it is possible for men to contract gonorrhoea, the questions arise. Was the infecting agent a parasite of the normal urethra which became metamorphosed into the gonococcus ? or, Was the agent derived from the female genitals ? We know really so little, if anything, of the biology of the gonococcus before it is found in the pus of the male, and from that experimented with, that I think we should be slow in making absolute statements con- cerning it. That it is frequently found in the female genitals, where it is often a source of infection to man, no one can doubt. But, on the other ^ Now that the culture of the gonococcus is more readily accomplished, and may be more generally practised, this test as to the nature of the secretions in suspected subjects may be used in addition to the microscope. THE ETIOLOGY OF CWNORRHCEA. 105 hand, in a vast number of women giving gonorrhoea it cannot be found. My studies very clearly convince me that we shall never arrive at abso- lutely precise knowledge of the etiology of gonorrhoea until all the microbes of the female genitals have been studied with the microscope, by means of cultures, and by experimental inoculation. Further than this, we must have similar knowledge of the microbes of the normal and diseased male urethra. I am absolutely of the opinion that our present limited know- ledge of the bacteriology of the male and female genitals does not warrant our throwing aside as obsolete and untrue the results of accurate and pains- taking clinical observation of such men as Ricord, Fournier, Bumstead, and many others. The Neisser school claim, first, that faulty observation led these observers to fail to see gonorrhoea, and to consider the process a catarrhal one, because the symptoms were not those of florid gonorrhoea ; second, that they are worthless, because they were made before the gono- coccus era ; and third, that through error, lack of thoroughness of exam- ination, and perhaps by reason of the deceit and misrepresentations of the women, localized spots, patches, or follicles of gonorrhoea! inflammation in the urethra, in urethral and juxta-urethral follicles, in vulvar follicles, Bartholin's glands, and in the os uteri escaped observation, and were the seats from which infection was derived. In the cases above reported and in others I kept in mind the pitfalls of error and false judgment ; I was prepared for deceit and falsehood, yet I failed to find gonococci in the secretion of women from whom men virgin to gonorrhoea contracted typ- ical blooming infections. That the gonococcus is found in acute gonor- rhoea of the male, and is seemingly the morbific agent, I have already cheerfully conceded. But where, in very many cases, does it come from ? Is it a metamorphosed and virulent microbe which has originated in a harmless denizen of the normal or diseased urethra? or is it a torpid inhabitant of the vagina, unrecognizable in that stage as the gonococcus, but which under sexual excitement and alcoholic stimulation becomes a formidable agent with intensely virulent properties ? I have in my read- ing seen it stated that man is the natural incubator of gonorrhoea. Is it possible that the male ui'ethral mucous membrane is the tissue most suit- able to the nurture, fructification, and maturity of this peculiarly virulent microbe ? Many authors speak of a virulent form of gonorrhoea — and I have seen many such instances — which is sometimes contracted by men from women in coitus during or just after the menstrual process. These menstrual gonorrhceas in most cases present the typical clinical picture of florid gonorrhoea, and they may pursue the same course and be attended by the same complications. Many of these women never had gonorrhoea ; some are absolutely free from all genital abnormalities ; others may have some abnormal but simple, non-specific condition, yet at the menstrual epoch they become poisonous. Can it be that the hyperaemia and bloody fluid for a time vitalize the usually inoff"ensive microbes Avhicli are present in all vaginae, and endow them with virulent principles. We cannot to-day answer this question, but we can say that during menstruation some per- fectly pure and healthy women at times give men typical gonorrhoea. It is further claimed that the secretions from the cavity of the uterus, •from the swollen and exulcerated cervix, from laceration of the cervix and perineum, those due to uncleanliness of the vulva and vagina, and 106 QONOBBHCEA AND ITS COMPLICATIONS. arising from chronic simple inflammation of these parts, may give rise to gonorrhoea. In such cases the Neisser school will claim that there are gonococci in the pus or that the resulting infections in the men are simple urethritis. Yet let any one study these cases without bias or prejudice, and he will find that many times the gonococcus is absent from the female discharge, Avhile the male has typical gonococci-urethritis.^ The trend of all this is that this subject of the etiology of gonorrhoea is yet in an unsettled state, and that opinions should be formed in all cases with care and reserve. It is possible for a man to have a urethral discharge containing true gonococci which he contracted from a woman who never had gonorrhoea. According to doctrines now largely prevail- ing, the gonococcus in the male is presumptive evidence of guilt of the woman. Such a doctrine is too absolute, and even cruel, and may be the cause of much unhappiness, suffering, and misery. This question often involves the virtue of wives and the loyalty of mistresses, and demands our earnest attention. Dr. Bumstead, in a passage which shows very conspicuously the kindly nature of the man and the broad conservatism of the physician, says on this subject : " The importance of this truth whenever a physician in the exercise of his profession incurs the great responsibility of passing judgment upon the virtue of a woman, and thus affecting her reputation and happiness (and often that of many others with whom she is connected) for life, cannot be overrated. In all such cases the accused should receive the benefit of any doubt which may exist, and the physician Avho withholds it from her out of a morbid fear that he may be imposed upon, and thus runs the risk of convicting an innocent person, is unworthy of his calling. His province is to decide from the symptoms, taken in connection with the known facts of the case, and unless these are sufficient to establish guilt beyond the shadow of a doubt humanity demands at least a verdict of ' not proven.' " ^ ^ This statement is strikingly supported by a very important case which is just now under my care : A young man who had never had gonorrhoea had connection with his mistress, a strong and healthy girl, who likewise never had gonorrhoea, under the condi- tions of prolonged excitement and liberal alcoholics. In three days he experienced the typical signs of incipient gonorrhoea, which developed in a florid manner, the secretion showing numerous gonococci. I carefully and thoroughly examined the woman, and found no inflammation about her genitals and no gonococci whatever. Violating all the directions given him, the man in the fourth week of his gonorrhoea ventured to have coitus with this woman, he then noticing only a slight amount of discharge in the morning. By this act he was rendered much worse. Four days after this coitus the young woman, who had been perfectly well in the interval, complained of pain on urination, and three days after this I found her with a profuse purulent discharge from tlie urethra and acute vulvitis. Gonococci in abundance were found in the urethral and vulvar pus. In this case the man certainly was the incubator of the gonorrhoea, which he gave to his consort. ^ The justice and force of the foregoing remarks are well brought out by the following cases : A married man, twenty -six years old, returned after a month's absence and cohab- ited with his wife. In two days he noticed the usual symptoms of acute gonorrho?a, and consulted a physician, who informed him that he was suffering from that disease. To the patient's remaik that he had only had connection with his o^^^l wife, the physician replied that gonorrhoea came from gonorrhoea — ergo, the wife liad that disorder. The patient being incredulous, the physician fortified his position by quoting from the work of a prominent author from whose teachings he had gained his belief. Such was the patient's anger that he immediately confronted his wife, who was at the full table of a large boarding-house, and in vile and blasphemous language accused her of infidelity and of giving him a foul disease. Amid shame and distress of mind the wife indignantly spumed the charge, but to no effect. The husband left tlie house and went elsewhere, but took occasion to inform his wife's relatives of the state of affairs. At this time a second visit to the physician resulted in a more positive asseveration of his opinion. Such Avas the THE PERIOD OF INCUBATION. 107 CHAPTER VII I. THE PEEIOD OF INCUBATION AND THE PEEDISPOSING CONDI- TIONS AND CAUSES OF ACUTE ANTERIOR URETHRITIS OR GONORRHCEA. Though the fact was denied in years gone by by Ricord and others, gonorrhoea certainly has a period of incubation. In this it resembles the many and varied infectious processes. Mechanical and chemical irritation or damage result promptly in inflammation of the urethral mucous mem- brane, and little time elapses between the receipt of the injury and the appearance of the discharge. In urethritis, however, more or less time elapses between the infecting coitus and the onset of the inflammatory symptoms. This lapse of time is called the period of incubation, or, as I suggested before, the period of microbic colonization. In this time the micro-organisms seated on the mucous membrane are increasing in num- ber, spreading, and gaining a firmer foothold before involving the deeper parts. The length of the period of incubation varies in diff"erent cases, being sometimes quite short and again rather prolonged. In intelligent, watch- ful patients it is commonly easy to determine with considerable definite- ness the exact length of this period. Then, again, in careless and obtuse patients unsatisfactory data only are to be obtained. Patients very fre- quently, for various motives, make false statements as to the length of this period. In the following table are contained the records of 505 cases very carefully observed at my clinic (Vanderbilt Venereal and Genito-urinary Clinic). These cases are instances of first attacks or infections. They were seen in the acute stage, when the symptoms were severe and typical and the discharge profuse and purulent. Time was wanting in which to search for the gonococcus in these cases : desperate state of affairs that the husband consulted a lawyer with a view of getting a divorce. At this juncture the wife' s brother insisted that her husband should accompany her to my office, with the view of settling the matter. It was a memorable interview with the sullen and angry husband and the indignant and outraged wife. The husband's first question was, Could "a man contract gonorrhoea from a wife who was not thus aflected ? To which I replied, emphatically. Yes. I then went over with him the various sources of origin of gonorrhoea, and instanced cases which I had met in which groundless suspi- cions had been entertained between husband and wife. When I came to inquire into the . circumstances of his case, I learned that liis wife had some time previously been the sub- ject of an operation upon the uterus, and that she suffered from leucorrhrea. This was sufficient to clear her of all suspicion ; but when I mentioned the fact that menstrual fluid sometimes caused severe gonorrhoea, the wife eagerly and triumphantly said to him that he had forced her on that night to have intercourse in spite of her waning menstruation. The liusband was chagrined and humiliated. Later on, domestic haiipiness was restored. A still sadder case was jDublislied in an old French M'ork on venereal diseases : A young man, after having lived with a young girl for some years, married her. Some montlis after he was compelled to take a journey of some distance, and while travelling was attacked with gonorrhoea. He consulted a physician, and informed him that lie luid never had connection with any woman but his wife. The physician laughed and made a sarcastic reply. Some days after, when the testicle swelled, the latter informed him that if liis wife was virtuous he must have liad "une affaire" witli other women. The young man wrote to his wife an indignant and passionate letter and blew out his brains. The unfortunate v/oman, who was found to ])e free from disease, miscarried and died. 108 GONOBRH(EA AND ITS COMPLICATIONS. Days. 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . Cases. 1 17 67 79 66 36 105 35 Days. 9 . 10 . 11 . 12 . 13 . 14. Cases. . 47 . 27 . 6 . 8 . 2 ■ 14 505 It will be seen that in this table the greatest number of cases had an incubation of seven days, but that a goodly number of cases are recorded as occurring on the second, third, fourth, fifth, and sixth days. It will be further noted that from the eighth to the tenth day, inclusive, the number of cases is 107, being rather more than are contained in the figures for the first seven days.^ These statistics therefore show that the early symptoms in the great majority of cases of gonorrhoea occur within ten days after the infecting coitus. From the tenth day on to the fourteenth the cases are small in number, and from that time up to the twentieth day are still smaller. In this connection the recent statistics of Lanz ^ are interesting, since in each instance the presence of the gonococcus was said to have been demon- strated. Lanz's figures are — Days. 1 . Cases. 2 . 15 . 4 . 9 . 4 Days. 8 . 10 . 14 . 20 . Cases. . 1 . 1 . 1 ■Jl 39 Thus it appears that out of 39 cases the incubation-period was within seven days in 34, the majority occurring on the. third and fifth days. Comparing now my own statistics, those of Lanz, together with those ^ Finger has also collated from the statistics of Eisenmann, Hacker, and Holder the following table of the duration of incubation in acute anterior urethritis : 1 day in 11 cases ; 2 days 59 3 126 4 62 5 49 6 10 7 63 8 12 23 11 days in 6 cases ; 12 " " 8 " 13 •' " 6 " 14 " " 19 " 19 " " 2 " 20 " " 1 case ; 30 " " 1 " Uncertain " 9 cases; 479 cases. It thus appears that in 380 out of 479 cases, or more than two-thirds, tlie period of incu- bation was within the first week. In my own statistics the incubation-period was within the first week in 361 cases, which is a little under three-quarters of the whole number. The statistics of Le Fort {Gazette hebdomadaire de Med. et de Chir., 1869, Nos. 23 and 24) are also of interest in this connection. This observer studied the incubation-period by exact record in 2070 cases of gonorrhcea, many of whom, however, had one or more previous attacks. In 778 of these cases the disease appeared within four days, being 37.5 per cent. ; in 869 it began between the fifth and eighth days, being 41 per cent. ; in 276, between the ninth and twelfth days, or 13 per cent. ; in 112, from the thirteenth to the sixteenth day, or 5 per cent. : and in 17 patients only between the seventeenth and twen- tieth days. According to these statistics, gonorrhcea most commonly appeared between the fourth and eighth days, there being 1647 cases, or 79.5 per cent. In only 35 out of the total 2070 cases did the incubation-period extend beyond fifteen days. ^ " Ein Beitrag zur Frage Incubationsdauer beim Tripper," Archivfiir Derm, und Syph., 1893, pp. 481 et seq. THE PERIOD OF INCUBATION. 109 of Finger and Le Fort, we find that the vast majority of cases of gon- orrhoea begins within seven days of the infecting coitus. In the cases of gonococci-inoculation/ as we have seen in the experi- ments of Welander, Bumm, Aufuso, and Wertheim, the period was two or three days. Much doubt should be placed on the statement that the incubation- period was only one day. In such cases preputial irritation is undoubt- edly mistaken for the true gonorrhoeal symptoms, or the cases are those of second, third, fourth, or fifth infections, in which inflammatory symp- toms show themselves very promptly. As a general rule, it will be found that the period of incubation is two or three days, but sometimes five, six, or seven days.^ Considerable incredulity is warranted in cases in which the history of the incubation is beyond ten days, and the statement that it is twelve to twenty days or longer needs strong substantiation. I have no doubt that errors have crept in in the histories of many of the cases of prolonged incubation included in the table of very old cases col- lected by Finger. To sum the matter up, Ave may say that the symptoms of gonorrhoea may appear as early as forty-eight hours after infection ; that they commonly appear about three to five days after it ; and that periods ^ Experimental inoculations with pus have thrown much light on the incubation- period of gonorrhoea. These experiments have been made with gonorrhoeal pus and with pus from virulent ophthalmia. Thiry [Eecherches nouvelles siir la Nature des Affections blennorrhagiques, Bruxelles, 1864, pp. 32 et seq. ) took gonorrhoeal pus from the urethra and placed it in the conjunctival fiac. In twenty-four hours an acute purulent inflammation was produced. Pus from the infected eye was placed in the urethra of a man who had never had gonorrhoea. In forty-eight hours a true gonorrhoea was produced. Pauli de Landau {De la Nature de rOphthahnie d'Egypte, Wurzburg, 1858) placed the pus of ophthalmia neonatorum in the urethra of a healthy man, who in three days suf- fered from acute gonorrhoea. He similarly infected a woman, in whom also the incuba- tion-period was three days. Guyomar ("Les Ophthalmies et les Urethrites contagieuses," These de Paris, 1858) introduced a sound smeared with pus of purulent ophthalmia into the male urethra, with the result of producing gonorrhoea in two days. Welander, as elsewhere stated, produced gonorrhoea in two days by the inoculation of gonorrhoeal pus. ■■' This estimate is further in accord with the views of most of the recent writers. Lesser {Lehrbuch der Haut- und Gescklechtskrankheiten, 11 Theil, 1888, p. 8) says that the average is two or three days — that the incubation is seldom shorter or longer. Six to seven days would be the outside limit. Giiterboch {Die Chirurg. Krankheiten der Ham- und Mdnnlichen Geschlechtsorgane, 1890, Band i. p. 45) says that seven days is the longest incubation-period, while Fiirbringer {Die Krankheiten der Ham- und Geschlechtsorgane, 1884, p. 273) thinks that the average is four days. Neumann {Lehrbuch der Venervichen Krankheiten und der Syphilis, 1888, p. 75) says that the incubation -period is variable. His average is from two to five days. Podres {Die Chirurg. Erkrankungen der Ham- und Geschlechtsorgane, Theil i., 1887, p. 84) thinks that the incubation-period of the first gonorrhoea is twenty-four to forty-eight hours, and in later infections it is longer, lasting from sixty to eighty hours. Kopp {Lehrbuch der Vener. Erkrankungen, 1889, p. 14) calculates the average to be three to four days, recognizing rare cases in which it is ten to twelve days, and others in which it is six or seven days. Letzel {Lehrbuch der Geschlechtskrankheiten, 1892, p. 17) places the period at two to four days, sometimes earlier and sometimes later. .Jullien {Traite pratique des Maladies veneriennes, 1886, p. 29) thinks that the average is from three to five days, but that in first infections it may be four, five, even six days. Finger, on the other hand {Die Blennorrhoeder Sexualorgane und ihre Complicationen, 1891, p. 43), maintains that the incul):ition of a first gonorrhoea is shortest, that the aver- age is three to five days, and that in later infections it is seldom more than six or seven days. 110 GONOBRH(EA AND ITS COMPLICATIONS. of infection of seven to ten, and even fourteen, days' duration may occur, but not very frequently.^ I have known such periods of incubation, and even longer ones up to twenty days, to be observed in patients suffering from pneumonia, typhoid fever, and erysipelas. On the other hand, the period of incubation is sometimes made shorter by prolonged sexual inter- course and alcoholic excesses. Then, again, the intensity of the infecting pus containing abnormally large quantities of the gonococcus may have an influence upon the suddenness of the attack. It is also safe to assume that the tissues of some individuals are more prone to the attacks of micro-organisms than those of others. Under these circumstances an incubation of twenty-four to thirty hours is possible. The fact of there being a variable period of incubation in gonorrhoea suggests the advisability of a patient refraining from coitus, hymeneal or social, for a goodly number of days after intercourse with a doubtful or suspicious woman. In striking contrast with this virulent infective process, with its well- marked period of incubation, are those forms of purulent urethritis due to the passage of sounds and bougies or caused by strong injections, in all of which the discharge comes on in a few hours. Predisposing Conditions and Causes. — The size and conditions of the penis are frequently factors in the contracting of gonorrhoea. Thus a very long organ is frequently infected by pus from the uterine neck or fornix vaginae, while a shorter one may escape. A very large and thick oro-an mav scive rise to friction and irritation, and in that wav become infected. Patients with naturally large meatuses, and particularly those in whom unnecessarily large meatotomy has been practised, are also very susceptible. A meatus which opens on the under surface of the glans, resembling hypospadias, and the condition of hypospadias itself, predis- pose the bearer to gonorrhoeal infection. Then, again, cases are seen in which this form of the opening exists, and with it shortness and tightness of the frsenum, and perhaps of the prepuce. In such cases there is much redness of the fossa navicularis and a marked tendency to acquire gonor- rhoea. In these cases, and in those of hypospadias where the meatus is thus placed low in the glans, it is probable that the secretions of the vagina, which gravitate to its posterior wall, are sucked in by capillary attraction, and find easy entry into the fossa navicularis and there produce infection. Phimosis, natural or acquired, tends to render its bearer liable to gonorrhoea by reason of the hypersemia which it induces in the lips of the meatus and the urethral tissues immediately beyond. In the same ^ Several cases of very long incubation have been recently reported. Ehlers {Annales de Dennatologie et de ki SyphUigmphie, 1892, p. 556) reports the case of a physician who had not previously suflered from gonorrhoea, who had connection Nov. 30, 1891, and on Dec. 22 felt a sensation of heat at the meatus, which was followed Dec. 28 by a purulent discharge containing gonococci. In this case the incubation-period was twenty-two days. Lemonnier {ibid., 1892, pp.732 et seq.) reports an unsatisfactory case in which he thinks that there was an incubation of twenty-eight days. Lanz {op. cit.) i-eports a case in which the patient claimed that ten weeks had elapsed between the coitus and the evidences of infection. The same author also reports a case in which the incubation is stated as of five weeks' duration. In this case the patient had suffered from gonorrhoea three and a half years previously, and satisfactory evidence is not offered to clear away the doubt, which is warranted, that the case was one of the lighting up of an old smouldering inflammation. THE PERIOD OF INCUBATION. Ill manner balanitis and balano-posthitis, either resulting from phimosis or, as frequently occurs, from inattention and uncleanliness, produce a hypersemic condition of the distal urethral mucous membrane which ren- ders it favorable to the growth and multiplication of the gonococci or other pus-producing microbes. Warts at or near the meatus are frequent causes of urethral suppu- ration. Scars, contractions, and hyperaemia at the meatus, left by antecedent syphilitic infiltrations, primary or late, and chancroids, not uncommonly tend to render their bearers susceptible to gonorrhoea. Long- continued copulation, particularly in persons under the influence of alco- holics, is a potent factor of infection. In such cases ejaculation is long delayed, the penis and vagina are much irritated, and gonorrhoea very frequently follows. Indeed, venereal excesses are common and prolific causes of gonorrhoea. Persons who have recently recovered from an attack of gonorrhoea are especially predisposed to subsequent infections. Then, again, lesions of the urethral walls from the meatus to the bulb, which generally consist of submucous thickening, with granular, papillo- matous, or exulcerated hyperaemic patches, are a constant menace to their bearers, who contract gonorrhoea at seemingly slight provocation. I have many times seen men who in an early gonorrhoea had suffered from in- flammation of one or more of the glands or lacunae of the urethra, which, not going on to abscess-formation, had resolved and left an inflammatory focus, who thereafter were prone to gonorrhoeal infection even when guilty of no excesses. Masturbation may produce such a hyperaemic condition of the meatus. and fossa navicularis that infection may readily occur. There can be no question that in some cases of early syphilis the distal parts of the urethra are rendered more prone to the invasion of gonococci and other microbes. This tendency may be brought into action by ab- normal conditions of these parts, and may exist in cases where no abnor- mality is present. An active syphilitic diathesis can undoubtedly be at the root of the persistence of a gonorrhoea, and may also be a factor in the induction of relapses. It must be borne in mind that the disease then is not syphilitic in nature. It is an infective urethritis, due to micro-organisms, occurring in a syphilitic in whom the diathesis is still active and whose tissues are more vulnerable to irritation and microbic invasion than those of a previously healthy person. Though it is contended that patients suffering from gout, rheumatism, anaemia, the so-called scrofula, and tuberculosis are more liable than others to gonorrhoea, as yet no truly scientific evidence has been offered in proof thereof. 112 GONOBRHCEA AND ITS COMPLICATIONS. CHAPTER IX. ACUTE ANTEEIOE GONOEEHCEA, OE UEETHEITIS. By the term " acute anterior gonorrhoea or urethritis " is meant an infective process attended by abundant suppuration, caused by micro- organisms which may involve the urethra from the meatus to its bulbous portion, and which may stop at the triangular ligament. In the majority of cases the infective process spreads from the meatus, like other infec- tious diseases — for instance, erysipelas — to parts beyond, traversing the pendulous urethra, reaching the bulbous portion, and there, under favor- able circumstances, stopping, in the minority of cases. By some it is claimed that acute gonorrhoea is generally limited to the region of the fossa navicularis, to the pendulous urethra, and that it may reach the region of the bulb. This may occur in second and later infections and in cases of persistent relapses, but long observation has convinced me (and my conclusions are in accord with those of many recent writers) that in acute primary gonorrhoea the suppurative process quite promptly extends back to the bulbous urethra and even beyond. I have many times verified this statement by the very careful use of the endoscope and by examination of the urine. Acute anterior gonorrhoea in primary or secondary attacks means suppuration of the canal from the meatus to the triangular ligament. Exceptionally we see cases — but they are usually instances of second and even later infections or of repeated relapses — in which the disease is seemingly limited to the region of the fossa navicularis ; other cases in which more or less of the pendulous urethra is involved ; while in others still the morbid process rapidly runs back to the region of the bulb and there becomes most intense. Thus we come to speak (a) of gonorrhoea of the fossa navicularis ; (b) of the pendulous urethra ; and ( fifth " 5 = 8j\ sixth " 7 = 11-5- -^ -^ 1 n seventh " 2 = 3fV eighth " 1 = 1t% ninth " 2 = 3i% eleventh " 1 = lA These observations show very clearly that in more than 50 per cent. 01. gaultheriae, gtt. xvj. Mix the copaiba and liquor potasses and the extract of liquorice and sweet spirits of nitre separately, and then add the other ingredients. The dose is from one to four teaspoonfuls three times a day. The following is a particularly effective combination, but it is some- times distressing to the stomach : ^. Bals. copaibse, 01. santal. fl., ad. ^ss ; Liq. potassse, 3vj ; Syr. aurantii cort., 5ij ; Aq., q. s. ad §iv. Dose, one teaspoonful three or four times a day in a wineglass of water. All antiblennorrhagics should be taken at the end of stomach diges- tion, usually an hour and a half after eating. The following prescription is of benefit in cases of delicate stomach ; !^. Copaibse bals., sij ; Magnesise, 3J ; 01. menth. piperitse, gtt. xx ; Pulv. cubebge, Bismuthi subnitrat., da. Sij. ^ I have often been asked whether the formula of the Lafayette mixture was a favorite prescription brought over from France by its ilhistrious and grateful namesake. Its real origin is as follows : It was a remedy which a druggist in Greenwich street, named Lud- wig, dispensed to sailors, and was in great demand. This was about the time of Lafayette's third visit to America, and his advent was honored by this mi.xture being named after him. Thirty or forty years ago a similar mixture was called the Washington mixture, but the patriotism of Americans frowned this name down. 140 GONORBH(EA AND ITS COMPLICATIONS. M. and divide into pills of five grains each, and coat with sugar. Dose, three to six pills three times a days. This prescription gives a good idea of the bases of cubeb and copaiba paste. There is much latitude in this direction for the exercise of phar- maceutical skill. Pastes containing cubebs, copaiba, and oil of santal- wood may be of decided benefit, and they may be paraded as novelties if a few antiseptics are judiciously interspersed in the combination.^ Kava-kava has little antiblennorrhagic effect in the declining acute stage, but it is beneficial a little later on. The sphere of usefulness of these antiblennorrhagics is in the declining stage of acute gonorrhoea and in those subacute suppurations of the urethra which are really relapses or exacerbations of a smouldering process. It is important to know when to stop this form of internal treatment, since it may be pushed to the patient's disadvantage. As a rule, Avhen the urethral discharge found in the urine consists of mucus with very little pus and more or less epithelium — in other words, when cure is in sight — it is well to cease using these stimulant remedies. There can be no ques- tion that their prolonged use really tends to keep the inflammatory state in a slumbering condition, with the discharge scant in quantity. Many men are thus over-treated, and they promptly get well when the medicine is discontinued. The foregoing measures constitute what the patient should do for him- self in the declining acute stage. It is in this declining stage really that the most effective treatment of gonorrhoea may be used. At this time, in first infections, the subepithe- lial exudative inflammation is in a favorable condition to yield to proper measures. The new tissue-cells are yet young and not firmly developed, and their absorption may then be brought about. The hypergemic and catarrhal condition of the mucous membrane is on the wane, and can be acted upon noAV with better effect than later on. What is now needed is an application which shall be astringent and sufficiently stimulating to cause absorption, and yet not to set up irritation. There is no known remedy which answers these requirements and indications so well as nitrate of silver.^ The delicate point in its use is the determination of the strength of solutions which will do good and produce no harm. My studies on the action of nitrate of silver in gonorrhoea, acute and chronic, convince me that in very weak solutions it is an astringent of decided power. In rather stronger solutions it acts as a stimulant and an astrin- ^ As a matter of history it may be well to state that gurjun balsam, Peruvian balsam, balsam of tolu, the fluid extracts of matico, stigmata maidis, of senecio Jacobsea, of Indian hemp, of piscidia erythrina, and of schinus moUe, the oils of matico, eucalyptus, and erigeron canadensis, and turpentine, are remedies which have had in the past ephemeral popularity as antiblennorrhagics, used either alone or in combination with copaiba and cubebs. It is possible that some of these old friends may- be rejuvenated later on. ^ A silver preparation, named argentamine, has been used clinically and bacteriolng- ically by Schiiffer ( Wlen. med. Wochenschrift, 1894, No. 12), who considers it superior to nitrate of silver for the reason that it is not decomposed in fluids containing chloride of sodium and albumin, and that in its action it penetrates more deeply into the tissues. This preparation is colorless, of alkaline reaction, and consists of a solution of 10 parts of phosphate of silver in a solution of 10 parts of ethylendiamine (CjH^NHjj) in 100 parts of water. In due time the worth of this drug may be determined. Argentum natro-subsulphurosum, the sulphate of sodium and silver, was used by Friedheim (op. cit.), and, although it does not precipitate albumin, its action is more feeble than that of the silver nitrate. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 141 gent, and causes the absorption of the exudation into the mucous mem- brane. The critical point in its use is to get the astringent and absorp- tive effects, and this can be done by beginning with very mild solutions and increasing the strength very sloAvly and intelligently. When used successfully in the declining stage of gonorrhoea the evidence of benefit will be seen on examining the urine, in which pus-cells will be seen to gradually grow less in number and the epithelial cells to be more numer- ous and more fully developed. Used in a concentration stronger than that productive of absorption, this invaluable agent becomes a decided stim- ulant and a producer of suppuration. The tendency of to-day is to use this agent in too strong solutions, and it often fails in its salutary effects for this reason. In the declining stage, when the urine shows under the microscope some pus-cells and few or perhaps no gonococci and a predom- inance of epithelial cells, together with an excess of mucus, much can be done toward bringing the waning process to an auspicious end. This, in my judgment, is the critical period in gonorrhoea. If the patient can and will follow proper treatment at this time, he has a very good chance of being thoroughly cured. There are some cases of gonorrhoea, as of other diseases, which resist all treatment, however well directed. At this stage the surgeon should throw into the posterior urethra (assuming that a diagnosis of the infection of that segment has been made) a very weak and warm solution of nitrate of silver, beginning with 1 : 20,000 or 1 : 16,000, using the Ultzmann's hand-syringe. The soft- rubber catheter, sparingly lubricated with glycerin, is passed down the urethra until the urine flows, which will usually occur when the instru- ment has got as far as seven or seven and a half inches down. The bladder being empty, pressure on the piston then throws the injection into the prostatic urethra. It is well now to withdraw the catheter a little until its end is in the membranous urethra ; then on pressing the piston gently, resistance will be felt and no fluid will flow. This tells the sur- geon that he is in the membranous urethra, and that the irritation of his procedure has caused the conti-action of the compressor urethrse muscle. Then push the catheter inward about half an inch and inject again, when the fluid will pass readily. By this manoeuvre the eye of the catheter is placed just at the apex of the prostate and at the very begin- ning of the prostatic urethra. The injection is then slowly thrown in, and it passes through the whole of the prostatic urethra into the bladder. If only a rather small injection is to be given, about one-half of the con- tents of the syringe may be used posteriorly. Then, while still pressing the piston, the surgeon gently draws out the catheter, and finds that as its eye passes thi'ough the membranous urethra the flow stops again, but is at once resumed Avhen the eye reaches the bulbous urethra, which is then irrigated with the balance of the fluid. It may be necessarj^ to use one syringeful for the posterior urethra and another for the anterior. The sensations of the patient and the condition of the urine are the indices for the continuance of the treatment. Usually a feeling of benefit is produced, and the patient desires another irrigation in a day or two. It is always well to proceed very cautiously. If the treatment is well borne and the urine shows a decline in the quantity of pus and mucus, and the epithelial cells show rather more development, then one is safe in going on. It is most important not to give the injections too frequently, and 142 GONOEBHCEA AND ITS COMPLICATIONS. this point will be determined by the sensations of the patient and the examination of the urine. Just before the final cure there will be found an excess of mucus, which floats as a cobweb-like cloud, in the meshes of which are minute little pinpoint- or pinhead-sized granules of pus and epithelium. As the morbid process ceases these little granules disappear, and then for a short time there is only a slight excess of mucus, which Avill, under treatment, soon be reduced to its normal quantity, and then the patient may be pronounced cured. In very dilute solutions bichloride of mercury, 1 : 40,000-1 : 20,000, and permanganate of potassa, 1 : 10,000—4000, may, according to the fancy of the surgeon, be used in the manner just detailed in the declining stage of gonorrhoea. In like manner, very dilute solutions of alum and sulphate of zinc may be used. A large experience has taught me that the action both of the bichloride and permanganate of potassa is, as a rule subject to few exceptions, far inferior to that of nitrate of silver. The action of these two much- vaunted agents is superficial and expended on the catarrhal condition of the mucous membrane. They have very little, if any, effect in causing the absorption of the products of inflam- mation, so that, in my judgment, alum and zinc sulphate are far superior to them. It is appropriate here to call particular attention to the tendency very prevalent to-day to treat gonorrhoea in the acute stage in a heedlessly heroic manner. We read of cures being produced in five, eight, twelve, and twenty days, and persons not thoroughly versed in the knowledge and treatment of gonorrhoea may be influenced by these dazzling and misleading claims. The scheme of these treatments consists in the use of some antiseptic drug (preparations of mercury, silver, permanganate of potassa, and others), either in very strong solutions or in irrigations given sevei'al times a day, very hot. These treatments, and others men- tioned later, certainly cut short the severe symptoms and quite promptly cause the purulent discharge to become muco-purulent. These results are then paraded as astonishing, and cases presenting them are looked upon as having been cured. When these enthusiasts are asked in what a cure consists, they reply, " There may be some little redness of the mucous membrane left and a little sticky discharge, but the patient is all right." It is hard to understand how intelligent men can thus deceive themselves. Many patients thus treated, knowing little of gonorrhoea, consider themselves cured ; others see that they are really not cured, and they disappear and their cases are registered on the books as cures. Then, again, in this sticky condition antiblennorrhagics and the usual astringents are used to complete the cure, but if they are successful the credit is given to the heroic remedy which calmed inflammation and more or less rapidly changed the character of the discharge. In the majority of these cases, there can be no doubt, the patients are not in any sense cured. They have been rapidly pushed into the terminal stage, which in many cases has no end. Now, if we study these cases carefully (as, so unhappily, it is our frequent duty to do) in the light of the pathology of the gonorrheal process and of their pathological course, we see that the treatment has caused a much greater exudative inflam- mation into the submucous connective tissue than is seen in cases tem- perately treated, and that the catarrhal inflammation has been brought TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 143 down from suppuration to the production of a thick muco-purulent secre- tion. This is shown in the earlier times by the decidedly full, tense, and thickened condition of the pendulous and subpubic urethra, and by the examination of the urine, which, strange to say, is not insisted upon by the authors of these rapid-transit treatments, as they are called. Then the patients, if they have escaped epididymitis, have symptoms of posterior urethritis, urethro-cystitis, and often bladder incompetence, and more or less incontinence. They often further suifer from urine-dribbling, which is due to the infiltration into the urethral walls, which prevents the canal from performing the final expulsive acts of urination. As time goes on this exudative process, which involves nearly if not all of the anterior urethra, and perhaps the posterior part also, produces connective tissue, and as a result the canal is more and more constricted, until in some very bad cases a condition bordering on stenosis is left, accompanied by all the distressing conditions incident to the blockade of the bladder. This picture is not in one particular overdrawn, but is based on the unbiassed study of cases of acute gonorrhoea which have been railroaded into the terminal stage. It may be claimed by those who advocate this form of treatment that they never see tjiese results. Perhaps they fail to appre- ciate the deplorable condition the patients are in, but, as a rule, these same patients think that they have had enough of that sort of treatment, and they have sense enough to go elsewhere. It follows, therefore, that a treatment which is at once sufficiently active, but conservative and based on a knowledge of the pathology and course of gonorrhoea, is the one which in the end will give the best results and spare the patients much trouble and suffering, and perhaps permanent infirmities. Irrigations, Eetrojections, and Endoscopic Applications as Abortive Measures. — A treatment of gonorrhoea known as the method of Janet ^ is noAV attracting considerable attention both in this country and abroad. This treatment is essentially based on the fact, well brought out by Feleki^ (but known quite generally for many years), that as a result of a certain technique the posterior urethra and the bladder can be injected from the meatus without the aid of a catheter. It is assumed that the catheter may not only act as an irritant, but that it is a fruitful source of infection. Janet uses an irrigator or a fountain syringe, to which is attached about six feet of India-rubber tubing of 30 F. calibre. Into the distal end of this tube a goodly-sized conical glass nozzle is inserted, while an India-rubber stopcock completes the apparatus. The reservoir for the injection, what- ever it may be, is elevated above the patient about two feet when the anterior urethra only is irrigated, and about four and half feet when the posterior urethra and bladder are medicated. The patient, after urination, is placed on his back and the conical nozzle is well, but not forcibly, introduced into the meatus ; then the current is allowed to flow. If irrigation of the anterior urethra is practised, the stopcock is so held that the return current may run out of the meatus. When the deeper urethra and the bladder are to be irrigated, the nozzle is firmly held in the meatus. * "Traitement abortif de la Blennorrhagie par le Permanganate de Potasse, etc," 3d series, Annales de Derm, et de Syphil., vol. iv. pp. 1013 et seq. ^ "Experimentelle Beitriige zur Funktion der Harnrohrenschliessmuskeln und zur Ausspiilung der Blase ohne Katheterismus," Internat. Centrblt. fur de Physiol, und Pathol, der Ham- und Sex.-Org., 1890-91, vol. iii. pp. 80 et seq. 144 OONOBBHCEA AND ITS COMPLICATIONS. In some cases, after a little resistance, the compressor urethrae muscle and the feeble external sphincter yield, and the injection flows through the posterior urethra into the bladder. If any resistance is offered, the patient- must practise the little procedure recommended by Bennett^ — namely, "to strain as if to pass a very slow stream, or to strain a little." If the opera- tion causes a desire to urinate, the patient should be allowed to evacuate the bladder, and then the irrigation should be repeated. For the abortive treatment of acute anterior urethritis one or two irrigations daily are necessary. For gonorrhoea of the totality of the urethra, for the first few days two irrigations daily are given, and after that only one each day. The therapeutic agent employed by Janet is permanganate of potassa dissolved in warm water. The solutions vary in strength from 1 : 1000 of water to 1 : 4000. Toward the end of treatment, with the decline of the acute symptoms, the strength may be 1 : 500. For the irrigation of the anterior urethra about one pint of injection may be used, while for the bladder two lavages or irrigations of about a pint each may be intro- duced. By this treatment Janet claims that he not only aborts incipient gonorrhoea, but promptly cures cases in the acute purulent stage. The noticeable effects of these irrigations, as stated by Janet, are — first, the appearance of a whitish secretion, which soon becomes serous, and then an almost absolute dryness of the whole urethral canal. In unsuccessful cases after this dry stage the discharge again becomes purulent, in which case these lavages should be discontinued for eight days and then resumed. Janet says that on an average ten or eleven irrigations are sufficient to abort incipient cases, and nine for other acute cases, but in general the patient is cured by five lavages. As to the stability and validity of the cure, we find these significant words : " Sometimes there remains a slight mucous secretion;" "at other times the patient has a slight mucous dis- charge, in which case I gave a little irrigation of nitrate of silver, 1 : 2000, in the anterior urethra." It is astonishing how complacently exploiters of abortive treatments wdth uniformly favorable results look upon these mucous secretions and fail to appreciate their gravity. This treatment of Janet must, of necessity, be administered by the surgeon, to whom the patient must come once or perhaps twice a day, morning and evening. I have it from the word of mouth of gentlemen who have been thus treated that in the manipulations necessary for flushing out the anterior urethra and filling the bladder some of the injection, as a rule, escapes, and not only dampens but stains their linen. And what is the benefit ? It is claimed that the urethra is spared the irritation of a catheter and the danger of infection by this instrument (which with ordi- nary cleanliness is nit). A 12 F. velvet-eyed, soft-rubber catheter can be passed into the bladder after urination, the patient standing or lying down, and that viscus can be filled by means of a hand-syringe in a short time and without any discomfort whatever. Why, therefore, should a patient be subjected to this ordeal Avith all its technique, its drawbacks, and its compromising stigmata? There is no benefit derived in over- coming the resistance to hydraulic pressure of the compressor urethrae. If the small-calibred soft catheter is gently pushed into the bladder, in the vast majority of cases the compressor will off"er no hindrance, and ^ Journal Ciitan. and Gen.-urin. Diseases, vol. x., 1892, p. 284. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 145 then, if the surgeon elects to use Janet's solution in the conditions before indicated, the man can at least go home with an unsoiled shirt-flap. This method is one of the oft-recurring fads of which there seem to be no end. We have already seen that in a simple manner of application permanganate of potassa may be of benefit early in the course of gonor- rhoea. A treatment of gonorrhoea known as the hot-bichloride-retrojection method was held in high esteem by a few surgeons in New York some years ago. The method was invented by Dr. W. S. Halstead, but its most ardent advocate has been Dr. G. E. Brewer.^ A tin pail is sus- pended from the ceiling by means of a pulley, and under it is a Bunsen burner or an alcohol lamp. To a short tin tube at the lower part of the pail a long soft-rubber tube is attached. Into this tube a short glass-tube coupling is inserted, to the distal end of which an 18 F. soft-rubber catheter is attached. The patient having urinated, the catheter is oiled and passed into the urethra about five inches or even deeper, as far as the bulb. He then is seated at the edge of a stool over a large-sized slop- jar or pail. Then about two quarts of a solution of bichloride of mercury (1 : 40,000 of water, increased in some cases to 1 : 30,000 or 1 : 20,000) are passed through the urethra. The temperature of the injection at the beginning of the stance is about that of the body, but it must be increased until the solution is as hot as the patient can bear. Two or three such treatments are to be given each day. The result is said to be a diminu- tion of the inflammatory symptoms and a rapid transformation of the pus into a mucoid and watery secretion. If much pain is produced, the retro- jection should be suspended for a few days and oil of santal-wood given internally. When the discharge has been watery for three or four days, the bichloride is suspended and sulphocarbolate-of-zinc or subnitrate-of- bismuth injections are used. In uncomplicated cases the discharge ceases in from six to twelve days. The main objection to this treatment is that other surgeons cannot get the same results that its advocate says he gets. Personal observations, carried on in a perfectly unbiassed frame of mind, convince me that this treatment off"ers no advantages whatever over the older and more con- servative methods, and that it is attended with marked discomfort and inconvenience to the patients, who as a result of it frequently have severe posterior urethritis, urethro-cystitis, and even epididymitis. It is now more than ten years since this treatment was introduced in New York, and it has failed utterly to obtain even a limited acceptance. Cotes ^ recommends the following method of treatment of acute gonor- rhoea : After urination a well-oiled warmed endoscopic tube is passed down the urethra four or five inches, the patient lying on a couch. If necessary there may be a preliminary injection of cocaine. The canal is carefully mopped and rendered free from secretion, and examined by means of electric light. Then a tuft of absorbent cotton tAvisted around the end of an applicator is saturated in a solution of nitrate of silver (gr. x to sj of water), and pushed down the tube through its distal aperture. The tube and the applicator are then withdrawn, and as a result the urethra is thoroughly moistened by the solution. A second insertion and a similar ' A System of Oenito-urin. Disease, etc., vol. i., 1893, pp. 161 et seq. . " Lancet, Feb. 27, 1892, pp. 461 et seq. 10 146 GONOBBHCEA AND ITS COMPLICATIONS. application are made to the two inches of the urethra near the meatus. A saline purgative with an alkaline or copaiba mixture is given internally, and the patient injects, using a syringe which holds only two drachms, a solution made of one drachm of Condy's fluid to a pint of water. These injections should be given six times a day, the urethra having previously been cleansed by the injection of some warm water. Cotes claims for this treatment remarkable success in amelioration of the symptoms and quick cure in from five to twelve days. Seeing that in the great majority of cases the gonorrhoeal process promptly travels back to the bulb, it seems queer that Cotes, who began treatment, as he says, in most cases many days after the disease began, was able to " head it off" at from four or five inches. A startling novelty in the abortive treatment of incipient gonorrhoea has recently been offered by Dr. J. C. DaCosta.^ The urethra having been thoroughly cleansed by urination and by the injection or spray of equal parts of water and peroxide of hydrogen (15-volume solution), the part is then sprayed by means of a metal-nozzled atomizer with a mixture of oil of cinnamon and benzoinol. This mixture should consist of one drop of the oil to the ounce of excipient for the first day's injection, two for the second, and three for the third. In 40 cases of beginning acute urethritis of from three to five days' duration, in 6 the discharge ceased in two days and did not return ; in 12, in five days ; in 6, from eight to ten days ; in 10, from ten to fifteen days ; in 10 the treatment failed ; and 4 patients disappeared after their first visit. The injections or spray appli- cations should be made three or four times a day, always into a thoroughly cleansed urethra. When pain is caused by the stronger solution, a weaker one should be used. It will be interesting to learn whether other observ- ers can obtain like results from this method. Various New Agents and Methods of Treatment. — Iodoform. — This agent, on account of its decided antiseptic action, has been used in the treatment of acute and declining gonorrhoea. Campana^ claims good results from the following prescription : lodoformyl alcohol, 20 ; carbolic acid, 0.1 to .02 ; glycerini, 80 ; and water, 20 — used as an injection three times a day. He claims that this drug calms pains and cures gonorrhoea promptly when used as an injection consisting of 4 parts of iodoform to 80 of water. This should be well shaken and drawn up in a glass syringe. The patient should lie on his back, with the penis held vertically when the injection is entering ; then the iodoform will be carried down the urethra. Cheyne^ claimed success from the use of bougies made of iodoform, oil of eucalyptus, and wax. Thiery* used 10 grammes of iodoform suspended in 60 grammes of oil of sweet almonds. One or two injections of two drachms of this com- pound are thrown into the urethra once or twice a day after urination, and there retained for twenty minutes by compressing the lips of the meatus together. A complete cure was produced in from five to twenty- three days. He advises this method as an early abortive treatment. 1 3Ied. Neivs, Oct. 21, 1893, pp. 458 et seq. 2 La Salute, Ital. Med., Genoa, 1883, 2d Ser., vol. xvii. p. 33. ^ British Med. Journal, 1880, vol. ii. p. 124. * Annates des Mai. de Org. Gin.-urin., 1891, pp. 395 et seq. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 147 This agent has also been used in the form of wax and butter-of-cocoa bougies, and of antrophores, sometimes in combination with other anti- septics. On the whole, it is an unsatisfactory remedy for gonorrhoea. Resorcin. — LetzeP first used resorcin in acute and chronic gonorrhoea in 3 to 4 per cent, watery solutions as injections. He claims marked benefit and quick cures for this drug, which to be pure must be snow- white in color, and when dissolved in pure water should make a clear solution. Lychowski^ thinks that resorcin has an antiseptic and astringent efi"ect, quickly killing the gonococci. He used 2 to 3 per cent, solutions, and claims a cure on an average in six days. In the decline of the acute stage I have seen cases progress favorably while using a resorcin solution, 1 drachm to 4 ounces of pure water. I have yet to see any noteworthy effects of this drug as compared with the results obtained by nitrate of silver and the zinc salts. Thallin. — Kreis^ put forth the claim that a 4 per cent, solution of sulphate of thallin in water killed gonococci in the process of cultivation by making the culture medium sterile. He also claimed that it was para- siticidal against the anthrax bacillus and the staphylococcus aureus. Influenced by these results, Goll "* used a 2 to 2|^ per cent, solution of the sulphate of thallin in acute gonorrhoea, giving a double injection daily, the first being allowed to flow out, while the second one is retained for a few minutes. In chronic gonorrhoea he used 1 to IJ per cent, retro- jections, together with instillations of a few drops of 5 to 7 per cent, solution, and butter-of-cocoa-and-thallin pencils. He also prescribed the drug internally. Goll thinks that besides its specific effect on the gono- coccus, sulphate of thallin passes into the submucous connective tissue and into the crypt-spaces and there exercises a curative eff"ect. Irminger^ used with good results bougies containing 3J grains of sul- phate of thallin. He also gave the drug internally in 4-grain doses three times a day. Istamanoff"^ claims that he found a 2 per cent, solution the best of all injections for acute and chronic gonorrhoea. He, following the lead of Nachtigael, Fenwick, and Lohnstein, used antrophores of sulphate of thallin with prompt and good results. After repeated trials my own conclusion is that sulphate of thallin is no better than, and perhaps not as eff"ective as, the old-time chemicals. IcJithyol. — This drug was used by Jadassohn in a large number of well-observed cases in solutions of 1 to 5 per cent, in the anterior urethra and 1 to 10 per cent, in the posterior urethra. Jadassohn thinks its field of action is early in the acute stage of gonorrhoea, in which it is more eff'ective than resorcin, Aveak sublimate solutions, and permanganate of ' "Ziir Resorcin behandlung de Gonorrhoe," Allg. Med. Cent. Ztg., No. 66, 1885. ^ "Eehandlung des acuten Harnsrohren-Trippers mit Eesorcin," Guzeta Lekarska, Iso. 4, 1887. ^ "Ueber das Verhalten der Gonococcen zur Thallinsalzen," Corresp. Bltt.fur Schweiz. Aerzte, 1887, No. 1, pp. 9 et seq. ■* "Dn Traitement de la Gonorrhode par les Sels de Thalline," Gaz. med. d' Algerie, 1887, vol. xxxii. pp. 91 et seq. 5 Deui. med. Zeil., 1887, No. 77. ^ "Ueber die Behandlung des infektiosen Urethritis mittels der Thallin-Antrophore," Mmatshefte fur Prakt. Dermat, Dec. 15, 1888, p. 1215. 148 GONOBBHCEA AND ITS COMPLICATIONS. potassa.^ It causes the rapid disappearance of the gonococci, and as a result the pus rapidly changes into a serous fluid. In later stages it is beneficial, and in posterior urethritis, but does not rank with nitrate of silver. Many cases are refractory to the action of this drug. Colombini ^ observed that a strength of 2 and 3 per cent, ichthyol retarded the growth of the gonococcus in cultures : 1 to 2 per cent, watery solutions were well borne in acute gonorrhoea, while 8 and 9 per cent, solutions only caused a slight burning sensation. In very acute gonorrhoea a 1 per cent, solution calmed pain, diminished the number of erections, and caused the discharge to become sero-purulent, then serous. By increasing the strength to 2, 3, or 4 per cent, the discharge ceased in from ten to thirty days. In the acute stage 2 per cent, injections, whilst they change the character of the secretion, also cause an epithelial des- quamation which the author thinks aids in the elimination of the gono- coccus. In subacute gonorrhoea 3 to 4, and even 7 or 8, per cent, injec- tions usually cause the discharge to disappear in fifteen days. In chronic localized gonorrhoea Colombini used solutions of strengths as high as 8, 10, and 15 per cent., with the addition of 10 per cent, of glycerin, with good results. Ichthyol, according to this observer, possesses an undoubted anti- blennorrhagic action, and is well borne by the urethral mucous membrane, and, while he does not regard it, as Jadassohn does, as an ideal remedy, it is one of great value. Villetti ^ confirms the claims of Columbini as to the soothing nature of ichthyol injections. He found that the results were favorable and prompt, and that complications were avoided. Villetti used lavages of ichthyol (1 per cent.), one each day, in cystitis, by which he means pos- terior urethritis and urethro-cystitis. He found they had an antiseptic, curative, and analgesic efi"ect. The truth is, that ichthyol is perhaps about as effective as lead-water in acute gonorrhoea, and injections made of it are objectionable to patients by reason of their staining quality and of their unpleasant odor. Crallohromol. — Cazeneuve and Rollet^ claim that this drug is valuable in the treatment of gonorrhoea. They used it diluted in water (1 part to 100 or 1 part to 50) as both injection and lavage. They claim that in the acute stage it calms pain, acts antiseptically, reduces inflammation, and changes the purulent secretion into muco-purulent, and may cause a cure in from six to eight days. They significantly remark that it may happen that they have to prescribe the zinc salts. Letzel ^ used this remedy in 1 to 2 per cent, solution in the anterior urethra, and in 2 and sometimes 3 and 4 per cent, solutions in the pos- terior urethra. In some acute cases Letzel found the discharge to cease in from seven to ten days, and gonorrhoeal threads no longer to appear in ^ " Ueber die Behandlung der Gonorrhoe mit Ichthyol," Deut. med. Wochenschrifl, If OS. 38 and 39, 1S92. ^ " Ictiolo nella cura della Blennorrhagia," Commentario Clinico della Malaitie Cutanee e Genito-urinarie, 2d Series, 1893, fascic. 5, 6, and 7. ^ L' Ichthyol dans le Traitement des Urelhriiis et des Cystites, Rome, 1894. * " Traitement de la Blennorrhagie par le Gallobromol," Lyon Medical, No. 29, July 16, 1893. ^ " Gallobromol als Secretionsbeschriinkendes Mittel bei Gonorrhoe und Eczema," Aerztliche Rundschau, Ko. 13, 1894. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 149 the urine. In chronic gonorrhoea it was also very curative. Antrophores introduced into the urethra at night, together with the use of the sound, were beneficial. Miiller ^ tested the therapeutic value of gallobromol very carefully and reached the conclusion that it is inferior to ichthyol in calming the severe symptoms and in shortening the course of the disease. Neither ichthyol nor gallobromol, according to the opinion of this author, possess potent action against the gonococcus. Gallobromol is obj ectionable for the reason that it stains the patient's linen. Alumnol. — Chotzen exploited this drug as non-toxic, antiseptic, and astringent, acting not only superficially, but deeply in the tissues. In his first essay Chotzen^ claimed that this agent was preferable to nitrate of silver, for the reason that it does not cause pain or stain the linen. As a destroj^er of the gonococcus he gives it a prominence above all other therapeutic agents. In a second essay this author^ claims that in cultures alumnol promptly kills the gonococcus, and in 1 and 2 per cent, solutions it penetrates the tissues of the male urethra and of the cervix uteri, and exerts a specific action, killing the gonococci and causing the inflammatory process to wane. He makes the astonishing assertion that he cured a goodly number of cases of acute gonorrhoea in one week. The experience of Casper'* is not in accord with that of Chotzen. The former found alumnol in acute gonorrhoea no better than the old remedies, and in chronic gonorrhoea it was inferior to nitrate of silver. Samter,^ together w^ith Lewin, treated twelve cases of gonorrhoea with this remedy. They found that it does not exert a specific curative action, and their results were so unfavorable that they have renounced its use in chronic gonorrhoea. The foregoing experiences are interesting, since they conspicuously show how the exploiter or promoter of a new drug or treatment invariably sees specific results which no one else can obtain. Retinol. — Dubois^ experimented with the injection of balsamics, and used retinol alone or in combination with salol 10 to 15 per cent., copaiba 5 per cent., and creoline 1 per cent. These injections are said to favor- ably modify the discharge. PyoManin. — From its well-known afiinities for micro-organisms it would seem that this agent might be especially useful in the treatment of gonorrhoea. Burghard'' used pyoktanin in thirty cases with what does not seem a striking success. When injections (1 : 1000) were used, the discharge was in some cases decreased and in others increased. In all, smarting and scalding on urination were produced, together with much inflammatory reaction. When the solution was reduced in strength ^ " Ueber die Einwirkung von Gallobromol auf die Acute Gonorrhoe," Dermatologische Zeiischrifi, vol. i., 1894, pp. 516 et seq. '_ ^"Alumnol, ein neues Mittel gegen Hautkrankheiten und Gonorrhoe," Berl. Hin. Wochenschrift, 1892, pp. 1219 et seq. *" Alumnol, ein Antigonorrhoicura," Verhandl. der Deut. Derm, G eselhchaft, 4ih. Con- gress, Wien, 1894, pp. 673 et seq. ■* "Ueber die Wirkung des Alumnol auf die Gonorrhoe, etc.," JBerl. klin. Wochenschrift^ 1893, p. 306. * "1st das Alumnol ein specificum gegen Gonorrhoe?" ibid., 1893, p. 308. 6 Thise de Faria, 1891. ' " On the Action of Methyl Violet, with especial reference to its use in Gonorrhoea, etc.," Lancet, May 23, 1891, p. 1147. 150 GONOBBHCEA AND ITS COMPLICATIONS. (1 : 3000) it worked better. Burghard recommends this solution, 1 : 3000, to begin with, and then to cautiously increase the strength. Lindstroem^ is disposed to think that this agent is valuable in acute gonorrhoea when a strength of solution of 1 : 4000 or 1 : 2000 is used. The very decided staining quality of this drug will prevent its extended use, even if found beneficial in very dilute solutions. Antipyrine. — This drug, useful in many cases of painful complications and symptoms of gonorrhoea, has been used by some authors as an ingre- dient for injections. Audhoui,^ in several cases of acute and chronic gonorrhoea, claims success from the use of injections of the strength of 2^ per cent., dis- solved in water. Brindisi^ is said to have used the same solution with benefit. The paucity of its literature and the absence of the claim of specific action for this drug go to show that it has little if any therapeutic effect. Qitric Acid. — As a result of the knowledge of the energetic action of citric acid on the bacillus of diphtheria, Pellissier* has used this drug in acute gonorrhoea in fifteen cases, efi'ecting a cure in from fifteen to eigh- teen days. He uses a solution (1: 100 of water) as an injection six times daily. For lavages the solution employed is 8 grammes of citric acid to 1000 grammes of water. Dermatol, suspended in a thick mucilage made of Irish and Iceland mosses, was claimed by Vaughan* to act as a demulcent and to promptly cure acute gonorrhoea. This is one of the passing fancies in the treat- ment of gonorrhoea which appears and disappears with equal celerity. Sozoiodol pf zinc has been used with benefit by Taaks ^ in 2 or 3 per cent, watery solutions as injections in acute gonorrhoea in men and Avomen. Triedheim ^ used this salt, as well as sozoiodol of potassium and sodium, and claims that it distinctly lessens the purulency of the discharge. Lysol^ in 1 per cent, watery solution has been used by Carballo with the usual great success peculiar to new remedies. Oreoline is regarded by La Bosa ® as superior to corrosive sublimate and carbolic acid when used as an injection (1 : 100 of water). Salicylate of Mercury. — Schwimmer^'* recommends injections of sa- licylate of mercury in acute gonorrhoea, using a watery solution of 1 centigramme to 100 grammes of water, as an injection three times a day. This is said to cause the discharge to cease in a few days. This remedy proved efficient in Friedheim's hands." Salicylate of cadmium is considered by Cesaris ^^ an energetic antiseptic and astringent, useful in gonorrhoea as an injection (^ss to water ^viss). Quinine has been used by several surgeons, suspended in water as an injection in gonorrhoea, and some claim good results from its use. 1 Wralch, No. 37, 1890. ' Gazette des Hopitaux, Sept. 29, 1888. 3 Med. News, April 25, 1891. * Bxdl. de Therapeutique, Dec. 15, 1894. * New York Med. Journ., April 30, 1892. ^ Inaug. Dissert., Wurtzburg, 1889. ' Op. cit. ^ Monatshefie fur Prak. Derm., vol. xvi., 1893, p. 492, and Boletin de Medicina de Chile, 1892. 8 Giornale Ital. delle Malat. Ven. e. delln Pelle, 1890, p. 194. 1" Wien. med. Wochenschrift, No. 8, 1889, p. 281. " Op. cit. ^^ Bolletino Chim.-farm., 1894, p. 407, quoted from Merck^s Annual Beport for 1894, Darmstadt, 1895. TREATMENT OF ACUTE URETHRITIS, OR GONORRHOEA. 151 Harmonic' regards the drug as a mild antiseptic and of benefit in acute gonorrhoea. He used an injection composed of subnitrate of bis- muth 5 grammes, quinine 1 gramme, and water 130 grammes. The average strength of these injections should be 1 or 2 per cent. Ledetsch ^ used quinine in solution, 1 : 100, with brilliant results. In some chronic cases of gonorrhoea the author was astonished at the rapid- ity of cure, which resulted in a few days. A slight burning sensation is produced. JVaphthol has been found to have only very slight antiparasitic action upon the gonococcus by Critzman.* Ergotine comes in for a fair share of praise in the treatment of acute gonorrhoea by Roicki.* The injection used consists of 30 centigrammes of ergotine to 300 grammes of distilled water. The patient should also take internally two to four pills of this drug, containing two grains each, daily. Tannin has been extensively used in gonorrhoea in injection form, but its therapeutic action is very limited, and it sometimes is very irri- tating. Sea-water is said to have cured thirty-two cases of gonorrhoea when injected into the urethra eight times daily. O'Brien,* who is the sponsor for this treatment, claims cures in about eight days. The efficacy of the water is said to be due to its alkalinity and to its antiseptic and tonic properties, all of which are enhanced if it is slightly heated. Pyridin, or tricarboloxylic acid, has been used with prompt and good effect in gonorrhoea by Rademacher® in a watery solution, ^ a grain to the ounce, as an injection used three or four times a day. Silico-jiuoride of sodium is considered by Croskey ^ to be a valuable antiseptic agent and very effective in gonorrhoea in a 1 : 1000 solution in water. Four injections daily should be used. Pyrogallic acid, in 4 per cent, solution, was used by Friedheim ^ with slow effect, the drug being sometimes irritating even when used in 2 per cent, solution. Natrium chloroborosum was used in acute gonorrhoea by Friedheim' in 5 per cent, solution, with alleged good effect and no irritation. Carbonic-acid water has been exploited as an active injection in acute gonorrhoea, when used in a cold state. It sometimes causes much irrita- tion. Thermal sulphur waters have been regarded as curative when injected in acute gonorrhoea, particularly by the disinterested physicians who live at the springs. As examples of the fatuous methods of treatment recommended for gonorrhoea the inhalation of ethereal oils and turpentine-vapor baths may be mentioned as some of the most conspicuous. Bougies, Antrophores, Ointments, Sounds, Syringes, and InsuflBiatorSi — Of late years many authors have written in praise of certain applications ^ Annales Medico-chirurgicales et TTierapeutiques, July, pp. 219 et seq., 1886. " Prager med. Woehenschrift, No. 32, 1887, p. 275. ^ Annales des Mai. des Org. G^n.-urin., vol. vii., 1889, p. 244. * Ibid., 1891, p. 725. * British Med. Journ., Nov. 30, 1889, p. 1215. « Medical Herald (Louisville), Oct., 1887, p. 290. ' Med. Times and Register, Julv 6, 1889. * Op. cit. » Op. cit. 152 GONORRHOEA AND ITS COMPLICATIONS. to the anterior urethra, as far back as the bulb, used in the form of bougies, antrophores, and ointments. These agents perhaps may be useful in the chronic stage in some cases. Bougies have as their base lanolin, vaseline, and cocoa-butter, ren- dered comparatively hard and stiff by the admixture of a certain amount of white wax. A large number of drugs and combinations of drugs of an astringent and antiseptic nature have been incorporated with these basic substances, according to the fancy of the inventor of a "new treatment." These bougies, as a rule, have a calibre of about 14 French, and they may be of any length, but usually those of two or three inches are recom- mended. The following are the principal drugs used in bougieform in chronic anterior urethritis : nitrate of silver, sulphate and sulphocarbolate of zinc, subnitrate of bismuth, thallin, quinine, iodoform, oil of eucalyp- tus, corrosive sublimate, calomel, ichthyol, boric acid, and alum. These bougies may be introduced into the urethra once a day by means of an endoscopic tube ; the end of the penis is then enveloped in a tuft of ab- sorbent cotton held in place by an India-rubber elastic band. In Ger- many, Senftleben's ^ urethral pistol seems to be in much favor. This instrument consists of a cannula made of celluloid, into which an obturating staff of whalebone is inserted. Antrophores are soluble bougies composed of medicated gelatin moulded on a spiral wire. Into the gelatinous mass any one or several of the above-mentioned drugs may be incorporated as it may suit suit the fancy of the surgeon. As time goes on and as new antiseptic drugs are invented or discovered, we shall no doubt have new treatments in the shape of bougies or antrophores. Ointments have for their bases lanolin, vaseline, cerate, and cocoa- butter, and are less firm in structure than bougies. The therapeutic agents have already been named. These ointments for the urethra are introduced into that canal by means of sounds and syringes. In America we have used for years, and sometimes with benefit (when nitrate of silver, 3ss to §j, was the active agent), what is known as the cupped sound. At Fig. 62. Cupped sound. its distal portion there are six or eight cup-shaped depressions, into which the ointment is placed before the sound is passed. This treatment of chronic gonorrhoea by means of ointment introduced upon sounds into the urethra has been advocated quite warmly in Germany. Unna^ advises a quite stiff ointment, the essential part of which is nitrate of silver. This is liquefied in a lukewarm-water bath, and the sounds, of which he has invented a complete set, are dipped in it and then hung up to cool. Then they are introduced into the urethra, the warmth of which causes the oint- ^ "Eine neiie Methode der Tripper Behandling," Monutshefte fiir Prcik. Dei-mat., 1884, vol. iii. pp. 281 et seq. 2 Ibid., vol. iii., 1884, pp. 326 et seq. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 153 ment to melt and lubricate the parts. Szaclek^ advocates Unna's treat- ment in an article showing its scope and limitations. Casper^ has modified the cup-sound, and uses cylindrical steel sounds with four to six quite deep, narrow grooves about three inches long, which begin about an inch and a quarter from the tip, passing around the curve as far as the straight portion of the instrument. With Unna's instrument the ointment rarely comes in contact with all the mucous membrane traversed by the sound. With the cupped sound and Casper's sound, if care is taken to wipe off the instrument smoothly after the ointment has been deposited upon it, a quite sharply-localized application of the remedy on the urethral walls may be attained. In this ointment-sound treatment there is a combination of pressure and dilatation, with a decided astringent action. Cases must be carefully selected upon which to employ this treatment, which of necessity causes more or less inflammatory reaction. When there is much hypersemia with thickening, or w^here the morbid process is quite extensive, the treat- ment will in all probability produce harm. When the cell-infiltration is considerable and the condensation of the mucous membrane well marked, and there is not much hyperemia — in short, in certain sluggish cases — this treatment may be of decided benefit. It should only be adopted after a full study of the case, and it should be followed out with great care and watchfulness. Within recent years great activity has been displayed in the invention of syringes for the deposition of ointments in the urethra as far down as the bulb. Most authors who introduce new ointment-syringes and treat- ment speak of their methods as being the rational one, the inference being warranted that they regard other methods as irrational. In order that an idea may be conveyed as to what we have already on hand in this direction, I will give the chief literature on this subject, which may have the good effect of sparing us any further additions. All ointment-S3a'inges are modifications of silver catheters, uterine syringes, rectal syringes, and the ordinary penis-syringe. The simple fact is, that the ordinary uterine syringe, with its long tube, will do all that is needed of it in this treat- ment, particularly if the tube be bent like a steel sound. Tommasoli ^ has recently described a syringe which is a combination of the penis-syringe, at the end of which is a catheter with the open- ing on its end. This author had already invented a syringe, and had further modified it several years before. The next inventor was C. J. Smith,* who has favored us with a modification of a rectal syringe, and he was followed by Bransford Lewis, ^ who attached vulcanized soft- rubber stems to the ointment-box in order to produce a minimum of irritation. On old fad is now being revived in the shape of certain complicated insuflflators or powder-blowers. Rosenburg ^ described a complex instru- ment, called the " urethral exsiccator," by which he throws into the urethra ^ Archivfur Derm, und Syphilis, 1889, vol. xix. pp. 171 et seq. 2 Berl klin. Wochenschrift, 1885, No. 49, p. 806. ' Giornale lial. delle Malat. Ven. e delta Pelle, 1891, p. 255; also same journal, 1887, p. 270, and 1889, p. 283. * Lancet, Sept. 1, 1888, p. 418. '" The Medical Standard, Nov., 1889, pp. 143 et seq. * Die Behandlung der Gonorrhoe nach neuen Grundsdtzen, Berlin, 1 895 (brochure). 154 GONORRHCEA AND ITS COMPLICATIONS. a powder called by him " zymo'idin," which is composed of no less than seventeen drugs having an astringent and antiseptic action. Still another insufflator, rather less complicated in structure, is ex- ploited by Schalenkamp,' who gives minute directions for the deposit by it of antiseptic powders in the urethra. Future inventors should familiarize themselves with the mechanism of these instruments, lest they find themselves forestalled in some particular feature. Separation of the Urethral Walls and Drainage. — A number of writers have advocated methods of treatment of gonorrhoea the essential feature of which is to interpose some substance or instrument in the urethra, and thus keep its walls apart. Since it is just as important that the young practitioner should know what not to do in the treatment of gonorrhoea as it is for him to know what should be done, I will give an outline of these procedures, which may have some influence in deterring others from experiments in this direction. Pitts ^ recommends a method of treatment at once unique and radical. In order to "jugulate gonorrhoea in its incipiency " he first causes the patient to urinate, then washes out the urethra with warm boiled water, and cocainizes it if sensitive. If the meatus is small, it must be cut to the full size of the urethra to allow a metallic tube to be passed five inches. Through this tube a cotton tampon, saturated in a 1 : 20,000 bichloride solution, is passed well down the urethra. This tampon is tied to a silk thread. Then the urethra is again injected through the tube, and another tampon with silk thread is introduced. Thus he keeps on until the urethra is filled up. The strings hang from the urethra, and by means of them the tampons can be removed. The tampons should be kept in the urethra as long as they can be borne, and they should be renewed every seven days. In 11 cases a cure resulted, on an average, in twenty- five days, without sequelae. Nothing is said about the interference with urination thus induced, nor as to the amount of discomfort suiFered by the patient. Any one who has seen in practising endoscopy of the urethra how spasmodically that canal will contract on the cotton at the end of the applicator on some occasions, will have convinced himself that tamponing of the urethral canal is impracticable, by reason of the spasmodic condi- tion which will follow. McVaiP recommends an open wire arrangement which is to be con- stantly worn by the patient, " so that the discharge may drain freely away." His wire bougies are an inch and a half long, but he says that they may of necessity have to be much longer. We have already seen that in no case of acute gonorrhoea is the morbid process limited to the first inch and a half of the urethra longer than a day or two ; hence these short bougies would fail of their purpose even if the urethra were sufficiently quiescent to allow their presence. To drain the deeper and bulbous por- tion of the canal with these bougies is a simple impossibility, since they would become so bent at the peno-scrotal angle that they would fail in aiding drainage. ' " Die Insufflation trockener Pulver, etc.," Monatshefte fur Prak. Deimat., vol. xx., 1895, pp. 279 et seq. 2 Med. News, Sept. 27, 1893. * Bj-itish Med. Journal, March 15, 1884, pp. 306 et seq. TREATMENT OF ACUTE URETHRITIS, OR GONORRHCEA. 155 The principle of urethral drainage is carried to an extreme in an arti- cle by B. Foster.^ This author suggests that when the diagnosis of a first gonorrhoea is made the patient should be etherized, propei'ly pre- pared, and a button-hole opening made in the perineum and bladder drainage established. Then the anterior urethra should be thoroughly irrigated with appropriate solutions. If we could obtain the consent of the majority of gonorrhoics to this radical treatment, we should have to enlarge our hospital facilities to an extreme degree. The distention of the urethral walls and their separation by means of a mild powder with antiseptic properties are the essential factors in a mode of treatment advocated by Pixley and Zeisler.^ They use a rather complicated instrument, which is really a long metallic endoscopic tube with an obtura- tor and a hollow spiral made of wire. After urination the canal is flushed with a permanganate solution (1 : 10,000), then dried by stripping the urethra. Then the tube is introduced, the patient being on his back ; the obturator is withdrawn, the powder is put in the expanded part of the instrument, and the spiral is then introduced and twisted, thus carrying the powder into the urethra. Boric acid may be used, also a powder composed of calomel 1 part, subcarbonate of bismuth 10 parts, and boric acid 12 parts. I gave this treatment a fair trial, and found it, even when employed with the utmost care, discomforting and even painful to the patient, and productive of no good whatever. In the same line with the preceding is the following method : About twenty years ago injections of water mixed as thickly as possible with clay-earth were much vaunted by Gordon^ and Hewson as an abortive treatment of gonorrhoea. The effect thus produced was the deposit of an inert substance in the urethra which kept the walls apart. Since no one but its promoters could obtain beneficial results from this dirty treatment, it has remained unemployed all these years, and it is to be hoped that it will not be reintroduced. ^"The Ideal Treatment of Acute Gonorrhoea. Is it Justifiable?" Journal of Cutan. and Gen.-urin. Diseases., Sept., 1894, pp. 390 et seq. ^ Medical Record, Jan. 19, 1889, pp. 64 et seq. ^ Am. Journal of Syphilog. and Dermat., etc., Oct., 1874, p. 337. 156 GONOBBHCEA AND ITS COMPLICATIONS. CHAPTER XL ACUTE POSTEKIOR URETHRITIS, OR GONORRHCEA. It is now a well-established fact, as we have seen in a previous chap- ter, that anterior urethritis in between 80 and 90 per cent, of cases within the early days of the infection passes backward and involves the posterior urethra. When the disease reaches the bulb of the urethra, which it does within a few days in acute attacks, there is then an acute inflamma- tion and profuse suppuration in highly vascular tissues. The thesis is then no longer tenable that such is the tonus or the markedly-contracted condition of the compressor urethrse muscle that the lumen of the urethra is hair-like in calibre, and that the parts are, as we may say, so exsan- guinated that the extension of the infective process is thus prevented or barred. Such is not the case. The bulb in gonorrhoeal inflammation becomes a profusely suppurating pouch, and from it, in the majority of cases, the morbid process, by cell-to-cell invasion, attacks the membran- ous and prostatic urethra. In many cases the onset of posterior urethritis is unattended by any marked symptoms, and it is largely by reason of this absence of symp- toms pointing to the deep extension of the trouble that the opinion was held that the posterior urethra is invaded only in a minority of cases. It has been customary to speak of a deep burning pain between the testes and in the perineum as symptomatic of involvement of the bulbous urethra — a contention which is quite correct. But it is equally certain that this symptom occurs when the infective process has invaded the urethra beyond the triangular ligament. Its import has, therefore, fre- quently been misconstrued. Acute posterior urethritis, moreover, may exist and gradually decline in the manner and with the same symptoma- tology that we have seen the infection of the anterior urethra subside. In such cases there has been no suspicion of the invasion of the canal beyond the bulb, and in all probability the two-glass test and the lavage of the anterior urethra, followed by the one- or two-glass test, have not been resorted to. Thus it is that many instances of involvement of the posterior urethra have been unrecognized. If cases of acute gonorrhoea are carefully watched as to their symp- tomatology, and the urine is properly examined, it will be found that in a goodly proportion the only symptoms of posterior urethritis will be a slight burning deep in the canal, particularly after urinating, and a very slight increase in the number of urinations. In many cases these symp- toms will only come to light as a result of the care and acumen of the physician, since many patients say nothing about them or fail to take much notice of them. Then there are other patients who, when the discharge is profuse, will complain of the deep-seated burning pain and of an increased desire to make water. Many of these cases are able to go about and attend to their duties during the acute and declining stages of their trouble, which is gonorrhoea of the totality of the urethra. ACUTE POSTERIOR URETHRITIS, OR GONORRHCEA. 157 But the symptoms most strikingly indicative of invasion of the poste- rior urethra are a diminution in the amount of the suppuration or its entire cessation (even when it is profuse and also when it is on the decline) and a decidedly increased desire to urinate. In some cases the cessation of the discharge so pleases the patient that he gives himself little concern about the increased frequency of urination. In these cases by the two- glass test the first and second specimens of urine will be found to be opaque and to contain pus and tissue-elements. If no complications develop in such cases, the trouble in the posterior urethra may be more or less severe for a time ; then in most instances the discharge again appears, either copious or rather scanty, at the meatus ; the patient feels much re- lieved, and the case then behaves like one of anterior urethritis on the decline. In many cases in which a supposed anterior urethritis is declining in a satisfactory manner the patient will present himself and complain of a frequent and intense desire to urinate, together with pain deep down in the perineum at the end of micturition. By questioning the patient the mode of onset of his trouble will be made clear. He usually begins by urinating in a normal manner, but at the end of the act he experiences a dull pain and weight in the perineum or a short, sharp spasm. This leads him to think that he has not evacuated the bladder, and he then strains, but expels no urine, or at most only a few drops, the passage of which causes still more deeply-seated pain. Thus ushered in, the tenes- mus begins in varying degrees of severity. Examination of the urine shows cloudiness in both beakers when the suppuration is profuse, as it usually is in such cases. This desire to urinate may be very frequent and imperative, or the symptoms may be less pronounced. In some cases a patient may go about, while in others he is forced to go to bed. In severe cases a further symptom is added to the patient's discomfort, and this is a more or less profuse heematuria. In most cases the blood follows the urine, but in some it appears before it is all voided. There may be but a few drops or the quantity may be very profuse, in which case Guyon's simile is warranted, in which he says the patient has nose-bleed from the meatus. In some of these cases of hsematuria in posterior urethritis a small worm-like mass of coagulated blood may be passed in the first jet of urine. This coagulation is formed in the intervals of uri- nation by the escape of blood from the inflamed prostatic urethra. At the end of micturition the prostate and bladder sphincters contract and squeeze the inflamed and eroded lining membrane, thus forcing the blood from it, as we by squeezing force water from a sponge. Strange as it may seem, even in very severe and acute cases there is no systemic reaction, there is no fever, and there is no increase in the frequency of the pulse. There are, therefore, four well-marked symptoms and conditions of pos- terior urethritis, as follows : 1. Frequent and intense desire to urinate ; 2. Pain in glans penis and perineum at the end of urination ; 3. Hsematuria (sometimes absent) ; 4. Absence of systemic symptoms. In addition to the foregoing classical symptoms, there are two to which attention was directed by Leprdvost,^ which are complete retention and ^ Etude sur les Cystites blennorrhacjiquei^, Paris, 1884, pp. 34 et seq. 158 GONORRHCEA AXD ITS COMPLICATIONS. incontinence of urine. Temporary retention may occur in the less severe order of cases, due to spasm of the compressor urethrse muscle, and may pass away without the surgeon having to resort to the catheter. Complete retention, due to the same cause, may occur in severe cases in which there is urethral stricture, hypertrophy, or abscess of the prostate. In these cases prompt surgical relief is sometimes imperative. By the term "relative incontinence" is understood a relaxed or insuf- ficient condition of the compressor urethrge muscle, which fails, even when will-power is exercised, to keep back the urinary stream. This condition is observed in the more severe order of cases. A sudden impulse to urinate overtakes the patient, the bladder contracts, and some urine is expelled, perhaps in the patient's pantaloons. Hearing a stream of water flowing from a faucet or a hydrant or from a watering-cart, washing the hands, and even the flow of lager beer from the tap, sometimes causes in these patients vesical contraction and the escape of urine, the compressor urethrse being enfeebled and off'ering little or no resistance. Gruyon and Jamin have laid stress upon the intermittent expulsion of pus from the posterior into the anterior urethra when the suppuration is profuse in the former. Without any erotic sensation the patient imagines that he has had a seminal emission, and he finds a purulent secretion flow- ing from the meatus. Guiard,^ who has paid particular attention to this point bv minutely questioning all of his patients as to whether they have experienced such excitations, thinks that they are very rare — a view with which my own experience is in accord. In many acute cases we also observe such symptoms as painless erec- tions and pollutions. Pollutions are very signiflcant of the involvement of the posterior urethra, since they are due to the irritation of the inflam- matory process in the caput gallinaginis. Chordee is not observed, unless the inflammation still remains in the acute stage in the anterior urethra. In the general run of cases the increased desire to urinate only causes discomfort, and not much pain. Such patients generally go about and rest when they can. In other cases the patients' suff'erings may be said to be quite severe. Then, again, we sometimes see patients thus afilicted who become objects of the most profound sympathy. While in some patients the desire to urinate may occur every hour or so, in others it occurs every half hour or less. Then in very bad cases the imperious desire comes every five minutes, and in yet worse cases there is no inter- val : the patient sits over the chamber the whole time, groaning and cry- ing out with pain and drenched in a cold sweat, passing a few drops at a time of bloody urine. The pain is usually of a dull character, and felt at the end of the act of urination. Some patients complain of pain at the end of the penis before urination, as they do with stone in the bladder. This pain and tenesmus in severe cases radiates to the bladder, anus, lumbar region, spermatic cord, and the hypogastrium. Sometimes these patients also suffer from cramps in the legs. In many cases nocturnal exacerbations ai'e observed. In these very bad cases of acute posterior urethritis the urine in the second glass is more cloudy than that in the first. These patients seem instinctively to know that they suffer less when they pass considerable urine ; hence they drink large quantities of water in order to dilute the urine and to render it less irritating. ^ La Blennorrhagie chez t' Homme, Paris, 1894, p. 251. ACUTE POSTERIOR URETHRITIS, OR GONORRHCEA. 159 When the hemorrhage is very severe it escapes in the intervals of urination from the posterior urethra into the bladder, and then the first, and particularly the second, glass will be found to contain blood as well as pus. In such cases there is usually the same terminal flow of blood after urination as has already been described. Albuminuria^ is a symptom peculiar to severe cases of posterior ure- thritis. It is severe in proportion to the intensity of the tenesmus, and is said to be caused by the spasmodic contraction of the orifices of the ureters by the detrusor muscles of the bladder, which dams back the urine and leads to the escape of albumin from the glomeruli into the renal tubules. It will be seen that in inflammation of the posterior urethra the symp- toms may be slight and insignificant, and they may be severe, and even violent and atrocious. The duration of an attack of posterior urethritis is very uncertain. In the milder forms it may last weeks and months, according to the care taken and treatment advised. In moderately severe cases one or more weeks, even as many as six, may elapse before a condi- tion of comfort is established, even when the treatment is correct and the care of the patient perfect. In the most severe cases the duration is indefinite. Usually such a violent attack lasts two or more weeks, and then amelioration occurs and the disease becomes less severe. When posterior urethritis complicates the condition incident to hyper- trophy of the prostate, or when middle-aged or old men, having stricture of the urethra, are attacked with posterior urethritis, their condition is very often alarming and even critical. In such cases the symptoms are very severe and the sufi"erings of the patients very intense. This com- bination of acute and chronic disorder is the more dangerous as it may lead to rapidly-ascending gonorrhoea and an invasion of the kidneys. The first symptom pointing to improvement is the less urgent desire to make water and the greater length of the intervals of urination. Then the local and radiating pains become less, and the patient becomes more comfortable and hopeful. The progress toward recovery in very severe cases is usually slow and may be interrupted by relapses, which are often brought on by indiscretions of the patient in the matter of alcoholic ex- cesses, sexual imprudences, and bodily strains. In many cases the disease ceases to give the patient concern and settles down into a chronic con- dition, in which there may be no subjective symptoms whatever. In these cases the discharge is small in quantity and viscid in consistency, and the two-glass test fails to localize the inflammatory process. Resort to lavage of the anterior urethra, however, w^ill show that the posterior urethra is the seat of chronic inflammation. In very acute cases of posterior urethritis the secretion is purulent and profuse, like that of anterior urethritis, and in it the gonococcus can usually be readily discovered. As the process grows older the pus becomes mixed with epithelial cells and is seen in the form of threads. It is very ' In spite of many contributions on the subject our knowledge of the pathology of albuminuria in the course of gonorrho-a is yet very limited and unsatisfactory. Balzer and iSouplet in a recent communication reach the conclusion that it is due to general systemic infection. The reader is referred to the following essays by these authors: " Note sur I'Albuminurie liee ii la Blennorrhagie," Bulletin de la Societe fran^aise de Dermatologie et de Syp/iilif/raphie, vol. ii., 1891, pp. 235etseq. ; and " Nouvelle Contribu- tion al'Etude de I'Albuminurie compliquant les Phases aigueN de la Blennorrhagie," Annales de Derm, et de Syphiligraphie, 1891, pp. 113 etseq. 160 GONOBBHCEA AND ITS COMPLICATIONS. difficult to find this micro-organism by means of the microscope late in the course of posterior urethritis. Invasion of the posterior urethra menaces the following parts : the verumontanum, the ej aculatory ducts, the ducts of the seminal vesicles, the prostatic ducts, the epididymis and testes, the seminal vesicles, and the bladder. Posterior urethritis, therefore, may be the starting-point of various complications, all of which are painful and distressing, and some of them are more or less dangerous in their results. Diagnosis. — Commonly, the diagnosis of acute anterior gonorrhoea or urethritis is usually made by the patient before the physician is consulted. In some instances, however, a correct conclusion is not reached at the first consultation. Some cases of balanitis, in which the prepuce is rather tight, resemble gonorrhoea, for the reason that besides the discharge the meatus may be red and swollen, and perhaps there is slight uneasiness in urination. Retraction of the foreskin and cleansing of the parts will permit a thorough examination, and then the diagnosis can be readily made. In those cases of balanitis in which the preputial orifice is very small, even of pinhole size, more difficulty may be experienced. By means of intrapreputial injections the discharge may be removed ; the parts then being dried, slight pressure upon the urethra from behind for- ward will reveal the presence or absence of pus in the canal. By means of the microscope we can find gonococci in the pus of gonorrhoea, and it is not found in that of balanitis. When the initial lesion of syphilis is developed on or within the lips of the meatus, a slight mucous discharge is present, and doubt as to its nature may exist up to the period when the diagnosis of chancre is made. The initial lesion may occur at one or more inches down the canal, and give rise to a discharge which is usually sero-purulent and scanty. Such patients complain of a localized uneasiness and impediment to urination, and examination reveals a circumscribed thickening of the corpus spon- giosum. In these cases the endoscope and the microscope afford much aid. Gummatous infiltration occurs at any part of the pendulous urethra, and a scanty sero-purulent discharge accompanies its development. The absence of inflammatory symptoms, the localization of the lesion, and the history of the patient are usually sufficient for a correct if perhaps rather delayed diagnosis. The mucous fluid which exudes from the meatus when the seat of herpes progenitalis and the presence of vesicles establish the case as not one of gonorrhoea. The pus of chancroids of the meatus is of a rusty-brown color, difier- ing markedly from that of gonorrhoea. The points in the diagnosis of posterior urethritis have necessarily been given in the description of that condition. The diagnosis of acute posterior urethritis, it may be mentioned, is made by a consideration of the acute attack in the anterior urethra and the typical symptoms of deeper invasion. Prognosis. — In general, the prognosis of gonorrhoea is good, and a cure may be promised in from three to six or eight weeks if proper care and treatment are used. The disease is commonly very obstinate when acquired before puberty, particularly in scrofulous and tuberculous sub- ACUTE POSTERIOR URETHRITIS, OR GONORRHGEA. 161 jects. In plethoric persons, in high livers, and those addicted to drink, in rheumatic and gouty subjects, gonorrhoea is frequently very persistent. In those who are overworked, the subjects of mental worry, and those of neuropathic tendency the disease is often very tedious. Even in healthy subjects, in many cases, the inflammatory process is very rebellious, and shows a tendency to become localized in some part of the urethra, and there tax the bearer's patience and the surgeon's skill. By reason of its chronicity and its complications and sequelae gonorrhoea may become a serious, dangerous, and even lethal affection ; therefore its seriousness should not be underestimated. Treatment of Acute Posterior Urethritis. — In many cases, where the totality of the urethra is involved, the treatment of the posterior segment requires nothing more than the regular treatment for acute anterior urethritis, which has already been described. In the milder forms of acute posterior urethritis it is well to stop the use of antiblennorrhagics and the employment of injections into the anterior urethra if they give evidence of producing irritation. At first, in the severe class of cases, no local treatment should be used. The patient should be put to bed and placed on a milk diet, and he should take the alkaline and hyoscyamus mixture. His bowels should be kept loose by the use of mild cathartics. In many mild and in some severe cases the following mixture will produce much comfort. 3^ Fl. ext. tritici repent, Fl. ext. uvse-ursi, da. ^iss ; Liq. potassse, §ss ; Tr. opii, gtt. Ixiv to xcvj ; Aquae, ad 5iv. Dose, one teaspoonful every three or four hours in a wine-glass of water. It is well, in the milder order of cases, to give laudanum in small doses without producing any heaviness and sleepiness, since it calms and soothes the patient and improves his morale, which is sometimes much disturbed by the frequency of urination, tenesmus, and hgematuria. In the very severe cases hot sitz-baths, hot-water bags to the perineum and perhaps over the pubis, together with tolerably strong suppositories of morphine and belladonna, may be used according to the indications. In many cases warm enemata to clear the rectum, followed by an injection of cold water, Avill be very beneficial. It is a good rule to see that the bowels are rendered free once a day. Patients usually like large quantities of water; therefore Apollinaris, Stafford, Poland, and other waters which have a mildly demulcent effect may be freely allowed. In these cases a moderate amount of alkali is usually beneficial, but too much should not be given. Therefore Vichy and mineral waters should not be allowed when the patient is taking an alkaline mixture. Flaxseed, sassafras-pith, and slippery-elm teas may also be given, moderately sweet- ened and nicely flavored. As in anterior so in posterior urethritis, we should resort to local medication just as soon as we can do so without discomfort to the patient and increase of the inflammation. It is well, therefore, to begin with irrigations of Avarm boric-acid water, as directed in the section on the 11 162 GONOBBHCEA AND ITS COMPLICATIONS. Treatment of Acute Anterior Urethritis, and then to progress in the ordinary cases on the lines laid down there. In the severe cases it is well to begin with nitrate of silver in much dilution as early as possible, and to increase the strength of the solution, which should always be hot, until it reaches 1 : 8000 or 1 : 4000. By this time the tenesmus will be much lessened, the irritation less frequent, and the haematuria less copious. When these favorable symptoms are progressing it is well to use caution and not to abruptly increase the strength of the irrigation. Later on warm irrigations of alum, of sulphate of zinc, and of permanganate of potassa may perhaps be useful in giving the parts a rest from the action of the nitrate of silver. Under favorable conditions a cure is produced. Under no circumstances should sounds or bougies be passed into the bladder at these times, since very much harm may be produced by them. In the declining stage of these mild cases the antiblennorrhagics in mod- erate doses may be given for a time, but they should never be pushed. The fluid extracts of kava-kava and of buchu are sometimes of seeming benefit in the declining stage of acute posterior urethritis. In some very bad cases in which the tenesmus is dreadful in its severity and the hsematuria is copious, when other methods of treatment have failed to give relief, very often results little less than miraculous will be produced by the instillation (see section on Treatment of Chronic Urethritis) of a few drops of a solution of nitrate of silver ; 1 : 1000 or 1 : 500 may be given, care being taken that the urethra is not harmed by the passage of the catheter. In using this treatment it is well to be very careful to throw up only a few drops at first, and then watch the result. If, as sometimes happens, the patient's sufferings are calmed, on the next day or on the second day an injection of a larger quantity may be admin- istered. Usually in these cases good will be produced by the 1 : 500 solution, and caution should be exercised in going higher than that stand- ard. When the crisis is Avell over, mild boric-acid irrigation may be given, and further than that the cases should be treated according to the directions given in this chapter and in that on the treatment of acute anterior urethritis. When there is bladder complication in these cases the treatment is in the main similar. (See chapter on Urethro-cystitis and Cystitis.) In middle-aged and old men with stricture and prostatic hypertrophy we sometimes see acute anterior and posterior urethritis. In these cases the sufferings are very great, and they are much intensified by the chronic impediments to urination. In some cases I have had to resort to aspira- tion until the severity of the urethral symptoms had subsided ; then I went on with the usual local treatment as soon as I could get into the bladder with a very small catheter. Each case of this kind will present its special features, which should govern the surgeon in his efforts for relief. URETHRITIS IN YOUNG BOYS. 163 CHAPTER XII. URETHRITIS IN YOUNG BOYS. Until within recent years our knowledge of urethral discharges in male infants and young boys was very vague, and all cases thus affected were regarded by writers on venereal diseases, surgery, and pediatrics as evidences of catarrhal urethritis. To-day, though there are many points still unsettled, our knowledge is much broader and more precise. Pre- vious to the year 1885 attention had not been drawn to the possibility of acute suppuration in the urethrse of young male children originating in gonorrhoeal pus. Up to that date the underlying causes of this ure- thritis in the young were said to be masturbation, friction of the clothes, mechanical and chemical irritants (foreign bodies in the urethra, catheters, the passage of vesical and renal calculi and urine containing an excess of uric acid), and certain skin diseases — pediculosis, scabies, and eczema. There can be no doubt that chronic masturbation may cause a subacute urethritis, but this as a cause cannot, as a rule, be assigned in the cases of babies in arms. The various irritants and traumatisms above men- tioned may produce a urethritis, but its course, like that of the analogous condition in the adult, will be subacute and its duration short. This being the condition of medical opinion prior to 1885, new light was thrown on the subject by Cseri^ of Buda-Pesth in a paper which may be said to be the starting-point of our present broader views. Cseri re- ported the cases of two boys, aged four and five years, who had a profuse purulent discharge. Though the parents of these children were informed of the infectiousness of the disease, a fortnight later they brought an eight- year-old girl to Cseri suffering from purulent vulvo-vaginitis. In speci- mens of the discharge taken from these cases a micro-organism exactly similar in all particulars to the gonococcus was found. , Cseri therefore claimed the infectious nature of these cases. Though Cseri's conclusions , have been confirmed by Rdna,^ and though there is ample evidence to-day that there is a not infrequently occurring purulent urethritis of infectious character in young male children, we must not now go to the extreme in saying that all urethral suppurations in these young subjects are of gon- orrhoeal origin. My own experience leads me to confirm the statement made by Kop- lik,^ that there is a simple non-specific (certainly as to its origin) inflam- mation of the meatus and the anterior portion of the urethra. I have seen cases in which a mild urethritis of the distal part of the penis orig- inated in balano-posthitis resulting from great uncleanliness. In like manner the hypergemia caused by pediculosis, scabies, and eczema of the penis and glans may cause a mild form of purulent urethritis in children, ^ " Zur Aetiologie der Infecticisen Vulvo-vaginitis bei Kindern," Wien. med. Wochen- schr., vol. XXXV., 1885, pp. 707-739. ^ " Ueber Aetiologie und Wesen der ' Urethritis Catarrhalis ' der Kinder Milnnlichen Geschlechtes," Archiv filr Derm, und Syph., 1893, pp. 149 et seq. * " Urogenital Blennorrhcea in Children," Journ. Cut. and Gen. Diseases, 1893, pp. 263 et seq. 164 GONOBBHCEA AND ITS COMPLICATIONS. as they do in the adult. Koplik thinks that in the act of crawlinoj chil- dren may get filth on these organs, and from this infection may result. I have several times seen in boys from ten to thirteen years old well- marked subacute urethritis concomitant with balano-posthitis which originated in efforts to retract the prepuce for the first time and to break up adhesions. In these cases dirt, retained smegma, and urine undoubt- edly played a prominent causative part. The symptoms of mild urethritis in young male children are heat, swelling, pain on urination, and a scanty purulent discharge. This secre- tion may become encrusted on the glans or meatus, and when the crusts are removed a superficially eroded surface may be left. The course of this disease is tolerably mild and its duration short, pro- vided the exciting causes are removed. Gonorrhoeal urethritis in infants and young boys is not infrequently met with, particularly in the lower classes of society living in localities where children are closely herded together with adults. The disease is found in an endemic, quasi-epidemic, and sporadic form. Little is known as to the very early stages of this infection, and there are no reliable facts as to the period of incubation. The symptoms are similar to those of acute gonorrhoea in the male. The disease begins violently in heat, redness, and swelling of the penis, from which there is a profuse discharge of pus. The morbid process begins in the fossa navicularis, and promptly runs down to the bulb and into the posterior urethra. There is pain on urination, besides constant burning sensation in the urethra, and there may be painful nocturnal erections. In the early stage, by the two-glass test, the urine is found to be turbid in the first cylinder and clear in the second. But in most cases the posterior urethra becomes involved, and then the urine in both cylin- ders is turbid. With the invasion of the posterior urethra the symptoms resemble those of the adult similarly attacked. There is tenesmus, which which may be very severe and occur as often as every quarter of an hour in bad cases. In milder cases the desire to make water may occur every hour or at longer intervals. Sometimes mild and even severe hemorrhage may occur at the end of the act of urination. This disease runs the same persistent and rebellious course in the young that it does in the adult, and one or more months may elapse before cure is effected. The complications may be balano-posthitis, lymphangitis, epididymitis, orchitis, and vaginalitis. In some cases chronic posterior urethritis is a result. The virulent form of urethritis in the young may lead to stricture of the urethra. Rona reports two such cases. In one, a boy aged seven- teen, the stricture probably began in an infection at the age of ten. The second case was that of a medical student of twenty-one, who also was infected in his tenth year. It is very probable that to virulent urethritis occurring in early life may be attributed many of the cases of stricture in boys and young men in whom a history of recent gonorrhoea cannot be obtained. Etiology. — Enough has already been said of the probable causes of mild catarrhal urethritis in young male subjects. It is often difficult, and even impossible, to ascertain the cause and mode of origin of virulent gon- orrhoea in the infant under two years of age, but the facts presented by CHRONIC URETHRITIS, OR GONORRHCEA. 165 most cases warrant the opinion that the child had been tampered with by an older person and thus infected. Since intromission of the organ is not absolutely necessary for infection, it is probable that in some of these cases depraved women suffering from gonorrhoea place the child's penis in their vulva. Such instances have been known. Rdna records four- teen cases of virulent urethritis in young boys, and others can be found in medical literature, in some of which the infection was derived from an infected female child or young girl. Then, again, the disease has appeared among a number of boys without the aid of a female, and OAving to their ignorance, indisposition to talk, or to their persistent lying the mode of origin has not been learned. Crandall ^ reports the cases of a brother six and a sister eight years old who suffered from gonorrhoea. The sister claimed that she was contaminated by her brother, while the latter asserted that the girl infected him, and that she had been infected by a young man. Usually, then, in these cases of precocious depravity there is much diffi- culty in learning their origin ; in some, however, the boys are shameless and barefaced, and readily and sometimes proudly assert that they were contaminated by a girl. Treatment. — Simple catarrhal urethritis will promptly cease by the exercise of cleanliness and the use of a mild lead injection. The treat- ment of virulent urethritis of male infants and young boys should be that laid down for adults. The doses, however, should be adjusted to the patient's age, and the strength of the injections should be tempered in accord with the greater delicacy of the young suff"erer's tissues. CHAPTER XIII. CHRONIC URETHRITIS, OR GONORRHCEA, ANTERIOR AND POSTERIOR. In the terminal stage of gonorrhoea the inflammatory process in very many cases becomes localized in some part of the urethra, and there remains in a latent or dormant state. There are a number of conditions which tend to render the course of gonorrhoea chronic. In the first place, there is the natural tendency of the disease to linger indefinitely in the tissues. As we have already seen, gonorrhoea is not a simple superficial catarrhal condition, but a strongly-marked exudative and catarrhal inflam- mation which is very rebellious to our best-directed eff"orts in treatment. Then, again, many patients consider themselves cured just as soon as the discharge ceases, and will submit to no further treatment, though exami- nation of the urine shows the presence of tissue-exudates. Another and a prolific cause of chronic gonorrhoea — or gleet, as it is called — is sexual and alcoholic indulgence during the decline of the chronic stage. Still another cause of the indefinite perpetuation of the disease is a too active 1 New York Med. Joiirn., April, 26, 1890. 166 GONOBBHCEA AXD ITS COMPLICATIONS. and protracted treatment, either by antiblennorrhagics or injections, or by both combined. Many an obstinate gleet has thus been induced by the intemperate use of drugs. It is out of the question, in the vast majority of cases, to induce patients suffering from gonorrhoea to spare their physical forces. This is particularly the case in the declining stage. In the better class of intelligent patients we can in many instances control them to a certain extent, and cause them to avoid athletic exercises, horseback riding, bi- cycling, and other violent exercise. Among working-men, wage-earners, however, the daily necessities demand the daily toil, and in many of these cases the physical exercise tends to cause gonorrhoea to become chronic. The tissues of some subjects are more vulnerable than those of others; this particularly applies to weak, debilitated subjects, the scrof- ulous, and the tuberculous. In former years gleet, also called goutte militaire, was looked upon as a chronic inflammatory process seated in some portion of the anterior urethra. Its symptoms are the morning drops — the pus-accumulation of the night — which may be small in quantity and greenish-white in color. There may be a minute drop, a large pea-sized drop, or three or more drops. In other cases there is simply gluing of the lips of the meatus together, on the separation of which a film of glairy muco-pus is seen. In other cases there is not sufiBcient secretion to produce a drop. In a third class of cases there is simply increased moisture at the meatus, and a scanty colorless secretion, like glycerin, may be forced out by a little pressure. It is well to mention that some ovei'-anxious patients, who in time past have suffered from gonorrhoea, alarmed about themselves, come to the surgeon, stand before him. and by firm pressure and milking of the glans and meatus cause to exude a slight clear mucous' secretion, which they think is gleet. In very many instances their only trouble is the hyper- aemia induced by their own violent manipulations, which result in a slight increase of the normal mucus. There can be no doubt that in most cases of the morning drop there is an inflammatory focus in the anterior urethra, but it does not by any means follow that the posterior urethra is healthy, since it is frequently the more active focus of trouble. In former years gleet meant, in general terms, chronic anterior urethritis, and the treatment was based on that diagnosis. To-day we know that chronic gonorrhoea of the posterior urethra is a quite common affection, and that it may exist alone or in combination with localized anterior urethritis. Chronic gonorrhoea or urethritis, then, may be seated in some part of the pendulous urethra, particularly at the peno-scrotal junction or anterior to it, in the bulbous portion, and in the posterior urethra. A frequent combination is -posterior urethritis with inflammation of the bulbous urethra. Chronic inflammation of the urethra at the peno-scrotal junc- tion may exist alone or in combination with posterior urethritis. There are certain features of these localized forms of chronic urethritis which demand mention. In general terms it may be said that the morning drop is indicative of trouble in the pendulous urethra, the secretion of which flows toward the meatus during the night. During the day the secretion may not be CHRONIC URETHRITIS, OR GONORRHCEA. 167 noticeable, owing to the quite frequent flushing of the urethra by the urine. In some cases the lips may be glued together during the day by the scanty secretion which gravitates downward in the intervals of urination. In many of these cases of chronic anterior urethritis all discharge ceases to be seen at the meatus, and the true state of affairs can only be ascertained by the examination of the urine, or by the use of the endo- scope. If distinctly limited to the anterior urethra, the urine in the first glass will contain threads or masses of tissue-products, and that in the second glass will be clear. In all cases, however, the examination should be pushed still farther : the anterior urethra should be carefully and fully irrigated, and then the urine should be passed into one or two glasses. In the fluid which has been used in irrigation will be found the products of inflammation of the anterior urethra, and in the first glass those of the posterior urethra if it is the seat of inflammation. In the bulbous urethra the gonorrhoeal process shows a marked tend- ency to become chronic, and its persistency causes it to be very rebel- lious to treatment. In this part of the urethra the vascular supply is so great, the tissues are so succulent, and we may say relaxed, that every condition favorable to chronic inflammation is there present. Chronic urethritis of the bulbous urethra may give rise to no secretion visible at the meatus. Then, again, the pus may be so copious and fluid in consistence that it may glue up the meatus in the morning and perhaps during the day, or may escape once a day or oftener as a decided drop. Owing to the fact that the bulbous portion is in direct continuity with the membranous urethra, this portion may be the seat of hypergemia or in- flammation in bulbous urethritis. In these cases washing out the anterior urethra, and then examining the urine passed in a vessel, may not give exact information as to the seat of the lesion. In this event the parts may be examined by means of the endoscope, which should be used with great delicacy and as little backward and forward motion as possible. In this way the seat of the affection may be definitely ascertained. A chronic discharge, usually small in amount and viscid in consistence, may be developed as a result of chronic gonorrhoeal inflammation of the glands of Littre and the crypts of Morgagni. In these cases the lacuna magna and other large follicles may be the seat of inflammation. Chronic follicular urethritis is usually uncomplicated with posterior urethritis. It is found on the lips of the meatus, just within that orifice, and as far down as the bulb. Chronic inflammation of Cowper's glands has been known to cause a discharge into the urethra which Avas intermittent in character. In some cases of chronic anterior urethritis the patient suffers no inconve- nience whatever. In a few cases the patients complain of pain localized at some part of the urethra. Chronic posterior urethritis follows in many cases the subsidence of the acute process. Owing to the complexity of structure of the posterior urethra the symptomatology of this affection is often quite well marked. When there is simply uncomplicated chronic inflammation of the mucous membrane the symptoms may be negative or very slight in character. But when the prostatic sinuses, the orifices of the ejaculatory ducts, the utriculus masculinus, and the caput gallinaginis are, together or in 168 GONORBHCEA AND ITS COMPLICATIONS. part, the seat of trouble, we find a varied group of symptoms referable to the sexual sphere. In chronic urethritis distinctly limited to the posterior urethra there is usually no escape of pus into the anterior portion, for the reason that it is small in quantity and viscid in consistency. There are, however, border-line cases in the extreme terminal stage of the acute affection in which the pus is still rather copious, and it escapes through the mem- branous urethra and passes toward the glans. We have already seen that the compressor urethras muscle does not usually contract the lumen of the urethra to a hair-sized calibre, and that in general it is a mode- rately patulous canal at this point. There certainly is not, in the majority of cases, such a tonicity of the compressor urethrse muscle as will keep back a quite copious discharge.^ While in many cases, owing to its small quantity, the pus may be retained in the posterior urethra by the cut-off muscle, in some cases it certainly is not thus dammed backward. The cases of chronic posterior urethritis in which a discharge reaches the meatus are very rare, but they occur. In very many cases of posterior urethritis, there being no visible discharge and the patients complaining of no symptoms referable to the deep urethra, the affection remains dormant, latent, and unrecognized. Thus the cases may drag on for one or more, and even five, ten, and twenty, years without giving any indication of lurking trouble. In some of these cases an exacerbation occurs, and then the patient realizes that he has had an uncured gonorrhoea. In some instances the exacerbation of the posterior urethritis is sub- acute in character, attended only with mild or insignificant symptoms, and its presence would not be suspected or sought for had not an attack of epididymitis or epididymo-orchitis developed as a complication. In many cases of this deep-seated urethritis, in which epididymitis or epi- didymo-orchitis was developed in the initial attack, recrudescences in the testicular trouble are frequently developed at late and remote periods as a result of an exacerbation in the posterior urethra. In somewhat rare instances chronic posterior urethritis, usually as a result of excesses, becomes developed into a true acute attack with all its symptoms and its discomforts. It may thus run its course, but in some cases the inflammatory process extends forward into the anterior urethra, which also becomes the seat of an acute phlegmasia. In these cases, when the discharge is well established in the anterior urethra, the sufferings of the patient, experienced when the posterior segment alone was affected, cease, and the case then takes on the features of a gonorrhoea of the totality of the urethra in its declining stage. What has already been said as to the means of recognizing the exist- ence of acute posterior urethritis applies with equal force to the diagno- sis of the chronic affection. In this connection it is well to remember that small comma-like fleecy plugs or threads, which are thought to be formed in the excretory ducts of the prostatic glands and voided with the last drops of urine, being pressed out by muscular and prostatic contraction, are quite diagnostic of chronic posterior urethritis. * This is well shown in some cases of chronic prostatorrhoea in which the mucus constantly dribbles from the meatus, and of which patients make much complaint. CHRONIC URETHRITIS, OR GONORRHCEA. 169 The symptoms of chronic posterior urethritis are many and varied, mild and severe. This affection was formerly rather vaguely understood, and to it the names neuralgia of the bladder, neuralgia of the neck of the bladder, irritability of the bladder, cystite du coi, and contracture du col de la vessie have been given. In the light of modern study all these names may be dispensed with, and the term "chronic posterior urethritis" may be retained. Cases of this affection may be, for purposes of study, separated intO' groups according to the nature and severity of their symptoms. There is found in practice a goodly number of cases in which a fre- quent desire to urinate and some uneasiness at the end of the act, and sometimes at its beginning, are the only symptoms complained of. In some of these cases the increased frequency in urination is not much above normal ; in others it is well marked. In some cases the pain is slight and dull, or of a quick, stabbing, but very ephemeral character. In others it is dull, heavy, perhaps spasmodic, and radiates into the- rectum, pelvis, testes, and groins. In these cases the act of urination may go on smoothly, or it may be interrupted by slight or severe spasm of the compressor urethree muscle or of the detrusor vesicae muscles. This condition has been called " cysto-spasmus." It is liable to occur after coitus or difficult defecation. In other cases there is no disturb- ance of urination at all, but patients complain of dull or aching pain in the perineum, deep in the pelvis and prostate, and in the rectum. Sometimes these patients complain of pain over the pubis and of uneasy, vague pains in the cord and testes. In some cases mild and even severe neuralgic pains are complained of in the loins, groins, and thighs. (These painful symptoms, particularly when severe, are fortunately not continuously present.) They vary from day to day, so that the patient has intervals of comparative comfort. Perhaps the most serious and, for the physician, trying cases of posterior urethritis are those in which there is some disturbance of the sexual function. Some patients complain of a severe stabbing pain at the moment of, or after, ejaculation of the semen. Others state that all pleasurable sensations are either absent or lessened in degree in sexual intercourse, and they are thereby much worried. In still other cases- the ejaculations occur before intromission or shortly afterward. In some cases pollutions are frequent, and Avith their occurrence a diminution in the sexual appetite is felt. Many of the patients become weak, nervous, and apprehensive. Their digestion becomes poor, and they suffer from constipation. Then the passage of a hard fecal plug presses on the prostate and expels the accumulated muco-pus, which appears at the meatus, causing the patient to think he is losing semen. In some of these cases some of the secretion of the seminal vesicles is at the same expelled, and this also to many is convincing proof that they are suffering from spermatorrhoea. Occasionally these patients are much alarmed at the occurrence of bloody pollutions, which are due to great hyperaemia of the ejaculatory ducts. In any of these cases of disturbance of the sexual function Ave are liable to find more or less deterioration of the health. This may consist simply of weakness and lassitude, and it may be a condition of great nervousness, of melancholia,. 170 GONORRHOEA AND ITS COMPLICATIONS. or even of true neurasthenia. Between these two extremes there are many degrees of bodily and mental debility. The pathological appearances of chronic urethritis are quite varied, and in the main striking. " So little is shown by the ocular examination of post-mortem specimens of urethrge the seat of chronic trouble that the details will not be given, particularly as the minute pathological changes have already been described. By the use of the endoscope the morbid appearances of the urethra -are well shown. In general it may be said exploration of the urethra by the endoscope should be confined to the anterior urethra, which may thus be examined without damage and detriment to the patient. The •condition of the posterior urethra can be so well determined by the ■examination of the urine and by rectal exploration of the prostate, and in many cases by a consideration of the symptoms, that endoscopy, ■which is (except to skilled experts) a difficult procedure and often fol- lowed by local injury, should only exceptionally be resorted to. Chronic urethritis of the follicles shows itself in small deep-red pus- oozing spots of the size of a pinhead to that of a pea. The lacuna magna and similar crypts may thus show evidence of inflammation or the orifices of the follicles of Littre may be involved. The most constant morbid condition seen in chronic anterior urethritis is a rather deep-red, even purplish, color of the mucous membrane, which is more or less thickened. This redness may involve a segment of the canal or a limited portion on one or two sides of the canal. In these cases more or less pus, thin or inspissated, may be seen in the examina- tion. Thickened red circumscribed spots or plaques of chronic inflam- mation are very common. The next appearance quite commonly seen is called by some granular urethritis. The membrane is thickened, red, ■even purplish in streaks, and rough and studded with small projections, which consist either of epithelial hyperplasia or of little eminences caused by the growth of new capillary vessels. This condition is fre- quently found in the bulbous urethra and also in the pendulous portion. A further advanced form of this granular urethritis is called papillo- matous urethritis, in w^hich minute but distinctly defined raspberry-like masses of new growth are scattered over a segment of the canal. In 3ome cases there may be but one tuft of papilloma, and in others there may be many such. These little new growths are formed of round-cell infiltrations, new capillaries, and epithelial hyperplasia. They are usually found a foAV inches from the meatus and as far down as the bulbous expansion of the urethra. Since the most careful passage of a soft bougie or catheter in cases of papillomatous urethritis will often cause slight bleeding, the occurrence of this symptom may lead to a suspicion ■of its cause. Erosions and ulcerations of the urethra are frequentl}'- the cause of chronic urethritis. In the erosive form the mucous membrane is thick- ened and red, and in spots the epithelium is seen to be lost. Ulcers of the urethra are usually small and sharply limited, and the evidence of loss of tissue can be clearly made out. The erosive form and the ulcer- ative form of chronic urethritis may coexist, and may involve only a limited portion of the urethra. Then, again, we sometimes see involve- ment of a considerable segment of the canal in redness and swelling, CHRONIC URETHRITIS, OR GONORRHCEA. 171 yrhich is studded here and there Avith erosions and ulcers and granular and papillomatous growths. Now, it must be remembered that all these changes are secondary to the chronic exudative process in the submucous connective tissue, which is the primordial lesion. As a result of this morbid process the changes in the mucosa and in its vessels, glands, and epithelium result which are revealed to the eye by the microscope. The morbid appearances of the mucous membrane of the posterior urethra are not conspicuously striking. They consist of thickening, more or less papillation, together with increased redness. Frequently the caput gallinaginis and the orifices of the prostatic ducts are seen to be swollen. The underlying pathological process is precisely similar to that of the anterior urethra. In the threads which contain pus and epithelium of various kinds gonococci are rather infrequently found. In a recent essay Neisser ^ claims that the gonococcus can be found in many cases of posterior urethritis and of chronic prostatitis if the proper measures are taken to discover it. Neisser washes out the anterior urethra thoroughly with boric-acid water. Then a solution of carbolic fuchsine is throAvn into the posterior urethra, and this stains all tissue- products present there. The patient then urinates, and thus frees the posterior urethra of its tinted contents. Then the prostate is " stripped," after which the patient urinates, and with the urination the expressed contents of the prostatic follicles are carried aAvay. Another method is to Avash out the posterior urethra (presumably after urination) Avith boric- acid Avater, which the patient expels from the bladder. When this fluid comes aAvay clear, it is safe to say that all secretion seated on the mucous membrane of the prostatic urethra has been carried aAvay. Then, some boric-acid water still being in the bladder, the prostate is "stripped," and the patient then expels the contents of the bladder as well as all deep-seated inflammatory products. The question of the infectiousness of the secretion of chronic gonor- rhoea is one which frequently arises, and concerning Avhich Ave have no precise data. In order to treat the subject intelligently Ave must study the peculiarities of each case and be guided by the results obtained. It will not suflfice to merely state generalities, or to harp on the persistence of the presence of the gonococcus, or to endeavor to draAv conclusions from statistics. We knoAv by experience that in the third to the sixth month after the decline of a case of gonorrhoea in many patients a still infecting pus may be found in the urethra. In many other cases no such pus can be found a month or tAvo after the cure of gonorrhoea. It folloAvs, therefore, that there is danger of contamination of Avomen, in many cases, by men Avho Avere seemingly cured of gonorrhoea six months previously. Consequently, Ave must be on our guard when men having Avithin half a year only recovered from gonorrhoea ask our opinion as to the propriety of marriage. In such cases the urine, particularly that of the early morning, should be carefully examined. If pus-cells are still present, together Avith epithelial cells, the patient should be subjected to further treatment, even though the gonococcus cannot be discovered in the microscopic field. 1 " Zur Bedeutuns der Gonorrhoischen Prostatitis," Verhandl. der Deut. Dermatol. Gesellschafi, Wien and Leipzig, 1894, pp. 325 et seq. 172 GONOBBHCEA AND ITS COMPLICATIONS. My own experience convinces me that, in general, after the lapse of six months from the time of cure, provided there has been no recurrence, it is safe for a man to marry. It is a matter of common experience to see men who have only one or two months before recovered from gonor- rhoea have intercourse with various healthy women with absolute safety to the latter. Though we can thus speak positively concerning these cases where men do as they please, we must be guarded when we are called upon for an opinion and do our utmost to protect the innocent. There can be no doubt that many women escape infection by men recently recovered from gonorrhoea by reason of the fact that the secretion is small in amount and is washed out of the urethra in urination. I am so constantly seeing men who have chronic anterior and posterior urethritis, who have intercourse over long periods with women, wives and mistresses, without communicating gonorrhoea to them, that I am led to the belief that in very many of these cases the pus is inactive or effete. In such cases the microscope often shows a field covered with small with- ered pus-cells and large, flabby epithelial cells studded with small fat- globules. When I see these features I am generally pretty certain that the secretion is not liable to cause infection. Exacerbations of such a low grade of morbid process may, however, produce a pus competent to infect. I think it may be stated without fear of contradiction that if the vast number of cases of chronic suppuration of the urethra which are known to exist in men gave issue to infecting pus, gonorrhoea in women would be as common as it is in men. This certainly is not the case, for there are at the very least thirty cases of gonorrhoea in men to one case in women. This, is under- rather than over-stated. To sum. up, we may say, on general principles, that danger lurks in all forms of urethral pus, particularly in that which is found within six months after the supposed cure of gonorrhoea. In older cases it may be dangerous, but daily experience shows us that for some reason or other women may with impunity cohabit with men whose urethras secrete pus sparingly. In many cases personal cleanliness and the salutary effects of urination may be the undei'lying causes of this immunity. In this con- nection it is well to repeat what has already been said. Too much stress is laid by some authors upon gonococci and other microbes in chronic urethritis. In very many cases the gonococcus has produced its path- ological results and has disappeared, leaving an inflammation of the vessels and cell-infiltration behind it, which is then uninfluenced by microbes. This smouldering inflammatory patch gives forth pus which may not contain microbes ; hence it produces no bad result. This phoe- nix-like character given by many to the gonococcus is in most cases a myth. Treatment of Chronic Urethritis, Anterior and Posterior. — When gon- orrhoea, or urethritis, has lasted three months, and is then in a decidedly subacute condition, it may be called chronic. It must be clearly borne in mind that only in rather exceptional cases is the morbid process strictly limited to the anterior urethra. In very many cases the posterior urethra is involved, and with it usually the con- tiguous portion of the anterior urethra, including the bulbous segment, and even parts beyond that, may be similarly affected. In some cases the posterior urethra alone is involved. In the treatment of chronic gonorrhoea the history of the case must be CHRONIC URETHRITIS, OR GONORRHCEA. 173 carefully considered. Then it is necessary to determine the seat and extent of the morbid process and its nature and physical character. In every case the first diagnostic points should be obtained by the careful examination of the urine. At the first examination instruments for diag- nostic purposes should be guardedly used. The disease lurks, particularly in very chronic cases, in various parts and exists under diff"erent conditions, so that there are scarcely two cases which thoroughly resemble each other. The consequence, therefore, is that there is no specifically routine treatment for chronic urethritis, but each case must be treated on the basis of its morbid process and of the therapeutic indications presented by it. The duration of the urethritis has an important bearing upon its treat- ment. Let us first consider the cases in which the disease has lasted only a few months. Such patients may complain only of the morning drop, or they may state that they seem well so long as they use an injection, abstain from coitus, and do not drink beer and alcoholics or eat highly-seasoned food. When they cease injecting and indulge in creature comforts and excesses, the morning drop reappears, with perhaps a more or less profuse discharge during the whole day. Examination of the urethra in these cases shows a catarrhal and exudative condition from the bulb forward, perhaps nearly to the meatus. In many of these cases the posterior urethra is also involved. The morning urine is rather cloudy, like turbid cider, contains much mucus, and some long thin or thick threads (sometimes three or four inches long). There may or may not be a few gonococci present. In these cases the best treatment is irrigations of the posterior and anterior urethrge, using at first warm solutions of alum and sulphate of zinc after the manner of Ultzmann,^ beginning with a strength of 1 : 500, and increasing according to the result obtained. Usually one irrigation daily is sufficient, but perhaps two may be well borne. The sensations of the patient and the condition of the urine are infallible guides as to the required frequency of treatment. As a general rule, after one or two weeks' treatment these irrigations seem to lose their efiicacy, hav- ing done some good, but not having produced a cure. Perhaps in these conditions permanganate-of-potas,sa irrigations (always hot), 1 : 1000 or 1 : 2000, may bring about a cure. If this remedy fails, we resort to nitrate of silver, beginning with solutions of the strength of 1 : 16,000 or 1 : 8000, and sometimes even weaker ; and this usually brings about a cure if the treatment is carefully administered. If the morbid process is more severe in the anterior urethra, the bulbous reflux catheter (see Fig. 57) should be introduced as far as the bulb, and one or two syringefuls of the irrigating fluid should be injected. The posterior urethra should then be similarly treated. Sometimes it is necessary to finish Avith quite strong, deep injections. In these cases much pain is frequently produced by the passing of sounds, particularly of large ones. This fixct should always be borne in mind, since many patients thus treated suff"er severely, while in others the disease is so aggravated that it is most difficult to cure. Some of these cases are rendered practically incurable even if the most judicious and prolonged treatment is followed. Too much atten- tion cannot be paid to the fact that in some cases of chronic gonorrhoea sounds may be productive of incalculable harm. ' Pyuria, etc., New York, 1884, pp. 64 et seq. 174 GONOBBHCEA AND ITS COMPLICATIONS. When the disease is limited to the bulbous portion, where it shows a great tendency to remain indefinitely, the retrojections of alum, sulphate of zinc, and nitrate of silver may be used. These injections will mate- rially modify the morbid process, and sometimes cure it, but they often fail to bring about a thorough cure. In that event it is well to make direct local applications of solutions of nitrate of silver, beginning with a solution of 1 : 2000, and perhaps going as high as 2 : 500. Guyon' and his followers advocate very strong solutions of this drug, such as 1 : 30, 20, and 10. My experience has taught me that we get better results and cause less pain by using weaker solutions. For the treat- ment of chronic gonorrhoea of the bulbous urethra Guyon's syringe is a Fig. 63. Guyon's svrine:c very useful instrument. It consists of a Pravaz syringe with a screw piston to which is attached a conical cannula grooved screw-like on its external surface to ensure its retention in the expanded proximal end of the bougie a houle. The bulbs of the bougie vary in size from 10 to Author's syringe. 20 French. By turning the handle of the piston once around two drops are expelled from the syringe. It is well, before the introduction of the bougie, to turn the handle until it is filled with the liquid and all air is expelled. A less complicated and perfectly effective syringe is the one generally used by me. There is nothing whatever original about this syringe. It is simply a well-made instrument, very easily worked, having a ring and shoulders for the thumb and fingers, and a very con- ical nozzle, which will fit into any small soft catheter. The piston is marked Avith numbers to regulate the drops. The injecting medium is any well-made soft-rubber catheter, 10 to 12 or 14 French, cut ofi" to measure eight and a half inches in length. When the catheter is intro- duced six or six and a half inches, its end is in the sinus of the bulb, and the very slight impediment it encounters there shows the operator that ' "Le9ons clin. sur les Urethrites blennorrhagiques," Annales des Mai. des Org. G6n.- urin., vol. i., 1883, pp. 612 et seq. CHRONIC URETHRITIS, OR OONORRHCEA. 175 he is just at the opening in the triangular ligament. This little catheter, being slowly passed, never causes pain or irritation. Then ten or fifteen drops of the silver-nitrate solution may be thrown into the urethra. This treatment may sometimes be varied by using 1, 2, or 3 per cent, sulphate-of-copper solution, or 3 to 6 per cent, sulphate-of-thallin solu- tion. This treatment may be administered by the surgeon every five days or twice a week, and perhaps oftener if the indications of the case point to the necessity of increased frequency. In the intervals the patient may use mild stimulant and astringent injections by means of the penis-syringe. This form of chronic urethritis being very rebellious, it is sometimes necessary to pass an endoscopic tube down to the bulb, and, having ascertained the morbid appearances, to sparingly apply on cotton at the end of an applicator or j^orte remade a strong solution of silver nitrate (gr. 30 to 3J water). In the more chronic cases of anterior urethritis we find spots, patches, and areas of inflammation at the peno-scrotal angle (sometimes seem- ingly caused by the pressure of the suspensory worn during the declin- ing stage) and in the pendulous urethra as far as its beginning. The first essential in the treatment of these cases is to locate the trouble and to determine its nature. Now, in this part we find sub- epithelial infiltration with or without a greater or less epithelial hyper- plasia, erosions, and superficial ulcerations, always accompanied with submucous thickenings and follicular inflammation. The thickened mucosa may be granular, villous, or papillomatous. The urine can do little in enlightening us as to the exact nature of the morbid process unless it contains old flabby and fatty epithelial cells, which point to an old ulcer which is in too atonic a condition to heal of itself. In these cases much aid can be obtained as to location by the bougie a houle} This instrument consists of conical or acorn-shaped heads with a well- marked sharp but gently rounded shoulder, which is attached to a flex- FiG. 65. Boufjie k boule. ible gum-elastic staif. (See Fig. 65.) For the cases under considera- tion we may need these bougies a boule in size ranging from 18 to 30 French. For strictures we may use the smaller sizes, which begin as small as 8 or 10 French. ' The instruments made by the J. EUwood Lee Co. of Conshohocken, Pa., are far superior to any imported. 176 GONOBBHCEA AND ITS COMPLICATIONS. Now, it must be distinctly understood that all of the above-mentioned inflammatory conditions cause a greater or less thickening of the urethral walls, and they impinge more or less upon its calibre. There is a very prevalent tendency now-a-days to call any condition which may interfere with the easy passage of the hougie a houle forward or backward a stric- ture, and thousands of men have been cut for stricture when they had only one or more of the above-mentioned conditions. A little thickened patch of infiltrated mucous membrane, perhaps seated on one side of the canal or perhaps encircling it, will prove an obstacle to the easy-sliding forward and backward of the bulb, and the case might be mistaken for one of annular stricture of large calibre. An ulcer or erosion with its concomitant thickening will ofi"er some resistance, and the bulb on its return may jump and jerk over it. The epithelial hyperplasias which often accompany submucous infiltration jut up in the canal and more or less narrow its calibre and impair its suppleness. A swollen follicle may act in a similar manner. Papillomata will offer more or less resist- ance, but as they bleed so readily, even on gentle manipulation, their nature may be suspected. All inflammatory conditions render the ure- thra, particularly its pendulous portion, thickened and less supple, and more or less impinge on its calibre and destroy its expansibility. Bear- ing these facts in mind, it is a serious matter to decide without full, painstaking examinations that a man has stricture. Having ascertained that there is a localized chronic inflammatory spot or area, the injection of a few drops of nitrate-of-silver solution, 1 : 1000 or 1 : 500, may be made twice a week or oftener. When cases resist this treatment, it is well to resort to the endoscope in order to determine just what condition exists. Erosions, ulcerations, granulations, and urethral thickenings require circumscribed applications of solutions of nitrate of silver per- haps as strong as 2 : 500, and very rarely indeed stronger — 1 per cent. These applications should be skilfully and carefully applied, in some cases through the endoscopic tube, in others by means of Guyon's syringe or my own syringe. The patient in the intervals of treat- ment may use astringent injections with the penis-syringe. When the inflammatory condition is just external to the bulb, particularly when it is seated in the pendulous urethra in cases where there is not much hypersemia, much benefit can be derived from the introduction of the Fig. 66. __--=-^ — --r-iiiililll FORD "II "llllllllllllli" Conical straight sound. straight steel sound and the gentle pressure or massage of the urethral canal for a few minutes. Care must be taken that no violence be done. In some cases this procedure aids the nitrate-of-silver injections in the absorption, of the effused cells. Inflammation of the urethral follicles, particularly when several inches down, is a condition which resists treatment and is difficult to handle. The parts must be exposed by means of the endoscope, and touched with a strong nitrate-of-silver solution on cotton at the end of a very fine silver probe, which, if possible, should be gently pushed into the duct. Some CHRONIC URETHRITIS, OR GONORRHCEA. Ill authors recommend the destruction of the follicle by means of a very minute galvano-cautery needle. Great care and circumspection should be used when this rather heroic procedure is resorted to. After any of these applications it is well to inject the urethra with lead-Avater twice a day. Follicular sinuses in the fossa navicularis and just within the lips of the meatus may, after thorough irrigation, be injected with a few drops Fig. 67. ,I,EMAN,N Ultzmann's deep urethral syringe. of silver-nitrate solution (2 : 500) by means of the hypodermic syringe, the needle of which is made blunt by the removal of its point. In several cases of juxta- and intra-urethral sinuses I have produced a cure by ap- plying on a small silver probe a coating of nitrate of silver obtained by melting the drug with heat. A few grains of the silver salt are placed in Fig. 68. Ultzmann-Keyes syringe. a small platinum crucible, Avhich is exposed to an alcohol flame until liquefaction occurs ; then the probe is dipped into the crucible and is thus charged. In the treatment of posterior urethritis with or without anterior ure- thritis great care is required to determine as nearly as possible the exact condition of affairs. In the more recent cases we sometimes find some evidence of bladder incompetence (the urine showing no involvement of that viscus), which shows itself by the escape of a little (gij to 5ss or more) residual urine when the eye of the catheter reaches the neck of the blad- der. In these rather early cases mild irrigations of the astringents and of permanganate of potassa may be used, and perhaps with benefit. The most uniformly effective agent here also is the nitrate of silver, Avhich may at first be used well diluted, 1 : 16,000 or 1 : 8000, in the form of hot irrigations. These may result in cure, but if the result is not perfect in- jections of the same drug may be used. For injecting the posterior urethra the Guyon syringe, to my mind, is objectional)le, for the reason that its bulbs, particularly when the larger ones are employed, cause more or less spasm of the compressor urethrte muscle, and as a result an uneasy and even painful sensation is left after its withdrawal. The Ultzmann syringe and the Keyes modification, in which the syringe is soldered to the cannula, and to it two wings or holders for the fingers are added, unless used with the greatest care often cause patients dis- 12 178 GONORRHCEA AND ITS COMPLICATIONS. comfort and even pain. By them minute quantities of fluid may be thrown into the posterior urethra with much accuracy. The introduction of these instruments often provokes vigorous spasm of the compressor urethras muscle. In my opinion the use of these instruments should be confined to the purposes for which they were originally intended by Ultzmann — namely, to apply a few drops of very strong silver-nitrate solution to the posterior urethra and verumontanum in case of sexual disability, in pros- tatorrhoea, and in spermatorrhoea. They certainly are not instruments to be used by unskilled hands or by persons who use them very infrequently. My preference is decidedly in favor of the simple little syringe with the small-calibre, soft-rubber catheter already described. When it is neces- sary to inject the posterior urethra, using the small catheter cut off at eight and a half inches, this tube should be introduced about seven or seven and a half inches, when, in the majority of cases, the eye of the instrument will be just at the beginning of the prostatic urethra. In men with very long urethrse a catheter thus introduced might only reach the membranous urethra, and then pressure on the piston would not be fol- lowed by the expulsion of any fluid, owing to the compression exerted on the catheter. In this event it is only necessary to push the catheter a little farther onward, into the prostatic urethra, where no obstacle will be encountered. By this syringe we can inject ten or twenty drops of a silver-nitrate solution, beginning in the more recent cases with 1 : 2000 or 1 : 1000, making an injection once a day, every second day, or at longer intervals, according to the result produced and the patient's sensations. It will rarely be necessary to use stronger solutions than 1 : or 2 : 500. As these cases progress gradual dilatation may afibrd aid, provided great care and caution are used. If this little operation causes pain, and if the urine shows more pus- or tissue-elements than it did before, it is well to desist and keep on with the injections. For older and very chronic cases of posterior urethritis the stronger silver-nitrate injections, 1 : 500 or 250, may be used. In my expe- rience, fifteen drops or more of these solutions produce better effects than a more sparing injection of stronger solutions. These injections should be given every third or fourth day. They may, however, pro- duce benefit in some cases if made more frequently. Daily injections are liable to cause acute suppuration, which means irritation, and that must be avoided. Posterior urethritis, accompanied by sexual disability, premature ejaculations, pollutions, and absence of erections and loss of sexual desire, usually requires the injection of a few drops of the stronger solutions just mentioned. In these cases especially it is well to care- fully examine the prostate per rectum. This organ is frequently found rather swollen both laterally and toward the rectum, and the finger-tip may produce an uncomfortable sensation and even pain. In many of these cases gentle repeated pressure with the finger-tip on the organ causes a thick, viscid, grayish secretion to escape from the meatus, and as a result of three or four such treatments patients frequently are benefited. In these cases the disease has invaded the prostatic follicles, and within them is stagnated muco-pus which keeps up the irritation. Besides these local measures, patients thus afflicted need fresh air, relaxation, good hygienic conditions, and attention should be paid to CHRONIC URETHRITIS, OR GONORRHOEA. 179 their sexual hygiene. In some of these cases, where there is much hyperesthesia of the posterior urethra, accompanied by erotic symptoms, much benefit may be produced by the introduction of steel sounds pre- viously chilled with ice. This procedure should be cautiously carried out and its effects carefully watched. It should not be very frequently adopted, and at the most two seances a week should be given, and on these days the deep injection should be omitted. If good is going to follow, the patient will at once speak of his improvement. Should it produce a dull pain or an uneasy sensation, its use is contraindicated. It is always well not to use very large sounds ; those having a calibre of 20 or 22 French are the best. Some surgeons may desire to try other measures and methods of treatment for chronic urethritis, in which event I would refer them to the various views and exploitations, as well as instruments and methods, detailed in the chapter on the treatment of acute urethritis. They cer- tainly will find food for serious thought there, and perhaps suggestions which may be of practical benefit in a deterrent direction. The Use of the Endoscope. — In the treatment of chronic urethritis the endoscope is useful under certain sharply-drawn restrictions. As a means of localizing an inflammatory focus, of viewing surface appear- ances, and of allowing the use of topical applications under free ocular inspection it is often of signal benefit. It is an instrument of reserve rather than of routine, and it always should be used in a rational and conservative manner. It is to be regretted that it has been used very much as a toy, and has been to some simply a surgical hobby. There are those who have been so unkind as to say that some surgeons osten- tatiously display and use it as a means of impressing patients with their skill and science. Patients, however, as a rule, are only profoundly impressed when science and skill give them relief, and they are corre- spondingly disappointed, and even indignant, when they have been submitted to discomforting and elaborate manipulations which have done them no good and perhaps some harm. As a general rule, it may be said that when in the treatment of chronic anterior urethritis the case resists the usual methods properly applied, then it is well to use the endoscope to determine the exact seat and nature of the lesion. It is well to sound a note of warning as to the inspection of the posterior urethra. It is safe to say that many persons who cajole themselves with the idea that they have inspected this region have greatly deceived themselves. It is often very difficult to efface the subpubic curve with the endoscope tube, and often much damage is done in the attempt or in its accomplishment. A skilled expert only should make endoscopic examinations of the posterior urethra. The precipitate use of the endoscope at the first examination of a case, before the other and less radical methods of examination have been tried, is to be very much condemned. The efficient use of this instrument requires much time, study, and observation. The aim of the surgeon should always be to use such deli- cate care and circumspection that the operation is made as little trouble- some and painful to the patient as possible. At the present time the tendency is to use only the large and complicated instruments, and we see little, if any, mention of the simple endoscopic tubes. These simple 180 GONOBBHCEA AND ITS COMPLICATIONS. tubes can be very readily introduced, and a good view of the urethra as far as the bulb may be obtained by their means, supplemented by the sun's rays or the electric light thrown down their lumen by means of a hand or a forehead mirror. I strongly advise any one beginning the study of endoscopy to employ the Weir meatoscope or the F. N. Otis endoscopic tube. The first instrument will give a clear view of the whole fossa navicularis, Avhile Otis's tube will show fully six inches of the canal. By means of endoscopic tubes longer than those of Otis the Weir's meatoscope. urethra as far down as the beginning of the membranous portion can be inspected. Weir's instrument (Fig. 69) is made of hard rubber, and by otis's endoscopic tube. it fully two inches of the canal can be inspected. (Fig. 70) is of similar structure. Otis's instrument Urethral speculum. Endoscopic tubes being solid, and not fenestrated, only admit of inspection of the urethra at their distal ends. For examination of the CHRONIC URETHRITIS, OR GONORRHCEA. 181 fossa navicularis (for follicular abscesses and sinuses, suspected incipient gonorrhoea, chancroids, and exceptionally for hard chancres) the little speculum designed by me (Fig. 71) Avill often give material aid. For a close inspection of the urethral walls for about six inches the speculum of F. T. Brown (Fig. 72) may be satisfactorily employed. Care must Brown's wire urethral speculum. "be exercised in using these two-bladed specula that harm is not done. It is always well to first examine and familiarize one's self with the ap- pearances of the normal urethra, since by this course the study of abnor- mal conditions is rendered much easier and clearer. It would be a waste of space to give a description of the various endoscopes which have been invented. The Mathieu endoscope (Fig. 73), a very excellent one, will give a clear view of the canal, but will Fig. 73. Mathieu' s endoscope. not permit of synchronous examination and topical applications. By its use, however, one may obtain much knowledge of the morbid appear- ances of the urethra. The simplest of the elaborate instruments, both as to construction and use, is the perfected endoscope of W. K. Otis. By its means not 182 GONOBBHCEA AND ITS COMPLICATIONS. only is the canal rendered perfectly visible, but under the eye direct topical applications may be made. Since the inventor can always describe his own instrument more clearly than another man, I quote Dr. Otis's words : " This instrument consists of a metal tube or cyl- inder an inch and a quarter in length by half an inch in diameter, Fig. 74. W. K. Otis's "perfected" urethroscope. closed at one end. A quarter of an inch from the open end of this tube is a plano-convex lens, so arranged that it may be easily removed for cleaning. On the inferior surface, near the closed end of the tube, an elbow is let in, a quarter of an inch in length and half an inch in diameter, through which the source of illumination (a small incandescent electric lamp) is introduced, a row of holes being bored at its base to allow of ventilation. The handle of the instrument consists of a piece of hard rubber an inch long by half an inch wide, the electrical con- nections running through it to the lamp, which is placed on top. This handle fits into the elbow by means of a bayonet joint, bringing the lamp immediately behind the plane side of the lens. A thumb-screw ' switch ' in the handle places the lamp under control, so that it may be turned on or off at pleasure. " The instrument is attached to the urethroscopic tube by means of a stout wire an inch and a half in length, with hinged joints at each end, which swing in opposite directions and are furnished with set screws, thus allowing the instrument to be put in any position, though when once adjusted it will rarely be necessary to move it. If the ordinary form of tube is used, the distal end is provided with a simple ring sliding joint ; but .... I greatly favor the use of the tube of Dr. Klotz. I have arranged the instrument for this form of tube. " When the instrument is in position and the lamp illuminated, a strong beam of light is thrown down the urethroscopic tube, and the urethral mucous membrane is more easily and clearly observed than with any other form of urethroscope with Avhich I am familiar. " The advantages of this instrument are — " 1. The exclusion of all extraneous light, the presence of which is a most annoying fault both in the urethroscope of Leiter and in my own improvement on it. CHRONIC URETHRITIS, OR GONORRHCEA. 183 "2. A very much more ready access to the urethral field, both to the eye and for instrumental applications. " 3. Increased illumination. " 4. By abandoning the funnel and sliding joint an inch and a half in distance is gained from the source of illumination to the distal end of the urethroscopic tube, increasing the illumination and alloAving the eye to be placed just so much nearer the mucous membrane to be examined. " 5. Its extreme compactness and lightness, -weighing less than one ounce, even when constructed of brass. " 6. Its great simplicity, which should ensure a moderate cost."^ A six-cell electric-light battery answers all purposes. We have already considered the features offered by urethrae (see page 170) the seat of a chronic gonorrhoeal process, and therefore need but to allude to them now. In some cases the discharge depends on a simple red spot of inflammation with infiltration, Avhich may be limited or quite spread out. A velvety or granular condition is not uncommonly seen, while spots of follicular inflammation are not uncommon. Erosions and superficial ulcerations are commonly encountered, and with the latter lesions there is frequently a hyperplasia of the epithelial strata. Papil- lomatous urethritis Avill be encountered in various degrees of develop- ment. Sometimes the little new growths of vessels, connective tissue, and epithelium are of the size of millet-seeds, and they may reach the dignity of true vegetations. Dr. Briggs" has described and figured some of these lesions taken from an illustrative case, and has given a drawing of their microscopic structure. Polypoid growths are some- what rarely encountered, even of such a size as to materially obstruct the lumen of the urethral canal. Dr. H. Goldenberg^ has written instructively upon some personal cases in which these growths were found. He also depicts their histological structure. The applications suitable for endoscopic treatment are, in the main, solutions of nitrate of silver, 5 : 10 to 100 of water. These should be applied by means of swab-holders or applicators carrying a tuft of absorbent cotton moistened in the medicated fluid. Strong solutions of sulphate of copper, 5 : 20—100, may be used, and in some cases such severe remedies as solution of perchloride of iron, liquor hydrargyri per- nitratis, or Lugol's solution, may, of necessity, be resorted to. These latter solutions should always be applied sparingly and only on the morbid surfaces. Papillomatous urethritis may require operative meas- ures if the little growths cannot be scooped off" with the end of the endo- scopic tube. They, with polypoid growths, may sometimes be removed by tampon ecrasement, which means the introduction of a plug of cot- ton on the end of an applicator, which is pushed forward and backward and rotated from side to side until the growth is detached. After this a strong nitrate-of-silver application should be made. In some cases the urethral-polypus forceps may be employed.* 1 N. Y. Med. Journal, Dec. 17, 1892. "^ Boston Med. and Sure/. Journal, Oct. 24, 1889, pp. 403 et seq. ^ N. Y.Med. Journal, May 9, 1891 (with bibliography), and Med. Record, Nov. 4, 1891. * The reader is further referred to the elaborate works of Oberliinder, Lehrbuch der Urethroscopie, Leipzig, 1893 ; of Griinfeld, Die Endonkopie der Harnrohre und Blase, Stutt- gart, 1887; of Berkeley Hill, On Chronic Urethritis, London, 1890; of Horteloup, Legons 184 GONORBHCEA AND ITS COMPLICATIONS. CHAPTER XIY. URETHRO-CYSTITIS AND CYSTITIS. Until within the past few years posterior urethritis, acute and chronic, was described as cystitis, which was said to be a frequent complication of gonorrhoea. To-day we have very clear ideas as to the nature and course of posterior urethritis, acute and chronic (see sections on these subjects), and we know positively that in very many cases of these troubles there is no involvement of the bladder whatever, the phleg- masia being quite sharply united to the membranous and prostatic urethra. The inflammatory process, however, may invade the bladder in part or in totality. In the majority of cases only that portion of the bladder near the internal sphincter, particularly on its sides and also at the base or trigone, is attacked. This limited bladder-inflammation, together with the posterior urethritis, constitutes what Finger very properly calls ^' urethro-cystitis." This limited process, however, may extend, and in time involve the whole bladder, in which event there is a true cystitis resulting from gonorrhoeal inflammation. The pathology of gonorrhoeal cystitis is not yet clearly demonstrated. In acute cases of posterior urethritis the pus quite commonly contains the gonococcus, but as the process grows old this microbe disappears and other forms of cocci seem to take its place. This same condition is observed in the pus of urethro-cystitis and of cystitis, in the secretions of which it is impossible to find the gonococcus, except very rarely in very small numbers, but which show very plainly myriads of cocci and bacteria. Much study is necessary to clear up this interesting subject. The theory of a mixed infection being the cause of this trouble sug- gests itself, but it cannot, as yet, be strongly urged. Urethro-cystitis may be acute or chronic. When the inflammation is still acute, and that portion of the bladder near its neck becomes swollen and red and secretes pus, the symptoms are those of acute posterior urethritis. (See section on that subject.) These are mostly tenesmus, pain at the end of micturition, and perhaps hsematuria. Ex- amination of the urine shows opacity in the two cylinders, but instead of the second specimen being less cloudy than the first, as is the case in posterior urethritis, it is as cloudy, and even may be more cloudy, than the first. In some cases, but not in all, if the patient urinates into three glasses, the urine in the first, which clears out the posterior urethra, will be very cloudy, the second specimen less so, while the con- tents of the third glass, which come directly from the inflamed viscus in a state of tonic contraction, will be very cloudy, OAving to the forcible extrusion of pus from the texture of the mucous membrane. If hemor- sur V Urethrite ckronique, Paris, 1892 ; and to articles by Klotz, .V. Y. Med. Journal, Nov. 27, 1886, and January 28, 1895, and to the monograph of Burckhardt, Beitr. zur Uin. Chir., Tubingen, 1889-90, vol. i. pp. 261 et seq. VRETHRO-CYSTITIS AND CYSTITIS. 185 rhage is small, only the third portion will contain blood, but if it is copious, all three specimens will contain it. The urine is usually of acid reaction, and presents a milky or kero- sene-oil-like appearance, according as the morbid process is mild and superficial or severe and deep-seated. Whenever the tenesmus is great, albumin may be present. Alkalinity of the urine may be caused by heematuria. When allowed to stand, as a rule the tissue-products do not settle promptly ; hence fully twenty-four hours may elapse before the pus, epithelium, and mucus have settled to the bottom of the cylin- der. Then we see a grayish granular and quite thick layer, in which are pus-cells and bladder-epithelium ; if hsematuria exists, there is a red layer of blood over this, and floating, cloud-like, over all is the readily movable mucous layer. Microscopical examination of the urine of urethro-cystitis shows a conglomeration of tissue-products. The various forms of epithelial cells derived from the posterior urethra Avill be found inextricably mixed with the large flat bladder-epithelium. These, with pus-cells, mucous corpuscles (perhaps a few gonococci), many and varied cocci and bac- teria, and blood-corpuscles cover the whole field. When decomposition of the urine has occurred, it emits a foul odor, and contains, besides the foregoing elements, triple phosphates and myriads of bacteria. Cystoscopic examination in cases of acute urethro-cystitis shows a redness and swelling of the prostatic urethra and a thickened and quite uniformly deep-red, velvety appearance of the portion of the bladder- walls involved. The vessels sometimes show very distinctly an arbor- escent interlacing which is well marked. Besides the prompt and acute invasion of the lower part of the blad- der from the posterior urethra which has just been considered, there is a subacute and chronic form which is equally as common. Subacute urethro-cystitis may develop as a result of an exacerbation of chronic posterior urethritis. When this occurs, it is usually as a result of sexual and alcoholic excesses, great physical strain, particularly in horseback riding, wrestling, and bicycling. Exposure to cold in the various ways incident to daily life is also productive of this extension. In some cases long delay in urination, and in others the introduction of catheters or sounds, have caused the phlegmasia to spread from its urethral seat to the bladder-walls. In these cases of chronic urethro-cystitis the symptoms are similar, but less pronounced than in the acute form. As the chronicity of the case increases, the tenesmus, and other symptoms may grow much less and in some chronic cases cease to exist. In some cases of first attack, as well as in relapses later in the declining stage, patients complain of a dull and uneasy sensation long after urination, and they speak of a feeling as if the bladder yet contained urine. The catheter being passed, half an ounce to an ounce, or even more, of urine flows out. In these cases, owing to the swelling in the mucous mem- brane and its subjacent connective tissue, the bladder is unable to expel all the urine. This uneasy sensation is in marked contrast with the sharp, sometimes radiating, pains felt at the end of urination. It is a symptom of residual urine. As a result of the chronic inflammation, in some rare cases around and near the bladder-neck, a villous condition of 186 GONORRHCEA AND ITS COMPLICATIONS. the mucous membrane, as shown by a quite thickened and velvety ap- pearance, is produced, which gives rise to hsematuria, particularly at the end of urination. In some of these cases the existence of a bladder- tumor might very properly be suspected. Acute cystitis — meaning inflammation of the whole of the mucous membrane of the bladder — is a very rare complication of gonorrhoea, since acute posterior urethritis, even when it invades the bladder, usually only involves an inch or two, or perhaps more, of tissue near the inter- nal sphincter. Very exceptionally the phlegmasia extends and involves the totality of the mucous membrane. In these cases the symptoms are still those of acute posterior urethritis, besides which there may be pain over the symphysis pubis, malaise, and fever. The urine is very opaque and contains bladder-epithelium, pus, and bacteria. When the urine is tested in these cases, the second and third speci- mens are even cloudier than the first. In the early stages the urine is acid and has no foul smell ; later it may be alkaline and offensive. This form of cystitis may end in one or two months, but there is a marked tendency in these cases for the process to become subacute and chronic. Chronic gonorrhoeal cystitis is a very persistent affection, and often resists the most intelligent treatment directed against it. Usually, with the involvement of the whole bladder, the symptoms of posterior urethritis cease, except perhaps that a little increased frequency of uri- nation remains. In the older cases we frequently hear patients com- plain of a burning or scalding pain on urination, with uneasiness some- times amounting to a paroxysm of pain at the end of the act. Urina- tion may be quite or very frequent both during the day and the night. With the continuance of the cystitis, the morbid process, which at first was superficial, involves the deeper parts of the mucous membrane, and forms what is called "parenchymatous cystitis." Progressing farther, ulceration of the bladder may result or the morbid process may extend up the ureters and involve the kidney and its pelvis. In cases of chronic parenchymatous cystitis the urine is usually alkaline, and has a very foul, even feculent, smell. The diagnosis of gonorrhoeal cystitis is to be made by a study of the history of the case and of its symptoms, together with examination of the urine. The history and symptoms have already been fully given. The urine varies according to the severity and chronicity of the cystitis. It may be simply purulent urine of acid reaction or alkaline and fetid. The three-glass test will show cloudiness in each specimen, more par- ticularly in the last. In this connection it is important to remember that alkaline urine from phosphates, carbonates, and urates very com- monly has the cloudy look of purulent urine, but its nature is soon revealed by the simple method recommended by Ultzmann. If the cloudiness is due to urates or uric acid, it vanishes by the use of heat. If it is due to phosphates, carbonates, or pus, heat increases the turbid- ity, but a few drops of acetic acid will clear up phosphaturia and carbo- nuria (the latter with much effervescence), while, if the opacity then remains, it is caused by pus or bacteria. In all cases the microscope should be constantly used in the exami- nation of the urine, and the following features will generally be found reliable guides in diagnosis: If the cystitis is still rather young and the URETHRO-CYSTITIS AND CYSTITIS. 187 urine is still acid, on its examination various forms of urethral epithe- lium, bladder-epithelium, and pus will be discovered. This combination, the history being in accord, will usually warrant a diagnosis of urethro- cystitis, partial or general. When the process is old and the urine alkaline, and, as it then usually is, of foul smell, withered-up pus-cells, bladder-epithelium, and triple phosphate will dominate the field and establish the diagnosis. The absence of casts and renal epithelium will show that the morbid process is still confined to the bladder. Treatment. — In acute urethro-cystitis and cystitis the patient should at once assume the recumbent position. A plain, bland diet of bread and milk, and rice and Indian meal with milk, should be ordered. The bowels should at once be acted upon and kept mildly relaxed. Pain may be relieved by suppositories or by opium by the mouth or morphine by hypodermic injection. If there is much suprapubic pain, an ice-bag may be applied and kept on if it affords comfort. In some cases a hot- water bag or hot flaxseed poultice will be indicated. Hot sitz-baths and full hot baths may give comfort. In the very acute stage all treatment by injections should be stopped. The older practitioners placed much reliance upon flaxseed and slip- pery-elm tea, taken quite hot and copiously. They are certainly very acceptable to many patients, particularly if sweetened a little and flavored with a little lemon- or orange-peel. They undoubtedly act in a beneficial manner in diluting the urine. Infusions of buchu and of uva-ursi some- times seem beneficial. The fluid extract of triticum repens and of kava- kava also may be used, either alone or in combination. Thirty drops of each in plenty of water, with two or three drops of laudanum when the pain is severe, may be given every three or four hours. When opium in any form is administered, the condition of the bowels must be carefully looked after and constipation avoided, either by the use of enemata or of aperients or cathartics. In some cases alkalies produce a soothing effect. Bicarbonate of potassa and citrate of potassa in thirty-grain doses, dissolved in water or carbonic water, may be given three times a day. With the decline of the acute and the onset of the subacute or chronic stage the use of antiblennorrhagics, cubebs, copaiba, and oil of santal, may be of signal service in some cases, whereas in others they may cause actual discom- fort. Their effect, then, should be carefully watched, and if they give decided relief they may be continued; if not, discarded. Injections into the bladder of warm solutions of boracic acid and of Thiersch's mild solution may give comfort to the patient. In the subacute and chronic stages the most reliance is to be placed on the action of solutions of nitrate of silver, used at first very w'eak and increased as the treatment is continued. In many cases much benefit follows the injection into the posterior urethra of a hand-sjn'inge- ful of a warm solution of nitrate of silver (1 : 16,000, and as strong as 1:4000). This agent irrigates the posterior urethra and passes into the bladder, the lower part of which it acts favorably upon. It may be retained for half an hour, and then voided, and as it passes out it again favorably affects the morbid surfaces. Such an irrigation may be made daily, but the sensations of the patient must be the guide in deciding its frequency. As the case progresses the strength of the solution 188 QONOBEHCEA ASD ITS COMPLICATIONS. should be cautiously increased, until toward the last instillations of a stronger solution of nitrate of silver (see Treatment of Posterior Urethritis) are resorted to. Solutions of permanganate of potassa (gr. j to warm water gvj to 5viij) also produce good results in some cases. Resorcin (gr. xlv-lxxv to water ^iij) may also be injected into the bladder, as recommended by Finger. Chronic cystitis from gonorrhoea is usually found in young and middle-aged patients. Cystitis from stricture and hypertrophy of the prostate is usually found in more advanced subjects. The diagnosis beino; made, and the absence of stricture being deter- mined, general and local treatment should be instituted. The diet must be regulated and be confined to bland, easily-digestible articles. Coffee, spices, beer, alcoholics, are to be interdicted. As much bodily quiet and ease as possible should be observed. In these cases care must be exercised in the use of alkalies, which some physicians seem by instinct to prescribe indiscriminately. The tendency is toward alkalinity of the urine, therefore we should be on our guard. When the urine is alkaline, dilute nitric acid, dilute nitro-muriatic acid, and dilute muriatic acid may produce decided benefit. Salol, sa- licylate of sodium, benzoic acid, and salicine may be of benefit in tend- ing to restore an aseptic condition of the bladder, Avhich is the chief aim of treatment. Warm injections of boric-acid-water, of Thiersch's mild solution, and of borax and water, to all of which a little laudanum may be added, may be of benefit for a time. Then the indications are for the use of more decidedly active injections, such as nitrate of silver, permanganate of potassa, and in some cases of alum and sulphate of zinc in combina- tion. The strength of these solutions should be adapted to the case, and their action should be carefully watched. In some cases benefit follows the injection of solutions of bichloride of mercury. It is well to begin with the strength of 1 part to 30,000, and increase if progress is made, or desist if a feeling of discomfort is produced. These cases are frequently very trying to the patient and to the surgeon, whose therapeutic armamentarium they sorely tax. As a last resort, perineal section should be performed and the blad- der washed out and drained. Boric solutions and Thiersch's solution may then efi"ect a cure, but it may be necessary to resort to nitrate of silver, permanganate of potassa, or bichloride of mercury. MEMBRANOUS DESQUAMATIVE URETHRITIS 189 CHAPTER XV. MEMBRANOUS DESQUAMATIVE URETHRITIS. Under the foregoing title a number of cases have been described in which patients have passed membranous flakes or cylinders or casts from their urethrse. In the cases thus far reported we find a marked variation in the character of the membranes and in the subjective and objective symptoms of the patient passing them. Griinfeld^ by means of the endoscope found that in the anterior and posterior urethra the walls were covered with grayish-white strips of membrane parallel with the long axis of the canal. He sometimes found casts of the urethra, but only in the anterior portion. The cases examined Avere those of acute gonorrhoea. In like manner Rdna^ saw in two cases of acute gonorrhoea some whitish layers of tough membrane, which under the microscope showed the elements of croupous membrane. In these cases the fossa navicularis alone was involved. These cases, therefore, are illustrative of croupous inflammation oc- curring in acute gonorrhoea, and limited to the fossa navicularis and to the anterior and posterior urethra. In all acute gonorrhoeas there is more or less croupous exudation, which passes out as detritus in the pus. Zeissl^ reports a case in which flakes and cylinders one and a half inches long were passed from the urethra of a patient who suffered from violent pain in the perineum. The author considered the case to be one of croupous inflammation in a chronic catarrhal process caused probably by strong injections. Oberlander describes an inflammation of the urethra in Avhich small layers of a croupous membrane are found. The affection is subacute in character and unattended with pain. These flakes may be thrown off for many months. They gradually grow thinner in structure, and finally disappear. Oberlander thinks that this urethral inflammation is similar to that seen in the mouth and called "leukoplakia buccalis." Zeissl's and Oberlander's observations go to show that there is a chronic form of desquamative croupous urethritis. Two very interesting cases have been reported by Pajor,* in which patients suffering from chronic gonorrhoea and certain peculiar nervous phenomena passed true epithelial tubes and flakes from the urethra. The first case was that of a soldier who had gonorrhoea at nineteen, which was followed by orchitis, pollutions, and cystitis. Nine years later he suffered from neurasthenia sexualis, pollutions, burning in the perineum, and itching in the anus, anaesthesia of the right half of the penis, and trembling of the muscles of the neck and extremities, and general prostration. Endoscopic examination showed that the mucous membrane was hard and rough from the prostatic urethra to the fossa ^ Die Endoscopie der Harnrbhre und Blase, 1881, p. 120. '^ " Adatok a buja-sborhetegs," Orvosi fietilap., ] 884. ^ Zeitschrift der Gem'lhchafl der Aerzte, Wien, 1852, i., quoted by Pajor. * " Urethritis meinbranacea Desquamativa," Archiv fur Derm, and Syph., 1889, pp. 3 et seq. 190 GONOBRHCEA AND ITS COMPLICATIONS. navicularis, so the surface was touched Avith a 1 per cent, tincture of iodine. Two such applications seemed to give the patient relief. He then passed a fine milk-white membranous tube about four inches long, resembling the delicate inner membrane of an egg. Fine folds or creases ran both longitudinally and laterally in this membrane, and gave it the appearance of a snake's skin. This patient passed other shreds, but was soon cured by the local treatment both of his urethral trouble and of the various other morbid phenomena mentioned. In the second case the man had suifered for ten years Avith chronic gonorrhoea, and he entered the hospital complaining of frequent stran- gury, pain in the urethra running to the groins, and a profuse grayish- white discharge. The endoscope showed that the mucous membrane of the urethra, from the membranous division to the middle of the pendu- lous portion, was of a whitish color. Applications were made of tincture of iodine, nitrate of silver, and lead-water. A few days later the patient passed a similar membrane to that of the preceding case. This was repeated three times ; then the strangury and discharge ceased, and the patient was reported as improved. Histological examination of these membranes showed that they were composed of stratified pavement epi- thelium with large nuclei, round-cells, and wandering cells. The points of interest to be emphasized in these cases of Pajor are the peculiar symptoms and the formation of true epithelial cylinders. In these cases the morbid process involved both the anterior and poste- rior urethra at the same time. In the cases of Grrunfeld, Rona, Zeissl, and Oberlander the urethra was involved more or less in its continuity and in regions and spots. Though a fcAV cases will not warrant sharply-drawn conclusions, these seem to point to the conclusion that there is a croupous urethritis and a Avell-defined epithelial desquamative urethritis, the one being acute, the other chronic. CHAPTEE XVI. EXTERNAL URETHRITIS, PREPUTIAL FOLLICULITIS, JUXTA- URETHRAL SINUSES, AND FOLLICULAR ABSCESSES DUE TO GONORRHOEA. Under the title " external urethritis " we understand several varieties of chronic inflammation which have their origin in gonorrhoea, are seated in the follicles and crypts of the external surfaces of the penis, and are of a very chronic and relapsing character. Inflammation of the Preputial Follicles. During the course of acute gonorrhoea or following such an attack we sometimes see running in the long axis of the penis, between the EXTERNAL URETHRITIS, ETC. 191 two layers of the prepuce, a little line of inflammatory tissue, the end of which is usually on the free border of the prepuce or just within its mucous layer. Careful inspection will usually show that this little line ends in a minute opening of the size of a pin's head or of a pinhole, but sometimes it may not be visible except by the use of a magnifying glass. Pressure on this little blind canal usually causes a small droplet of greenish or grayish pus to exude from it. This sinus-like lesion may be only about half an inch long, and it Avill rarely be seen longer than an inch. The calibre of these lesions varies, since in some only a horsehair can be introduced, while in others a very thin probe passes by means of gentle manipulation. Sometimes these little tubes, which are really long abscesses, are of a deep even a dull red, but as they grow older they lose their color wholly or in part, and are then recog- nized by touch as small firm cords between the skin and mucous mem- brane. They may thus remain months, and even years, when untreated. At times they give issue to no discharge ; then, again, particularly after sexual excess, they become red and a little painful, and pus may be expressed from them. These little sinus-abscesses are usually seen on the sides of the prepuce, sometimes down toward the frsenum, and again on the median line corresponding to the dorsum of the penis. This may be said to be the first form of gonorrhoeal preputial follicu- litis. There is, however, a second form, in all probability an intensifi- cation of the first form, in which we find a little cherry-stone-sized nodule or abscess-cavity situated between the two layers of the prepuce in about the same position as that of the first form. In some cases I have seen these little round or oval abscess-cavities have a well-marked outlet duct. In other instances the opening leads almost at once to the abscess-cavity. This lesion usually runs a chronic and uneventful course, but in some cases there are remissions and exacerbations of inflammation in greater or less degree. In many cases at their onset these little tumors are the seat of pain, heat, and swelling of the contiguous tissues. This prodro- mal inflammation usually subsides in a few days or in a week or two, and the afi"ection then passes into the chronic condition above described. In short, it may be stated that in all forms of follicular inflammation about the penis the course of the disease may resemble gonorrhoea in its acute development, merging into subacute and chronic conditions. Usually there is but one follicular abscess; very rarely two are found. During the exacerbations of these chronic sinuses and abscess-cavities there is danger of auto-infection of the urethra. They may at these times also be the source of infection of women. It is therefore a follicular abscess, which may be of conical shape or its surface may be flattened. These lesions are peculiar in the fact that they are localized and circumscribed abscesses, and are not usually attended with the diffiise spreading of the process into the connective tissue which we find in periurethral abscesses. There is still a third form of preputial abscess. During an attack of gonorrhoea a small red spot is sometimes seen on either side of the frse- num in the foss?e formed by its prominence and the folding over of the mucous layer of the prepuce where it covers the glans. This little red nodular spot soon becomes enlarged and elevated, of the size of a pea or larger, and at its apex a minute opening may be seen. An abscess of 192 QONOBBHCEA AND ITS COMPLICATIONS. this kind may burst and heal up, or after the pus has been discharged and the inflammation has subsided it may be again infected by the urethral discharge, and again be the seat of abscess. This process may be repeated several times. Besides this nodular lesion of the frsenum Fig. 75. Follicular abscess of the prepuce near the frsenum, due to gonorrhoea. there is sometimes present there a tube-like or sinus-like lesion, such as is found in the prepuce. This blind sinus is affected, as the other lesions are, by varying degrees of suppuration. In some cases, after the evacuation of the pus, usually by pressure or perhaps by a slight incision, the morbid process ceases and the part again becomes healthy. In other cases, however, the abscess is very persistent and rebellious to treatment. It seemingly heals, and then only a little hard nodule of fibrous tissue seems to be left. This is usually so small that the dangers incident to its existence do not occur to a person unfamiliar with it. Then, most unexpectedly, perhaps as a result of gonorrhoea, of sexual excess, or want of cleanliness, the abscess-process occurs again. This may again seemingly pass away, and again break out anew after a short or long interval. This morbid condition may exist over a period of many years. Then, again, in some cases the nodule grows larger and deeper, and perforation of the urethra may occur, the process not being in any way chancroidal. I have seen several fistulse thus produced, a part of the urine passing through them ; and the possibility of this occur- rence has taught me always to deal promptly and radically with these not-infrequently-occurring frpenal abscesses and nodules. Persons hav- ing a long, tight, or a straight prepuce or one with a small orifice are the ones Avho suffer most from the chronicity and ofttime recurrence of these little lesions. Then, again, persons who for any reason suffer from balano-posthitis or who are frequently the victims of gonorrhoea are peculiarly liable to these abscesses, with their annoying exacerba- tions and remissions. It is not uncommon for one of these abscesses to become active, and for its pus to infect the urethra of its bearer, with- out any infection in coitus. In the present state of our knowledge it is impossible to definitely say just what structure is involved in the chronic suppurative process in the prepuce. Odmansson' thinks that they originate in closed and dilated lymph-channels which have opened upon the skin or mucous ^ " Om urethritis externa, silrskildt hos mannen ocli oni cystabildningar a forhuden," Nord. Med. Ark., xvii., No. 5, 1885. EXTERNAL URETHRITIS, ETC. 193 membrane. He claims that he has found small lymph-crypts in the prepuce. These statements are seemingly not based on histological study, and have not been generally accepted. Careful histological studies of these preputial sinuses and abscesses have been made, in all, in five cases by Touton,' Jadassohn,^ Fabry, ^ and Pick,* and they reach the conclusion that the structures they removed and studied were in all probability sebaceous or Tyson's glands, so altered by the morbid pro- cess that an absolutely certain opinion could not be formed. Neither of these observers thought the lesion occurred in the diverticula of the skin, the cysterna of Von During, or in invaginations of the epithelium. As a result of the investigations of these four observers it seems settled that an acute suppurative process is set up by the gonococcus, and that this pathogenic agent retains its virulence for a longer or shorter period. After a time, however, it disappears, and then the chronic suppurative process is kept alive by the ordinary microbes of suppuration. Suppuration of Follicles of the Cutaneous Investment of the Penis. We sometimes see on the under surface of the penis, along the raph^ even as far back as the scrotum, small suppurating sinuses and follicles which usually have a well-marked outlet which is directed forward toward the glans penis. Sometimes these lesions are tube-like, and again they feel like minute nodules. They may be seen in an active state, but usually they are shown to the surgeon when there is no complicating hypersemia and only the slight discharge on pressure from the outlet duct. There is, as a rule, one such lesion, but sometimes there are two, rarely more. The structures involved in these cases are undoubtedly sebaceous fol- licles, and they are usually associated with hair-follicles. Similar fol- licular inflammation may be found along the dorsum of the penis, on the middle line, as far as the symphysis pubis. One or more follicles may be involved. When inflamed, any of these follicular swellings may to a superficial observer look like chancre or chancroid. Jadassohn thinks that these cutaneous follicular abscesses are caused by the gono- coccus. It is probable that in some cases the pyogenic microbes are the cause of them. Juxta -urethral Sinuses. Not infrequently patients present themselves to the surgeon com- plaining of a slight but persistent discharge, Avhich they say comes from one or both lips of the meatus. Sometimes the affected part is distinctly red, and again it may appear normal in tint. It sometimes happens that a distinct opening can be seen, and it is usually of the size of a ' "Ueber Folliculitis prseputialis et paraurethralis gonorrhoica, etc.," Arckiv fiir Derm, und Syphili% vol. xxi., 1889, pp. 15 et seq., and " Weitere Beitriige zur Lehre von der Gonorrhoischen Erkrankungen der Talgdriisen am Penis, etc," Berlin, klin. Wochemchriff, No. 51, 1892, pp. 1.303 et seq. These essays of Toiiton contain elaborate and interesting studies as to the mode of invasion of the gonococci in epithelial tissues. a "Ueber die Gonorrhcie der Paraurethralen und Prilputialen Giinge," Deut. med. Wochevschrift, 1890, Nos. 25 and 2f). ^ "Zur Frage der Gonorrhfie der Paraurethralen und Prilputialen Giinge," Monatshejte fiir Prak. Derra., vol. xii., 1891, pp. 1 et seq. * "Ueber ein Fall von Folliculitis Priiputialis Gonorrhoica," Verhandlungen der Deut. Dermatol. Gesellschaft zu Frag, 1 889, pp. 258 et seq. U 194 GONOBRHCEA AND ITS COMPLICATIONS. pin's head or of a pinhole. Very often this opening is hidden in the uneven papillary surface of the meatus, and the use of a magnifying glass is required to make it clearly visible. Usually pressure on the glans, particularly in the morning, will cause a droplet of pus to exude, and thus the outlet of the sinus is revealed. Then, again, in some cases a thin, minute crust forms from escaping pus, and removal of this crust* reveals the hidden orifice. These sinuses, which have been called by my friend, Dr. Otis,^ "follicular sinuses," and by several " gonorrhoeal folliculitis," have been studied by Diday,=^ Harmonic,^ Campana,* Jamin,^ and others. They are usually seated on one or both lips of the meatus at about a sixth or third of an inch from its inner margin. In most cases the sinus is seated in the middle of the lip of the meatus, but in some cases it opens at the posterior, and quite rarely at the ante- rior, commissure. There may be one or two such sinuses on one side, which are entirely distinct from each other ; then, again, cases are seen in which it is probable that the two sinuses are connected. These morbid canals usually run backward parallel with the urethra, but in some cases they pass obliquely backward and inward, and open in the fossa navicularis, forming the meato-navicular fistula. I have seen several cases in which the opening was just within the lip of the meatus. It is not at all uncommon to find small follic- ular sinuses which open upon the urethra as far back as an inch from the meatus. These little lesions may exist for years, giving issue to a slight discharge and causing no uneasi- ness of mind or body. Some patients have them and pay no heed to them ; to others they are a source of worry and annoyance. In some cases we get a clear history of their onset during an attack of gonorrhoea; in others they seem to originate in balanitis and balano-posthitis. I have seen several cases in which these sinuses appeared and disappeared with each attack of gonorrhoea. As a rule, however, they remain indolent for an indefinite time, but are liable to periods of exacerbation in which they become minute but conspicuous abscesses, as may be seen '^''^perfo1i^'fixa?eTba'tk)n°^ ^ by inspection of Fig. 76. The introduction of a minute probe shows that these sinuses vary in length from one-third to one-half an inch, and, very exceptionally, a little longer. It sometimes happens that these follicular lesions of the meatus appear at the same time that those of the frsenum do. This is well shown in a Fig. 76. 1 Stricture nf the Male Urethra, etc., New York, 1878, pp. 9 et seq. 2 " De la Blennor-rhagie des Follicules muqueux dn Meat, de I'Urethre chez I'Homme," Guz. hebdom. de Med. et de Chir., 1860, vol. vii. pp. 725 et seq. 3 " Des Folliculites blennorrhagiques de rHomme," Annates Med.-Chir. de Marlmeau, Sept., 188.3. * " FoUicolite blennorrhagica," Gior. Ital. delle Mai. Ven. e delta Pelte, 1884, pp. 193 et seq. 5 "Des Fistules juxta-urethrales du ^leat," Annates des Mai. des Organ. Gihi.-urm., Yol. iv., 1886, pp. 409 et seq. EXTERNAL URETHRITIS, ETC. 195 case reported by Molinie/ in which there was a sinus on each lip of the meatus, and one near the fr?enum. All these sinuses made their appear- ance on the third day of an attack of acute gonorrhoea. These suppurating canals may be the cause of auto-infection, and in some cases they may secrete gonococci-containing pus by which the female may be contapainated. Much has been written as to the bacteriology of these juxta-urethral lesions, but true scientific knowledge concerning them is not in our possession. According to my reading and study, the case may to-day be stated as follows : It is probable that during and for some time after an attack of true gonorrhoea these sinuses give forth a gonococci-con- taining pus, and that in their chronic condition this secretion contains the ordinary pus-microbes. Arising as they do both during gonorrhoea and simple balano-posthitis, it is probable that in some cases they have as a morbific agent the gonococcus, and in others the ordinary pus- microbes. No histological examinations of these sinuses have yet been made. It is probable that they originate in a persistent Tyson's gland or in a misplaced Littre's follicle. Treatment. — In the treatment of the preputial follicular lesions the best course is thorough extirpation as soon as possible. If the surround- ing tissues are in a state of hypersemia, it is well by pressure or. the use of the knife to let pus out, and then reduce inflammation by the use of antiseptic lotions. Usually there is such a redundance of tissue in the prepuce that thorough removal of the morbid parts is possible without any damage to the penis. In the fosste of the frsenum, however, these lesions are sometimes imbedded deep in the tissues and are adherent to to the corpus spongiosum. In such cases the curette may often be freely used to advantage. Each case will present its peculiar surgical indi- cations, and upon these the judgment of the surgeon must be based. It is well to remember that in some cases these lesions of the frsenum are kept in an active state by balano-posthitis, and that after circum- cision the source of irritation ceases and the part soon gets well. Cir- cumcision, therefore, is of benefit in some cases. When there are two follicular abscesses, one on each side of the frasnum, it will be necessary to carefully dissect them out, and perhaps at the same time remove that fibrous cord. In some cases in the subacute stage gentle, firm pressure of the lesion once a day will express the contents, and in the end may cause healing. Prompt and radical measures may be adopted for the cure of suppu- rative follicles of the integument of the penis. After careful asepsis the lesion may be incised and thoroughly curetted. It will then heal readily under antiseptic dressings. The treatment of juxta-urethral sinuses is much more difficult. It is sometimes expedient to enlarge the sinus Avith a very small bistoury, and then endeavor to obtain healing from the bottom by means of stimulating injections and, if possible, a minute tampon. The ordinary hypodermic needle, blunted by the removal of its point, is very useful in the treatment of these cases. After careful cleansing and antisepsis ^ " Folliculite glandulaire blennorrhagique," Journal des Mai. Cut. et Syphil., March, 1893, p. 165. 196 GONOBBHCEA AND ITS COMPLICATIONS. a drop or two of a 3 or 4 per cent, nitrate-of-silver solution may be injected every second day. I have seen good results from the intro- duction of a fine probe coated with pure nitrate of silver which had previously been melted by heat. It is important to remember that not infrequently these lesions heal spontaneously as a result of daily firm but gentle pressure ; therefore it is not well to commence an active treatment until evidence of chronicity is assured. Martineau claims that he cured many cases of follicular lesions about the penis by applying the galvano-cautery cold to the mouth of the folli- cle, and then suddenly turning it on to a white heat. If used at all near the meatus, great care and judgment must be exercised. CHAPTER XVII. PERI-URETHRAL ABSCESSES. Abscesses of medium and large size are not infrequently found upon the penis near the frsenum and along the course of the organ as far back as the peno-scrotal angle. It must be borne in mind that these lesions are of greater extent and severity than those described in the preceding chapter as follicular inflammations. Peri-urethral phlegmon or abscess near the fr^enura is usually a con- comitant of acute gonorrhoea or it may occur in the chronic stage of that process. In some cases, in primary attacks, it appears during the height of the urethral suppuration, in others toward the period of decline, and only exceptionally in the later stage. It usually begins as a red and tender spot on one side of the fr^enum. This inflammatory condition may increase rapidly, and again its growth may be rather slow. In either event it is soon seen that an abscess is in process of formation. These abscesses are in general round and globular, but their shape is determined by the topographical arrangement of the frsBnum and the tissues forming its fossae and the prepuce. Sometimes the tumor is round, and again it may be oval shape. In Fig. 77 an oval abscess of the left frsenal fossse is well shown. In this case the inflam- matory process was very active and gave rise to oedema, which produced moderate paraphimosis. Perhaps in the majority of cases these abscesses occur unilaterally and are tolerabl}^ well circumscribed. When of goodly size the inflam- matory oedema which accompanies the suppurative process may involve the tissues on the unafi'ected side of the penis. This is also well shown in Fig. 77. Then, again, in somewhat exceptional cases an abscess forms in one frsenal fossa, increases rapidly and extensively, and, passing under the PERI-URETHRAL ABSCESSES. 197 frjBnum, involves the other fossa in the suppurating process. This is ■well shoAvn in Fig. 78, in which all the connective tissue at the under Fig. Fig. 78. Abscess near the franum, producing moderate paraphimosis. Abscess near the frsenum, involving both fossee. The frgenum then Fig. 79. part of the glans is involved in abscess-formation, divides the abscess into two lobes. It also happens, somewhat rarely, that the tissues of each fossa of the fraenum become affected separately, in which event there are two distinct abscesses. This oc- currence is well shown in Fig. 79. In any of these cases the patient ex- periences more or less pain at the part in- volved. In somewhat rare instances there is constitutional disturbance, as shown by chills, fever, and loss of appetite. The pressure of the tumor upon the urethra may affect the force and shape of the stream of urine or occasion dysuria amounting even to retention. It is not definitely known how and where the suppurative process begins in these cases. It certainly originates in the pus of acute or chronic gonorrhoea. I have paid particular attention to this point, and as a result of careful inquiry I can say that I never saw an abscess of the frsenum without there being obtainable a history of gonorrhoea more or less recent. It may be that this affection begins, as does that described in the previous chapter (page 193), in a follicle or crypt. If that is the case, the walls of these structures are soon de- stroyed, and a diffuse cellular-tissue abscess is produced. Clinically, Abscess 111 each fossa of the fraenum. 198 GONOBBHCEA AND ITS COMPLICATIONS. however, we have the two forms of lesions as I have described them — the one quite circumscribed and probably of follicular or cryptic origin, the other a diffuse cellular-tissue abscess, which may possibly have had its origin in an infected follicle or crypt. When incised and properly treated these abscesses may heal up promptly. In some cases, however, particularly when proper care has not been taken, the abscess-cavity con- tracts into a small, firm, inflammatory nodule which remains indefinitely. This inflammatory nodule sometimes redevelops into an abscess with each recurrent attack of gonorrhoea. I have seen cases in which they led to the formation of a urethral fistula. Abscesses of the Follicles of the Urethra. — These lesions begin as inflammatory foci either in Littre's follicles or the crypts of Morgagni. During the acute and declining stages of gonorrhoea we frequently feel with the finger-tips one or more or many little millet-seed and even larger nodules in the corpus spongiosum. These little circum- scribed swellings are undoubtedly swollen follicles. In most cases, for the reason that we find gonococci in the pus coincidently with the follic- ular inflammation, it is fair to assume that the morbid process is caused by those microbes. Follicular inflammation occurring after the cure of gonorrhoea — a not very frequent condition — may be due to the action of other microbes, perhaps the streptococci or staphylococci. It may be stated quite positively that in most of the cases of gonorrhoeic follicular inflammation resolution takes place synchronously with the cessation of the major process. Follicular abscesses of the urethra may develop m the fossa navicu- lars. These suppurations are here, as a rule, not of large extent, the abscess being usually of the size of a pea. The smallness of the follicu- lar abscess in this region is probably due to the density of the tissues and to the absence of much connective tissue. Usually, when the pro- cess is complete, pus is discharged into the urethra, and a short sinus Fig. 80. Abscess of the follicles of the urethra. leading to a small cavity is left. This may heal of itself or may require local treatment. In somewhat rare cases the abscess of the fossa navicu- laris extends deeply into the tissues and opens on the outside in either fossa of the frasnum. In this event there is much danger of a perma- nent urethral fistula. Careful treatment, aided by naUire, or nature PERI- URETHRAL ABSCESSES. 199 alone, may close up the wound, but there is always a strong probability that the fistula will be permanent. Farther down the urethral canal follicular abscesses are not at all uncommon. They begin as small, round, painful swellings, which in their early stage are easily circumscribed by the fingers. They usually Fig. 81. Unilateral abscess of tlie follicles of the urethra. go on more or less promptly to suppuration, which is attended by much inflammatory oedema of the corpus spongiosum and the connective tissue external to it. In Fig. 80 is well shown a follicular abscess which began about one inch behind the fossa navicularis. Occasionally the follicular abscess is seated on one side of the penis, Fig. 82. Large abscess of the follicles of the urethra during gonorrhoea. though the inflammatory oedema may extend to the other side. This is well shown in Fig. 81, in which the abscess was seated about an inch and a half from the meatus. The two preceding figures (80 and 81) 200 GONOBBH(EA AND ITS COMPLICATIONS. will give a good general idea of the size of these lesions. But these abscesses in the pendulous portion of the penis sometimes become very large — a fact well brought out by the appearance presented by Fig. 82. It will be seen that the phlegmonous process complicated an acute attack of gonorrhoea. In quite rare instances the abscess increases sloAvly and without marked inflammatory symptoms. The swelling becomes more and more salient above the tegumentary level of the penis, until in the end a well- marked pedunculated tumor or abscess-formation is produced. This feature is clearly portrayed in Fig. 83. In this connection it may be Fig. 83. Chronic pedunculated abscess of urethra. Abscess of the follicles of the urethra (tenth attack.) interesting to remark that I once saw a pea-sized sebaceous tumor or wen on the under middle part of the pendulous portion of the urethra. As a result of irritation the integument over this wen was inflamed and tender, and the appearances were strikingly suggestive of follicular abscess of the penis. The tendency to relapse observed in these follicular urethral lesions is shown in Fig. 84, in which a large swelling (the tenth of a series) of the middle of the under part of the penis is portrayed. As is common in these relapsing phlegmons, the inflammatory process was not very acute, though there was considerable suppuration. In most of these cases of follicular suppuration of the urethra the swelling is out of all proportion to the amount of suppuration. There is, as a rule, very much inflammatory oedema, but the suppurating cavity usually contains from half a drachm to a drachm of pus. In very large phlegmons two or three drachms may be found. There are two dangers to be looked for in these cases of follicular abscess of the urethra. The one is urethral fistula ; the other is the for- mation, after the abscess bursts into the urethra, of an inflammatory nod- PERI-URETHRAL ABSCESSES. 201 Tile. This inflammatory nodule is always a menace to the patient. It resolves itself into a little lump, in most cases easily felt, usually on the lower wall of the urethra. In this latent condition occasionally it may be so small and insignificant that it can be scarcely felt, but during erection its presence is readily made out. It may thus remain for months or years. But, as a rule, with every recurrence of gonorrhoea the sup- purative process lights up again and a new abscess is formed. This may occur again and again for many years. I have seen as many as twelve recurrences of this process. In many cases in these repeated attacks the swelling is about of the same severity in each. In some cases, how- ever, the abscess-formation becomes more intense, and pus is discharged externally through the inflamed and eroded skin. In these unfortunate cases a urethral fistula remains, which is usually permanent and requires for its relief a plastic operation. In favorable cases the inflammatory nodule undergoes contraction, and finally ends in a small cicatrix. In many of these cases of follicular phlegmon of the urethra the mor- bid process is limited to the urethral wall proper, and it is in these cases, even when suppuration occurs, that resolution and cure commonly result. In the more severe cases the follicular abscess increases beyond the urethral tissue proper into the connective tissue between it and the corpus spongiosum. It may continue still farther and involve more or less or all of the corpus spongiosum. As the suppurative process thus progresses outwardly, in most cases a wise provision of Nature occurs. With the establishment of the suppurative process in the deep part of the urethral wall, or in the contiguous connective tissue, or in this and in the corpus spongiosum, an adhesive inflammation obliterates the little follicular cavity in the urethral wall, the damage is repaired, and the then outlying abscess is shut off from all communication Avith the ure- thra. This abscess then has as its base the healed urethral wall, while its sides and roof are formed by the infected tissues of the corpus spon- giosum, the subcutaneous connective tissue, and the skin itself. In some cases, unfortunately, this walling off" of the abscess-cavity by adhesive inflammation does not occur, and then there is much reason for apprehension that a permanent fistula will follow the resolution of the inflammatory process. Even should urine escape in these cases, all hope need not be given up, since sometimes, most unexpectedly, healing takes place, the urethra is not left perforated, and we find at the seat of the trouble a little line or nodule of firm structure which Ave know is the cicatrix. When, however, the parts are well healed and a sinus re- mains, it may usually be looked upon as permanent, unless relieved by a. plastic operation. There is still another condition which is sometimes observed. The abscess opens into the urethra, and there is left a cavity and an internal blind fistula or sinus leading to it. In favorable cases the parts retract until the lesion ends in a little cicatricial mass. But sometimes this happy result is not attained, and the cavity and its duct remain. Then urine leaks into the wound, and sloAvly or (juickly an abscess again forms. This may occur again and again, and may finally end in a fistula leading from the urethra to the outside. Then, again, even when abscesses have repeated themselves under these conditions many times, thorough healing may finally occur. 202 GONOBRHCEA AND ITS COMPLICATIONS. Abscesses of Cowper's G-lands. — These abscesses, which are not common, begin in these glands, which are seated between the two layers of the triangular ligament. They usually occur at about the same period as epididymitis, during the third or fourth week of gonorrhoea or later. Usually but one gland is affected, quite exceptionally two are involved, and in this they are similar to abscess of Bartholin's gland. The peculiarity of these abscesses is that they are seated on either side of the raphe or median line. In their early stages these phlegmons are felt as little cherry-sized round or oval swellings just at the triangular ligament. With the development of the abscess-process the patient experiences pain, uneasiness, and tension in the perineum near the bulb, which is aggravated in the sitting position, in walking, and by pressure and friction of the clothes. With the increase in the phleg- monous process the pain becomes severe, and in many cases there are chills, fever, and malaise. Owing to the swelling, the urethra is not un- frequently pressed upon, and dysuria, and even retention, may result. As the abscess increases in size it pushes outward and forms a tense red Fig. 85. Abscess of Cowper's gland. swelling in the perineum, or it pushes forward and juts out at the peno- scrotal angle. While at first the swelling is seated on one side of the raph^, when it becomes very extensive it encroaches on the opposite side. PERI-URETHRAL ABSCESSES. 203 This condition is well shown in Fig. 85. When the abscess is very large, as it somewhat rarely is, the whole perineum becomes red and swollen. In most cases abscess of Cowper's glands is an acute process, but in some it takes place quite slowly. Usually the swelling extends from the bulb into the tissue beyond, and the abscess either opens or is opened in the perineum or in the scrotum. The further course of these abscesses is similar to that of those just described. The abscess may be walled off, and then when opened may be healed from the bottom, or the sinus leading into the urethra may remain patulous, in which case there is left a perineal or scrotal fistula. In my experience, in the majority of cases the urethral wound, which consists of the duct of the gland in a state of inflammation, heals, and no bad results are finally left. In rather exceptional cases a fistula is left. It sometimes happens, particularly when the abscess is not very large, that it opens through the duct into the bulb, and the pus then escapes through the urethra. In this event it may happen that subsequent con- traction may obliterate the abscess-cavity and its duct. Then, again, it is rather more common to find that considerable contraction occurs — that the morbid process becomes circumscribed to a nutmeg-sized or even larger mass, and this may remain indolent. This condition is always one of ill omen, since it so frequently forms a focus for the re-forma- tion of abscesses. Thus one phlegmon after another may form and burst into the urethra over a period of many years. Sometimes this recurrence of the phlegmonous process is lighted up by fresh attacks of gonorrhoea or by exacerbations of a chronic gonorrhoeal process. Then, again, in many instances the new suppuration is seemingly due to the leakage of urine into the inflamed nodule. Quite rarely still another course may be taken by the Cowper's-gland abscess. In the original inflammation there may be considerable oedematous hyperplasia of the gland and tissues immediately surround- ing it, and some pus may be formed, but the whole abscess-swelling is of a subacute character, and less in size than a walnut. After the escape of the pus a nodule is left, which for a time may or may not remain quiescent. Then it gradually grows, and a firm somewhat pain- ful swelling, without much redness, appears in the perineum. This swelling, which is for a long time on one side of the raphe, increases very slowly, occupying two and even many months in its course. It presents a hard, firm structure, and fluctuation cannot be detected for a long time. Finally, the necessity for opening the abscess becomes evident, pus escapes, and usually a fistula leading to the bulbous urethra is left. But even in these cold chronic abscesses the walling oflf of the suppurative process may occur and no fistula may be left. In all probability, abscesses of Cowper's glands begin originally by infection from gonococcus-invasion. Pellizzari^ cautiously collected the pus of three peri-urethral abscesses, and in it found the gonococcus. In three hospital cases of Cowper's-gland abscesses, every precaution against contamination having been exercised, in all specimens of the pus the gonococcus in sparing quantity was found by me. Treatment. — All these forms of abscess should be treated on general i"Il Diplococco di Neisser negli ascessi hlennorrhagici peri-urethrali/' Giornale lial. delle Mai. Ven. e delta Pelle, 1890, pp. 134 et seq. 204 GONOBBHCEA AND ITS COMPLICATIONS. surgical lines. Until the suppurative process is ripe it is well to apply cooling lead-and-opium or muriate-of-ammonia or carbolic lotions. When fluctuation is felt, a good, liberal, but careful incision should be made, and the abscess-cavity should be thoroughly cleansed with a bi- chloride solution or irrigation with carbolic water. Then the wound should be dressed with iodoform or aristol and stuffed with gauze. In the event of a fistula being left leading into the urethra, it will be neces- sary to resort to a plastic operation when the inflammation has fully subsided. In cases of abscess of CoAvper's glands it is not well to be too prompt in operating. In these cases poultices do much harm by causing a spread of the inflammatory oedema. The best plan of treatment in the developing stage of this abscess is to keep the parts well covered with absorbent cotton saturated with lead-and-opium wash or with a 2 per cent, carbolic-acid watery solution. It should always be remembered that sometimes these abscesses, even when they have attained the size of a large walnut, may gradually undergo retrogression and finally dis- appear. The best rule for guidance is to watch the case carefully, and as soon as fluctuation is well made out to incise the parts freely, and then irrigate and dress the wound antiseptically. In most cases the abscess does not perforate the urethra, and healing promptly occurs. When there is a fistula into the urethra, the parts may often be healed and their integrity restored by careful and methodical packing of the wound from the bottom. In these somewhat deep wounds balsam-of- Peru gauze is often very beneficial. CHAPTER XVIII. GONORRHCEA OF THE RECTUM. Within the past few years our knowledge of this subject has been much increased and has been made more precise. So many well- authenticated cases of gonorrhoea of the rectum have been reported that no doubts are now entertained as to the susceptibility of this gut to the irritation of gonorrhoeal pus and to the occurrence of a resulting specific suppurative process in it. It is an affection more or less fre- quently observed in countries in which sodomy is practised, but instances of it are not frequent in the United States. I have seen^ in all, three well-marked cases, and in the discharge from one (a recent case) I found gonococci. Much of the literature of this subject is unsatisfactory ; therefore I shall merely mention some of the cases reported within a few years : Thiry ^ reports the case of a woman, aged twenty-four, who suffered from weight and shooting pains in the pelvis, pain in defecation, and a ^ " Kectite blennorrhagique, et cet.," Presse Med., Beige, 1882, xsiv. pp. 201-203. GONORRHCEA OF THE RECTUM. 205 constant thick discharge from the rectum. She had a funnel-shaped anus, the folds of which were obliterated, and the sphincter was weak and dilated. The lower portion of the rectum was acutely inflamed and studded with bright-red points which bled freely. The follicles were enlarged and from them pus escaped. The woman confessed to sodomy with men suffering with gonorrhoea. Winslow ^ reports an epidemic of gonorrhoea in a Baltimore institu- tion for boys from nine to twenty-one years old, which originated in the following manner : A boy who Avas on leave of absence contracted gonor- rhoea from a girl, and was suffering from it on his return to his duties. Before he was cured he had anal coitus with another boy, who from it became infected. From this boy with rectal gonorrhoea many other boys contracted the disease. Ten such cases are recorded, and it is stated that it w^as probable that there were other cases which were not reported. The most satisfactory case is that of Frisch.^ It was of a girl seven- teen years old who, fifteen days after unnatural intercourse, complained of burning pain in the rectum, particularly during defecation. The peri-anal region was reddened and excoriated, and from the anus, nar- rowed by inflammation, a thick greenish-yellow pus escaped. In this secretion and in that from the genitals myriads of gonococci were found. Tuttle^ reports two cases of rectal gonorrhoea in men and one in a woman due to sodomy, in the secretions of all of which gonococci were found. Cases of women suffering from rectal gonorrhoea in which the gono- coccus has been found have been reported by Neisser and Bumm. Cases of auto-infection with rectal gonorrhoea have also been reported. Rol- let* reports the case of a man suffering from gonorrhoea who was also affected with constipation. It was his custom to aid defecation by introducing his finger into the rectum. By this manoeuvre his finger, being soiled with pus from his urethra, infected that organ. Dock^ reports a case of urethral inflammation in a male twenty-five years old, which, as regards its gonorrhoea! nature, is not quite satisfactory, but which presented a typical clinical picture of gonorrhoea of the rectum. In this case infection is supposed to have occurred by means of a finger soiled with gonorrhoeal pus which was introduced into the rectum for the insertion of suppositories. Careful microscopical examination showed the presence of gonococci. Etiology. — It will be seen from a consideration of the foregoing cases that a virulent proctitis is not uncommonly met with, due to infection with gonococci-containing pus. In most of the cases the infection occurs as the result of sodomy, more frequently in women and 3^oung boys, but also in older males, the active agent suffering at the time from ^ " Report of an Epidemic of Gonorrhoea contracted from Rectal Coition," 31cd. News, Aug. 14, 1886. ^"Ueber gonorrhoea rectalis," Verhandl.der Phys.-med. Gesellsch.zu Wurzbtin/, 1S91-92, N. R., pp. 167 et seq. '^ "Gonorrha-a of the Rectum," N. Y. Med. Journal, April 3, 1892, p. 379. * Diciionnnire eneyclop. des Sciences med., art. " Anus (Maladies v^n^riennes de I'Anus)," 1870, p. 495. ^ "Gonorrhoea of the Rectum," Medical Newfi, March 25, 1893, p. 325. 206 OONOBBHCEA AND ITS COMPLICATIONS. gonorrhoea. In some cases the gonorrhoeal pus is carried to the rectum by means of a soiled finger. It is claimed that in acute gonorrhoea in women the pus, escaping from the genitals, may infect the anus and rectum. This accident is, of course, possible, but as a broad general rule it may be stated that rectal gonorrhoea results from the intromis- sion of an organ secreting or soiled with virulent pus. Symptoms. — The first symptom of gonorrhoea of the rectum is an uneasy sensation, attended Avith more or less heat. This may be com- plained of within from two to ten days after contamination. Heat and burning increase, defecation becomes painful and often more frequent, and soon a discharge is noticed which may at first be watery or milky, but which promptly becomes purulent and even streaked or mixed with blood. At this time burning heat and itching are felt in the anus, Avhich becomes red and swollen, and a deep dull, aching pain in the rec- tum is felt. Defecation becomes more and more painful, and sometimes is so severe as to be agonizing. Frequent calls to stool keep the patient in a condition of apprehension and suffering. The purulent and bloody secretions often become offensive in smell, and ooze constantly from the inflamed and relaxed anal orifice. In well-marked cases decided consti- tutional reaction is observed at the end of a few days or a week. The patient looks haggard and worried, there is some rise in temperature, the pulse is rapid and small, and general malaise and debility are expe- rienced. This condition may last one to three weeks, when amelioration is experienced. In many cases this affection is not attended with the severe symptoms above described, and it ceases gradually under simple treatment. The milder cases are usually those in which the anal region alone is involved; in the more severe and intractable cases the lower part of the rectum is the seat of inflammation. The objective symptoms of gonorrhoea of the rectum and anus are striking. The mucous membrane becomes red and swollen, and in patches excoriated and ulcerated, with here and there red mammillations corresponding to inflamed follicles ; a foul, tenacious pus bathes the rectal walls and escapes from the anal ring, which is thickened, red- dened, excoriated, and perhaps the seat of several small- or good-sized fissures. In some cases fleshy tabs are developed, presenting the appear- ance of hemorrhoids, while in others, particularly those in which treat- ment has not been followed, simple vegetations may develop. In passive pederasts and sodomists the anus is frequently of a decided funnel shape, its folds are more or less obliterated, and the tonicity of the sphincter is decidedly impaired. Diagnosis. — It is frequently diificult to determine positively the gon- orrhoeal nature of a suppurating rectal inflammation. In some cases the history or concomitant circumstances point to a gonorrhoeal origin. Very many patients Avill, from motives of shame, deny any unnatural practice and will endeavor in every way to mislead the physician. Others, again, will, with barefaced candor, promptly admit the shameful mode of origin of their trouble. In women suffering synchronously from purulent dis- charge from the vagina, urethra, or vulva the diagnosis is often easy. As a rule, the severity and persistency of a rectal or anal suppurating process will excite the suspicions of the physician. Then, again, the GONOBBHCEA OF THE RECTUM. 207 sudden onset and quick, prompt development of rectal gonorrhoea (the facts of which can generally be obtained without difficulty from the patient) will be an aid in determining the nature of the aifection. In many cases a diagnosis can be readily made by the microscopic examination of the pus, which must be taken on a platinum-wire loop from the surface most actively inflamed. To this end a speculum must be passed into the anus or rectum, as the case may be. Pus which has escaped from the anal orifice is liable to be mixed with other forms of cocci ; therefore it should never be used. In the early stages of an acute process there will usually be little difficulty in finding specimens of pus in which there are gonococci. In chronic cases of gonorrhoea of the rectum a number of forms of cocci will be found, chiefly, however, staphylococci and streptococci. Erythema, eczema madidans, intertrigo, and excoriations about the anus may be mistaken by superficial observers for gonorrhoea of the rec- tum. Hemorrhoids and vegetations about the anus sometimes, as a result of uncleanliness, undergo inflammation, which spreads to the con- tiguous skin and perhaps to the margin of the anal orifice. These cases might be looked upon as instances of rectal gonorrhoea. Prognosis. — Though the course of this aff"ection is often severe and sometimes alarming, its tendency in healthy and cleanly persons is toward recovery. It is stated that in tuberculous individuals local manifestation of their diathesis may occur and a lethal result follow. I have had no experience with such cases. Treatment. — The patient should be confined to the house and placed in a recumbent position. Warm sitz-baths should be taken, and the rectum should be freely injected several times a day with a saturated solution of boracic acid, warm or cold according as it is agreeable to the patient. Enemata, hot or cold, of lead and opium are sometimes very soothing and efficacious. Lead- water and boric acid solution in combina- tion are also of much benefit. It is necessary to free the bowel of fteces, and for this purpose castor oil or Epsom salts may be given. In the intervals of defecation suppositories of morphine or opium, sometimes with iodoform, may be used if necessary. When the intensity of the symptoms has passed, slightly stimulating enemata of sulphate of zinc and laudanum may be used. Solutions of bichloride of mercury have not proved of value as injections. Toward the cessation of the suppu- rating process solutions of nitrate of silver (gr. j-ij— 3viij-xvj) may be very useful. To these solutions wine of opium or fluid extract of bella- donna may be added. Gonorrhoea limited to the region of the anal orifice requires constant attention to cleanliness and sitz-baths, and the application (when acute) of lead-and-opium wash, and, later, of bland dusting powders. 208 GONOBRHCEA AND ITS COMPLICATIONS. CHAPTER XIX. GONORRHCEA OF THE MOUTH. Our knowledge of gonorrhoeal infection of the mouth is very incom- plete, and further observation and careful clinical and bacteriological studies are necessary before a satisfactory account can be given of it. A study of the cases thus far reported warrants the assumption that there is a specific inflammation of the mouth contracted by beastly and unnatural practices, and perhaps caused by the gonococcus. From the following cases an idea of the clinical history of this affection may be obtained. One of the earliest cases is reported by Baum^s.^ It was that of a workman in whom the left half of the lower lip was engorged, red, shin- ing, and painful. The surface was covered with whitish granulations, and from it a scanty purulent secretion exuded. This morbid surface looked like the neck of the uterus when the seat of gonorrhoea. The patient stated that this inflammation came on six or eight days after he had kissed the vulva of a woman who he afterward learned was suffer- ing from gonorrhoea. The affection was very rebellious to soothing treatment. Holder^ states that mouth-infection may occur from direct contact with the infected male genital organ. He relates the case of Petrasie, which was that of a young man who had this form of unnatural coitus with a man suffering from urethral gonorrhoea. The day after he had pain in the lips and gums. On the fourth day the mucous membrane of the lips and buccal cavity became intensely red, the gums were spongy and inclined to bleed, with a tendency to recede from the teeth, and the buccal secretion was increased in quantity. Motion of the mouth was painful. Holder states that the affection begins with a sensation of heat and dryness in the mouth, which at first appears very red. Soon a purulent secretion flows from the swollen and inflamed parts, which may be covered with an aphthous-like exudation. The affection in this case was cured by an alum gargle in eight days. Cutler^ also reports a case which is fully as striking as Petrasie's, It was that of a woman who had coitus ah ore with a sailor who was found to be suffering from gonorrhoea ; the next morning her mouth was raw and sore and the saliva had a horrible taste. On the second day little sores appeared on the lips, and on the third day the gums and tongue became swollen and painful. By the fifth day the whole buccal cavity was so inflamed that she, could not eat, and a whitish fluid, mixed with blood, having an unpleasant odor and taste, Avas secreted. Ex- amination shoAved the mucous membrane of the lips and cheeks was ^ Precis theorique et pratique sm?' les Maladies veneriennes, vol. i., Paris, 1840, pp. 210 et seq. ^ Lehrbuch der venerischen Krankheiten, Stuttgart, 1851, p. 288. ^ "Gonorrhoeal Infection of the Mouth," New York Medical Journal, Nov. 10, 1888, p. 521. GONORRHCEA OF THE MOUTH. 209 thickened, reddened, denuded of epithelium in spots, and covered in areas with a false membrane, which was readily detached, leaving an excoriated surface. The gums Avere swollen, retracted from the teeth, and bled readily on pressure. The tongue was swollen and very tender, and could only be slightly protruded, and then only with much effort and pain. The surface Avas red and glazed and covered with small ulcers which secreted a thick yellow pus. The soft palate and pillars of the fauces were much inflamed, but the parts beyond were in a normal condition. The breath was very offensive. There was little salivation. The mouth-secretion consisted of mucus, pus-cells, and epithelium, and contained a large quantity of bacteria. In the false membrane a micro-organism resembling the gonococcus was seen, but its identity was not fully established. Soothing applications brought about an amelioration of the symptoms. It is unfortunate that an absolutely satisfactory microscopical exami- nation was not made of the secretions of the man and the woman. Much light can in the future be thrown on such cases by the culture of the micro-organisms of the secretions. Whenever possible confronta- tions should be obtained. Dohrn^ reports a series of cases of very young children, born of mothers infected with gonorrhoea, who presented a peculiar form of purulent stomatitis which he thinks is of gonorrhoeal origin. The first case was that of an infant born at term, in whom, when eight days old, the mucous membrane of the alveolar borders, the dorsum of the tongue, and the soft palate became inflamed, eroded, and covered Avith a grayish coating. The affection ran an acute course and was cured in four weeks. Portions of the false membrane were examined microscopically and cultures were made from it, with the result, it is claimed, of demonstrat- ing the presence of the gonococcus. The infant also suffered from gon- orrhoeal ophthalmia. Dohrn, in association Avith Rossinsky, observed four similar cases, all of them in the offspring of Avomen suffering from gonorrhoea. Dohrn thinks that the mucous membrane of the mouth of infants is particularly susceptible to infection by the gonococcus. This particular subject also needs further and extended study, aided by careful microscopical exami- nations and culture-experiments. Menard ^ claims that an ulcero-membranous stomatitis may occur in patients profoundly infected Avith gonorrhoea. In support of this asser- tion he published the histories of four cases. In the first case there appeared at the tenth Aveek of gonorrhoea, in a man forty-five years old, first a generalized erythema, then orchitis, and finally ulcero-membran- ous stomatitis. The second case was that of a young medical student Avho had gonorrhoea Avhich Avas complicated Avith monoarticular hydrar- throsis, and later by ulcero-membranous stomatitis, Avith SAvelling of the parotid gland of one side and painful enlargement of the submaxillary and cervical glands. The third case Avas that of a man thirty-five years old, Avho, while suffering from old gonorrhoea, had orchitis and ulcero- ^ Mercredi medical, .July 15, 1891, p. 352. '■^ " De la Stomatite ulc^ro-inembraneuse chez les Blennorrhagiques," Annales de Derm, et Syphiligraphie, deuxienie serie, vol. x., 1889, pp. G79 et seq. 14 210 GONOBBHCEA AND ITS COMPLICATIONS. membranous stomatitis, limited to the region of the left lower molar tooth. In the fourth case (that of a soldier twenty-six years old with severe gonorrhoea) rheumatism, orchitis, and a typhoid condition of short duration were observed, and were followed by ulcero-membranous stomatitis. This author claims this mouth-lesion as a direct result of gonorrhoeal infection, and that it is not a simple coincidence. He thinks it due to blood-infection by the gonococcus. More light is required on this sub- ject, of which I have no personal knowledge. In this connection it is well to record some cases in which it is claimed that gonorrhoea was contracted by men from the mouths of women. These cases, however, lack many essential points and do not warrant dogmatic conclusions. Horand^ reports the case of a medical student Avho had natural coitus with his mistress thirteen days prior to July 10th. On that day he had coitus (which was of short duration) with a woman by the mouth. The next day he felt heat in the urethra and saw in the meatus a drop of white fluid. On the third day the discharge was abundant and puru-. lent, and there was pain on urination. At this time gonococci were found in the discharge, and in one pus-cell there were seventy of these organisms. By the use of injections the discharge disappeared in fif- teen days, and the man had natural coitus and also by the mouth with his mistress, without any bad results to either. The woman from whom this infection was thought to be derived was found healthy as to her genitals and mouth. Horand thinks that infection occurred from the presence in her mouth of gonorrhoeal discharge left there from a previ- ous suction. The weak point in this case lies in the fact that it was so promptly and thoroughly cured in fifteen days. As the search for the gonococcus was made as long ago as 1884, when the knowledge of it was not complete and its differentiation from other urethral microbes was not known, the suspicion is warranted that the infection originated in some micro-organism less virulent than the gonococcus. Delefosse^ reports the following case: A man, thirty-nine years old, having had three attacks of gonorrhoea, but having had no urethral dis- charge for seven years, submitted to prolonged suction of the penis by a woman. Five days later prodromal symptoms showed themselves, which were followed by a typical severe attack of gonorrhoea. No examination of the woman was made nor Avas the secretion examined by means of the microscope. ^ " Blennorrhagie contractee dans un rapport ab ore," Lyon Med., vol. 1., 1885, pp. 279 et seq. = " Sur un Cas de Blennorrhagie apres Snccion de la Verge sans Coit," Journal des Malad. cutan. et syphil., vol. i., 1889 and 1890, pp. 305 et seq. CONGESTION OF THE PROSTATE, ETC. 211 CHAPTER XX. CONGESTION OF THE PROSTATE, ACUTE PROSTATITIS, AND PROSTATORRHCEA. The most common form of inflammation of the prostate in the course of gonorrhoea is congestion of more or less severity. This condition occurs with, and is dependent upon, acute posterior urethritis. In the latter condition the submucous connective tissue is the seat of an acute phlegmasia, and as a result the substance of the prostate becomes hyper^emic. With this further extension of the gonorrhoeal process the patient has still other symptoms, besides those of posterior urethritis. He complains of a sensation of dull weight and pressure in the peri- neum deep in the pelvis, and an uneasy sense of fulness in the rectum or anus. In severe cases rectal tenesmus may add to the patient's dis- comfort. The vesical tenesmus may be increased^ and often in defeca- tion the patient experiences severe pain in the prostate when the fecal mass passes under it. When there is much swelling the stools are small and ribbon-shaped. Rectal examination reveals a swollen organ, broader than normal from side to side, and bulging considerably into the rectum. The finger-tip reveals the fact that the part is hot and decidedly painful, and on its withdrawal vesical and rectal tenesmus frequently ensues. In many cases pollutions are a distressing symptom. In the great majority of cases this congestion is temporary. It may last a few days or two or three weeks ; usually, however, resolution takes place in about ten days. With the decline of the posterior urethritis the swelling and tenderness usually subside. In some cases the involution of this congested condition of the process occurs suddenly and unexpectedly a few days after its onset. A congestion of the prostate may be due to violence from sounds, catheters, lithotrity instruments, to the irritation of a stone in the blad- der and of a fragment of stone, or of small stones impacted in its mucous membrane, and to stricture. It is not very probable, as claimed by some, that injections used by patients in the anterior urethra cause congestion of the prostate. In chronic posterior urethritis ephemeral congestion of the prostate may be caused by sexual and alcoholic excesses, by masturbation, and by violent exercise, particularly in horseback riding and bicycling. Examination of the urine gives the same results as are seen in acute posterior urethritis. In quite rare cases rectal examination shows that certain parts of the prostate are more swollen and harder than the rest. In this condition it may be that certain groups of follicles are the seats of greater oedematous hyperplasia than the balance of the tissue. In some cases of congestion of the prostate the patient experiences difiiculty in urination, and complains of a sensation as if his urethra was too small to allow the stream to pass through it even with great straining. It will be seen, under these circumstances, that the stream is small and 212 GONOBRHCEA AND ITS COMPLICATIONS. weak, even hesitating and intermittent. In some cases, such is the swollen condition of the organ and of its urethral mucous lining that the patient cannot void his urine, and has to be relieved by the introduction of the catheter. In bad cases there may be vesical and rectal tenesmus superadded, and in some there is spasm of the compressor urethrge muscle. Under these circumstances the patient often fails to thoroughly empty his bladder, and then the residual urine accumulates and causes continuous vesical tenesmus. The bowels are frequently constipated, and when the vesical tenesmus comes on the patient makes painful and often vain efforts to free them. Congestion of the prostate usually ends in resolution, but it may go on to abscess-formation. Parenchymatous inflammation of the prostate may develop from the milder or congestive form. In this phlegmasia there is usually suppura- tion in some part of the organ — hence the name " abscess of the prostate" — which may be a tolerably mild affection, and even a severe and a fatal one. The formation of pus in the prostate is usually attended by quite well- marked symptoms, such as chills, fever, general depression, a sensation of throbbing in that body, and a feeling as if there was a lump in the rectum. There may also be pain along the urethra in the perineum, rectum, and lumbar region. The further symptoms are painful micturi- tion and defecation. In some cases the urethral canal is entirely occluded by the swelling, and the patient is unable to pass any of his urine. He of necessity lies on his back and flexes his thighs, thereby avoiding all pressure on the perineum. Abscess of the prostate always begins in one or more follicles, which become acutely inflamed. From this focus the morbid process increases and forms abscesses of various sizes. As a rule, the lateral lobes are more frequently the seat of abscess than the third portion. There may be one or two abscesses, and in exceptional cases there may be as many as from six to twenty. In this event as many different follicles have become the seat of abscess as there are abscesses, Avhich are usually of the size of a pea and even smaller. When the abscess is limited to one lobe and points toward the urethral canal, it may partly or wholly block it up. The introduction of a catheter then to relieve retention will be accomplished with more or less difficulty, and its point will deviate in the opposite direc- tion from the lobe involved. Rectal examination will reveal general en- largement of the organ, and it may happen that the surgeon will be able to ascertain that the process is unilateral. The size of these abscesses varies considerably. They may contain a teaspoonful, an ounce, and even as much as eight ounces, of pus. The contents of these abscesses may be pure pus free from odor, or it may be sero-sanguinolent ; it may be mixed with the debris of the gland or it may be of a very unhealthy character and very fetid. Abscesses superficially seated in the prostate and pointing toward the urethra cannot, as a rule, be clearly defined by rectal examination, but their presence may be detected by the passage of a catheter of medium stiffness. When the abscess is deeply seated in the prostate, it can generally be well made out by the finger in the rectum. Abscess of the prostate may also form in an insidious manner, without provoking any general or local symptoms pointing to its existence. I CONGESTION OF THE PROSTATE, ETC. 213 have seen two instances following gonorrhoea, in which, after apparent cure, the patients on passing water were surprised at the escape of nearly an ounce of pus. In these cases rectal examination showed enlargement of the organ with moderate tenderness. Perfect healing took place. Pitman ^ reports a case in which prostatitis followed gonorrhcea and ter- minated fatally, with an entire absence of systemic symptoms or of local distress. At the autopsy an extensive abscess, unsuspected during life, was found between the bladder and the rectum. As a rule, however, when the abscess is fully formed, the constitutional symptoms are much more pronounced than at first. The rigors are more severe and are attended with flashes of heat ; there are great thirst, restlessness, and jactitation, very high fever, and sometimes delirium. The pain becomes more violent and the throbbing more distressing, and the sensation of fulness and weight at the neck of the bladder and in the rectum and anus causes agony. These symptoms, together with the fre- quent scalding urination, made drop by drop or in a thin, feeble stream, stamp abscess of the prostate as one of the most acutely painful and dis- tressing maladies known to man. With the bursting of the abscess, naturally or by operation, every- thing is changed. The patient is immediately relieved of his suffering, he can urinate freely, and his febrile symptoms soon disappear. If the inflamed tissues contract and efface the abscess-cavity, as they commonly do, all is well and the patient is spared further trouble. Unfortunately, however, prostatic abscesses may open into the bladder, the rectum, the vesico-rectal space, the perineum, and the peritoneal cavity. In this connection the statistics collected by Segond^ are very interesting. In 102 cases he found the abscesses burst and burrowed as follows : Into the urethra, 64 times ; into the rectum, 43 ; into the perineum, 15 ; into the ischio-rectal fossa, 8 ; into the inguinal region, 3 ; through the ob- turator foramen, 2 ; through the umbilicus, 1 ; through the sciatic notch, 1 ; at the edge of the false ribs, 1 ; into the abdominal cavity, 1 ; and into the cavity of Retzius, 1. It will be seen that in rather more than one-half of the cases the abscess burst into the urethra, and it is safe to say that at least in a large majority the patients experienced no ulterior trouble. When the abscess is developed in the posterior portion of the gland the tendency is for it to burst into the rectum, which is a serious condition. It then leaves a fistulous tract which is very difficult to heal, and which allows the escape of urine into the rectum. The pus, however, may bur- row downward and point as a red indurated area in the perineum anterior to the anal orifice. It may also pass through the ischio-rectal fossa and appear in the perineum. It may extend toward the scrotum and sheath of the penis, and may pass down to the thigh or upward to the region of the fiilse ribs. The other modes of burrowing are quite rare, but each of them pre- sents its individual indications for surgical relief. In the course of these aberrant burrowings many complications may occur, and there is always danger of pytieraia. ^ Lancet, Am. ed., .Jan., 1S61, p. (iO. ^ "Des Absces chauds de la Prostate et dn Phlegmon periprostatique," Thise de Paris, 1880. 214 GONOBBHCEA AND ITS COMPLICATIONS. The bursting of the abscess into the peritoneum always causes great pelvic pain and very severe, even alarming, constitutional symptoms. Death usually ensues in a day or two. In the progress of the burrowing process the patient may experience more or less pain in the parts, which become red, swollen, and hard. Congestion and abscess of the prostate are generally found in young men from twenty-five to thirty years of age. Abscess of the prostate is not of frequent occurrence. Ballou^ ob- served 3 cases of it in 1000 cases of all varieties of gonorrhoea. Even this is a large percentage, according to the statistics of my clinic and of my hospital services. Prognosis. — Abscess of the prostate is almost always a painful afi'ection, and sometimes a dangerous and even deadly one. In quite rare cases the abscess when not recognized and untreated causes pyaemia and death. The rectal fistulae are very hard to cure, and they cause much discom- fort and suffering to the patient, who becomes an object of aversion to those who come in contact with him. When the patient is young, otherwise healthy, and of firm fibre and of good habits, his chances of recovery, even when afflicted with bad fistulse, are usually good. In elderly and sickly individuals the prog- nosis is usually grave. Prostatorrhcea. As a result of chronic posterior urethritis, of stricture of the urethra, and in subjects who, as a consequence of confirmed masturbation and of venereal excesses, have produced a hypersemic condition of the posterior urethra, we sometimes see a chronic mucoid discharge to which the term " prostatorrhoea " is applied. This condition, which is also called by some authors " chronic prostatitis," is not a common one, and is mostly seen in young and middle-aged subjects. It may be an affection of little gravity, and then, again, it may be attended with very serious symptoms and asso- ciated with a severe form of neurasthenia. In anaemic and neurotic subjects it is often a most distressing disorder. It is also observed in men with markedly strong sexual propensities who commit great excesses, and also in those who suffer from unsatisfied sexual desire. This affection may be permanent and it may be intermittent in character. Then, again, when it persists in a chronic form it may (generally owing to excesses) undergo exacerbations of a very high degree. The most constant symptom is the escape from the meatus of a clear mucous fluid or of a mucus mixed with pus and perhaps a little blood. This mucous fluid may be scant in quantity, only a few drops appearing at the meatus in a day. It may also be more copious, and keep the end of the penis in a moist condition continuously, and in very pronounced cases the escape is so excessive that patients complain of a constant and annoying "dripping," which may wet and stain a large part of their shirt- fla23 or of the handkerchief which they instinctively make use of under these circumstances. The escape of this discharge in large quantities occurs frequently during the act of defecation, particularly when the fecal bolus is hard and firm. In some cases the escape of the mucus 1 New York Med. Journ., July 25, 1891, p. 99, CONGESTION OF THE PROSTATE, ETC. 23 5 causes a peculiar tickling feeling in the prostate and urethra, while in others it produces pleasurable voluptuous and lascivious sensations. Some patients claim that they can feel the escape of the fluid from the prostate into the urethra. In rather rare cases the escape of mucus, particularly after defecation, is attended with a sickening sensation of great faintness, which may last for several minutes. Many of these cases have been treated for spermatorrhoea. Riders of some forms of bicycles notice that a clear viscid secretion escapes from the meatus, particularly after long and rough riding. Seeing that in these cases there are no symptoms which point to prostatic or ves- ical disturbance, it seems probable that the fluid comes from hypersemic mucous follicles and Cowper's glands. Although we have no pathological knowledge on the subject, it seems fair to assume that in prostatorrhoea there is such an atonic condition of the compressor urethrse muscle that it cannot prevent the escape of the fluid into the anterior urethra. The next most constant symptom is in- creased frequency in urination, which may be very excessive or only about twice as often as the normal desire. There may be decided un- easiness at the end of the act, and there may be a slight pain or decided scalding sensation Avhich passes from the prostate to the end of the penis. In many cases the stream is small and weak — a condition which seems to point to an atonic state of the detrusors. A sense of dulness and weight is often felt in the prostate and in the rectum, and pain and uneasy sensa- tions are experienced in the perineum, thighs, and lumbo-sacral regions. Some patients sufl'er from chronic prostatorrhoea without becoming much disturbed in mind by it. But there are others to whom this afi"ec- tion is little less than a calamity. They become exceedingly nervous about their trouble, even to the extent of melancholy. They lose flesh, strength, and appetite ; they become irritable and incapable of mental and physical exertion. In fact, in some cases the whole morale of the man seems lost. Besides these cases, in which the trouble is of long duration, we some- times see patients — particularly continent young men — who are constantly seeing and caressing their sweethearts prior to marriage, and men who fruitlessly try and hope day by day to have connection with a certain woman, who have an acute attack of prostatorrhoea, even with quite pro- nounced mental and physical disturbance. Intercourse and sexual hy- giene, with tonics and fresh air, usually bring around these suff'ering swains. In many cases of prostatorrhoea there is more or less disturbance in the sexual function. In some subjects it is morbidly exaggerated; in others there is much desire, much erethism, many erections, but very little is accomplished, owing to precipitate ejaculations. In still other subjects there is little if any desire, even as a result of much excitement, and the penis and scrotum seem cold and lethargic. In subjects of prostatorrhoea every new gonorrhoea shows a tendency to run back to the posterior urethra and there pursue a severe course. As a result of the hypen^emia the whole organ may become, as time goes on, much hypertrophied. Rectal examination of cases of prostatorrhoea, which should be made from time to time, reveals an enlarged organ, usually jutting more or less 216 GONOBBH(EA AND ITS COMPLICATIONS. backward on the gut, and being decidedly broader than normal. Some- times it feels soft, and again it may seem decidedly indurated. There is commonly more or less tenderness, even severe pain, on pressure by the finger-tips. Urethral examination, even with a small and not stiff instru- ment, often causes a great outcry from pain when the tip passes through the prostatic urethra. In the study of cases of prostatorrhoea the surgeon must bear in mind that during intense sexual excitement, with partial or complete erection, without ejaculation and satisfaction, a viscid, glycerin-like looking fluid very commonly escapes from the meatus in considerable quantity. This is not a pathological secretion at all, but is the product of Cowper's glands and of the urethral follicles, which have become suddenly the seat of hy- persemia. The prostate is not in any way concerned in its development. This symptom has often been considered by patients and physicians as due to spermatorrhoea. This secretion is called urethrorrhoea ex Ubidine, and has its congener in the flow of saliva produced by the sight or odor of a tempting meal. The character of the secretion varies in different cases and in different stages of the aff"ection. If the case is one of simple uncomplicated pros- tatorrhoea and seen early, we sometimes find under the microscope amy- loid bodies in concentric strata, cylindrical epithelial cells in double stratiform disposition, with their prolongations running into a cluster of small round-cells (Fiirbringer), and small, fairly refractive granules of half the size of red corpuscles. According to Fiirbringer,^ the addition of a drop of a 1 per cent, solution of acid phosphate of ammonia to a drop of the prostatic secretion placed on the glass slide will, after a couple of hours' contact, reveal the presence of what are called "spermatic crystals," and also Boettscher's crystals, the basis of which exists only in the pros- tatic secretion. In the majority of cases, however, there has been, either as a result of gonorrhoea or of instrumental interference, infection of the posterior urethra, and a purulent secretion is produced. Under the micro- scope the appearances of this secretion are similar to those of posterior urethritis. (See page 75.) When the prostatic secretion is viscid and small in quantity, the urine in the first glass will be cloudy, and the second perhaps quite clear. In some cases, however, it will be observed that, Avhile the first urine is cloudy and the second specimen clear, the third will be more or less faintly cloudy and may appear milky, and the specimen Avill give forth the odor of semen. In this event it is very probable that the final contraction of this prostate squeezed its follicles quite forcibly, and thus expelled some of their secretion. Examination of this rather exceptional third specimen will sometimes reveal the appearances just described of amyloid bodies, cylinder epithelium, etc. The condition of the prostate and of its secretion may be quite clearly made out by the procedure advocated by Von Sehlen.^ The patient urinates into two small glasses, thus leaving some urine in the bladder. He then leans forward, placing the trunk at right angles with his legs (Von Sehlen prefers the genu-pectoral position), and the surgeon with his 1 Op. cit. ^ " Zur Diagnostik und Therapie der Prostatitis chronica," Intern. Centralbl. der Harn- und Sexucd-organe, vol. iv., 1893, pp. 310 et seq. CONGESTION OF THE PROSTATE, ETC. 217 finger in the rectum kneads or massages the prostate. This operation causes the escape of prostatic fluid (if there is any) into the urethra. The patient then passes the remainder of the urine, which carries all this pressed-out secretion into the third glass. After settling the various spe- cimens of urine may be examined, and their contents studied in connection with the clinical symptoms. Treatment. — When, during gonorrhoea, symptoms of congestion of the prostate are observed, the patient should at once be put to bed and treated on antiphlogistic principles. The bowels should be kept free and the diet should be of gruel or bread and milk. In the case of strong individuals six or more leeches may be applied just in front of the anus, and the patient then put in a hot sitz-bath. No general rule can be laid down as to the use of heat or cold. In some cases heat gives marked relief, and in others cold acts equally as beneficially. Hot flaxseed poul- tices or the hot-water bag, with the intervention of some lint well moist- ened with water, may be applied to the perineum. In these cases very warm enemata act well on the prostate and free the rectum of fseces. In case cold is more grateful, an India-rubber bag filled with ice-water or broken ice may be applied to the perineum, on which a folded towel must be placed so that the intensity of the cold may be moderated to suit the patient's feelings. Injections of a few ounces of cold water at intervals into the rectum, the insertion of a small well-rounded piece of ice or irrigation, with the double catheter apparatus recommended by Finger, may be tried. From either heat or cold much relief may be obtained. All urethral injections being suspended, the patient may take the potassa- and-hyoscyamus mixture (see page 131), and drink freely of diluent waters of various kinds, according to the preference of the surgeon. Morphine or opium should be given generously, if necessary, by the mouth or in the form of suppository in order to relieve pain. In favorable cases, which are most common, resolution occurs within two weeks, and often in a shorter time. When the patient is up and around again he may be much benefited by lavages of a very mild solu- tion of nitrate of silver, gr. j-§viij— §xij, which should be given every second day, and every day if well borne and beneficial. If during the course of congestion of the prostate complete retention of urine occurs, it should be carefully drawn off". For this purpose an aseptic silk or lisle-thread catheter (which is both flexible and at the same time firm and very smooth), of a calibre of not more than 12 or 13 French scale, should be introduced into the bladder. The treatment of abscess of the prostate should be based on general surgical principles, together with the observance of strict antisepsis. The first essential is to determine, if possible, in which direction the abscess points. If the inflammatory swelling pushes into the urethraj the surgeon will very often have timely warning by reason of the difl^culty, and even impossibility, of urination which the patient experiences. In such cases the catheter must of necessity be used, and, fortunately, it very often causes the abscess to open and discharge. In desperate cases supra- pubic cystotomy with direct puncture of the abscess has been recom- mended, but it is a- question in my mind whether a patient so sorely tried as is a man having a severe prostatic phlegmon near the urethra could un- dergo the manipulation necessary for opening the bladder by this route. 218 OONOBBHCEA AND ITS COMPLICATIONS. While in general the abscess-cavity in the prostate granulates, con- tracts, and heals up without leaving a marked if any depression, it is well, if the organ remains swollen, as determined by rectal examination, to throw into the bladder hot boric-acid solutions or hot Thiersch's solu- tion once or twice a day. When the prostatic abscess points toward the rectum, it is always best to open it by an incision made with a long sharp bistoury directly in the median line, about half an inch in front of the anus. The fore finger of the left hand should be placed in the rectum, while the surgeon makes this incision, which before the withdrawal of the knife should be made sufficiently large for irrigation and ample drainage. When the abscess is so extensive that it has produced oedematous swelling in the anterior wall of the rectum, it may be punctured and evacuated by the introduction of the long curved trocar. After this ope- ration it is absolutely necessary to prevent the reaccumulation of pus by gentle massage with the finger-tip, and to irrigate the parts once or twice a day with hot boric-acid solution or Thiersch's solution. The treatment of aberrant forms of prostatic abscess should be based on the anatomical and pathological indications presented by each case. Periprostatic phlegmons should be treated in the same manner as those just considered. The local treatment of prostatorrhoea is in the main that of chronic posterior urethritis. When the affection is in an acute condition, so fre- quently seen in exacerbations, hot boric-acid solution may be of decided benefit. It sometimes happens that intravesical injections, even of the blandest nature, by the way of the posterior urethra, give rise to discom- fort, in which event they should be stopped, as Avell as all other operative interference. Later on lavages and instillations may be used with benefit. It is always well to remember that in these cases very strong solutions of any kind do more harm than good. Care also must be taken in the use of sounds, since in these cases over-distention is often productive of much harm and suffering. In the treatment of anaemic, neurotic, and neurasthenic subjects af- fected Avith prostatorrhoea all morbid indications should be sought for and efficiently met. Sexual hygiene is of the very first importance, and the surgeon should thoroughly familiarize himself with all facts relating to it and institute appropriate measures of relief. There is such a disparity of conditions in these cases that further amplification would occupy too much space. For such cases good food, fresh air, relaxation, and all good hygienic surroundings are great aids. Medication, good advice, and encouragement based on common sense will do much for the relief and cure of these chronic and often trying cases. INFLAMMATION OF THE SEMINAL VESICLES. 219 CHAPTER XXI. INFLAMMATION OF THE SEMINAL VESICLES. This aflFection, also called seminal vesiculitis (Dolbeau and Le Dentu), spermato-cystitis (Naumann), and gonecystitis (Gouley), though treated of more or less fully by Lallemand, Civiale, Gosselin, Fournier, Rapin, and others, was very little understood and very frequently unrecognized until within the past few years, and it is mainly through the writings of Mr. Jordan Lloyd ^ that an impetus in its study has been inaugurated. Mr. Lloyd claims that this affection is among the most common of the complications of gonorrhoea, and that its signs and symptoms are misun- derstood or misinterpreted and attributed to different organs altogether. It is well to bear in mind the structure, situation, and relations of the seminal vesicles. (See pages 52 and 53.) Seminal vesiculitis may be acute or chronic. The acute form has many points of analogy with epididymitis. Both affections are almost always secondary to gonorrhoea occurring in the third or fourth week, or to hypersemia of the posterior urethra due to masturbation and venereal excesses, or to inflammation of this region resulting from traumatism, catheterization, endoscopy, and strong injections. In both there is inflammation of the mucous membrane and hyperplasia of the connective tissue. In epididymitis the testicle does not swell, and in seminal vesicu- litis the prostate is not usually affected. In both cases suppuration, in the sense of abscess-formation, is the exception and resolution the rule. The symptoms of the acute form of seminal vesiculitis are quite simi- lar to those of posterior urethritis and to those given as diagnostic of the several varieties of prostatitis. The patient first experiences pain, either of a dull or throbbing character, or a sensation of weight, which he refers to the deep portion of the pelvis just within the anus or at the neck of the bladder or in the perineum. There is markedly increased frequency in urination, and tenesmus sometimes mild, again quite decided, and in some cases very severe. As the bladder fills the painful symptoms increase in severity, and there may be pain at the end and sometimes at the root of the penis. There may be fever, chills, and malaise. All these symptoms may be present in posterior urethritis, so that the crucial test in diagnosis is palpation of the prostate and seminal vesicles by means of the finger in the rectum. If the case is one of acute posterior urethritis, the pros- tate will be tender, even painful, on pressure, and perhaps swollen. If seminal vesiculitis is present and explored for early, one or both vesicles will be found to be much enlarged in all directions in the shape of a dis- tended leech, hot, brawny, and exquisitely tender. In a few days the ^ " On Inflammatory Disease of the Seminal Vesicles," Brit. Med. Journ., vol. i., 1889, pp. 882-884, and on "Spermato-cystitis (Inflammation of the Seminal Vesicles)," Lancet, Oct.. 31, 1891, pp. 974 et seq. The reader is also referred to an admirable chapter on the seminal vesicles and their pathology by Professor Gouley in his IJiseruses of the Urinary Apparatus, New York, 1892, pp. 263 et seq., and to the essay of Gu^lliot, Des Vesieules seminales, Anatomie et Pathologie, Paris, 1883. In this essay will be found a good bibli- ography of the whole subject up to the time of publication. 220 GONORRHOEA AND ITS COMPLICATIONS. swelling may still further increase, and then moderate fluctuation may be felt. In some of these cases the patient presents a pitiable spectacle. He suffers from pain in the perineum, rectum, bladder, and at the top of the sacrum. He has frequent desire to urinate, and the act is attended "with much pain, or, again, in some cases, there is very distressing dysuria. Defecation is very painful, and perhaps complicated with rectal tenesmus, and may be attended with vesical spasms ; sleep is heavy and unrefresh- ing, and often during the night painful erections and pollutions, perhaps bloody, may add to the patient's suff"erings. The urine may contain pus and epithelial cells, but these tissue-elements may be absent for hours or for days, during which the urine is clear ; and in this feature acute semi- nal vesiculitis diff"ers from acute posterior urethritis, in which the dis- charge of pus or blood is constantly seen. At the onset, and early in the course, of seminal vesiculitis the gonorrhoeal discharge may disappear entirely, and in this it resembles epididymitis. But in a short time the discharge reappears, and it may be more or less bloody. In seminal vesiculitis the blood is mixed with the pus or the latter is streaked with it, whereas in posterior urethritis the blood follows the act of urination, or there may be a worm-like thread of coagulated blood with the first jet of the urine. The inflammatory stage of seminal vesiculitis usually pursues a course similar to that of epididymitis, and at the end of a week or ten days the symptoms become ameliorated and resolution gradually sets in. In all probability, in many cases the parts sooner or later become normal again. In some cases after resolution of the vesicular inflammation the urethral discharge reappears, while in others the urethra is left in a healthy condi- tion. In this acute stage of inflammation the morbid process resembles that of gonorrhoea in the redness and swelling of the mucous membrane and in the submucous cell-increase. When, however, the phlegmasia becomes intense, a true suppurative process or abscess forms, in which event the local and general symptoms are more pronounced and the suffer- ings of the patient greater. Rectal exploration then reveals a large boggy, painful SAvelling at the base of the bladder, beyond and to the outer edge of the prostate. This swelling is very large when both vesicles are involved. Dr. Gouley's remarks on this subject are very pertinent. He says: " If the swelling is in the form of a single, hard, oblong tumor extending from the base of the prostate upward, backward, and outward, the pre- sumption is that the phlegmasic process has not extended beyond the proper capsule of one vesicle. If, however, there is a diff'use, doughy swelling extending beyond the median line, it is likely that both vesicles are involved, that perforation of their walls has taken place, and that the ambient connective tissue is infiltrated." While the ejaculatory duct of the seminal vesicle remains patulous the contained pus may escape, or perhaps may be milked, by means of the finger-tip, into the urethra, in which event full resolution without ulterior bad results may occur. If, however, the duct becomes occluded by the swelling of its mucous membrane or by being plugged up by sympexia or masses of mucus dislodged from the diverticula of the vesicle, the abscess may attain a very large size, and the pus may perforate its wall and burst into the ischio-rectal fossa or around the rectum into the bladder, the INFLAMMATION OF THE SEMINAL VESICLES. 221 rectum, and the peritoneum, sometimes causing death, and generally lead- ing to the formation of fistulous tracts which are very difficult to cure. Mr. Mitchell Henry ^ reports the case of a sailor who simply com- plained of pain in the loins and hip, the joint of which Avas painful on motion. The urine was loaded with pus and blood. Acute peritonitis developed and caused death. At the autopsy an abscess of the left semi- nal vesicle was found, the pus of which had first burst into the bladder and then into the peritoneum. A similar case was reported to Mr. Henry by Mr. Cock. Velpeau ^ reported the case of a young man suffering from gonorrhoea who had abscess of the seminal vesicles which perforated the recto-vesical cul-de-sac, causing peritonitis and death. A similar case is reported by Peter,^ in which peritonitis originated in an abscess of the seminal vesicle. It is probable that seminal vesiculitis may eventuate in hydrocele of these diverticula. Dr. N. R. Smith * reports the case of a man having a pyriform tumor occupying the cavity of the pelvis and extending above the umbilicus. This tumor was situated behind the bladder and in front of the rectum. It was regarded at first as a distended bladder. A catheter being passed, an ounce of perfectly normal urine was obtained. On push- ing the catheter upward and forward the tumor glided upward. The finger in the rectum found a normal prostate, and on its left an elastic tumor, pressure on which caused motion of its fluid to be appreciable on the abdomen. Ten pints of a brown serous fluid were drawn. The cyst disappeared after two tappings. Dr. Ralph ^ describes a similar case in which this condition was verified at the autopsy. Mr. Lloyd states that the abscess never ruptures into both bladder and rectum. In any of these very painful events examination of the parts is necessary, and from it the line of operative procedure will be arrived at. The intimate relations of the vas deferens, the ejaculatory duct, and the seminal vesicles are such that the last structures and the testicles may be involved at the same time. It is probable that in many cases seminal vesiculitis and epididymitis coexist, but that the violence of the svmp- toms of the testicular trouble masks that of the vesicular affection. It is also very probable that the intrapelvic pain which so frequently accom- panies acute epididymitis, and which we have been taught is due to a complicating phlegmasia of the pelvic part of the vas deferens, is some- times really symptomatic of involvement of the seminal vesicle. There is a field for observation in this direction, and much may be learned from digital exploration of the rectum in cases of acute testicular inflammation. The statement of Mr. Lloyd that this affection is a common accompani- ment of gonorrhoeal epididymitis needs confirmation. It can be readily understood, after a consideration of the foregoing facts, why acute seminal vesiculitis has often been wrongly diagnosticated as posterior urethritis, as acute prostatitis, and by many, under the influence of old ideas, as inflammation of the vesical neck and floor of the bladder. Chronic Seminal Vesiculitis. This form of seminal vesiculitis may result from the non-occurrence 1 Med.-Chir. Transactions, vol. xxiii. p. 307. ^ Med.-Chir. Rev., 1857, vol. i. p. 270. ^ L' Union medirxde, 1836, x. p. 562. * Lancet, vol. ii., 1872, p. 559. * Ibid., vol. ii., 1876, p. 782. 222 GONORBHGEA AND ITS COMPLICATIONS. of resolution in the acute affection, and in this event the clinical his- tory is tolerably clear and striking. But in the majority of cases of chronic seminal vesiculitis it begins as a low-grade inflammatory pro- cess in persons, particularly of neurotic or neurasthenic types, who may suff'er from chronic subacute posterior urethritis or chronic prostatitis, and! in confirmed masturbators and in those given to excessive venery and alcoholics. The difficulty in the study of the chronic form of seminal vesiculitis is that in many cases the symptoms are so few and so vague, and point so indefinitely, if at all, to trouble in these vesicles, that often- times their origin is not suspected by the physician. Then, again, cases are seen in which the symptoms are very clearly and strongly marked, yet they may be with seemingly good reason attributed to trouble in the pos- terior urethra and in the prostate. Cases of seminal vesiculitis which follow quite directly a recent or more or less remote attack of gonorrhoea very often present such a group of symptoms that the surgeon is led to suspect their origin in inflammation of the seminal vesicles, particularly if no trouble is found in the posterior urethra. Such patients state that since an attack of gonorrhoea or a relapse they have not felt well as regards their sexual organs. Some complain that they are sexually weak, that they have little desire, or that they have premature and perhaps painful ejaculations, which in some cases are mixed with blood. Others, again, are subject to a constant slight or profuse discharge Avhich is of a mucous or muco-purulent character. Again, this form of discharge may be intermittent. There may be, how- ever, a decided chronic seminal vesiculitis without any discharge which is perceptible. Not infrequently patients having a history of one or more attacks of gonorrhoea state that they suff'er with a mild or moderately severe, even burning, pain or itching, or a sense of weight in the course of the urethra, in the perineum, bladder, anus, and. rectum. In addition to this they often give a history of sexual erethism with or without grati- fication in coitus, and sometimes of increased desire, while little relief, and even aggravation of symptoms, may follow the sexual act. Gouley lays stress on the occurrence of painful spasmodic contracture of the anal sphincter both in acute and chronic seminal vesiculitis. He very rightly calls attention to spermatic colic due in all probability to the lodgement of sympexia, retained semen, and mucous masses or plugs in the duct of the vesicle. In the cases of pronounced masturbators, in those given to excessive sexual indulgence, particularly with the addition of alcoholic excesses, chronic seminal vesiculitis may sometimes be found. These cases are often those of anaemic, neurotic, and neurasthenic subjects who respond very indifferently to treatment. Such patients may complain of some pain or disturbance in the urethra, bladder, anus, or rectum, and they may present a discharge ; then, again, all these symptoms may be Avanting. Most of them, however, give a history of a disturbance in the sexual function similar to those just detailed. These disturbances are mainly of two forms : first, those of lowered poAver, and, second, those of erethism of the sexual organs. In the first order of cases we find absence or in- completeness of erections, pollutions from slight causes, Avithout enlarge- ment of the penis. In these cases there is often a haunting desire for erection, with no response. Very often these patients suffer from a con- INFLAMMATION OF THE SEMINAL VESICLES. 223 stant dribbling of a dirty gray or brownish mucus, Avhicli may during the day be so copious as to saturate one or two pocket handkerchiefs. Then, again, some of these patients have no such discharge, but an emission of a thin, gray, watery, and sometimes brownish and even curdy fluid occurs daily or more frequently. Such is the erotic condition of these patients that the sight of a pretty woman, of her breast or her ankle, throws them into a high state of nervousness and sexual erethism. I have known several instances in which one woman only exerted this morbid influence upon the man. Accidental slight contact, the glance of the eye, the sound of the voice, and the grasp of the hand served to so excite and exalt them sexually that an orgasm, with or without partial erection, would result. These cases run a somewhat peculiar course. In some the symptoms and conditions continue in a more or less subdued manner, and, though they disturb the patients considerably, the latter arrive at a state of mind by which they bear their troubles more or less philosophically. In this class of cases the affection runs on from year to year in a monotonous way. Such patients are neither healthy nor very sick. But cases are sometimes seen in which the chronic, uneventful course of the afl"ection is varied by the development of more or less severe exacerbations. In this event the health becomes deteriorated, the patients lose their appetite and weight, and present the appearance of very weak and sick men. Con- comitantly with this condition the nervous system becomes much dis- turbed and the patients present the symptoms of neurasthenia. A nerv- ous apprehension and anxiety are very frequent concomitants. Such an exacerbation may last one month or many months, and may lead to per- manent invalidism. In old men suff'ering from hypertrophy of the prostate a low grade of seminal vesiculitis is a not uncommon concomitant. In many of these cases the vesicular complication passes unnoticed, for the reason that it may give rise to no symptoms at all, or, if present, they are not pro- nounced in character. Then, again, they may be masked by the dis- turbances produced by the prostatic aifection. Tuberculosis of the seminal vesicles will only be touched upon lightly here. The onset of the aff'ection is attended with moderate and not well- defined symptoms, which are frequently referred to the posterior urethra and the prostate. When the aff'ection begins, as it rarely does, primarily in the vesicles, the symptoms may be for some time so mild and vague that they are not understood. Beginning in the prostate, as so commonly occurs, tuberculosis either goes backward to the vesicles or downward to the testicles. With the involvement of the posterior urethra the symp- toms are increased frequency of micturition, pain with the act, occasional hemorrhages, and a purulent discharge. With the extension backward to the seminal vesicles these symptoms become more pronounced. The rectal touch then shoAvs that the prostate is swollen and hard, with well- defined borders and an irregular nodulated surface, on which there may be spots Avhich feel soft. At the distal end of the prostate the seminal vesicles also are swollen. In the early stages of the process that portion only which merges into the prostate is thickened, hard, and perhaps nodular. With the further extension of the disease the whole organ becomes enlarged, hard, uneven, and nodulated. This period of density 224 OONOBRHCEA AND ITS COMPLICATIONS. and nodulation of the vesicles may be only transitory, and there is left a voluminous, smooth, and perhaps doughy tumor. Richet compares the sensation conveyed to the finger-tip to that of sebaceous cysts or to a pocket injected with tallow. This sensation is due to the softening of tuberculous matter. Guelliot emphasizes the point that induration and nodulation are not, as we have been taught, absolutely constant in tuber- culosis of the seminal vesicles. Out of fifty cases examined by him, he only observed these signs eight times. In addition to the symptoms already given of tuberculosis of the seminal vesicles (and it must be remembered that this aifection is gener- ally a concomitant of a similar process in the prostate), there is much sexual erethism. In some cases the genital excitation amounts even to torment. Erections are strong and constant, desire for coitus is con- tinuous and imperative, and pollutions are frequent. This excitation is the outcome of the hypergemic condition of the infective process. As degenerative changes take place in the tissues the condition changes, the desire slowly abates, and finally the genesic function is wholly lost. This form of genital tuberculosis is usually concomitant with involvement of other vital parts which in the end leads to death. Cases are on record, however, which go to show that tuberculosis of the seminal vesicles may undergo degenerative changes — caseation and absorption, followed by atrophy and fibroid degeneration. There is an important point in the clinical history of chronic seminal vesiculitis concerning which our knowledge is very limited, and which requires much future study on a scientific basis. This may be formulated in these questions : Is chronic seminal vesiculitis the starting-point of tubercular infection ? and about how frequently does this infectious com- plication occur ? It is as reasonable to suppose that a chronically inflamed seminal vesicle may become tuberculous as it is that an epididymis simi- larly affected may be, and Ave know that such is sometimes the case. But as regards the seminal vesicles we have little knowledge of a scientific nature.^ Diagnosis. — The diagnosis of seminal vesiculitis, in whatever form it may exist, is to be arrived at mainly through palpation of the parts by the finger inserted into the rectum. It has already been shown how little light the subjective symptoms throw upon the nature of the trouble. It is not, as a rule, as easy as it is claimed to be by some to make out clearly the outlines and dimensions of the seminal vesicles. In the examination some authors state that the patient should bend the body forward as far as he can, his feet being about a foot apart. It is always well that the bladder should be full, for in that condition the vesicles are more readily ^ In an interesting essay Dr. E. Fuller (" Persistent Urethral Discharges dependent on Subacute or Chronic Seminal Vesiculitis," Journal Cutaneous and Ge)iito-iirina.ri/ Dis- eases, June and July, 1894) reports 22 cases of chronic seminal vesiculitis, in 7 of which he thinks that there was tubercular involvement. This subject is so important that we must insist on strong proof before accepting statements regarding it. There is no abso- lutely clear history in Dr. Fuller's cases of a coexistent tubercular affection elsewhere in any of his patients, except in three cases, and in them it is vague, and the diagnosis is mainly based on the patient's poor condition, the failure of stripping of the vesicles to cure the trouble, and the improvement under good hygiene and nutritive treatment. On so important and yet so obscure a subject we should be slow to make dogmatic statements regai-ding tubercular complication, knowing, as we do. that seminal vesiculitis is not infrequently a concomitant of a state of ill-health which may even be alarming. INFLAMMATION OF THE SEMINAL VESICLES. 225 detected. Then the finger (which should be a long one) is introduced into the rectum, and then, having defined the outline of the prostate, the vesicles are sought for above and to the outside of this body. This examination can also be made with the patient on his back in the lithotomy position, in which event the bladder, being full, tends to sag down in the pelvis. It is easy to conceive that in some patients in the bending-forward-and-standing position the bladder may tilt forward toward the abdominal Avail, and then the vesicles will be more inacces- sible. At the prostate the two vesicles approach to within a finger's breadth of one another, and on the inner side of each is the vas deferens, which at this part frequently becomes much ampullated. I myself think that very often this ampullation of the vas deferens, which may be increased in size by the gonorrhoeal or chronic hypergemic process, is mistaken for enlargement of the seminal vesicles. It certainly is next to impossible to say from rectal examination in life that the vas deferens is not swollen and the vesicle is. These parts are in such intimate juxtaposition that it is nearly impossible to distinguish between the two. It is important, also, to have a good knowledge of the structure and physical characters of the vesicles in their normal state. To this end study on healthy men is necessary. The seminal vesicles in health have a firm, somewhat resistant structure, which, while not presenting a brawny feel to the touch, gives the sensation of having tolerably thick walls. Therefore the surgeon must not enter upon the examination with the idea that he is to feel two oblong, rather soft, and readily-compressible little bladders. If diseased, the seminal vesicles will, in the acute stage, feel much swollen in all directions, tender, perhaps hot, and may present a doughy sensation, like that of the over-filled leech. In the stage of abscess the swelling will be great, the pain intense, and the symptoms severe and pointing to intrapelvic trouble. In the chronic forms a large flabby tumor may be felt. If both ves- icles are involved, the base of the bladder beyond the prostate is the seat of the tumor, which is usually of goodly size, often very large. Abdom- inal pressure, exerted deep down and toward the pelvis, may often afford much aid in these examinations. Some authors lay stress upon the pres- ence of a sound in the bladder, pushing it base downward toward the rec- tum, as being of great help to the finger in the rectum. Perhaps in some cases this procedure may be admissible or practicable, but it should never be resorted to without due thought concerning the nature of the case and the state of the deep urethra and prostate. In all acute cases the intro- duction of the sound as an accessory aid to diagnosis is strictly interdicted. In chronic cases the surgeon must always remember that the posterior urethra may be the seat of a low grade of inflammation, and that the prostate may also be at least hypersemic. This same caution applies very strongly to the cases of old men who are suffering from enlargement of the prostate and also from a chronic inflammatory condition of the seminal vesicles — a complication which is sometimes met with. Examination and manipulation of the seminal vesicles by means of the finger-tip cause a flow of pus, with perhaps blood, into the urethra when the inflammation is recent and active. In the subacute cases the discharge is muco-purulent and mucoid, containing masses of inspissated semen, 16 226 GONORBHCEA AND ITS COMPLICATIONS. masses of mucus, sympexia, and sometimes very minute calcareous con- cretions. Pathology. — In the acute gonorrhoea! stage it is probable that the lesion of the mucous membrane is similar to that of gonorrhoea of the urethra. This is a field worthy of careful study. As yet the observa- tions have been macroscopical rather than microscopical. In the main, the morbid process consists of swelling of the mucous membrane .and small-cell thickening in the submucous connective tissue. The vesicles then may be much dilated, or, again, they may, by contraction of the newly-formed tissue, become much shrivelled. Within the vesicles a brownish mucus, muco-pus, spermatozoa alive or dead, sympexia, and calcareous concretions may be found. Gouley states that of sixty dissec- tions of the seminal vesicles made in cases of prostatic enlargement, in three-fourths of them the vesicles were shrivelled and hard. Cancer of the seminal vesicles is very rare, and usually secondary to involvement of the prostate, testicles, bladder, a'hd, very rarely indeed, of the rectum. Gu^lliot could only report one case in which it was probable that the malignant process began primarily in the vesicles. Out of 13 cases of secondary cancer of these structures, he found it consecutive to cancer of the testicles in 1 case, to cancer of the rectum in 1 case, to can- cer of the bladder in 3 cases, and to cancer of the prostate in 8 cases, Gouley alludes to one case, but gives no particulars. Zahn, according to Kocher,^ has reported a case which he believes to have been one of pri- mary sarcoma of one seminal vesicle. The patient was seventy-six years old, and his urine was passed by drops. At the autopsy infiltrations of sarcoma, which were regarded as secondary, were found in the heart, mes- entery, and small intestine. The prostate was healthy, but both seminal vesicles were enlarged and infiltrated with round and spindle-shaped sar- coma-cells. Prognosis. — In the acute form of this trouble resolution usually takes place. In the chronic forms amelioration and cure may be obtained. In some cases, however, the morbid process goes on to the formation of large tumors which require operative measures. Tubercular infiltration of the seminal vesicles may perhaps undergo resolution or lead to cicatrization or caseation, but in most cases it is continuous with or concomitant to a similar aflFection of other organs, and in the end death results. In malig- nant new-growths a lethal outcome is inevitable. Treatment. — -When recognized in the acute stage, seminal vesiculitis is to be treated on the general principles which govern the management of all phlegmasise of the genital and urinary organs. Hughes of Dublin recommends the application of three or four leeches to the anterior wall of the rectum (previously cleansed and disinfected) near the vesicles. This procedure will always be found to be difiicult and disagreeable, so that the best plan is to apply a large number, of leeches upon the peri- neum and the murgin of the anus. Injections of cold water may be used, and the rectum may be packed with ice if the procedure is pleasant to the patient. Opium in suppositories, diluents, and saline cathartics may be administered as necessity requires. Should an abscess form, it may be reached by means of a long incis- ion, as suggested by Mr. Lloyd, in the perineum just anterior (about ^ Die Krankheiten der Mannlichen Geschlechtsorgane, Stuttgart, 1887, pp. 638 et seq. INFLAMMATION OF THE SEMINAL VESICLES. 227 three-quarters of an inch) to the anus, great care being taken that the membranous urethra, the prostate, and the rectum are not cut. In this operation much aid will be given by means of the finger in the rectum. The incision may be made in the median line laterally, or, if both vesi- cles are the seat of acute suppuration, it may be crescentic. Then the dissection between the base of the bladder and the rectum must be cau- tiously made. The resulting cavity should be treated on general surgical principles. When the abscess is not large, but is well defined, Gouley recommends that the "parts should be brought to view by means of a Sims speculum in the rectum, and a slightly-curved aspirating needle, not less than two millimetres in calibre, should be thrust into the abscess and the cavity quickly emptied, and then well irrigated with a warm subli- mate solution (1 : 5000). A single aspiration may sufiice, but in case the cavity refills the aspiration and irrigation should be repeated." In more acute and extensive abscesses Gouley recommends free incis- ion through the rectal wall, followed by careful antiseptic packing. If these operative procedures through the rectal wall are adopted, it is im- portant to remember that the after-treatment must be conscientiously carried out, bearing in mind the great danger of sepsis and the possibility of the formation of fistulae. In the treatment of chronic seminal vesiculitis, in which we may find distended pouchy vesicles, much stress has recently been laid by Dr. E. Fuller ^ upon what he terms stripping or milking the vesicles. This pro- cedure is accomplished by the finger-tip gently but firmly pressing or kneading as much of the organ as is within reach from above downward, so as to express the contents through the ejaculatory duct into the pros- tatic urethra. Fuller causes the patient to bend his body at right angles to his lower extremities, and in this position he introduces the finger, all the while making counter-pressure on the abdomen, the bladder being, if possible, well filled. Should there be resistance of the perineal muscles, it is recommended that the surgeon should rest his foot on a chair, then, with the knee well braced against the elbow, such firm and continuous pressure may be exerted as will enable the surgeon's finger to reach the vesicle, the resistance of the muscles having been overcome. By this manoeuvre Fuller thinks that he has succeeded in some difficult cases. As has already been said, it is no easy matter in many cases to reach the vesicles and clearly define their size and shape, even when every favoring condition is present. Then, again, at the best, only the lower half of the vesicle is really accessible to the stripping process. Further than this, it must be very clearly remembered, as has already been pointed out, that the seminal vesicles are made up of blind-ended tubes or diverticula, and that they have not the structure and arrangement of racemose glands, firm pressure on which will cause the contents to exude into the excretory duct. An inspection of Fig. 30 will clearly show that it is a physical impossibility to cause the contents of the third tube — or, as we call it, the handle of the jack-knife — to exude into the urethra, for the reason that it is a blind sac or pouch, its non-patulous part ending downward near the prostate. This portion of the vesicle is fully as large as the other two-thirds are, and the contents of this large part cannot in any way be extruded into the urethra. For anatomical reasons it will be ^ " Seminal Vesiculitis," Journ. Cut. and Gen.-urin. Diseases, Sept., 1S93. 228 GONORRHCEA AND ITS COMPLICATIONS. clearly seen that the utmost that can be accomplished in stripping or milking a vesicle is to act upon about one-quarter of its whole structure. I have no doubt that the ampullation of the vas deferens, which is so common near the prostate, has often been mistaken for enlargement of the seminal vesicles. In theory, stripping the vesicles seems to be a rational treatment, in that it seeks to rid these organs of retained chronic inflammatory matter and to restore the tone in muscular and mucous tis- sues which have become relaxed and flabby. Undoubtedly, in some cases benefit may result from the proceeding, but as yet the cases in 'which it has been employed are so small in number and so wanting in conspicu- ously brilliant and uniform results that it must for the time be considered simply as a therapeutical suggestion, and it is for the future to determine the extent of its worth. Certainly the muscular movements of urination, defecation, and emission must and do produce much efl"ect upon the condi- tion of the seminal vesicles, and in all probability the normal state of these sacculated appendages is largely dependent upon these normal ^' strippings" and "milkings." The treatment of the cases of chronic seminal vesiculitis in which there is neurasthenia, debility, and often great mental depression belongs largely to the domain of general medicine. Such cases require good hygiene — if possible an entire change of scene, rest, and pleasant sur- roundings. Tonics combined with nux vomica and ergot produce much benefit. Iron, quinine, and coca are also indispensable in some cases. The urethra, bladder, prostate, and seminal vesicles should be very care- fully examined by instruments and by inspection of the urine. If there is, as so frequently happens, a coexistent posterior urethritis, this should be properly treated. I have seen cases of cure in which the foregoing measures have been carried out. Then, again, only amelioration of the symptoms may be produced. In some cases the health seems to be re- stored for a short or long period, and then a relapse occurs and the whole treatment has to be repeated. In the treatment of large hydroceles of the seminal muscles one or more tappings above the pubis may eff"ect a cure. In cases of abscess- formation the cyst, which is usually of large size, must be reached through an abdominal incision, well sterilized, packed Avith gauze, and allowed to heal from the bottom. CHAPTER XXIL EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS (SWELLED TESTICLE). The most frequent complication of gonorrhoea is an inflammation of the epididymis which may be sharply limited to that appendage or it may also involve the testicle. The former is called "epididymitis," and the latter "epididymo-orchitis," and both are known under the title "swelled testicle." In some cases of swelled testicle there is a concomitant inflam- EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 229 mation of the vas deferens in more or less of its extent, and to this phleg- masia the terms " deferentitis " and " funiculitis " have been applied. This complication is also called, less correctly, " inflammation of the sper- matic cord" when that portion near or in immediate continuity with the epididymis is involved. Acute inflammation of the tunica vaginalis, with a greater or less amount of efl"usion, also occurs in cases of swelled testicle, particularly when the morbid process is centred in the epididymis. In former years swelling of the testicle in the course of acute and chronic gonorrhoea, and as a result of instrumentation in the urethra, was explained by such vague and unsatisfactory terms as sympathy, reflex action, and metastasis. In the light of our present knowledge of the gonorrhoeal process these hypotheses have no scientific worth whatever. The testicular inflammation results undoubtedly from the extension of the gonorrhoeal process into the utriculus masculinus, and from there into the ejaculatory duct, the vas deferens, and testis. Though the anatomical and clinical facts thus far in our possession do not clearly show that the inflammation creeps step by step along the mucous membrane of the whole length of the vas deferens, there can be no doubt that such a pathological condition does take place. Reasoning by analogy in the light of the undisputed fact that the gonorrhoeal process begins at the fossa navicu- laris, and passes backward by direct continuity of tissue, and not by jumps, to the bladder, it is fair to assume that this process further spreads along the whole length of the vas until it reaches, and in most cases local- izes itself in, the testis. Why the whole length of the vas deferens is not rendered swollen, inflamed, and painful in each case, together with the testis, we cannot say. That the inflammation may be arrested along the canal at various parts there can be no doubt. In the majority of cases of epididymitis, as we have seen, the gonor- rhoeal process first invades and localizes itself in the posterior urethra, from which it spreads to the testis. Jadassohn ^ and Neisser ^ both claim that the epididymis may be attacked, while the posterior urethra yet remains intact. Neisser says " that patients may sufi'er from epididy- mitis without there being any possibility of finding gonococci or even an inflammation in the posterior urethra, even if examinations are frequently repeated. I do not know how the gonococci get there, but the fact is certain." Jadassohn says : "The bacteria which have reached the pos- terior urethra may have been carried away by the stream of urine, whilst those already in the ejaculatory duct are safe in this respect ; or by the inflammation of the epididymis the catarrhal process in the posterior urethra may have been brought to an end for a time or finally, as also happens in the anterior urethra." I have seen and carefully examined a case of epididymitis in which I could not at any time, even remote, discover any evidence whatever of involvement of the posterior urethra. So it may be that in some cases, as the infective process travels along the vas deferens toward the testis, it wholly ceases in the posterior urethra. We certainly see cases of men who after gonorrhoeal epididymitis have no longer any urethral discharge, and never thereafter any relapse of their gonorrhoea. ^ Op. Ci7., pp. 188 and 189. ^ " Zur Bedeutung der Gonorrhoisclien Prostatitis," Verhandl. der Deut. Dermat. Oesellschaft, Wien und Leipzig, 1894, pp. 325 et seq. 230 GONOBBHGEA AND ITS COMPLICATIONS. There is very frequently in cases of epididymitis and epididymo-orchitis a swollen and painjpul condition of the vas deferens as it leaves the epi- didymis and ascends. This swelling of the vas may extend an inch and even more up the tube. It is usually lost sight of by reason of the greater prominence and painfulness of the testicular phlegmasia. Bergh of Copenhagen,^ an acute and accurate observer, in two series of cases of gonorrhoeal epididymitis, numbering in all 348, found coexistent localized involvement of the vas deferens in 182 cases. This same complication was studied by Hassing,^ who found the proportion still higher. Swelled testicle, therefore, may consist only of inflammation of the epididymis, but this is usually complicated with acute inflammation and more or less copious efi'usion into the cavity of the tunica vaginalis. This combination, with in some cases some involvement of the vas deferens, constitutes the majority of the cases of swelled testicle from gonorrhoea. The less common combination is inflammation of the epididymis and testis, in which case the tunica vaginalis is very apt to be affected, with perhaps a limited invasion of the vas deferens. Until within the last few years the statement was made and quite gen- erally accepted that swelled testicle appeared as a complication in the third week of gonorrhoea, chiefly toward its end, and then rather less frequently in the three following weeks. Cases, of course, were observed in which the complication appeared later. This statement, that the testicle became affected chiefly in the third week, was based on the erroneous idea that gonorrhoea, as a rule, travelled back leisurely, and if it reached the pos- terior urethra at all, it did so generally in the third week. This view has been shown to be incorrect (see page 123), since in most cases the onward advance of the gonorrhoeal process is very prompt, and it is the rule rather than the exception that the posterior urethra should be attacked. The date of the onset of epididymitis has been carefully studied by Bergh in 926 cases, as will be seen in the following table : Appearance of Cronorrhoeal Epididymitis. In th e 1st -^^ 'eek in 70 cases. In the 4th month in 19 cases. a 2d 229 " oth " 7 " H 3d 176 " 6th 15 " (C 4th 135 " 7th " 1 " 11 5th 79 " 8th 2 " a 6th 52 " 9th 5 " a 7th 39 In 1 year in 3 " 11 8th 23 " IJ years in 2 " ti 9th 32 " 2 2 " u 10th 11 " 3 " 3 " a 11th 12 926 cases. « 12th 9 In these 926 cases the testicular complication developed in the first three weeks in 475 cases, which is rather more than one-half of the whole num- ber. Now, when it is remembered that gonorrhoea usually lingers for a day or two, and perhaps longer, in the prodromal stage at the fossa navic- ularis, it will be seen how promptly the testicle was attacked in so many cases in which we may deduct one, two, or, exceptionally, three days. • All ^ "Beitrag zur Kenntniss der Entstehung der Urethritischen Epididymitis," Monats- hefte fur Prac. Dermat, 1884, pp. 161 et seq. ^ See Bergh's essay. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 231 these figures are in support of the view that gonorrhoea promptly spreads backward and invades the posterior urethra. It does not follow, however, that the infective process will pass through the ejaculatory ducts and down to the testes. This further extension may perhaps depend on the condition of the openings of the ejaculatory ducts. If these openings are lax and patulous, the infection may readily pass into them and onward. On the other hand, if the calibre is small and they are tightly compressed, they may not offer a favorable condition to the spread of the inflamma- tion. It is difficult otherwise, then, on these anatomical grounds to ex- plain cases in which in every attack of gonorrhoea the testis is aff"ected, and why in some cases where there has been no extraneous source of irri- tation or injury of the parts the extension of the phlegmasia has been so prompt. It must be remembered that in many cases the spread of the disease is due to hard work, violent exercise, to excesses, alcoholic and sexual, and to the intemperate use of very active treatment, perhaps with a view of aborting the disease. Summing up the results of the observations of Bergh, which are fully in accord with my own, and which further have the support of the statis- tics furnished by Unterberger,^ it may be said that within the first three weeks of gonorrhoea the testis is attacked in the majority of cases of swelled testicle, and that between the fourth and sixth weeks, inclusive, it is attacked rather less frequently. Thus there were 475 in the first three weeks, inclusive, and 266 cases between the fourth and sixth weeks, inclu- sive. These, therefore, are the periods in which acute gonorrhoeal inva- sion of the testis most frequently occurs. When epididymitis develops after this period of six weeks, which corresponds to the period of decline of the gonorrhoea, it is usually the result of some extraneous influence acting on the disease in the posterior urethra. Double epididymitis sometimes occurs, in which case usually the second testis is attacked from one to three weeks after the first one. In some cases, however, the second testicle is not involved until later — eight, ten, or even twelve weeks. An epididymis or testis once the seat of gonor- rhoeal inflammation is thereafter very liable to be affected with each repeti- tion of the infection, and also when a chronic deep urethral inflammation undergoes an exacerbation and an acute condition results. Further than this, mechanical injury, over-exertion, undue pressure on the testis, may for years after light up a more or less severe recrudescence. Cases have been reported by Castelnau, Vidal, and others in which epididymitis developed from three to ten days before the appearance of the urethral discharge. Bergh speaks of two cases in which epididymitis appeared in four and six hours after a violent coitus, and in Avhich the discharge appeared several days later. These cases used to be looked upon as curiosities, and the pathological conditions underlying them Avere not clearly grasped. Their pathogenesis, however, is not difficult of explanation. In all such cases there has been a previous antecedent gonorrhoea which has left a latent posterior urethritis. In sexual and alcoholic excesses this latent condition becomes an acute one, and for some reason, perhaps anatomical, the phlegmasia travels through the ejacula- tory duct into the testis before it spreads forward and invades the anterior ^ " Zur Frage iiber den Zeitpunkt des Auftretens des Epididymitiden, etc.," Monatshefte fiir Prak. Dermal., 1884, vol. iii. pp. 97 et seq. 232 GONOBBHCEA AND ITS COMPLICATIONS. urethra. As we have seen (see page 168), a latent posterior urethritis may undergo exacerbation, and the inflammatory process may in one or several days spread into the anterior urethra. There is nothing inexplic- able or wonderful, therefore, in cases in which the testis is attacked before the urethral discharge appears. In years gone by there was much discussion as to which testis, the right or the left, was more frequently the seat of gonorrhoea! inflamma- tion. It was claimed that the condition of the veins on the left side, and the fact that men " dressed " on that side, tended to produce inflammation in that testis. Others, again, claimed that the right testis was more fre- quently affected than the left. It seems strange that such a minor point should cause so much discussion and give rise to such a formidable array of statistics as it did. From my own experience I am inclined to agree with Bergh, who has gone quite carefully over the subject, and who says that on an average both epididymes are attacked in about the same pro- portion. There is great discrepancy in the statements of authors as to the fre- quency of swelled testicle in gonorrhoea. The truth is, that no general statement can be nnade. Hospital statistics always show a large percent- age, for the reason that in very many cases poorer patients, owing to the severity of the aff'ection, are forced to enter them. In dispensaries and clinics the proportion is also quite large, but patients who frequent them are men who have to work hard and cannot spare themselves, Avho are careless in their habits, perhaps given to drink, and who often induce the disease by the intemperate use of balsamics and injections. In private practice, particularly among the middle and upper classes, swelled testicle cannot be said to be common. As a general rule, it may be said to depend very largely on the method of treatment followed. Active interference in the acute stage, aggressive attempts at aborting the disease, the too early use of balsamics and strong injections, are the under- lying causes of many cases of swelled testicle. On the other hand, a mild and palliative treatment in the acute stage tends to make the per- centage of these cases quite small. Bergh is disposed to think that in private practice in each 100 cases of gonorrhoea 7 will become affected with swelled testicle. In my judgment and experience this percentage is far too high : I think even 3 per cent, a high figure. Symptoms. — Before the onset of the affection the urethral discharge usually, but not always, ceases, and patients complain of varying symp- toms. In some a pain in the groin, at the external ring, and along the vas deferens, either in the external or in the pelvic segment, is complained of. In somewhat rare cases pain is experienced in the whole length of the vas deferens. Some patients even complain of a pain which reaches to the kidney. In some cases the pain seems to be at first in the deep urethra or in the- seminal vesicles, and these patients sometimes suffer from pollutions Avhich may be painful and bloody. The most common history given by patients is that they felt at first a dull pain and a sensation of weight in the scrotum, which they perhaps attributed to cold or to a strain or jarring motion. In general, there are no premonitory constitu- tional symptoms, but as the intensity of the inflammation increases a chill and fever of various degrees, with malaise, waiit of appetite, great thirst, EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 233 a frequent desire to urinate, and perhaps constipation, may supervene. As a rule, the systemic reaction is not great, but in very severe cases, and particularly those in which the vas deferens is involved, there may be well-marked fever with all its concomitants — namely, hot skin, coated tongue, rapid pulse, together with nervousness and agitation. In some rare cases there are nausea and vomiting. The invasion of the affection may be prompt or slow. Many patients walk and attend to their duties with mild and bearable discomfort for one or more days before they are forced to assume the recumbent position. In other cases, particulai'ly those in which one or more exciting causes are active, the affection is well under way and the patient on his back within twenty-four hours. Early examination of a case shows that the epididymis, with perhaps the vas, is swollen and painful, and that the scrotum over it is somewhat reddened. In some cases the pain and swelling are confined to the globus minor or tail of the epididymis, which becomes of the size of a hickory-nut, and the affection may thus be limited : usually, how^ever, the body and globus major or head of the organ are promptly involved. Then a large tumor is found seated superiorly and posteriorly to the testis, and the furrow which naturally exists between that organ and the epididymis may be present or it may be obliterated. The shape of the tumor varies in dif- ferent cases. The epididymis, becoming enlarged, may cover the testis like a cap, or it may grow longitudinally and form a semilunar tumor, which rests on the organ like a crest on a helmet, the head of the append- age reaching well forward and the tail Avell upward. There is also usually more or less lateral expansion of it, sometimes almost enveloping the testis. Pressure on the testis in such a case usually causes no pain, but when the sw^ollen epididymis is held between the thumb and fore finger the patient winces or cries out. While at rest in the horizontal position, with the scrotum well supported, the patient may be tolerably comfortable. Coincidently with this inflammation, the scrotum on the affected side becomes of a deep, even purplish, red, very much swollen from oedema, and adherent to the testis. Pain is at this time severe, sometimes almost unendurable, and continuous, with paroxysms at night. Slight motion tends to increase the patient's sufferings, and pressure even of the bed- clothes causes agony. Coincident involvement of the cord is attended with a still greater amount of pain, which extends up to the inguinal canal. In these very severe cases the testicle is also, as a rule, the seat of inflammation. When the epididymis alone is inflamed, the swelling is very considerable, but when it and the testis are involved, it is great, so that a tumor of the size of a small fist is formed. The testis will be found to be very painful and tender, and a much larger area of the scro- tum will become inflamed, thickened, and of a deep red. While at first there is only moderate and localized adhesion of the upper portion of the organ to the scrotal wall, when epididymo-orchitis is present there is adhesion of a large surface corresponding to the size of the swollen testi- cle. In proportion as the testicular inflammation is great, the tunica vaginalis becomes aff'ected and the seat of serous effusion, by which the size of the tumor is materially increased. With this concomitant the acme of the inflammation may be said to be reached. The patient then wdll complain of pains in the perineum, in the thighs, the groins, and the lumbar regions. In some cases patients complain bitterly of deep 234 GONOBBHCEA AND ITS COMPLICATIONS. pelvic and rectal pains, which are due to a complicating inflammation of the seminal vesicles. In the acute stage particularly, and also in the period of decline of epididymo-orchitis, examination of the prostate, and sometimes the semi- nal vesicles, by means of rectal touch will in many cases reveal swelling and congestion of that organ, sometimes in its totality, and again on the side corresponding to the testicular inflammation. Lucas ^ in 285 cases examined found that in 174 there was no perceptible change in the pros- tate, and that in the balance the organ was more or less swollen and painful. In its full height swelled testicle consists of inflammation of the epi- didymis, of the testis proper, of the tunica vaginalis, which is the seat of effusion, and of exudative oedema of the subscrotal connective tissue and of the scrotal wall, Avith perhaps inflammation of more or less of the cord. At this time it is difficult to detect fluctuation in the hydrocele unless the effusion is very copious. The tissues are too hypersemic and opaque to admit of the light test for translucency. This hydrocele is due to inflam- mation of the tunica vaginalis testis, and is called vaginalitis. This com- plicating extension of the gonorrhoeal process, although a very frequent, is not a constant, symptom, and is always consecutive to the inflammation of the epididymis. There is commonly an effusion, varying in quantity and character, within the tunica vaginalis. This may consist only of serum, and be apparently due to simple obstruction of the circulation, or it may contain fibrin and other products of inflammation. Sometimes bands of lymph bind the two opposed surfaces together, as in pleurisy. The subscrotal cellular tissue also participates in the inflammatory action, and is thickened by oedema or fibrinous deposit. As a rule, well-marked swelled testicle reaches its acme within forty-eight or seventy-two hours. Much depends in these cases upon the vigor and efficiency of the treat- ment, which may prevent the affection from reaching the point of full development, and which will usually superinduce the stage of decline. Swelled testicle may exist in a severe form from one to five days in un- treated cases, when subsidence of the inflammation begins. In carefully- treated cases the intensity of the symptoms need not last longer than twenty-four or thirty-six hours. The first symptom of improvement is amelioration of the pain, and soon it is noticed that the patient can move in bed with more freedom than before. The redness and oedema of the scrotum become less, and its adhesion gradually passes away, and the swelled organ becomes smaller and can be more freely manipulated. The swollen epididymis may be quite clearly made out, the testis can be dis- tinctly felt, and if any hydrocele is present it may be detected by palpa- tion or perhaps by the light test. At this time the general health of the patient will improve ; he will lose his anxious look, drink less of fluids, and ask for food. As a rule, the course of swelled testicle in bad cases occupies from ten to fourteen days, during which time the patient will have been confined to his bed. At the end of this time, though he may go about, he is far from well, and should be looked after Avith the most careful attention. Unless removed by tapping, the hydrocele remains for a long period, and while it does the testis remains swollen and tender. When there is no hydrocele the testis is found to gradually become smaller 1 These de Paris, 1894. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 235 and softer, and soon the line of demarcation between it and the epididymis can be made out. During this period of involution the epididymis also grows smaller, but much more slowly, and for longer or shorter periods it is found to be enlarged and indurated. Its continuance in this state is governed largely by the duration and intensity of the inflammation. With the oedema of the part there is cell-exudation, and the future of the case depends on the extent and severity of this morbid condition and whether it is appropriately treated. So rapid and complete is the involution of the swelling of the epididymis in some cases that it seems scarcely credible ; in others it is slow, occupying several months ; while in others permanent enlargement and induration are left. In severe cases — luckily, not com- mon — the testis, tunica vaginalis, epididymis, and vas deferens are left in a state of induration and chronic subacute inflammation. During an acute attack of swelled testicle the suff"erings of the patient, as in gonorrhoea, are sometimes increased by the occurrence of nocturnal emissions. As a rule, the first attack of swelled testicle is the most severe, and it renders the patient very liable to relapses. The afiection is usually uni- lateral, though rarely both testes are involved. Exceptionally, inflam- mation of one organ is followed by that of its fellow, and this condition is called see-saw epididymitis, the epididymite a bascule of Ricord. Much gradation in intensity is observed in swelled testicle. Some patients simply complain of a little uneasiness and heaviness in the scrotum, and the surgeon is the first to find the epididymis more or less enlarged. Other patients present more marked subjective symptoms, with moderate epididymitis and often involvement of the testicle, yet by means of medical applications and with the support of a suspensory they are able to go about with moderate freedom. Resolution of the inflam- mation also varies considerably in difi"erent subjects. In some cases with very little care the testis soon returns to its normal state, while in others it is sloAV, in spite of the most careful treatment. In a normally-placed testis little difficulty is experienced in determin- ing the extent and localization of the inflammation, but it must be re- membered that exceptionally there exist malpositions of the epididymis, when confusion may occur. The most common form of malposition is where the epididymis is placed anterior to the body of the testis, in which the features observed in the normal testis would be reversed. Then it may be seated on one side, either external or internal, in which event the diag- nosis need not be difficult. In the third variety the epididymis and vas deferens are attached superiorly, the long axis of the testis being in the antero-posterior direction. In a fourth variety the epididymis and vas deferens form a loop or sling from before backward around the testis. It is always important to make a correct estimate of the position of the parts, particularly if puncture of the tunica vaginalis is decided upon. It is a good rule to find the vas deferens high up in the scrotum, and if practicable trace it downward between the tips of the thumb and fore finger. Sometimes, even when the epididymis is normally placed, its weight and bulk are so much inci'eased by inflammation that it falls downward and forward with the testis above it. Examination then reveals the tail of the epididymis anteriorly and the head posteriorly, the organ hanging 236 QONORRHCEA AND ITS COMPLICATIONS. antero-posteriorly in the scrotum. Then, again, owing to the heaviness of the epididymis, it sinks down to the bottom of the scrotum, and the testis then lies directly on top of it. Gonorrhoeal inflammation, when it attacks an undescended or mis- placed testis, has frequently been unrecognized. Berkeley Hill speaks of the case of a young man suifering from gonorrhoea, obstinate con- stipation, stercoraceous vomiting, fever, and great abdominal tenderness, particularly in the left iliac region. The right testis was found in the scrotum, but the left one could not be discovered. After death, from peritonitis, a small inflamed testis was found close to the internal ring. Undescended testis in the inguinal canal need ofi'er no diagnostic difiiculty. Ricord mistook a perineal swelling for abscess of Cowper's gland, but examination of the scrotum showed absence of one testis, and a diagnosis of misplaced and inflamed testis was made. An interesting case of testis in perineo, complicated by congenital inguinal hernia and acute orchitis, is reported by Dr. J. A. Williams,^ who gives the bibliography up to the date of his essay, with a synthetical table of the cases. Gosselin reported the rare occurrence of gonorrhoea attacking the epididymis seated in the scrotum while the testis Avas retained in the inguinal canal, in which the first diagnosis was epiplocele. It very often occurs, as pointed out by Le Double,^ that in patients having varicocele, inguinal hernia and ectopia of the testis, epididymitis develops on the side on which either of these conditions exists. Of 14 cases of hernia observed by Le Double, the epididymitis appeared on the affected side in 12 cases. In 8 out of 9 epididymitis developed on the side on which the vai'icocele was present. In these cases the testicular trouble often aggravates the condition of the varicocele, while the latter may tend to induce atrophy of the testis. Statistics seem to shoAv that swelled testicle occurs more frequently on the left than on the right side, presumably, according to some authors, from the fact that men usually "dress" on this side. As to the fre- quency with which different tissues of the testis are attacked, the statistics of Sigmund show that in 1342 cases of swelled testicle the epididymis alone was involved in 61 ; the epididymis and tunica vaginalis in 856 ; the epididymis and cord in 108 ; and these three parts together in 317. Gronorrhoeal inflammation of the vas deferens outside of the inguinal canal, without involvement of the corresponding testis, is a rather rare complication. In the three cases which I have seen there w^as a fusiform or cylindrical swelling of the size of one's finger or of a sausage, begin- ning at the external ring and ending near the epididymis. The overlying skin was hot, red, rather oedematous, and not freely movable over the in- flamed cord. There was moderate fever in two cases, and the pain was severe ; in the third case the febrile symptoms were well marked, and the patient vomited and was much constipated. These symptoms, in addition to which the patient said that he first experienced pain after prolonged coughing, led my house-surgeon to think the case was one of hernia. The existence of a discharge led to inquiries, which settled the diagnosis, which was further confirmed by palpation. 1 The British Med. Journal, July 21, 1883. ^ Be I' Epididymite blennorrhagiqiie dans les Cas de Hernie inguiiude de Varicocele on d' Anomalies de rAppareil genital, Paris, 1879. EPIDIDYMITIS AXD EPIDIDYMO-ORCHITIS. 237 Gosselin reported a case in "which the swelling began below the external ring and extended to the level of the head of the epidid^^mis. It was of the size of a hickory-nut, hard and painful, and from it a cord of the size of a goosequill stretched to the tail of the eiDididymis. Above the tumor the vessel was hard and cord-like. Localized inflammation of the vas deferens within the pelvis sometimes occurs, and causes much deep-seated pain during acute gonorrhoea. In some cases the swelling can be made out by physical examination. In other cases the swelling is inaccessible, but the history of the case and the symptoms point to involvement of the vas. Sometimes the surgeon sus- pects the case to be one of intra-pelvic abscess. In very exceptional cases a considerable part of the pelvic portion of the vas may be involved. Mauriac^ reports the case of a man suffering from acute gonorrhoea in whom the vas could be felt as a hard, painful cord, and, owing to the extreme leanness of the patient, it could be followed into the pelvis. By the finger-tip in the rectum the seminal vesicle of the same side was found to be swollen. Induration of the epididymis may exist without impairment of the function of the testis. In some cases so copious and dense is the prolif- eration of cellular tissue that constriction, even to the extent of oblitera- tion of the vasa eiferentia, is produced, rendering the testis sterile. This is especially to be feared when the globus minor is involved, since at this point the tubes unite into one, whereas at the globus major there is a mul- titude of minute eiferent vessels, some of which may escape. Unilateral induration of the globus minor may cause obliteration of the deferent duct and sterility of one testis. When it occurs on both sides, absolute steril- ity may be produced, but, as a rule, such patients have their usual sexual desires, and their erections and ejaculations are complete. Their semen, however, is entirely wanting in spermatozoa. Further, the size and con- sistency of the testes remain as before, and atrophy is very rarely pro- duced. It has been observed that in favorable cases treatment has more or less perfectly removed the induration, and that the spermatozoa have again been found in the semen. Atrophy of the testes has been known to occur in a few cases follow- ing epididymo-orchitis, and hypertrophy is not very uncommon, particu- larly in subjects who have had repeated attacks of the affection. I have seen two well-marked cases of atrophy due to acute urethritis, and Rona ^ has published an interesting case of this complication. Abscess of the testis is a not frequent complication of gonorrhoeal epididymo-orchitis, the focus of the trouble being usually in the epididy- mis. It should be promptly opened and the wound treated antiseptically, otherwise fistulse and fungous growths are liable to form. It does not, of necessity, follow that the vas deferens will be occluded. In these cases of abscess of the epididymis or testis following gonorrhoea a suspicion of tuberculosis is warranted, and the patient should be well looked after and placed in the best of hygienic conditions. Cysts in the epididymis some- times follow swelled testis, and are sometimes the seat of acute pain, and may be mistaken for circumscribed abscesses. Abscess of the body of the testis somewhat rarely occurs during gon- ^ Annales de Dennat. et de Syphilif/raj)hic, No. 6, 1891, pp. 407 et seq. ^ Monatshefte fur Prak. Dermat., vol. v., 1886, jip. 360 et seq. 238 GONORBBCEA AND ITS COMPLICATIONS. orrhoeal epididymo-orchitis. An incision should be made as soon as fluc- tuation is discovered. In some cases the wound heals and the integrity of the organ seemingly remains. In other cases a hernia of the testis tissues occurs, and protrudes as a fungous mass from the opening in the scrotal walls. In some of these cases the morbid process may be of a benign character and the mass may be due to simple hyperplasia. In some cases tuberculosis may be present. Consequently, all such cases should be carefully examined and watched. Chronic hydrocele is frequently caused by swelled testicle. V^tault thinks that the eifusion is due to congestion of the vessels of the tunica vaginalis, caused by presence of the indurated tissue in the head of the epididymis. It is also probable that the acute inflammation during gon- orrhoea leaves a tendency in the vessels of the testis and the tunica vag- inalis to engorgement and consequent effusion of serum. Gangrene of the scrotum is a somewhat rare complication of swelled testicle ; and of it I have seen two cases — one in a diabetic patient, and the second in a man suffering from Bright's disease. It usually begins, particularly in cases which have been poulticed, at a dependent portion of the sac as a black spot, Avhich spreads and destroys more or less of the walls, laying bare the testis or testes, which, however, are not invaded. After the cessation of the gangrene the parts usually heal and cover the organs again, unless the destruction has been very extensive. Gangrene of the testicles is a very rare complication of acute gon- orrhoea. Bogdan ^ reports a case in Avhich both testicles were destroyed by gangrene. Gangrene of the scrotum may follow gangrene of the testes. In a case of acute gonorrhoea Samter^ observed the development of trismus, for which no other etiological cause than the urethral inflamma- tion could be ascertained. Neuralgia is a not uncommon sequela of swelled testicle. It may exist as a slightly painful sensitiveness of the organ and along the cord, par- ticularly on pressure or during active motion, or as a distinct dull pain subject to irregular and fugitive paroxysms. Usually, in these cases the epididymis is found to be enlarged and very sensitive. It is commonly seen in weak, sickly subjects, particularly those of neuropathic tendency, and subjects given to worry and fretting. Reflex neuralgias, first fully described by Mauriac,^ are not infrequent complications and sequelae of swelled testicle. The pain is generally uni- lateral and confined to the territory supplied by the lumbar and sacral nerves of the affected side, but may cross the median line and extend in various directions. Spinal pain, seated at the junction of the lumbar and sacral plexuses, is sometimes complained of, and it may be bilateral and more severe on the unaffected side. Deep-seated pain, as if in the kid- neys, extending from the ribs to the sacrum, pains radiating from the lower part of the lumbar portion of the cord and radiating upon the abdomen and lower extremity, and a sense- of a constriction encircling the body under the level of the umbilicus, are also sometimes experienced. ^ Annates de Dei~m,. et de Syph., 1893, pp. 1211 et seq. 2 Bed. klin. Wochenschrift, 1889, No. 9. '^ Etude sur les Nevralc/ies reflexes symptomatiques deV Orchi-epididymite blennorrhagiqueSy Paris, 1870. EPIDIDYMITIS AND EPIDWYMO-OECHITIS. 239 Pains and vague unpleasant sensations are felt at spots along the inter- costal nerves and in the course of their distribution. The pains aifecting the leg are not uncommon, and they may be seated in the anterior crural or posteriorly in the sciatic nerve. The pains in the anterior crural nerve involve the anterior aspect of the thigh as far as the knee, rarely below that, though Mauriac says that the internal saphenous nerves may be the seat of pain. The pains in the sciatic nerve are referred to the sciatic notch, from which they may extend forward to the great trochanter or downward to the popliteal space. In many cases they are limited to the buttocks and postero-external portion of the thigh. The pains may be of a neuralgic character, continuous or with exacerbations, sometimes of a fulminating character, and remissions, or mav exist as more or less extensive hypersesthesia of all those parts supplied by the lumbar and sacral nerves and their branches. The intensity of these pains sometimes amounts to agony, and they cause insomnia, nervous excitement, and prostration and emaciation : they may last several days or several months, but in the end they cease. It is frequently observed that a relapse of the epididymo-orchitis is accompanied or followed by some neuralgic manifestations. Such morbid phenomena emphasize the necessity of careful and intelligent treatment of the testicular lesion. Patients who have suffered from epididymitis, particularly those in whom relapses have been frequent and whose epididymes are thickened, are prone to engorgement and gummatous infiltration of these parts if they subsequently contract syphilis. The same tendency is observed in cases in which the testis proper has been inflamed during gonorrhoea. Chronically inflamed and indurated epididymes sometimes become the seat of caseous degeneration, and in sickly, scrofulous, and tuberculous subjects tuberculosis may attack them. Orchitis and Epididymo-orchitis occurring- in the Course of Various Diseases, Inflammation of the testicles, alone or in combination with epididymitis and vaginalitis, may also occur as a complication of a number of infective diseases. In the course of mumps the testicle may become painful, swollen, and hard. The affection called mumps, or parotidean orchitis, may be limited to the gland and it may involve the epididymis and the tunica vaginalis. The onset of this inflammation is brusque and its course rapid, so that in from three days to a week it may cease. Involvement of the second tes- ticle sometimes occurs. In this form of orchitis resolution may be perfect, but not uncommonly total atrophy occurs. Under the title orchite amygdalienne, or tonsillar orchitis, French • authors^ have described an acute and ephemeral orchitis in men suffering from tonsillitis. The onset of this affection is sudden, its course rapid, and resolution may take place within a few days. The affection is observed in adolescents, and is usually unilateral. It may result in ^ Verneuil, "Les Epanchements dans la Tunique vaginale, metastatique de I'Arriere bouche," Archives gen. de Medecine, 1857, and Joal, " Orchite et Oviirite aniygdalienne," ibid., 1886, vol. xviii. pp. 678 et seq. 240 GONOEEHCEA AND ITS COMPLICATIONS. abscess and atrophy. According to Monod and Terrillon,^ this orchitis is an anomalous form of mumps-orchitis. During the course of small-pox the testicle, its envelope, and its appendages may be attacked with more or less violent inflammation. This complication may occur in men who have previously suffered from gonorrhoea and in those who have not. According to B^raud,^ whose essay is admirable in every respect, the affection is usually unilateral, of ephemeral duration, and is not followed by any serious consequences or permanent lesion. It is the consensus of opinion of authors that orchitis is not a common complication of small-pox. In 432 cases observed by Curschmann^ it was present 4 times. This complication has been studied in an exhaustive manner, micro- scopically, by Chiari,'* who found in fifteen cases of old and young subjects parenchymatous inflammation studded Avith colonies of cocci. Orchitis accompanied by epididymitis and vaginalitis is a very rare complication of scarlet fever. Two cases have been reported as occurring in boys six and eight years old. In one case observed by Henoch ^ the tunica vaginalis was distended to the size of a fist. In Horteloup's^ case the organ was much enlarged, and there was swelling of the epididymis and effusion into the tunica vaginalis. Resolution occurred in this case. Orchitis may develop during the course of, or subsequent to, whooping cough. In a boy aged fifteen years, otherwise healthy, just recovering from this trouble, acute orchitis suddenly developed. This was accom- panied by such alarming symptoms as stupor, delirium, very high tempe- rature, and very rapid pulse, which lasted a short time and rapidly disap- peared. The testes also underwent resolution. This case, reported by Pierse,'' seems to be unique. There have been so many cases reported in w:hich orchitis developed during malarial fever, and for which no other pathogenic cause or condi- tion can be assigned, that it seems reasonable to accept the latter as cause and the former as effect. One testis or both may be attacked. Magnani^ reports two cases in which there was no evidence of gonorrhoeal origin, and in which he thinks that the plasmodium of malaria was the patho- genic agent. The cases reported by three French army surgeons — Bertholon,® Schmidt,^" and Charvot ^^ — stationed in Africa are very significant, since they were carefully observed for long periods. In these cases the epidid- . ymis was suddenly attacked, together with the testis, and sometimes the ^ Traite des Malad. du Testicule, Paris, 1889, p. 369. ^ "Eecherches sur I'Orchite et I'Ovarite varioleuse," Archives cjen. de Medecine, 1859, vol. xiii. pp. 274 et seq. ^ Ziemssen's Handb. der Spec. Path, und, Therapie, vol. ii., 2d part, 1877. * "Orchitis variolosa," Zeitsch.fur Heilkunde, vol. vii.-, 1886, pp. 385 et seq. ^ Berlin klin. Wochenschr., 1865, No. 12. ® Diet, enyclop. des Sciences med., 3d Series, vol. xvi. p. 578, art. " Testicule " (case of Augagneur and MoUiere). ' Lcmcet, Aug. 3, 1889. ^ " Sull I'Orchite d'origine pallustre," Gazz. Med. Itcd. Lombard, 1887, vol. vii. pp. 415 et seq. ^ " Orchites paludeennes primitives," Archiv. de Med. et de Pharm. milit., Oct., 1886. ^" " Orchite paludeenne," ibid., March, 1887. ^^ " Orchite paludeenne," Annates des Malad. des Org. Gen.-urin., 1887, p. 733, EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 241 tunica vaginalis. The clinical picture was that of acute orchitis. The tendency of the disease is to quite prompt resolution, after which, in some cases, atrophy may occur and an indurated epididymis may be left. The pain incident to this inflammation is usually severe, sometimes continuous, and, again, it may be intermittent. Quinine has an excellent effect in aborting and causing the resolution of this inflammatory process. Mazel ^ reports tAvo cases in which the epididymis and the vas deferens became acutely inflamed in malarious subjects, and in which also quinine produced excellent results. Southern surgeons Avho practise in malarious districts of this country from time to time meet with orchitis as a result of malarial infection. There is abundant evidence to prove that influenza, or la grippe, may be the exciting cause of orchitis in subjects who have never suffered from gonorrhoea or any phlegmasia of the urinary tract. This infectious disease also has been known to cause recrudescences of epididymitis and orchitis in organs previously the seat of gonorrhoeal inflammation. The physical signs generally are those of acute gonorrhoeal inflammation, but as a rule resolution occurs more promptly. Zampetti ^ reports three cases of orchitis, in one of which there was a testicular abscess caused by the grip. Other cases with satisfactory histories have been reported by Har- ris,^ Briscoe,* and Kelly .^ In most of the published cases the physical signs are those of acute gonorrhoeal orchitis. In some cases the phleg- masia seems to be greatest when limited to the testis proper. In other cases the tunica vaginalis and epididymis are involved. Thus Fiessinger^ reports the case of a boy nine years old who had very severe vaginalitis, with three distinct exacerbations during its course, and the inflammation in the last outburst invaded the epididymis. Walker^ reports a still more severe case in a man twenty-four years old, in whom a suppurating vagi- nalitis led to gangrene of the testes. That the epididymis alone may be attacked is well shown in a case reported by Lamarque,^ in which double epididymitis attacked a man during the decline of an attack of influenza. In this case there were absolutely no gonorrhoeal antecedents. In some cases of grip-orchitis there is a mild muco-purulent urethral discharge. Lamarque reports such a case, which was in no way depend- ent upon gonorrhoea. When uncomplicated these testicular affections due to grip run an acute course and quite rapidly go on to complete resolution. During the course of pneumonia and for some time after its deferves- cence inflammation of the testicle or epididymis may occur as a result of that infective process. I have recently had in my hospital service the case of a man in whom a destructive abscess of the testicle occurred, for which no other origin than pneumonia could be ascertained. In this case there was no antecedent gonorrhoea nor testicular affection. Prioleau* ^ "Fimiciilo-epididymite palud^enne," Journ. de Med. et Chir. pratiq., Feb., 1889- ^ Gazz. degli Oqndali Milan, 1890, vol. xii. p. 578. » Lancet, vol. i., 1892, p. 22. * Ibid., p. 193. ^ m^i^ p. 359. " Gaz. med. de Paris, Feb., 4, 1893. '' Correspond. Blatt. filr Schiveiz Aerzte, Aug. ], 1890. 8 "Complications g^nito-urinaires de la Grippe," Annates des Mai. des Organ. Gen.- win., Sept., 1894. 8 Le Mercredi medical, 1894, No. 36, p. 439. 16 242 GONOBRHCEA AXD ITS COMPLICATIONS. reports the case of an old man in Tvliom suppurating orchitis developed in the interval of tAvo attacks of pneumonia. In my case and in that of Prioleau there wei'e concomitant chills and fever. In the pus of my case pus-cocci were found, and in the pus of Prioleau's case diplococci were discovered. Testicular inflammation ^ occurs somewhat rarely during the course of typhoid fever, Liebermeister having found 2 instances in 200 cases. Gren- erally, it is toward the end of the fever that the epididymis is attacked, either in a subacute or a brusquely acute manner. There is usually a concomitant rise in the temperature and an ephemeral return of the gen- eral symptoms. In some cases this complication appears early in the dis- ease, and in others after full defervescence and cure. Usually this form of epididymitis is unilateral, and resolution takes place slowly, leaving no trace after it. Then, again, induration has been known to follow. In some cases the testis and vas deferens are attacked. Jaccoud^ reports a case of suppurative orchitis in a typhoid-fever patient. Abscess of the testicle, however, is not common. Hanot ^ reports a case in which abscess began in the epididymis and led to the destruction and extrusion of the testicle. In another case reported by Hanot* atrophy of the testis occurred. Jaccoud and Kocher^ claim that they have found the typhoid bacillus in the pus of typhoid orchitis. Several cases have been reported in which during typhoid fever chronic urethritis has undergone recrudescence, and epididymo-orchitis has resulted. It is claimed by some that inflammation of the testicle may occur during the course of. acute articular rheumatism. This assertion is made on the basis of cases reported many years ago. The reader desiring further information is referred to the essays of Stoll ^ and Bouisson,'' if they are accessible to him, though they are not to me. The essential lesion is said to be an acute vaginalitis. I have never seen such a case, nor has one been reported within this generation. The same doubt exists as to the etiological relation of gout to testicu- lar inflammation. Cases have been reported in support of this relation- ship, but they are so lacking in essential detail as to the previous history of the patient and to the pathogeny of the aff'ection itself that I deem it wise not to quote them. Here, then, is a field for careful and discrimi- nating clinical observation. During the course of pyaemia and of grave phlegmonous inflammation in bones orchitis may supervene. Epididymo-orchitis from Operations in the Urethra. The introduction of bougies, sounds, and catheters for various condi- tions is not infrequently followed by epididymitis or epididymo-orchitis. ^ In the Revue de Medecine, Paris, Oct. and Nov., 1883, Ollivier gives the resuhs of the study of twenty -seven cases. ^ Annales des Mai. des Org. Gdn-urin., vol. ix., 1891, p. 262. ^ Sociele anatomique, 1873. * Archiv. gen. de Med., vol. ii., 1878. ^ Op. cit, pp. 265 et seq. " Encydopedie des Sciences med., Paris, 1837, 7th division ("M4d. pratique," by Stoll, p. 234, quoted from Monod and Terrillon). ^ Montpellier medicale, 1860, vol. iv., p. 336, quoted as above. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 243 In the course of gradual dilatation for stricture and for chronic urethritis, as a result of catheterism in retention of urine in acute gonorrhoea, and in the retention which sometimes follows severe operations, chiefly about the rectum and abdomen, and also elsewhere, inflammation of the testicle sometimes occurs. In young and old subjects, upon whom lithotrity,^ litholopaxy, and lithotomy have been performed, the testicle may become damaged. This accident not infrequently occurs when a catheter or other instrument is tied in the bladder. In cases of hypertrophy of the prostate, in which the necessity for the introduction of the catheter is more or less urgent, testicular inflammation is not very uncommon. In many of these cases the testicular complica- tion may be traced to the use of a too large catheter, to one which has by age become rather rough, and often to dirt which has been carried on the catheter owing to the patient's carelessness. While, in general, the symptoms of this, as we may call it, traumatic epididymo-orchitis resemble those of gonorrhoea, they present certain somewhat distinctive features. As a rule, the testicular inflammation comes on quite promptly after the receipt of the injury. Then, again, the onset may not occur for several days, and then may be slow, halting, and intermittent. In the cases where the inflammation is slow in devel- opment its course is usually prolonged, and resolution comes on rather tardily. In some cases, however, the invasion is rapid and brusque, and in these particular cases we not unfrequently observe quite prompt, even markedly rapid, resolution. The physical signs diff"er in various cases according to the mode of invasion. In the slowly-developing cases the patient may sufi'er little pain, and may discover, sometimes by accident, that the tail or head of the epididymis is somewhat swollen, hard, and perhaps a little tender on pressure. The swelling may then increase slowly, limited to one part of, the epididymis, or it may spread and involve the whole of it. It then feels like a hard, firm, quite bulky crescent seated on the testis. This condition may remain indolent for a varying period, and it may quite fully disappear, or it may lead to a permanent swelling and induration of the epididymis. There may be a moderate eff"usion into the tunica vaginalis. The course of the cases in which the onset is brusque and rapid is, in the main, quite like that of acute gonorrhoea. Abscess, however, is more frequent than in the latter condition. In a goodly proportion of young and middle-aged patients this post- instrumental inflammation is limited to the testicle, with sometimes the involvement of the tunica vaginalis. In a rather larger proportion the epididymis is attacked. In elderly and very old men, while the process may be limited to the epididymis, it more commonly attacks the testis also. In these cases the epididymo-orchitis may be slow in development or the onset may be quite rapid. When the testis is involved there is usually much pain. Abscess of the epididymis, of the tunica vaginalis, and particularly of the parenchyma of the testis, is a not uncommon accident. Abscess of the testis in old men may lead to the total extrusion of the gland and ^ According to Pilven ("Orchite consec. au Passage des Instruments," Thhe de Pari^, 1884), Guyon observed testicular inflammation in 13 out of 188 cases of calculi in which exploratory or lithotrity instruments had been used. 244 GONOBBHCEA AND ITS COMPLICATIONS. its appendages. This sequela may, but quite rarely, be observed in young and middle-aged men. Orchitis due to Muscular Contraction. So many cases have been reported in Avhich epididymitis and orchitis, separately or combined, have developed as a result of muscular injury — orcTiite par effort — that to-day this causative factor is quite generally admitted. In these cases the pain on the receipt of the injury may be at first slight, and may gradually become severe, or it may be violent and sickening from the first. In most cases the left testis is affected, and the clinical picture resembles that of gonorrhoeal inflammation of these parts. There is considerable difference of opinion as to the mechanism of the traumatism in these cases, in which patients slipping with violence, lifting heavy Aveights, or by any means rudely shaken become attacked by testicular pain and inflammation. According to Velpeau and Roux, violent contraction of the abdominal muscles, particularly of the fibres of the rectus abdominalis muscle, which are present in arched form over the cord at the external abdominal ring, injures the cord, and the inflammation then descends to the testis. This theory, for obvious reasons, meets with much opposition. Another view is that advocated by Tillaux, who claims that the injury results from violent contraction of the cremaster muscle, which jerks the testis against the pillars of the external rings by what French authors call the coup de fouet, or whip-snap, action. The most ' rational explanation of this action is that of Martin,^ who says : " The spermatic plexus of veins is peculiarly under the influence of intra-abdominal pressure : the vessels are provided with but few and imperfect valves, are feebly supported by the surrounding tissues, and hence are especially subject to disease. This varicosity of these veins is one of the most common surgical affections, and the effect of the contrac- tion of the abdominal parietes and the diaphragm upon these dilated vessels is so marked that succussion on coughing or straining in any way is sufficiently distinct to simulate that of omental hernia. Given, then, a sudden and violent increase of pressure in these vessels, it is perfectly possible to conceive that rupture may take place Such rupture would naturally take place in the cord, in the epididymis, or even in the substance of the testicle." In addition to this action, I think that spasmodic contraction of the cremaster and of the fibres of the rectus muscle may also, in some cases, play an accessory part. In many cases of this form of epididymo-orchitis the patients have previously been free from venereal diseases, gonorrhoea especially. In some cases patients will absolutely deny any previous gonorrhoeal infection. There can be no doubt that a latent subacute inflammatory condition of the testis or cord may be transformed into an acute condition by means of muscular traumatism. Duplay and his ^l^ve, Delome,^ claim that the underlying causes in these cases are latent urethritis, cystitis, and prostatitis. ^ " Epididymitis caused by Abdominal Strain," Med. News, Nov. 29, 1890. ^ " De I'Orchi-epididymite prdtendue par effort," These de Paris, 1877. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 245 This form of testicular trouble usually goes on promptly to resolution, though induration of the epididymis and enlargement of the testicle may result. Terrillon ^ has published a case in which atrophy of the testis occurred, which was attended with such severe pains that castration was resorted to. The microscopic examination of this testis showed the cha- racteristic lesions of traumatic orchitis. Strangulation of the Testis and Epididymis from Torsion of the Cord. — There are in medical literature less than twenty -five cases recorded in which the testicle, seated either in the inguinal canal or just in the scrotum, became acutely swollen and painful as a result of torsion of the spermatic cord. Of these cases the majority were those of boys from thirteen to twenty-one years old, while in the great minority were old men and young children. In most of the cases there is a history or evidence of undescended or imperfectly descended testis ; consequently, as a rule, the swelling is found in the inguinal canal or just within the upper part of the scrotum. The objective symptoms are localized swelling, oedema, and redness. The subjective symptoms are varied, and they may point to strangulated hernia, traumatism, or inflammation of the appendix ver- miformis. There are pain, some fever, and frequently constipation and vomiting, which, however, is not stercoraceous. As distinguished from hernia, it will be noted that the constipation is not so persistent, the shock is decidedly less, and there are no abdominal symptoms. The tumor is harder than that of hernia, and is absolutely without impulse and is irreducible. Though the position and quite sharp localization of the tumor, together with its history and concomitant symptoms, point very convincingly to the testis (and it is absent from the scrotum in the majority of cases), it sometimes happens that a diagnosis is not arrived at until an exploratory incision has been made. Then the testis and epididymis are found to be swollen, of a deep-blue or even black color from hemorrhagic infarction, and sometimes they are gangrenous. When the tumor is below the internal ring the finger-tip pressed over that part will show that the case is not one of hernia. Hernia may be found as a complicating condi- tion of this accident to the testis. The exciting causes of torsion of the cord are, in the main, excessive labor and violent and sudden strain. In some of the reported cases no exciting cause whatever could be ascertained, and in some instances the condition developed while the patient was asleep. Usually torsion of the cord leads to destruction of the testicle. Van der Poel,^ however, reports an interesting case in which this accident occurred at various intervals of time, and was promptly remedied by taxis. The twist of the cord may be partial or complete, or the cord may be twisted several turns. The essential and underlying cause of torsion of the cord is due to disturbance in the development of the vaginal process of the peritoneum, in which the mesorchium is either too slender or too long, and hence does not give the testis the necessary amount of fixation. The mesorchium then allows greater movement than normal, and the testis ^ " De rOrchite par Effort sa Termination par Atrophic testiculaire," Annales des Mai. des Org. G^n.-urin., vol. iii., 1885, p. 239. '^ Medical Record, June 15, 1895. The reader is referred to this essay for a r&um^ of the published cases. 246 GONOBBHCEA AND ITS COMPLICATIONS. may, as a result, encounter difficulty in entering the inguinal canal and impediment in traversing it. When it is in the inguinal canal the flat condition of the testis militates against its replacement, and renders this impossible as soon as inflammation has become established. When it occurs in the scrotal sac, torsion of the cord may be reducible. Hemorrhagic infarction of the testis and epididymitis calls for prompt incision and extirpation. Neuralgia of the testis sometimes follows epididymo-orchitis and epi- didymitis. Usually but one testis is the seat of pain. In some cases the pain is in the testis itself; in others it is said to radiate and extend to the groin. The pain may be mild and constant, and readily made Avorse by exertion. In some cases the pressure of the clothes causes much suff'er- ing. Then, in other cases, the pain is severe and paroxysmal, "svith inter- vals of full comfort. In many cases neuralgia of the testis is a distinct morbid entity, and in these cases treatment will usually give relief. But testicular pain and pain in the spermatic cord are often complained of by neurasthenic and neurotic patients and cranks in whom no treatment seems to do any good, and in whom no abnormality of the parts can possibly be discovered. Such patients, by reason of their complaints and importunities, act as thorns in the flesh of the surgeon. Happily, there are not many of them. Neuralgia of the testis may depend on chronic inflammation in the posterior urethra, and also on the pressure on the nerves of the parts by the effused tissue. It must be remembered that neuralgia of the testis may be sympto- matic of stone in the bladder, various diseases of that viscus, and kidney disease. Induration of the epididymis following gonorrhoeal inflammation may be limited to the tail, to the head, or may involve the whole appendage. In some cases it is absorbed, and in others it remains permanently. It sometimes feels like a little mass of flrm structure of rounded or ovoid shape when seated at either head or tail. In general, the swelling is not very large, but it may remain for a long period localized to the head, and be nearly as large as the testis. In some cases, when the whole epididy- mis is chronically indurated, it forms a half-moon-shaped mass whose bulk is greater than that of the gland. The most frequent form of induration of the epididymis is that in which the part is about as thick as a lead pencil or a peanut. It is hard to say which is most frequently found — induration of the head or the tail of the epididymis. Hard enlargement of the whole appendage is less common than the localized induration. The surface of simple gonorrhoeal induration of the epididymis is usually smooth or of rounding or wavy outline, in marked contrast to the nodulated and angular feel of tubercular "epididymitis. In chronic syphilis the epididymis is sometimes enlarged in whole or in part, and the general outline of the swellins^ is much like that of the s:onorrhoeal affection. In these cases the diagnosis depends ver}^ largely on the history of the cases and on the presence of concomitant lesions or of salient stigmata. Causes of Epididymitis and Epididymo-orchitis. — Gonorrhoea being the predisposing cause, various exciting causes are often the starting-points EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 247 of the trouble. These are the early use of strong injections, particularly when used to abort the disease, and the premature administration of copaiba, cubebs, and oil of santal ; indulgence in alcoholic stimulants ; and sexual excitement, with or without coitus, since men, either from lust or with a mistaken idea that they may thus rid themselves of their trouble, often have connection while suffering from gonorrhoea. In the majority of cases, walking, activity in business, lifting heavy weights, pulling vio- lently, dancing, riding, particularly on horseback, bicycling, and skating, are the immediate causes. Passage of sounds and catheters toward the decline of gonorrhoea is frequently followed by epididymitis. Conse- quently, such instrumentation should not be adopted in the declining stage of cronorrhoea, or when stricture of the urethra is followed bv a mild and ephemeral epididymitis or epididymo-orchitis. Diagnosis. — Commonly, no difficulty is experienced in the diagnosis of swelled testicle, since the history of the case and the nature of the lesion are so clear. In some rare cases of acute hydrocele doubt might exist, but it would be soon dispelled by a consideration of the history of the case and an examination of the parts. Swelled testicle, with redness and oedema of the scrotum, is said to have been mistaken for erysipelas of that pouch. Such an error will rarely occur, and with ordinary care will be promptly found out. Haematocele of the tunica vaginalis may at first resemble gonorrhoeal swelled testicle, but the history of traumatism will settle the question. The same remarks apply to orchitis of trau- matic origin. In epididymo-orchitis, or epididymitis accompanied by inflammation of the cord as far as the external ring, a mistaken diagnosis of hernia may be made, particularly when there is much fever, with constipation and vomiting, as sometimes occurs. The error need not be of long dura- tion, since in the scrotal lesion there is a history of gonorrhoea, while in hernia there is usually a history of a fugitive or permanent tumor in the groin, and perhaps of antecedent inflammation or strangulation of the hernial sac. Epididymitis of a misplaced or undescended testis sometimes is difii- cult of recognition. In such cases the history of an urethral discharge should cause suspicion, when the examination of the scrotum will show absence of one testis. It must be remembered that the testis may be retained within the abdominal cavity, in the inguinal canal, and that it may be found in the perineum. In all cases it is of importance to assure one's self of the relation of the epididymis to the testis, since puncture of the tunica vaginalis is so frequently necessary. It is important to ascertain whether inversion of the epididymis is present, since puncture under these circumstances might wound or destroy the vas deferens. In swelled testicle the seat of inversion the tumor is long antero-posteriorly, with the epididymis well, forward and the testis under and rather behind it. In cases of inflammation of the vas deferens it is well to seek it as it leaves the tail of the epididymis, and trace it until it will be found to be lost in the swollen meshes of the cord, since it may not be possible to examine it as it escapes from the canal. The diagnosis of these cases is more difficult when the portion of the cord between the external and in- ternal rincrs is also swollen. 248 GONORRHCEA AND ITS COMPLICATIONS. Prognosis. — The prognosis of swelled testicle from gonorrhoea is, in the main, good, since more or less complete resolution generally occurs. It depends, however, largely upon the promptness and efficiency of the treatment and on the nature of the patient. Careless habits, intolerance of restraint, and poor fibre tend to make the prognosis more serious. The occurrence of the various structural complications already detailed, and the supervention of the various neuralgias, of course make the condition more serious. The fecundity of a man is not imperilled by induration of one epididymis and the occlusion of its vas deferens, but the total occlu- sion of both of these ducts renders him sterile. Though his procreative power is lost, his ability to copulate remains. The question of the ster- ility of a man often becomes an important matter in domestic relations. It must not be stated with absolute positiveness that when no spermatozoa are found in the semen a man is absolutely sterile, since it may be that there is present a temporary stenosis due to exudation, and for the reason that under treatment resolution of the infiltration may be produced. It is only in cases where the semen examined over long periods is found to be wanting in spermatozoa that the existence of absolute sterility may be asserted. The prognosis is always better when the lesion is seated in the head of the epididymis, and correspondingly worse when in the tail, since in that the spermatic vessels have converged to form one — the vas deferens. Since relapses of epididymitis frequently have their origin in chronic subacute, deep-seated urethral inflammation, their occurrence will suggest the neces- sity of the removal of the cause. Apart from the varying conditions of the morbid process as influencing the prognosis, the latter largely depends on the treatment of the testicular disorder in its declining and chronic stages. If in these periods active conservative treatment is followed, full resolution may be obtained in the majority of cases. Treatment. — Absolute rest in bed is the first indication in the treat- ment of the severe form of gonorrhoeal epididymitis. During the pre- monitory stage the sooner the patient takes to his bed the better for him. The next indication is to place the swollen organ in a position of rest and comfort ; and for this the suspensory bandage is generally useless. A number of excellent procedures are at our command. The simplest is to form an immovable platform or shelf on which the organ may rest. This may be done with India-rubber adhesive plaster ; and, though regarded as dirty and objectionable by some, it by a little trouble can be made cleanly and serviceable. A sufficiently long strip of adhesive plaster, three to five inches wide, is placed across the thighs of the recumbent patient so high "up that its superior border touches his perineum, whose scrotum for the moment has been carefully lifted toward the body. While sufficient adhesive surface is applied to the thighs, that portion of the plaster which forms the bridge between them may be covered with gutta- percha tissue, which, being folded under, adheres to the adhesive plaster. We have thus a water-proof platform or bridge upon which the scrotum may be placed. The objection that this application involves the immo- bility of the patient has no weight, since he is better ofi" in that con- dition. The next method of fixing the testes is to take the heel of a good- sized firm stocking, upon one end of which two pieces of tape, seated EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 24& about one inch apart, are securely sewn, while on the other end two simi- lar pieces of tape are sewn about three inches apart. A waistband having been put in place, the suspensory is applied to the scrotum with the two tapes, which are nearer together underneath, each one of Avhich should be passed outward and upward over the thigh and pinned on the waistband at about the anterior superior spine of the ilium. The remaining or superior tapes are brought up on each side of the penis and fastened to the waistband in the median line. The third efficient method requires a soft linen or silk handkerchief, which should be folded diagonally so as to form a triangle, in the centre of the base of which two pieces of tape are to be sewn. Having placed a firm waistband around the body just above the iliac crests, the scrotum is elevated and the centre of the base of the handkerchief triangle is placed in accord with the raph^ of the scrotum. The tapes are carried around the thighs on either side, and are secured to the waistband near the iliac crests. Having thus rendered the bandage firm, the two outer ends of the handkerchief are brought upward along the folds of the groin and secured to the waist-bandage, while the apex of the handkerchief triangle is brought upward in the median line and also secured to the band. By these means the testes may be kept at rest and any form of application may be used. What is known among athletes and actors as the jock-strap is also very useful in cases of swelled testicle either when the patient is abed or on foot. The scrotum may also be supported by a wad of oakum or absorbent cotton placed between the thighs. The next indication is to administer a brisk cathartic in the form of pills or a powder of from five to ten grains of calomel and bicarbonate of soda. The diet must be mild and sparing, preferably of milk or of toast and weak tea. In the acute stage anorexia is very common, and the thirst is great, for which Vichy, Apollinaris, Poland, and Stafford waters are very good. Little internal medication is necessary, though the mixture of bicarbonate of potassa with tincture of hyoscyamus, spokeii of in the treatment of the acute stage of gonorrhoea, may be given. In nausea and sickness of the stomach medicine is not beneficial. For the relief of pain, particularly at night, some preparation of opium may be used in the form of pill, suppository, or hypodermic injection. The resulting constipation should be attended to, if necessary, by enemas. I have found pulsatilla a very uncertain remedy in acute and painful swelled testicle, and far inferior to laudanum in small and repeated doses. Considering the infectious nature of the gonorrhoeal swelled testis, it is very difficult to understand what action such a drug can possibly exert. Many cases of swelled testis, for unaccountable reasons, improve, and in such instances I have no doubt pulsatilla has got the credit of the amelio- ration of symptoms. Salicylate of soda has been exploited as a valu- able remedy in these cases, but it has failed utterly in my hands to comfort the patient or affect the phlegmasia in any way. Henderson,^ however, used salicylate of soda in twenty-grain doses, given three times a day, very successfully in three cases of gonorrhoeal epididymitis. Other authors claim that they have seen beneficial eifects follow its use. 1 Lancet, Dec. \Q, 1892. 250 GONOBBHCEA AND ITS COMPLICATIONS. In general, a strong lead-and-opium wash, perhaps combined with muriate of ammonia, and applied to the organ properly fixed on old linen or lint or absorbent cotton or gauze, is a most efficient and reliable remedy. At the onset of the affection ice, guardedly applied, may be tried. Small pieces may be placed in a bladder or in the India-rubber bag made for the purpose, and these should be placed on the testis, upon which several layers of linen or lint had been already laid. A little experimentation Avill soon determine how much intervening linen is neces- sary to produce benefit and avoid pain. In some cases this treatment, when thus used, is attended with amelioration of the patient's sufierings and a decrease in the intensity of the inflammation. In other cases, how- ever, it cannot be borne. Its range of usefulness, therefore, is not great. While some patients are benefited by cold applications, others require hot ones, the best of which are poultices of slippery elm or flaxseed, with which may be incorporated, in the proportion of 8 to 1, fine chewing tobacco, or of 16 to 1 of hyoscyamus, belladonna, or digitalis leaves. Should these narcotics produce exhaustion, sickness of the stomach, or other pathological efi"ects, they must be abandoned. Dr. Bumstead thought well of the following, applied on lint to the scrotum : ^. Ext. belladonnse, 3ij ; Glycerinae, 5ss ; Aquae, Ij.— M. Also this : 1^. Pulv. opii, Sij ; Glycerinse, §j . — M. When these prescriptions are used the scrotum must be enveloped in gutta-percha tissue or oiled silk, and held in place by a suspensory if the patient goes about. The following ointments are often of service when spread thickly on lint : ^. Pulv. opii, 3ij ; Pulv. camph., 3ss ; Vaseline or glycerinse, §j. — M. And ^. Pulv. opii, Pulv. amyli, da. ^j ; Glyceringe, q. s. Make paste of the thickness of tar. Ichthyol pure or in ointment form (gij to ^j cerate) has been recom- mended, but after several trials I have abandoned it. When the intensity of the inflammation is on the wane, due to the use of either heat or cold, a more radical treatment may be followed. Every efi"ort must be made to cure the inflammation of the deep urethra. One of the most beneficial is the application at white heat of Paqnelin's cautery over the scrotum corresponding to the swelled testicle. The parts must first be shaved and thoroughly washed. The tip of the cautery ma^y then be applied rapidly and but for a second or two in ten or twelve spots well separated from each other. The scrotum is then to be enveloped in ab- EPIDIDYMITIS AND EPIDIDYMO-OBGHITIS. 251 sorbent cotton and put in a comfortable bandage. The cautery may be used every two, three, or four days. The effect will usually be promptly seen in the amelioration of the symptoms and the subsidence of the swelling. Very much benefit and comfort can be obtained by the withdrawal of fluid from the cavity of the tunica vaginalis just as soon as it can be done. This should not be forgotten. A hypodermic syringe may be used. Another method of treatment which has been employed, like the fore- going, in the declining stage in my ward at Bellevue Hospital with much benefit, is the application every day or two of a solution of nitrate of silver (60 or 120 grs. to the ounce of water). The whole of the affected side is painted and the parts treated as directed after the cautery treat- ment. In my experience the best method of treatment is to apply heat or cold as the case indicates, then, when the inflammation is on the decline, to use the cautery or the nitrate of silver or perhaps iodoform ointment. When the patient is able to get around (and this treatment requires seven to twelve days) he may apply the opium ointment or paste, with as much compression of the testes as he can stand with comfort. Internally or by suppository opium may be used if necessary. For the benefit of those who like to try various methods of treatment I describe in a few words those which are to-day most advocated, and I omit all old-time methods which have proved valueless : Trzcinski, a Russian surgeon, uses nitrate of silver in the form of oint- ment (1 part to 10 of cerate or vaseline), together with a cotton compress, and claims that much benefit and amelioration of symptoms result. Iodoform ointment (^ij to vaseline 5j) is sometimes very efficacious in the subsiding acute or declining stages. Diday and Lardier recommend the application of carbolic acid in alco- hol (1 : 10) as being of much benefit. This treatment is, however, so painful that, although it produces resolution of the swelling, it is not to be endorsed. Thidry and Fosse ^ advocate very hot vaporization or pulverization of carbolic acid and water (1 : 50), applied for twenty minutes two or three times a day. They consider this treatment analgesic, antiseptic, and resolutive. It is said to give rise to no local or general accident. Applications of solutions of carbolic acid in water (^ij to oviij) on gauze, cotton, or lint are sometimes very soothing in the acute stage. Ughetto ^ proposes a very radical treatment. He injects directly into the inflamed epididymis, by means of the hypodermic needle, a few drops of a 2 to 5 per cent, solution of carbolic acid in water, or a few drops of bichloride of mercury in water (1 : 1000), or a similar quantity of equal parts of tincture of iodine and glycerin. A cure is said to have followed in seventeen days. Dr. Samuel Alexander ^ has recently quite warmly advocated a method of treatment first used by Dr. W. Boeck. This consists in injecting into the posterior urethra watery solutions of nitrate of silver, 1 to 3, and even 8, grs. to the ounce. Local and general treatment is also used. 1 Gazette med. cle Paris, Nos. 44 and 45, 1891. ^ 11 Morgarini, Nov., 1892, p. 653. ' Journal of Cutaneous and Genito-uvinary Diseases, vol. ix., 1891, pp. 455 et seq. 252 GONOBBHCEA AND ITS COMPLICATIONS. In France the method of Ducastel ' is now somewhat the vogue. This is the so-called treatment by stypage, or local anaesthesia induced by refrig- eration due to the evaporation of methyl-chloride. The technique is as follows : A mass of absorbent cotton is sprayed with the methyl-chloride, and then applied over the affected testicle for twenty or thirty seconds once or twice a day. A skilled person may use this treatment directly to the part. The point to be observed is not to touch the unaffected parts with the chemical. Care must be exercised in order that dermatitis be not produced. The scrotum may be enveloped in cotton after the applica- tions. Ducastel and De le Valle ^ report that immediate relief and prompt resolution are produced, and that the duration of the treatment is seven days, and the sojourn of the patients in the hospital is eleven or twelve days. Practically the same method of treatment was tried for a short time at Charity Hospital in 1869. The refrigerating agent used was sul- phuric ether applied continuously on lint, the scrotum being supported by oakum. The idea, I think, originated with Dr. Assadorian,^ at that time one of the house-surgeons. The latest novelty in the treatment of epididymo-orchitis is the method of Balzer,^ who uses an ointment of guiacol in the proportion of 3 or 5 parts to 30 parts of vaseline. A watery solution of like strength may also be employed, either by compress or by spray. This agent is said to exert a very sedative action on the parts by easing the pain and rendering the patient comfortable. Strapping the testicle is never appropriate in the acute stage, though it may be beneficial in some cases of chronic swelled testicle. It is much less commonly, employed now than formerly, owing to the fact that it is difficult of application, is not cleanly, loosens quickly, and often gives rise to fissures and inflammation of the skin. The scrotum must be smoothly shaved before the plaster is applied. Mercurial, belladonna, or the plain rubber adhesive plaster may be used in strips of three-quarters of an inch in width. A better method of pressure to the enlarged testis is that recommended by Corbett, the object of which is to envelop the organ after the manner that a football is covered with leather. For this pur- pose oval India-rubber bulbs of various sizes, such as are found in the spray apparatuses, may be used. The upper part is cut off and forms the neck, around the free margin pf which may be sewn lead wire divided into two or three segments, by which means suppleness is retained and injurious pressure of the cord is prevented. The bulb is then cut lengthwise, and into the holes pierced on each side of the cut surfaces silk cord may be adjusted like laces in a corset. As the testis grows smaller, more and more of the bulb may be cut away, and thus the holes become placed farther back and further pressure is made. It is well to first envelop the testis in a layer of absorbent cotton, and, if indicated, ointments may be spread on it. Another method is the following, recommended by Escalier, which is a modification of the suspensory of Langlebert : The testis is grasped, and ^ " Traitement de rOrcliite par le Stypage au Chlorure de Methyle," Annales de Derm, et de Syph., 1890, pp. 429-430. ^ " Etude comparee de la Refris;eration et de la Compression dans le Traitement des Orchites," Thhe de Paris, 1890. * Am. Journ. Derm, and Syph., vol. i., 1870, p. 216. * Therapeutique des Maladies veneriennes, Paris, 1894, pp. 69-70. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. 253 around its upper portion a ring of adhesive plaster is fixed, and covered over with a piece of silk handkerchief, over Avhich is a thick layer of absorbent cotton, and over that again a layer of gutta-percha tissue. Then over the whole strips of adhesive plaster are passed in a circular manner, so that the ends may be drawn more or less tightly before being fixed. About every twenty-four hours it is necessary to tighten the adhesive strips. Removal of fluid from the tunica vaginalis is especially necessary in all cases before compression is applied. In those extremely severe cases in which the testis is also inflamed, together with serous effusion in the tunica vaginalis, prompt puncture of this sac is urgently called for, and is commonly folloAved by marked relief of the pain and tension in the organ. It is well to employ a small straight bistoury, and to make a number of minute punctures well down into the cavity of the tunica vaginalis, over its median and most rounded portion, taking care that the tunica albuginea is not wounded. When practicable, in these cases withdrawal of the fluid by the hypodermic syringe may be done. The older surgeons, particularly French and Eng- lish, advocated incisions fully six-tenths of an inch into the parenchyma of the testis. Such procedures were frequently followed by hernia of the testis-substance and atrophy of the organ, and should not be resorted to. In cases of swelled testicle in which the engorgement is very great a number of leeches, according to the powers of resistance of the patient, may be applied to the groin as far down as the scrotum, but not on it. Relief is rarely afforded unless at least six to ten or twelve leeches are used. The treatment of neuralgia of the testis following gonorrhoea, or indeed any morbid process, should be directed primarily to the affected part. Blisters with cantharidal collodion may produce much benefit. Paquelin's cautery and the various stimulating applications already detailed may be used. Opium and belladonna ointment may also be of service, according to the symptoms. If any thickening of the epididymis or cord can be made out, it should receive energetic treatment on the lines followed in treating induration of the epididymis. In every case the condition of the deep urethra should be ascertained, and if any inflammation be found, it should be treated. Any general morbid condition should be carefully considered, and proper medication and hygiene should be instituted. It is well to remember that, owing to fear, after recovery from gonorrhoea some patients remain bravely continent, and as a reward sometimes they have boring, aching, and dragging pains of varying severity in the cord and testes, which may be mistaken for neuralgia of the testes, and which may be relieved by physiological processes. Induration of the epididymis and enlargement of the testis, which sometimes follow gonorrhoea or other morbid processes, require some of the foregoing methods of treatment. Stimulation and compression are especially indicated. Strapping the testes and the use of the other com- pressing agents should be employed. In some cases benefit follows the continuous use of iodine or iodide-of-lead ointment. In some cases of chronic induration of the testis and epididymis, not due to syphilis, mer- curial ointment with compression will produce resolution. Then, again, I have seen great benefit folloAv the combined use of mercurial ointment and the mixed treatment, though the induration was wholly due to gonor- 254 GONOBRHCEA AND ITS COMPLICATIONS. rhoea, and not even remotely to syphilis. In obstinate cases it is always well to try this combination treatment. The local treatment of the miscellaneous forms of orchitis due to in- fectious processes and to traumatism should be based on the lines already laid down. Such surgical relief as may be rendered necessary by abscess- formation should be applied on general principles. The testicular inflammation due to malaria demands quinine, and the other infectious forms of epididymo-orchitis and epididymitis should be treated symptomatically on general principles. One golden rule should always guide the surgeon in the treatment of these testicular afi"ections, and that is not to cease treatment until all the products of inflammation have been removed by absorption. CHAPTER XXIII. aONORRHCEAL OPHTHALMIA AND SERO-VASCULAR CON- JUNCTIVITIS. Gonorrhceal Ophthalmia. GoNOERHCEAL, OPHTHALMIA is happily a rare accident rather than complication of gonorrhoea. According to statistics, it occurs 59 times in 37,034 cases of eye diseases, but probably in far greater frequency in the course of gonorrhoea. It is a violent and often destructive inflammation, and more intense than purulent conjunctivitis. It is developed in the eyes of young infants during delivery by gonorrhceal pus in its mother's vao^ina. The usual mode of infection is the transference of the pus from the genitals to the eyes by means of the fingers. In some cases the pus of the infected eye is carried to the other by the fingers during sleep or by accident during the day. Towels and linen are also said to be the vehicles of infection. The virulent form of ophthalmia has been shown (see p. 86) to be caused by pus-containing gonococci. The less virulent form is said to be due to pus not containing gonococci, but other pyogenic microbes. In the majority of cases of the milder affection the symptom-complex is much less severe than in gonorrhceal ophthalmia, but in some cases the severity is seemingly just as great. All forms of chronic urethral and vaginal pus should be regarded as dangerous. The pus of balanitis and of abscesses, though said to be innocuous to the eyes, should never be carelessly brought in contact Avith them, such is the danger of infection from every form of purulent secretion. This form of ophthalmia is said to be more common in men than in women, for the reason, probably, that gonorrhoea is so much more fre- quent in the former than in the latter. It may occur in the acute stage of gonorrhoea, but it is generally seen during the declining stage. It may be confined to one eye or may later on attack the other one. Symptoms. — The first symptoms, which usually begin in a few hours or as late as thirty hours after contagion, are hyperaemia of the con- OONORRHCEAL OPHTHALMIA, ETC. 255 junctiva, an itching sensation at the margin of the lids, as if caused by a foreign body, soon followed by increased lachrymation, a gumming of the cilit^ together, and collection of little masses of mucus at the inner canthus. The watery secretion soon becomes mucoid and very shortly purulent. A conjunctivitis, mild at first and limited to the lids, but later on of a severe type, involving the ocular mucous membrane, which is ele- vated above the sclerotic coat, is then seen. All of the conjunctival sur- face is then of a very deep-red color, much swollen, producing eversion of the lids, and roughened from distention of the papillae. The intense chemosis of the conjunctiva bulbi is well shown in Figs. 86 and 87, in Fig. 86. V\^\ A \ \ ■'■"" Gonorrhceal ophthalmia, showing well- Gonorrhoeal ophthalmia, showing com- marked ehemosis. mencing opacity of the cornea. which the red, swollen, and infiltrated membrane surrounds the cornea like a pad. At this time the secretion is purulent and profuse, and much redness and oedema of the integument of the lids is present, as seen in Fig. 88. The following account of gonorrhoeal ophthalmia by my late colleague, Dr. Bumstead, who to his many attainments added that of an accomplished ophthalmologist, is inimitably graphic : " An attack of gon- orrhoeal ophthalmia is so rapid in its progress that the early symptoms just now described may have passed away before the first visit of the surgeon, who is often called to see his patient only after the full development of the disease. He probably finds him sitting up, his head bent forward, his chin resting on his breast, and his handkerchief applied to his cheek to absorb the discharge, which irritates the surface upon which it flows. The eye- 256 GONOBBJKEA AND ITS COMPLICATIONS. Fig. 88. lids are swollen, especially the upper, which slightly overlaps the lower, and is of a reddish or even dusky hue. The patient states that he is unable to open the eye. His inability to do so is caused less by an in- tolerance of light than by the mechanical obstruction which the swelling of the lids occasions, and by the pain which is excited by any friction of the inflamed surfaces upon each other. " The surgeon now moistens the edges of the lids with a rag dipped in warm water in order to facilitate their separation, and proceeds with his ex- amination. In his attempt to open the eye he is careful not to make pressure upon the globe, in order to avoid giving unnecessary pain, and also lest the cornea, if already ul- cerated, may be ruptured and the contents of the globe escape. With one finger just below the eye he slides the integument downward over the malar bone, and thus everts the lower lid, the upper lid being ele- vated by a similar manoeuvre with the other finger of the same hand applied below the edge of the orbit ; or, again, he may expose the globe by seizing the lashes and margin of the upper lid with the thumb and finger, and drawing the lid forward and upward. All this may be accomplished with the left hand, the right being free to wipe away the discharge or to make application to the eye. " As soon as the lids are separated a quantity of thick yellowish pus wells up between them and partially obstructs the view : the swollen palpe- bral conjunctiva, compressed by the spasmodic action of the orbicularis muscle, may also project in folds. The collection of matter is now re- moved with a soft moist sponge or rag, and the surface of the ocular con- junctiva exposed. This membrane is found to be of a uniform red color, with the vessels undistinguishable from each other, and elevated above the sclerotica by an ejffusion of serum and fibrin in the cellular tissue beneath it. This swelling of the conjunctiva is seen to terminate at the margin of a central depression occupying the position of the cornea and filled with a collection of the less fluid constituents of the puriform dis- charge, which may at first be mistaken for the debris of a disorganized €ornea. On removing this matter, however, the latter structure may still be found clear and transparent at the bottom of the depression, where it is overlapped by the swollen conjunctiva. In less fortunate cases it may have become hazy from infiltration of pus between its layers, or ulceration may have commenced. If an ulcer is not evident on first inspection, it may be discovered at the margin of the cornea by gently pushing to one side the overlapping fold of the conjunctiva. Meanwhile, the secretion of pus is constantly going on, and it requires repeated removal. It is astonishing to observe how large a quantity of this fluid can be secreted OonorrhcBal ophthalmia, with great cedema of of the tegumentary parts. QONOBBHCEAL OPHTHALMIA, ETC. 257 by so limited a surface. It has been estimated at more than three ounces per day in some cases." The amount of pain occasioned by this disease varies in different cases. During the development and acme of the inflammation it is generally severe. It is described by the patient as a sensation of burning heat and tension in the eyeball, radiating to the brow and the temple. The system at large sympathizes with the local disease. For a time there may be general febrile excitement, but symptoms of depression soon appear ; the pulse becomes rapid and irritable, the skin cold and clammy, and the patient anxious and nervous. This depression of the vital powers is not invari- ably met with, but is the most frequent condition of the patient after the disease has continued for a few days ; and it may appear even at an earlier pei"iod when the health has been previously impaired from any cause. Notwithstanding the severity of the symptoms, resolution is still possible. Under proper care and treatment the inflammatory action may abate and the tissues recover their normal condition, leaving the eye as sound as before the attack. So fortunate a result is more to be hoped for than con- fidently anticipated. Prognosis. — The prognosis is always grave, especially so when both. eyes are attacked. If treatment is instituted at an early period, the chances of the patient are best. If ulceration of the cornea has taken place, they are bad. It generally begins at the corneal margin, either superficially or deeply, and may creep around or may advance toward the centre. Sometimes the whole cornea is extruded and the contents of the eye escape. An eye has been known to be thus destroyed within twenty- four hours, and even in a single night. The escape of the contents of the globe often gives the patient hope that he is recovering, whereas his sight is gone. According to the extent and situation of the ulceration the eye is more or less permanently injured. When superficial and marginal, the result- ing opacity of the cornea may not interfere with the sight, which may be impaired if the leucoma is central. Perforation of the anterior chamber and prolapse of the iris, when partial, may also be remedied by art ; but when the Avhole or the larger part of the cornea has sloughed away, and the prolapsed iris has become covered with a dense layer of fibrin, form- ing an extensive staphyloma, the case is hopeless. Trachoma or exuberant granulations of the palpebral and bulbar con- junctiva often follow gonorrhoeal ophthalmia, and are sometimes of much annoyance to the patient and resistant to treatment. Frequently a tend- ency to hyperaemia of the external ocular tissues from slight irritation is observed over long periods. Diagnosis. — So much do severe cases of purulent ophthalmia resemble those of the gonorrhoeal form that a sharp diagnosis is often impossible, owing to the meagreness of the history. Any intense form of ophthalmia, whatever may be its origin, must be looked upon in as serious a light as that due to gonorrhoea. In all cases the pus should be examined micro- scopically at once, and if the gonococcus is found it is absolutely certain that the case is of gonorrhoeal origin, and therefore a very grave one. In general, when less virulent micro-organisms are found, the diagnosis is not bad. The earlier a case of gonorrhoeal ophthalmia is seen and that a proper treatment is commenced, the better is the prognosis. In infants 17 258 GONORRHOEA AND ITS COMPLICATIONS. the prognosis largely depends on the care which the case receives. In early adult life there is such resistance of the tissues that with care the inflammation may be controlled. Toward middle age and in elderly sub- jects the tissue-resistance is not as great, and the prognosis then is more serious. Treatment. — The first indication in treatment is to procure a skilled, kind, and trusty female nurse — and preferably two, one for the day, the other for the night — who should be in constant attendance. She should, at the outset, be thoroughly impressed with the gravity of the case, in- structed as to her duties, and shown the technique of opening the eye and removing the pus. She must be warned of the intense contagiousness of the secretions, must be directed to keep her hands and nails in a thor- oughly aseptic condition, and she should provide herself with a pair of pro- tective concave spectacles having a diameter of two inches. In case one eye only of the patient is affected, the other may be covered by Buller's shield. This consists of two pieces of India-rubber adhesive plaster, one four and the other four and a half inches square, between which, in a hole in the centre, a deep watch-glass is fastened. The watch-glass is placed over the eye, which can then be inspected, while the margins are fastened to the nose, forehead, and cheek. It is well to leave a little space for venti- lation on the lower outer angle. Or the sound eye may be covered with cotton wool strapped down with adhesive plaster, over which a solution of gutta-percha is painted. In young subjects it is well to secure the hands. If seen before inflammation has fully developed, four to six leeches may be applied at the external can thus or to the mucous membrane of the corresponding nostril, or if not at hand cups may be used on the temples. The character of the inflammation being manifest, a careful, continuous, and energetic treatment must be followed. Constant appli- cation of cold is then absolutely required. This is accomplished by means of small pieces of linen of a single thickness, which, when thoroughly chilled upon a piece of ice, should be laid over the eye, and replaced by another every two or three minutes in very intense cases. These pieces of linen should be burned immediately after use. The further treatment of the case should be as follows, after the manner proposed by my friend. Dr. J. A. Andrews, which has been productive of excellent results at Charity Hospital : When the inflammation is fully established the indi- cations are to wash away the pus in the most perfect manner as soon as possible, and to render the conjunctival surface as nearly as possible aseptic. For this purpose a saturated solution of boracic acid is neces- sary. A bichloride solution, 1 : 10,000 or 20,000, may also be used. This may be used by means of Andrews' irrigator No. 2, made by Ford of New York, or by means of a piece of fine rubber tubing attached to a fountain syringe, and allowed to flow with the utmost gentleness. These irrigations must be repeated as often as necessary. Then, from the beginning of the disease, a 2 per cent, solution of nitrate of silver should be dropped, rather than brushed, into the eye, since it is then distributed by the movement of the eyelids. The more vascular and swollen the conjunctiva, the more frequent should be these instillations, which may be made from three to four times daily, according to indica- tions. Instillations of a four-grains-to-the-ounce-of-water solution of atro- pine may be used also at intervals during the severity of the attack. As GONOBRHCEAL OPHTHALMIA, ETC. 259 improvement takes place, the use of the solution of nitrate of silver should be more infrequent until it is finally dropped. If chemosis has taken place, the ocular conjunctiva and subjacent connective tissue should be divided by means of blunt scissors, and in case the eversion of the lids is not complete, the outer commissure should be freely divided, together with the canthal ligament, for the inflamed surfaces must be in such a condition that they can be thoroughly treated. Excessive oedema of the lids interfering with the opening of the eye may be relieved by minute punctures of the skin. After the subsidence of the acute symptoms the nitrate-of-silver solution, which toward the end has been used much less frequently than at first, may be replaced by a solution of sulphate of zinc, as follows : ^. Zinci sulphatis, gr. ij ; Glyceringe, gij ; Vin. opii, 3J ; Aquae, 3v. — M. This may be instilled into the eye by means of a glass-and-rubber drop- ping-tube. Should ulcer of the cornea occur, the pupil should at once be dilated with atropine solution and vigorous but prudent measures adopted. The granular condition of the conjunctiva should be treated by the application of a piece of sulphate of copper to the surface every second or third day. Patients suffering from gonorrhoeal ophthalmia should occupy a large, well-ventilated room, which should be moderately, not wholly, darkened, and they should be placed exclusively in the care of the surgeon and the nurse or nurses. At the onset of the disease a brisk aperient, even a cathartic, may be given, which should be repeated as necessary, care being taken that the patient's strength is not impaired by it. A mild diet, gruels and light broths, may be taken. Should evidences of mal- nutrition and debility appear, with weak and irritable pulse, more nutri- tious food of the most digestible character must be given, together with tonics, and perhaps ale, porter, milk punch, etc. It must be remembered that the vitality of the corneal tissue is very low, and that its destruction may be hastened by an impoverished state of the system. Convalescence is much hastened by change of air, particularly in the mountains. It is sometimes astonishing to observe how rapidly the nutri- tion of the patient increases, and how quickl}?- the trachoma and conjunc- tival congestion disappear, under the influence of country air. Sero-vascular Conjunctivitis. This is a rare form of purulent conjunctivitis of which little has been written. This form of ophthalmia is really a complication of gonorrhoea, and not one of its accidents. Though the pathogenesis of this affection has not been studied, much less made out, I think, reasoning by analogy, that it will later on be settled that it is an infectious process due to septic absorption, like gonorrhoeal rheumatism, etc. It certainly is not due to pus-contamination. 260 GONORBHCEA AND ITS COMPLICATIONS. This form of conjunctivitis is called by Fournier " blennorrhagic sero- vascular conjunctivitis." Fragne,^ an ^l^ve of Fournier, employs the title "blennorrhagic sero-vascular conjunctivitis without inoculation" as being more expressive. This affection begins in a painless and insidious manner, but its ob- jective symptoms are well marked. The patient at first feels a slight heat in the eye and a sensation as if some particle had lodged on it. Then the conjunctiva bulbi becomes rather swollen and hypersemic. This is followed by hypergemia of the conjunctiva of the lids. The secre- tion is at first serous and moderately copious, but in a few days it becomes slightly purulent. In the acme of the inflammation Ave find the whole conjunctiva rather swollen, with perhaps some oedema of the eyelids. The mucous membrane is of a quite deep-red color and of velvety appear- ance. The oedema is not usually very extensive. The affection runs an indolent course, and usually does not cause much pain or annoyance. One or both eyes may be affected. After cure a relapse is not uncom- mon. I have seen several cases in which patients were thus affected with each attack of gonorrhoea. The prognosis is almost invariably good. Treatment. — The eye should be irrigated with saturated boracic-acid water, and a few drops of a 2 per cent, solution of nitrate of silver may be dropped in the eye once or twice a day. Ice-cloths may be necessary. CHAPTER XXIV. GONORRHCEAL RHEUMATISM. The term "gonorrhoeal rheumatism" is applied to a complex inflam- mation, chiefly of the joints, fasciae, bursse, and tendinous sheaths, and also of the eye and fibrous tissues, which follows in the course of urethral gonorrhoea and gonorrhoeal vulvitis, vaginitis, and conjunctivitis. It sometimes complicates urethral suppuration caused by instrumentation, even as simple as the passage of a sound. This form of rheumatism does not complicate balanitis or simple inflammations of the external genitals of the male or female. Gonorrhoeal rheumatism attacks men more frequently than women^ and is seen in infants and in the young and the old. It has no etiological relation to a pre-existent rheumatic condition or diathesis, for the reason that we see many truly rheumatic subjects who may suffer from gonor- rhoea without becoming affected with its rheumatism. This affection may follow each attack of gonorrhoea, but such a course is far from being the invariable rule, since many men have thus suffered once after gonorrhoea, and never again after subsequent infections. Gonorrhoeal rheumatism is a rare affection if compared with the fre- 1 Thhe de Paris, 1888. GONORRHCEAL RHEUMATISM. 261 quency of gonorrhoea, and occurs in about 10 per cent, of all cases of that disease. It would be an utter waste of time to detail the old views and discuss the various contentions as to the origin and nature of gonorrhoeal rheu- matism. To-day, in the light of our knowledge of the pathological action of the gonococcus, the subject is quite clear. It is therefore worth while to present the experience which led up to this condition of enlightenment. As early as 1883 it was claimed by Petrone ^ that he had found the gono- coccus in the fluid of gonorrhoeal arthritis. This statement was further strengthened by the observations of Kammerer,^ Horteloup,^ Bergmann,* Hartley,^ and many others, who claimed that they also found the gono- coccus in the joint effusions of gonorrhoeal rheumatism. Owing to the fact that these various observers had only used the microscope in their studies, there was a doubt in the minds of many whether they had really discovered the gonococcus or some other diplococcus resembling it. As a result of various studies, the following hypotheses as to the origin and nature of gonorrhoeal rheumatism were entertained : First, that it was the direct result of gonococcus invasion of the joints and various fibrous tis- sues ; second, that it was the result of a mixed infection, in which the gonococcus and pyogenic microbes were the morbific agents ; third, that the process began by the invasion of the gonococcus, which prepared the way for pyogenic microbes ; and, fourth, that it was a phlegmasia pro- duced by toxines carried from the urethra by means of the circulation to the parts affected. These observations have since been confirmed by sev- eral observers. Deutschmann ^ found gonococcus in the interior of the pus-cells of two cases of the joint effusion of gonorrhoeal rheumatism, and later on Hock ^ was able to obtain pure cultures from a similar fluid. The latest and most important contribution to the subject is made by Finger,^ Ghon, and Schalgenhaufer. Finger found in the case of an in- fant suffering from purulent ophthalmia the gonococcus alone in peri- chondritis of the ribs, and the gonococcus and streptococcus in the in- flamed knee-joint, also affected with periarticular suppuration. In the temporo-maxillary articulation the streptococcus alone was found. This observation of Finger, made with so much care and detail Avith the aid of the microscope and culture-tests, supported by many observations and facts presented by others, is all-important in settling the doubt as to the caus- ative relation of the gonococcus to gonorrhoeal rheumatism. ' Rivinta Clin, cli Bologna, 1883, 3d series, vol. iii. pp. 94 et seq., and Centralblt. fiir Chirurgie, 1883, No. 37, p. 586. ^ Centralblatt fur Chirurgie, 1884, No. 11, pp. 49 et seq. * Gazette des Hopitaux, 1885, p. 1004. * St. Petersburg med. Zeitsch., 1885, No. 35. 5 Neiv York Med. Journal, April 2, 1887. Guyon and Janet have reported four cases of gonorrhoeal rhenmatism in the, joint eflfiisions of which they were unable to find the gonococcus or any other microbe. Too much stress need not be laid on these negative observations, for the reasons — first, that the particular specimens of fluid withdrawn might not have contained the microbes which were present elsewhere ; and, second, that the micro-organism itself might have been killed bv the inflammatory products which it had caused {Annales des Mai. des Org. Gin.-urin., 1889, pp. 462 et seq.). * Graefe's Archiv, vol xxxvi., 1890, pp. 109 et seq. ' Wiener klin. Wochenschrift, 1893, No. 41, p. 73. ® Archiv fiir Derm, und Syphilis, 1894, vol. xxviii.. Heft 1, pp. 2 et seq., and Heft 2, pp. 277 et seq. 262 GONORBHCEA AND ITS C03IPLICATI0NS. Hewes ' has recently claimed that he found and cultivated the gono- coccus taken from the joint fluid and blood of two cases of patients suf- fering from gonorrhoeal rheumatism. Dr. W. H. Welch ^ has reported the case of a woman suffering from gonorrhoea complicated by pyaemia and endocarditis, from whom during life he extracted some blood. This was mixed with agar, and as a result cultures were obtained which showed the gonococcus. This observation,, coming from so eminent an observer, certainly carries conviction with it, and clearly demonstrates that the gonococcus is carried into the blood- current, which may deposit it throughout the body. Welch also found the gonococcus in the purulent secretion of gonorrhoeal inflammation of a tendinous sheath. In the light of our present knowledge, therefore, we are warranted in stating that the essential inflammation in gonorrhoeal rheumatism is caused by the gonococcus and its toxines, and that the morbid process may be further complicated and aggravated by the concurrent or subse- quent action of pyogenic microbes. Whether the cases presenting ordi- nary serous eff"usion are due to the gonococcus alone or its toxic products, and whether the cases of articular and fibrous-tissue abscesses are due to the action of the gonococcus, aided by that of pus-microbes, we cannot to-day state with scientific precision. The results of observation seem, however, to show that when the joint effusion is serous or sero-fibrinous the gonococcus is found in it, and that when it is sero-purulent or puru- lent pyogenic microbes are found. There seems to be sufiicient evidence at hand to warrant the statement that in many cases the pyogenic mi- crobes dominate in the phlegmasia, and thus the gonococci perish in whole or in part. It is very difiicult to state definitely the date of the onset of gonor- rhoeal rheumatism. While the complication may and does occur in acute urethritis in a goodly number of cases, as I have myself seen, its onset then is in the second or third week at the earliest. Cases have been reported in which this form of rheumatism is said to have begun on the sixth day of acute gonorrhoea, but is very probable that there Avas an error in the observations. Thouo;h we have not absolute knowledge on the subject, it is probable that absorption of septic material does not take place until the infection has reached the posterior urethra. It is usually in the older and more chronic cases of gonorrhoea that its rheumatism appears ; consequently we more frequently see it develop in one, two, three, and four months after the beginning of the infection, and even later. From old and recent medical literature Finger^ has tabulated 375 cases in which the site of the disease is stated. They are as follows : Gonor- rhoeal rheumatism occurred^ 1 Boston Med. and Surg. Journal, No. 22, 1894. 2 Med. Record, June 15, 1895, p. 756. ^ q^ ^h_^ pp_ 296 et seq. * Bornemann's statistics (Studier over den Gonorrhoiske Rheumatismus, Copenhagen, 1887) are also interesting. They are based on the study of 278 cases. In these cases the knee was affected 240 times; the foot, 151 ; the shoulder, 68; the metacarpo-phalangeal joints, 51; the hip, 46; the elbow, 45; and the jaw, 12. It was noted that there was not uniformly an excess of synovial fluid, since in the 240 cases in which the knee was attacked it was only found 183 times. Affections of the tendons and burspe occurred in 41 patients ; 4 suffered from periostitis ; and in 3 the muscles were attacked. Out of the whole number of cases (278), endocarditis occurred in 2 cases and sciatica in 5. GONOBBHOEAL BHEUMATISM. 263 In the knee-joint 136 times. " tibio-tarsal joint ... 59 " " wrist-joint 43 " " finger-joint 35 " " elbow-joint 25 " " shoulder-joint .... 24 " " hip-joint ...... 18 " " maxillary joint ... 14 " In the metatarsus " sacro-iliac synchondrosis " sterno-clavicular joint " chondro-costal joint . " intervertebral joint . " peroneo-tibial joint . " crico-arytenoid joint . 7 times. 4 " 4 " 2 " 2 " 1 time. _J. ''__ 375 times. In about 60 per cent, of cases several joints are involved, and then the affection is termed polyarticular, and in 40 per cent, only one joint is involved, the affection then being called monoarticular. Besides the joints other structures are frequently involved in gonor- rhoeal rheumatism, either in combination with the joint lesions or as special inflammations. The bursse are quite frequently attacked. The bursa in front of the tendo Achillis and the one beneath the os calcis are most frequently involved, while those of the wrist, ankle, the patella, the tuber ischii, the bicipital, and of the psoas muscle are less commonly attacked. The tendinous sheaths may be affected in gonorrhoeal rheu- matism, either alone or in combination with joint lesions. The sheaths most commonly the seat of the inflammation are the extensors of the hands and fingers, the dorsal flexors of the toes and the flexor pollicis, the sheaths of the biceps brachii, and of the tendo Achillis. The external fibrous structures and ligamentous tissues of joints, particularly the large ones of the knee and the elbow, are not unfrequently involved by this form of rheumatism, which is called periarticular gonorrhoeal rheumatism. This may also be said of smaller joints, such as of the hands, feet, and toes. In these cases there is no intra-articular phlegmasia. The plantar and palmar fascia are quite rarely the seat of gonorrhoeal inflammation. The essential lesion of the joints is an inflammation of their synovial membrane, which may result in serous synovitis, sero-flbrinous synovitis, sero-purulent synovitis, which are the more common forms, and purulent synovitis, which is quite rare. Gonorrhoeal rheumatism is essentially an hydrarthrosis, and in very many instances the disease is confined to the synovial membrane of the joint during the whole course of the affection. In some cases the discharge ceases when the rheumatism begins, in others it is increased before its onset, and in still other cases there is no alteration in its course. Acute inflammation of one joint, particularly of the knee, and called gonitis, is the most common form of gonorrhoeal rheumatism. This form is called acute monoarticular gonorrhoeal rheumatism. In this affection there may be no premonitory symptoms whatever, and the patient's first complaint will be that his joint is rather painful and that he limps slightly. In other cases there is a slight chill and fugitive pains over the body, with malaise and mild fever. These symptoms usher in the hydrarthrosis. In more severe cases these symptoms are much accentuated. I have seen cases in which there was mild delirium, with a condition resembling typhoid fever in its third week. Again, I have seen cases — but rarely, however — in which the patient was stupid, dull, heavy, and very feverish (temp. 102° to 105° Fahr.), and presented the appearance of profound septic intoxication. The symptoms may, therefore, be very mild, quite severe, and exceptionally very severe and even grave in character. The acme of the constitutional symptoms is generally reached Avithin a week. 264 OONORBHCEA AND ITS COMPLICATIONS. and from that time onward they range in about the same degree of mildness or severity. Sweating, so common and so copious in ordinary rheumatism, is not observed to any marked extent in the form under consideration. In general terms, it may be stated that the symptoms are rather mild in cases of serous effusion, rather more severe when the effusion is sero- fibrinous, and most severe when it is sero-purulent or purulent. The pain in the joint is at first slight, but it speedily increases in intensity, particularly if the patient continues to go about. The evidences of serous effusion into the joint are soon seen. If the knee-joint is affected, the patella is soon elevated above the level of the femur, and two fluctuating cushions may be seen on each side of its upper portion and over the lower extremity of the femur, and two similar ones on each side of its lower portion over the head of the tibia. The patella floats in the fluctuating cushion, and if pressed downward it rebounds with a dis- tinct click. With the onset of the effusion heat, redness, and swelling a,re observed in the investing integument. In many acute cases there is no perceptible thickening in the fibrous structures around the joint. In the chronic form this extra-articular condition may be observed. In the acme of the affection the joint is much enlarged and distended, the skin is red and tense, and there is pain which may be dull and continuous or throbbing and stabbing. In many cases the pain is worse at night. As the phlegmasia in the joint increases the limb becomes more and more immobile. This monoarticular form of gonorrhoeal rheumatism may constitute the whole affection, but in some cases other joints become involved. When the disease thus spreads, there is no abatement of the morbid process in the joint first affected, but there may be an intensification of the general symptoms. Under favorable circumstances the acute dropsy of the joint, in the monoarticular form, subsides in from four to six Aveeks, but if the morbid process is more severe and the exudates are sero-fibrinous, sero- purulent, or purulent, then the duration is much longer — we may say indefinite. ~ Monoarticular gonorrhoeal rheumatism, also called gonocele, may begin in a slow and subacute manner, and may then develop into a chronic affection. In this event the patient experiences very little pain, and only some inconvenience in walking and moving the joint. Sooner or later he discovers that the joint is enlarged and the seat of serous effusion. There is no extra-articular inflammation and no general sys- temic reaction. In this condition the joint may remain for many months. In some cases visible improvement may be noted, which is usually followed "by an exacerbation of a low grade. In this way the case may hitch and halt until inflammatory changes in the synovial membrane and articular surface, and even the bones, are developed and arthritis deformans results. The less common form of gonorrhoeal rheumatism is that in which, as a general rule, two or three, and exceptionally many, joints are involved, and it is called polyarticular acute gonorrhoeal rheumatism. The symp- tom-complex of this form resembles that of the monoarticular form. The course of this joint affection, however, is different. Sometimes during the course of the inflammation in the first joint a second one is attacked, but GONOBRHCEAL RHEUMATISM. 265 there is usually no marked amelioration in the condition of the first. With each joint involvement the symptoms may undergo an exacerbation, which is soon followed by a remission ; and thus the case progresses until several or many joints are involved. Usually the number of joints in- volved is not as great as in articular rheumatism. I have, however, seen a case in which every joint of the body, even the temporo-maxillarv artic- ulation, was thus involved, and as a result became ankylosed. In this form also there is usually not the painful thickening of the fibrous tissues around the joint which is such a marked feature of articular rheumatism. The disproportion between the general symptoms and the joint lesions is so marked in gonorrhoeal rheumatism, and in such con- trast with what occurs in acute articular rheumatism, in which the symp- toms are severe and striking, that the nature of the complaint is readily determined. The course of this form of rheumatism depends largely on the nature of the effusion and of the exudates. If the lesion is simply a serous efiusion, the afi"ection may last two, three, or many months. If it is sero- fibrinous, it may last longer ; and if sero-purulent or purulent, the course may be indefinite. Chronic dropsy of the joint, more or less disorganization, and even ankylosis, may result. In very chronic cases atrophy of the muscles con- nected with the diseased joints may occur. As complications of the polyarticular form of gonorrhoeal rheumatism we sometimes see sclerotitis, iritis, aquo-capsulitis, bursitis, and inflamma- tion of tendinous sheaths. There are certain minor forms of gonorrhoeal rheumatism which may or may not present conspicuous objective and subjective symptoms. These are inflammations of tendinous sheaths, of bursse, of fascige, and of the extra-articular structures. The tendinous sheaths may be aff'ected alone or synchronously with the joints. Those most commonly attacked, are, as before stated, the extensors of the hands and fingers, the dorsal flexors of the toes and the flexor pollicis, the sheaths of the biceps brachii, and the tendo Achillis. The visible signs of this affection are redness and swelling along the course of the tendon. This elongated phlegmasia is more or less painful, and causes more or less functional impairment of the part aff'ected. So commonly is this condition due to gonorrhoea, and so strikingly in contrast with the phlegmasic non-painful tendinitis due to syphilis, that its nature will be readily perceived. Tuberculous inflam- mation of these structures may be attended with an acuteness of symptoms, objective and subjective, which may suggest gonorrhoea as their origin. This point should always be borne in mind. Inflammation of bursae due to gonorrhoea shows itself, at first, as a localized red and rather painful swelling of the part. If the affection becomes chronic, the redness in a measure disappears and the part be- comes less painful. The bursse of the tendo Achillis, of the os calcis, wrist, ankle, patella, and tuberosity of the ischium, are the ones most commonly attacked. This affection may be acute, subacute, and chronic in course. It is not uncommon to find concomitant inflammation of tendinous sheaths and of bursse in the course of polyarticular acute gonorrhoeal rheumatism. Inflammation of the investing structures of joints, and sometimes of 266 GONORRHCEA AND ITS COMPLICATIONS. the ends of large and expansive tendons, is a rather infrequent form of gonorrhoeal rheumatism, and is termed arthralgia. This condition may exist alone or in conjunction with a more extended development of the disease. It may attack the outer surface of one or more large joints in whole or in part. There may or may not be redness and swelling, but there commonly is pain of an acute, aching, persistent character. The area of pain may be limited to an inch or more of tissue, and it may be extensive. There is usually an absence of general symptoms. This affec- tion may last several weeks, and even months, but it generally yields to vigorous counter-irritation. I have many times observed in cases of chronic posterior urethritis, particularly during or near an exacerbation, patients complain of rheu- matic pains in the large and small joints, in the fasciae, and in diffuse form in the muscles. Sometimes these attacks of pain are not severe, and cease in a short time ; in other cases the pain is severe and persistent. In all the cases there is little if any systemic reaction. I am led to suspect that many cases of mild and anomalous rheumatism are in reality caused by urethral suppuration. The fasciae involved in gonorrhoeal rheumatism are the palmar and the plantar, but cases thus affected are very rare : I have seen one or two of each. During the course of polyarticular gonorrhoeal rheumatism the fibrous sheaths of muscles and their fasciae are sometimes attacked. In old and broken-down subjects, the victims of very chronic and sometimes never-ending gonorrhoeal rheumatism, after one, several, or many of their joints have become ankylosed, the disease goes on and on, attacking the fibrous structures of muscles and bringing about their atrophy. In such cases also we may find persistent arthritis of the bones of the hands and feet, which results in permanent disfigurement and sometimes great de- formity. In some cases of chronic gonorrhoeal rheumatism sciatica, mild or severe, may occur, as pointed out by Fournier,^ and in these cases peri- ostitis may sometimes be observed. Martel ^ describes as a rare complication of gonorrhoeal rheumatism a phlebitis of the saphenous, femoral, and iliac veins, which may undergo res- olution or lead to their obliteration. The eye and heart complications of gonorrhoeal rheumatism are de- scribed elsewhere. Diagnosis. — In many cases the existence of a gonorrhoea or the history of a comparatively recent attack will suggest the nature of the case under observation. In the main, the absence of sweating and the comparatively mild systemic reaction (in the majority of cases) will suggest gonorrhoea as the cause of the rheumatism. Then the predilection of the disease to attack the larger joints, particularly of the knee, ankle, wrist, and shoulder, and to only invade one, two, or three joints, is indicative of gon- orrhoea as its cause. Hydrarthosis is common in gonorrhoeal rheumatism, and is infrequent and slight in the ordinai-y form of the disease. The absence of a history of rheumatism is also significant of urethral suppura- ^ " De la Sciatique blennorrhagique," Bull, et Memoir es de la Societe med. des Hop. de Paris, 1869, vol. v. pp. 34 et seq. ^ " De la Phldbite dans le Cours du Ehumatisme blennorrhagique," 27iese de Paris, 1887. GONORRHCEAL RHEUMATISM. 267 tion as a cause. The coincident involvement of tendinous sheaths, fascise, and bursse, with perhaps the iris and conjunctiva, is a strong point against the case being one of ordinary inflammatory rheumatism. In any case of doubt careful examination of the urine should be made, and if threads largely composed of pus-cells are found, the investigation should be pushed in the direction of gonorrhoeal rheumatism. In all cases of obscure localized chronic rheumatism of the extra-articular structures, fascige, tendinous sheaths, and bursse, a suspicion of urethral suppuration should be entertained and followed up. Prognosis. — In all cases of involvement of the larger joints by inflam- matory eftusion the patient is a lucky man if he is well on his feet in six weeks or two months. When several joints are involved the illness will be still further protracted, and when the morbid process gives rise to sero- fibrinous or sero-purulent efi"usion the course of the case may be protracted for several or many months. In the more localized forms of gonorrhoeal rheumatism Avithout much systemic reaction, involving the extra-articular structures, the tendinous sheaths, fasciae, and bursse, one, two, or three, and even more, months may elapse before the patient is well and free from pain. In many cases the cure is largely dependent on the efiiciency and vigor of the treatment adopted. Treatment. — The golden rule in the treatment of all cases of gonor- rhoeal rheumatism is to cure the inflammation in the urethra, since that is the source and origin of the disease. If the suppuration is subacute or chronic, it must be treated accordingly, conforming to the directi(ms already given. Antiblennorrhagics have no perceptible effect in these cases. In general, very mild nitrate-of-silver irrigations, thrown into the posterior urethra, are suitable for subacute cases of urethral inflammation, and more concentrated solutions by instillation in chronic cases. It is wonderful to see the marked eff"ect amelioration of the urethral inflammation has upon the course of its resulting rheumatism. When joints are involved, the patient must at once be placed on his back and the part put at rest. When there is much heat, redness, and swelling of the joint, cooling applications, such as ice-bags, solution of muriate of ammonia, and lead-and-opium wash, may be used. In plethoric subjects temporary ease may be obtained by the use of leeches. In some cases a flaxseed poultice in which laudanum has been mixed gives com- fort. In every case the patient should receive (unless contraindicated) enough opium or morphine to make him comfortable. This agent rarely fails to give relief, but we may use antipyrine or phenacetin. Salol, sali- cylate of sodium, muriate of ammonia, nitrate of potash, oil of wintergreen, colchicum, iodide of potassium, and quinine may be used in appropriate doses. If these agents have any therapeutic eff'ect on this boxed-up infec- tive process in the joint, it is well; but, to say the least, they often do. exert a moral eff'ect upon the patient, who feels that he is taking medicine, and therefore doing all he can do in that direction. With the decline of the acuteness of the joint inflammation much val- uable aid can be given to the case by very active blistering of the joint. This may be done by the application of cantharidal collodion or a fly blister spread on sheep-skin. The fully-developed blister must be kept "open" by means of savin or tartar-emetic ointment. If healing of the skin takes place, the blister must be applied again in the same vigorous 268 GOXORBHCEA AXD ITS COMPLICATIONS. maDner. A little opium is a great help in keeping the patient's courage up while he is undergoing this persistent blistering process. "When blisters fail to cause the hydrarthrosis to subside, it may be necessary to draw off the contained fluid and to irrigate the joint with sublimate solution, 2 : 5000, or carbolic acid and water, 1 : 50. Reaccumulation of the fluid demands a repetition of the process. In all of the phlegmasiae produced by gonorrhoea! rheumatism the general scheme of treatment just outlined should be followed. Over limited patches and areas of a subacute or chronic nature strong tincture of iodine or pure ichthyol may be applied. In chronic cases, particularly those in which the joint-cavity is not involved, I have seen good results follow the liberal internal use of iodide of potassium. Indeed, in several cases in which there was absolutely no history of syphilis I have seen marked benefit follow the use of the mixed treatment in combination with stroncr mercurial inunctions and of mercurial fumigations. In two cases of gonorrhoeal rheumatism of the bursje in front of the tendo Achil- lis I produced a prompt cure by the injection of fifteen drops of a 5 per cent, watery solution of carbolic acid. This treatment may be used in all limited bursal and fascial inflammations due to gonorrhoea. Paquelin's cautery, applied to limited spots, sometimes tends to pro- mote resolution. In chronic cases mild (never severe) massage is some- times surprisingly beneficial. In all chronic cases, where practicable, pressure to the extent of tolerance should be applied to the parts by means of elastic bandages. India-rubber adhesive plaster, or plaster-of- Paris splints. When suppuration and destruction or ankylosis of joints occurs, the cases are to be treated on general surgical principles. Since in many cases of chronic gonorrhoeal rheumatism there is a synchronous general cachexia, tonics should be given, change of air ordered, and general restorative means adopted. CHAPTER XXV. PERITONITIS IX THE MALE DUE TO GOXORRHCEA. IxFLAMMATiON of the peritoneum of greater or less severity may result from the extension of the gonorrhoeal process from some part of the seminal apparatus to that portion of the membrane in close contiguity with it. Gonorrhoeal peritonitis may be developed by acute inflammation of the seminal vesicles. The infectious process then begins in the recto- vesical cul-de-sac, where it may localize itself, or it may spread indef- initely from that morbid centre. Gonorrhoeal inflammation of the vas deferens or of a limited segment thereof may be the cause of peritonitis, owing to the fact that these ana- tomical structures are for a considerable distance in direct contact with each other. PERITONITIS IN THE MALE DUE TO GONORRHCEA. 269 ZeissP claims that inflammations of the lumbar ganglia (which are situated immediately behind the peritoneum), due to the extension of the gonorrhoeal process, may also be the cause of peritonitis from contiguity. We have already seen that during the course of gonorrhoea a limited portion of the vas deferens might become swollen and painful and cause fear of peritoneal involvement. In these cases, however, the deep pelvic or iliac pain usually ceases when the epididymis becomes swollen, as it usually does. In the majority of reported cases epididymitis and peri- tonitis had existed at the same time. Consequently, the testicular in- flammation may often be an important diagnostic guide. Patients attacked by gonorrhoeal peritonitis commonly complain of colic at first, and soon direct attention to the tenderness in one of the iliac fossae or of the groin. With the extension of the process the Avhole hypogastrium may become swollen and tender, and from that the whole abdominal cavity may be attacked. The symptoms are rapid and small pulse, increased respiration, and high fever. The pain is intense, par- ticularly on pressure, and causes the patient to have a sallow, drawn, and anxious facies. There may be obstinate constipation, and exceptionally diarrhoea. In many cases vomiting, particularly of bile, has been ob- served. There is usually much distention of the abdomen. In this Avay the disease may run on and end in recovery, but a survey of the literature shows that in many instances death has ensued. In many cases rectal exploration reveals marked, even intense, ten- derness or pain in the prostate and seminal vesicles. Horowitz^ reports a case in which there was inflammation of the left epididymis, prostatitis, inflammation of the seminal vesicles, and swelling of a considerable portion of the left spermatic cord, which was complicated by peritonitis. In this case recovery took place. According to Zeissl, Wendelin observed a case in which there was much swelling of the vas deferens, together with peritonitis, Avhich ran such a severe course that perforation of the bladder and rectum occurred, and death followed. Faucon ^ relates a case of epididymitis in which there were severe gen- eral symptoms, together with a swelling at the internal abdominal ring which extended to the spine of the ilium. It Avas regarded as a sub- peritoneal phlegmon, and was incised, but no pus was let out. Recovery took place. Peter* reports a fatal case, with the post-mortem findings, which is interesting. The patient was a boy sixteen years old who had gonorrhoea and epididymitis. He was attacked by the usual symptoms of acute peri- tonitis, which eventuated in death. At the autopsy diaphragmatic pleurisy, general peritonitis, and engorgement of the liver and spleen, were found. The urethra was red in its anterior part, pale in the posterior. The right seminal vesicle was healthy, but the left was swollen and contained pus. The surrounding cellular tissue was red and swollen, and the peritoneum ^ "Peritonite causae chez I'Homme par Ur^thrite blennorrhagique," Annales des Mai. des Org. Oen.-urin., 1893, vol. xi. pp. 481 et seq. ^ " Ueber Gonorrhoische Peritonitis beim Manne," Wiener med. Wochenschrlft, 1892, Nos. 2 and 3. ^ " De la Peritonite et dii Phlegmon sous-peritoneal d'origine blennorrhagique," Arch, gen. de Med., 1877. vol. ii. pp. 385 and 545. * L' Union medicale, 1856, xso. 141, p. 562. 270 GONORRHCEA AND ITS COMPLICATIONS. in conticfuity with it was strongly hyperamic. The left vas deferens was swollen, and in intimate contact with the peritoneum which surrounded it. It is evident that in this case the infection of the peritoneum took place through the seminal vesicle and vas deferens. Treatment. — The patient must be put to bed as soon as the prodromal pains are felt. If he is of vigorous build, leeches may be applied over the painful part. Then hot poultices must be kept continuously over the abdomen. Opium should be given internally, and all symptoms treated according to their indications. CHAPTER XXYI. CARDIAC AFFECTIONS AND PYEMIA. Cardiac Affections. So many well-attested cases have been reported, particularly within the past ten years, in which cardiac lesions of varying degrees of severity have developed during the course of acute and chronic gonorrhoea that there is now no longer any doubt of their origin in this virulent infectious process. Cardiac complications of gonorrhoea, however, are very rare, since in all less than fifty cases have been reported. The male sex seems to be the one most liable to heart complications during gonorrhoea, for there are only two instances on record in which they occurred in women. In the majority of cases cardiac lesions are associated Avith or follow gonorrhceal rheumatism as complications of gonorrhoea. The fibrous and serous structures of the heart are the parts primarily attacked, the endocardium most frequently, and the pericardium in a smaller percentage of cases. The essays of Marty ^ and Gluzinski^ show very clearly that there are some cases in which the symptoms are comparatively mild, and in which recovery, though in most cases with impaired heart, may occur. In such cases the patients complain of a " stitch " in the left chest and palpitation of the heart, whose action is accelerated and increased. Sometimes a slight pericardial crepitant rale may be heard. In the mild endocardial form we find palpitations, the prolongation of the first sound, with rough- ness and frequency of the pulse. There may be prsecardial dulness and distress, and hruit de souffle at the base with the first sound. Soft blow- ing murmurs are sometimes heard at the apex. It is thought that the aortic valves are more commonly attacked than the mitral. In some of these milder forms of cases the cardiac complication maybe ushered in by rigors, fever, and intense headache, which are soon followed by dyspnoea, palpitations, and the symptoms given above. MacDonnell^ 1 " De I'Endocardite blennorrhagique," Arch. gen. de Med., vol. ii., 1876, pp. 66 et seq. 2 Epitomized from the Eussian in British Med. Journal, May 11, 1889, p. 1084. ^ " Cardiac Complications in Gonorrhceal Eheumatism," Am. Journ. Med. Sciences, Jan., 1891, pp. 1 et seq. CARDIAC AFFECTIONS AND PYEMIA. 271 reports an interesting case of peri- and endocarditis in which pleurisy with efiusion was a further complication. Recovery, however, took place, but the patient was left with a persistent mitral murmur. The possibility of the onset of cardiac trouble in patients suffering from o-onorrhoea should be kept in mind by the surgeon, and if found the patient should at once be put to bed and properly cared for. Gluzinski verv pertinently remarks that in these mild cases the patient may still keep on his feet despite the cardiac lesion, and that he is thereby much exposed to heart failure. There are about ten cases on record in which malignant endocarditis and pvoemia developed as a result of gonorrhoeal infection. In these cases the onset was sudden and severe, and attended with chills, high fever, and evidence of profound sickness. The details of two cases will give a tolerably clear idea of the very grave form of heart troubles following gonorrhoea : In Weichselbaum's ^ the patient had acute enlargement of the spleen, gonorrhoea (with gonococci-containing pus) of three weeks' duration, and endocarditis, from which he died. At the autopsy the aortic valves were found to be eroded and covered with a grayish and reddish-white mass of vegetations. There was loss of substance in the mitral valve and perforation through the wall of the aorta to the tricuspid valve. The streptococcus pyogenes was found in the vegetations, and was culti- vated artificially. Ely's ^ case was that of a man of twenty-eight Avho had a urethral dis- charge, and entered the hospital in a stupid condition. His temperature was 105.8° Fahr., and pulse 130. He became very restless, vomited, and passed urine and faeces involuntarily. He was attacked with partial hemiplegia, failed rapidly, and died. At the autopsy the brain, liver, - and lungs were found to be congested, the spleen large and soft and the seat of infarctions, and the kidneys large and studded with embolic foci. The aortic valves were normal, but the mitral valves had recent vegeta- tions along the margins. Microscopical examination of the mitral valve showed recent infiltration of the substance of the valve with small round- cells and fibrin, together wdth erosions of the surface, which w^ere covered with fibrin and teeming with micro-organisms, the principal of which were the staphylococcus pyogenes aureus and the streptococcus pyogenes. The pus from the urethra showed diplococci which resembled gonococci, and a large number of other micrococci. Schedler^ has reported a case of malignant endocarditis following gonorrhoea, in which joint-complications first developed, and later on were followed by the heart affection and death. Thus we see that a very grave, even deadly, form of endocarditis is a very rare complication of gonorrhoea. In these cases, though the heart affection is a very prominent feature, the essential morbid condition is really pysemia. This grave disorder seems to be caused by the pyogenic microbes staphylococcus and streptococcus. Much has yet to be learned as to the ^ "Zur Aetiologie der Aciiten Endocarditis," Centralbl. filr Bacteriol. und Parasitenk., vol. ii., 1887, pp. 209 et seq. ^ Proceedings of the. N. Y. Patholofj. Society, for 1888, pp. 155 et seq. ^ " Zur Casuisiik der Herzaff'ectionen nach Tripper," Inaug. Dissert., Berlin, 1880. 272 GONORRHCEA AND ITS COMPLICATIONS. pathology of these cases and of the role of the gonococcus and pyogenic microbes. The most concise statement that can now be made is that they are the result of mixed infection. The prognosis in all these cases is grave. The treatment must be based on the indications presented. Pyaemia. Besides the cases of endocarditis and pericarditis which have their origin in urethral suppuration, there are a number of cases of pyaemia, in some of which there were heart-complications, on record, in which the infection was derived from pus-foci near the urethra. Thus, Besan^on ^ reports two cases, in one of which the suppuration was in the seminal duct and the epididymis, and in the other in abscess of the neck of the bladder behind old strictures. Lancereaux reports^ two cases — one in which the infection was de- rived from the prostate, and in the other from the testicle. I had under my care a man who died from pyaemia following acute abscess of the prostate, which the attending physician had failed to incise. There are a number of similar cases reported, particularly in Continental medical journals. Roswell Park, in an interesting essay,^ reports the case of a man who, following gonorrhoea, had suppuration of the knee-joints and typhoidal symptoms, with high fever, which resulted in death. Classen* reports a similar case of a man thirty-two years old who, after suffering for some time with gonorrhoeal rheumatism, was attacked by severe chills followed by profuse sweating, great thirst, accelerated respiration, anorexia, together with a temperature of 104° and 106° Fahr. Death occurred at the end of a month. Pyaemia may also occur as a result of gonorrhoea in the female sex. Hutchinson^ reports in a clinical lecture the case of a young woman who presented typhoidal symptoms, together with pleurisy and bronchitis. The source of the infection was found in a profuse purulent vaginitis of gonorrhoeal origin. This woman later on developed abscesses, but finally recovered. According to Post,^ Delafield has seen the case of a prostitute who, while suffering from gonorrhoeal vaginitis and cystitis, was attacked by rigors and febrile movement, which rapidly passed into a typhoid condi- tion, which ended in death. At the autopsy acute cystitis, pyelitis, and numerous small abscesses in both kidneys were found. A somewhat similar case is reported by Murchison.^ Bryant ^ reports the case of a man suffering from urethral stricture, in ^ " Endocardite ulcereuse a point de depart genital chez I'Homme," L' Union Med., 1886, Nos. ] 00 and 101. ■■^ "Endocardite a point depart genital chez I'Homme," ibid., No. 100. ^ "Pysemia as a Sequel of Gonorrhoea," Journ. Cuian. and Gen.-urin. Diseases, vol. vi., i, pp. 441 et seq. ^ " Pysemia as a Sequel of Gonorrhnea," Albany Med. Annals, vol. xi., March, 1890, p. 51. Philadelphia Med. and Surg. Reporter, Feb., 1876, pp. 105 et seq. ® " Deaths from Gonorrhoea," Boston Med. and Surg. Journal, May 5, 1887. ' Transaction'^ of Clinical Society London, vol. ix., 1879. " New York Med. Journal, April 8, 1887, pp. 372 et seq. AFFECTIONS OF THE SPINAL CORD. 273 which five abscesses seated on the thigh, iliac crests, and near the axilla followed gradual dilatation. I have seen a case in which an abscess of the right sterno-clavicular articulation appeared during the treatment of a urethral stricture by gradual dilatation. Such complications are, however, exceedingly rare. It is well to remember the old-time cases reported by Yoillemier and Villeneuve, in which patients suffering from acute gonorrhoea "broke" their chordee and developed generalized pyaemia, which caused death. Several years ago I had under observation a case of chronic pygemia due to an abscess at the side of the bulb, which had developed as a result of a tight stricture just anterior to the part. For nearly a year the patient suffered from irregular and erratic chills and fever, which were sometimes mild and again severe. Nothing then was known of a urethral lesion, for the patient made no mention of such trouble, and quinine and Warburg's tincture were given in large doses without any result. The perineal abscess led to exploration of the urethra and the discovery of a very tight stricture. I performed external urethrotomy, and the patient has since remained well. A study of the various cases of pyjemia following gonorrhoea shows that some are mild in character and end in recovery, whilst others are of a malignant type and end in death. CHAPTER XXVII. AFFECTIONS OF THE SPINAL CORD. Within a few years cases have been reported in which there was inherent evidence that certain spinal affections and symptoms had their origin in urethral gonorrhoea. Such a pathological relation is claimed by Hayem^ and Parmentier, who report two cases in which spinal symptoms supervened upon gonorrhoea! rheumatism, in one case coincidently with a severe attack of gonorrhoeal inflammation of many of the joints. Dorso- lumbar pain, girdle pain around the lower part of the chest, lightning pains in the lower limbs, extreme hyperaesthesia, motor paresis, exaggera- tion of the reflexes, and epileptoid trepidation were observed. These symptoms, referable to disease of the cord and its meninges, recurred severely on these occasions coincidently with the articular lesions and the recurrence of the gonorrhoeal discharge. In the second case in the second week of acute gonorrhoea the patient was attacked with pain in the region of the crural nerves, doul)le hydrarthrosis, tarsal and tibio-tarsal arthritis, pains in the head, lightning pains, exaggeration of knee-jerks, epileptoid trepidation, tremor and spasm of the limb when the foot was placed on ^ " Contribution a I'Etude des Manifestations spinales de la Blennorrhagie," Ptev. de Med., Paris, 1888, viii., pp. 433 et seq. 18 274 GONOBBHCEA AND ITS COMPLICATIONS. the ground, muscular weakness, and dorso-lumbar pains, followed by muscular atrophy. These authors refer to a case of double sciatica following gonorrhoea, reported by M. Peter, and to a case of paraplegia of similar sequence reported by Tixier, and another by Stanley,^ as belonging to the same class. They are emphatic in their opinion that gonorrhoea, like other infectious diseases, may cause affections of the spinal cord in the form of congestion and a meningo-myelitis involving more or less of the lateral and posterior portions of the cord. Chavier and Fevrier^ report a case similar to the foregoing of a soldier who suffered from hypergesthesia of the skin and involuntary movement of the right upper and lower extremities following gonorrhoea. The lower part of the spinal column and the sciatic nerves were the seat of severe pain, the lower extremities were paretic, the reflexes were exag- gerated, and there was slight fever. There was also pain in the left knee and hip, with atrophy of the muscles and joint structures. A cure is said to have been produced in a month. Jaroschewski^ reports a case of gonorrhoeal rheumatism which was complicated by marked atrophy of the gastrocnemii muscles, exaggeration of the patellar reflexes, and foot-clonus. This patient had previously suffered from mild aphonia, hemicrania, and diabetes insipidus. Jaros- chewski thinks that in cases of involvement of the spinal cord by gon- orrhoea thei'e is a predisposition of the nervous system to inflammation — a condition of locus minoris resistentioe. Dufour* reports the case of a young man who in the third month of gonorrhoea was attacked by violent pains in the lumbar region, which lasted for a day, and were followed by a tingling sensation in the lower extremities, diminution in power and motility, and soon after complete paraplegia. There were also paralysis of the bladder, rectal incontinence, and exaggeration of the patellar reflexes. Later on there was loss of sensibility of the lower extremities, which were the seat of reflex shocks. General atrophy of muscles and lightning-like pains also developed. Death occurred in a crisis of dyspnoea. A study of the various published cases, according to Dufour, shows many clinical differences. The lesion in the medulla varies in its seat, its gravity, and its tendency to extension. The symptoms are mainly those of motility and sensibility, and they may be mild or severe. The most common clinical picture is that of dorso-lumbar myelitis, partial or diffuse, acute or subacute, with moderate fever, pains in the spinal cord, girdle pains, tingling sensations, muscular shocks or spasms in the lower limbs, rapid loss of sensibility and motility, troubles in urination and defecation, and some trophic troubles. The course is that of all infectious myelites, and the prognosis is death in one-third of all cases. The lesion is -due to microbic infection primarily of the fibrous struc- tures of the coverings of the spinal cord. We have no knowledge as yet as to the part played by the gonococcus ' Med.-Chir. Transactions, 1856. 2 " Manifestations spinales de la Blennorrhagie," Revue de Med., 1888, viii., pp. 1020 et seq. ^ " Ein Fall von blennorrhoischen Eheiimatisnius mit nachfolgenden spinalen symp- tomen," St. Petersburg med. Wochensckr., 1890, No. 5. * " Des Meningo-myelites blennorrhagiques," These de Paris, 1890. CUTANEOUS AFFECTIONS. 275 in this formidable affection, nor do we know that it is in any way caused by a mixed infection. We have no knowledge of the involvement of the cerebral meninges by the gonorrhoeal process. Panas^ reports the case of a man in the declining stage of gonor- rhoea who after exposure to cold had a severe chill followed by headache lasting for ten days, and the loss of the sight of one eye. Severe optic neuritis, passing to atrophy, was found in the blind eye, and mild neuritis in the opposite one. Panas thinks that the trouble began in meningitis, and then spread to the roots of the optic nerves, and that it was of gonor- rhoeal origin. CHAPTER XXVIII. CUTANEOUS AFFECTIONS. Within the past twenty-five years, and particularly within the past ten years, many authors, notably in France, have written essays in which cases of gonorrhoea complicated with acute skin eruptions have been reported. As a result of these contributions it is quite widely con- ceded that gonorrhoeal infection may give rise to dermal inflammation. Such a proposition carries with it nothing of a startling character, now that we know that the infectious agent of the disease, its morbid secretions or toxines, together with other pyogenic microbes, can be directly absorbed into the circulation. The only singular part of this question is that so many careful observers who have seen and studied a vast number of cases of gonorrhoea have lived and died and have never mentioned having seen a case. I have many times seen patients suffering from acute and de- clining gonorrhoea who have been attacked by eruptions resembling scar- latina, measles, oedematous erythema, and urticaria, and in some instances I have failed to find that gastric disorder produced by antiblennorrhagics has been the exciting cause. In my experience, copaiba, cubebs, and oil of santal-wood are the most common causes of skin affections during gonorrhoea. Perrin,^ in an essay in which he analyzes the recorded cases, and from which the reader can obtain the bibliography of the subject, reports a case in which a scarlatiniform eruption occurred in a gonorrhoea patient who had not taken antiblennorrhagics. Other cases have been reported by Besnier, Klippel, Mesnet, Andret, and others. Some of these cases seem convincing, while in others the statement that the patient had taken copaiba, cubebs, and oil santal several days before the onset of the erup- tion gives rise to doubt. Several cases have been reported in which purpura was said to have ^ " N^vrite Optique blennorrhagique," La Semaine medicale, 1890, p. 477. ^ " Des Determinations cutanees de la Blennorrhagie," Annales de Dermal, et de Syphil., 1890, pp. 773 and 859 et seq. 276 GONOEBHCEA AND ITS COMPLICATIONS. been produced by gonorrhoea. Their details, however, do not carry abso- lute conviction with them, since the exclusion of other infections is not clearly made out. Finger ^ reports three cases in which gonorrhoea and cystitis were complicated by purpura rheumatica, and in one of them pleurisy coexisted. In these cases relapses of the gonorrhoeal process were followed by renewed joint-swellings and purpura. Balzer and Lacour ^ report the case of a young man who during an attack of severe urethro-cystitis also suffered from a grave form of purpura haemorrhagica. Microscopical examination and cultures of the urethral secretion showed gonococci and other microbes. Similar studies with the blood demon- strated the presence of a large white staphylococcus. Other cases have been reported by Mathieu and Lailler. The most common of these eruptions are those of the acute erythema- tous and the multiform erythematous varieties. There is usually much gastric disorder and more or less fever in the course of these exanthemata. Vidal ^ has reported a case which is unique in medical literature. It was that of a man twenty-four years old who, after two attacks of gonor- rhoea (the interval between which being two years), had polyarthritis and a generalized eruption of symmetrical horny placjues or crusts, together with loss of the nails. In each attack the cutaneous lesions were similar. It must be conceded that our knowledge of the relation of these various dermal inflammations to gonorrhoea is yet wanting in many essential points. Eruptions following the Ingestion of Antiblennorrhagics. The ingestion of copaiba in some patients causes eruptions, chiefly of the erythematous type, which usually appear on the hands, arms, feet, knees, trunk, chiefly anteriorly, and also, rather exceptionally, on the face. In some cases a rash strikingly similar to scarlatina is produced, and less commonly the rash resembles measles. The most common rash is a diffuse, irregularly patchy eruption of rose-colored or deep-red spots of gyrate outline, grouped or discreet. In some cases distinct papula- tion and vesiculation may occur intermingled with the general rash. Urticarial plaques, together with small papules, may constitute the whole eruption, or these lesions may be intermingled with the erythematous rash. Copaiba rashes usually appear very suddenly, and are often accom- panied by pruritus, which may be intense or mild. With the discon- tinued ingestion of the drug the rash rapidly fades away, leaving some desquamation for a few days. In some cases small doses of copaiba at once cause an acute and general cutaneous outbreak, while in others the drug may be taken in good-sized doses for some time before the outbreak occurs. There is generally more or less gastro-intestinal distui'bance accompanying copaiba exanthems. Cubebs under similar conditions may cause a general acute miliary papular eruption and rashes resembling scarlatina and measles. ^ " Ueber Purpura rheumatica als Komplication blennorrhagischer Prozesse," Wiev. med. Presse, 1880, pp. 1532, 1.5(i4, and 1593. ^ "Ur^thro-cystite blennorrhagique compliquee d'embl^e de Purpura infectieux tres grave," Annales de Derm, et de Syphil., Sept., 1894, pp. 1015 et seq. ^ Bulletin de la Societe fran^. de Dermat. et de Syph., 1893, pp. 6 et seq. LYMPHANGITIS AND ADENITIS. 277 Copaiba and cubebs in combination not uncommonly cause rashes similar in all respects to those just described. Oil of santal-wood is very rarely the cause of cutaneous eruptions. In the few cases which I have seen the rashes resembled scarlatina and measles. CHAPTER XXIX. LYMPHANGITIS AND ADENITIS. Lymphangfitis. In the early days and throughout the acute stage of gonorrhoea the inflammation may extend to the lymphatics of the penis, and it may localize itself in the inguinal ganglia. Gonorrhoeal lymphangitis may either be seated in the principal trunks or in the reticular network of these vessels. I. In the former instance the course of the inflamed lymphatics can be traced as reddish lines, running, as is usually the case, along the dorsum of the penis from the prepuce toward the pubes. There may be one or several. In the latter case they may be united by transverse bands of erythema corresponding to the anastomoses of the vessels. To the touch they resemble hard or knotted cords which can be separated by the fingers from the adjacent tissues. Their sensitiveness varies with the amount of inflammation. There is often some oedema of the prepuce or of the penis, and tenderness of the inguinal ganglia. This state of things almost inva- riably terminates in resolution. Suppuration is reported to occur in rare instances in the form of several small circumscribed abscesses, which are usually of little moment, but which may undermine the skin to some extent and demand surgical interference. Zeissl says he knows men who have lymphangitis every time they have the clap. Fournier speaks of another form of this afi'ection taking place {a froid) without any signs of acute inflammation, and recognizable only by the hard and indolent cord or cords perceptible to the touch along the dorsum of the penis, and readily mistaken for the indurated lymphangitis attend- ant upon the initial lesion of syphilis. Inflammation of the lymphatic trunks along the dorsum of the penis has been mistaken for dorsal phlebitis. According to Fournier, the latter is an exceedingly rare aff"ection, a few cases having been seen by Ricord. It is distinguishable from the former by the greater amount of oedema, by the impossibility of grasping and isolating the vessel between the fingers, and bv the incruinal gano-lia remaining unaff'ected. II. The second form of lymphangitis, the one in which the general reticular network of the lymphatic vessels is involved, is usually confined to the prepuce, and is responsible for many of the cases of phimosis and paraphimosis and their sequelse (abscesses, perforation of the prepuce, etc.) 278 OONOBBHOSA AND ITS COMPLICATIONS. which have been described in another chapter. The part affected is of a uniform rose or red color, more or less tumefied and exceedingly sensitive. The trunks of the vessels along the dorsum and the glands in the groin usually show signs of participation. In Y&cj rare cases the whole penis is involved, attains an enormous size, is twisted upon itself at its extremity, and is the seat of the most violent pain. Micturition is difficult and painful, erections excruciating. General febrile reaction, chills, fever, loss of appetite, and even delirium (it is said), may occur. In most cases even these severe symptoms terminate without any un- toward result. Suppuration, however, is a consequence to be feared. " When this takes place it is almost always seated in the prepuce. Very rarely it involves the cellular tissue lining the sheath of the penis. The abscess shows great tendency to destroy the mucous membrane of the pre- puce and to empty itself toward the glans. When finally emptied, the swelling of the prepuce subsides, the tension disappears, the pains cease, and the skin can be felt to be thinned at the point affected. In some cases this thinning of the skin is so great that the membrane loses its vitality and is affected with gangrene. A perforation results, through which the glans may be seen. This accident is not the only one to which the patient is exposed. One of the most common, and at the same time least serious, consists in a hard oedema limited to that portion of the pre- puce corresponding to the frgenum, and which may be very persistent. In other patients the edges of the opening of the abscess become indu- rated, and it is then difficult to uncover the glans. Finally, in persons predisposed to phimosis there remains a narrowness of the preputial orifice or an induration of the whole membrane " (Hardy). Treatment. — The treatment of gonorrhoeal lymphangitis consists in rest in the horizontal posture, elevation of the genitals, full baths, local bathing with hot water, and incision of any abscess as soon as formed. Rules for treatment in cases of phimosis have already been given. Adenitis. It is rare to observe anything more serious in the inguinal ganglia in cases of gonorrhoea than slight enlargement and tenderness, which disap- pear in a few days. It is at once recognized by the physician and patient by the enlargement and tenderness of one or more glands in the groin, and it may occasion considerable pain and uneasiness in walking and standing. Buboes attendant upon gonorrhoea, uncomplicated with chan- croid, are "simple" buboes, of which a fuller description will be given hereafter in speaking of buboes in general. They may generally be made to disappear in a few days by keeping the patient quiet and applying ice or cooling lotions, and later on producing a little counter-irritation by painting the skin over them daily with tincture of iodine. Gonorrhoeal adenitis very rarely goes on to suppuration, except in very debilitated or tuberculous subjects. As a rule, the swelling in the ganglia entirely passes away, but exceptionally these little bodies are left in a somewhat swollen condition, and more or less severe recrudescences of the inflammation follow active exercise or redevelop with a succeeding attack of gonorrhoea. GONOBRHCEA IN THE FEMALE. 279 As a rule, both lymphangitis and adenitis are the result of the too actively aggressive treatment of gonorrhoea or of unusual bodily strain. According to my statistics, adenitis in the course of gonorrhoea in pri- vate practice is of the very greatest rarity, and in public practice it occurs about once in one hundred cases. CHAPTER XXX. GONORRHCEA IN THE FEMALE. Within the past ten years our knowledge of gonorrhoea in the female has been very much amplified, many doubtful and obscure points in its nature and diagnosis have been cleared up, and a flood of light has been thrown upon a series of grave consequences which supervene in its course. While to-day it may be said that our knowledge rests on a very satis- factory scientific basis, there are still many points which have yet to be investigated, and several questions concerning it which perhaps may be solved in the future. Undoubtedly, the studies and investigations made by gynecologists have been the chief means of enlarging and rendering more clear our ideas upon this once most obscure and much-neglected sub- ject. It also must be admitted that the discovery of the gonococcus has been a very great help, since by its study we have been able in the main to distinguish the mucous-membrane inflammations produced by it, and to quite sharply distinguish them from the simple forms of muco-purulent and purulent inflammations due to other causes. In earlier days the free escape of very green pus from the uterus and vagina Avas considered indubitable evidence of gonorrhoeal infection, and a gelatinous, mucoid secretion in fluid or plug-form from these parts was regarded as evidence of a simple non-infectious process. To-day, in the light of our more extended and precise knowledge, we find that the pus-secretion may be harmless, while infection may, in some cases, lurk in the seemingly inno- cent mucous plug. Notwithstanding our enlightenment, it must be confessed that there are many clinical points which have not been cleared up by the use of the microscope. In a large number of cases male patients suffering from gonorrhoea in the pus of which the gonococcus is readily detected have contracted the disease from females similarly aff"ected. On the other hand, particularly in private practice and in the better class of patients, Ave fre- quently see men having gonorrhoea, even first infections, which they con- tracted from females who Avere never infected Avith that disease, who may not have had any abnormal discharge, or who might have had a purulent or muco-purulent discharge as a result of simple processes — parturition, some new groAVth, or of some traumatism. In these cases the microscope gives us no help. The ardent advocates of the absolute and essential virulence of the gonococcus claim that in these cases there must have been in times past a gonorrhoea Avhich was not recognized, and that faulty or insufficient search and examination had allowed the microbe to escape 280 OONOBBHCEA AND ITS COMPLICATIONS. detection, or that this never-dying micro-organism existed in an involution form and was unrecognizable by means of our present methods of exami- nation. While, therefore, we may regret that our knowledge is not com- plete and clear, Ave certainly should be thankful that it has been so broadly increased and so materially systematized. Gonorrhoea in the female is certainly much less frequent than it is in the male, and usually runs a much less definite course. There being so much more surface of mucous membrane in the genito-urinary tracts of the female, and so many more communicating mucous-membrane passages than in the male, there is a corresponding complexity in the situation and course of the disease. In the main, gonorrhoea in women localizes itself in one or two parts, runs an acute course, becomes subacute, and ceases. Then in many cases it begins and remains in a subacute condition for a considerable or a long time. Then, again, in some cases it progressively invades the whole genital tract. Having become lodged in the cervix uteri, it may extend to the body of that organ, may pass through the ostia interna, attack the tubes and ovaries, and then the peritoneum. As the infectious process creeps higher up, the gravity of the disease increases and the sufferings of the patient are much greater. Then, localizing itself in the tubes and the ovaries, it produces foci of inflammation which lead to structural changes in the pelvic connective tissues, and may cause intermittent attacks of perito- nitis. Patients thus afflicted are usually sterile, they suffer intense discom- fort and pain, their health becomes impaired until they may become mental and physical wrecks. Not only do they become the subject for capital operations, but they lapse into a condition of poor health which renders them the prey to acute infectious diseases particularly tuberculosis. These sad results certainly do occur in a relatively quite large number of cases. Instances are not infrequent in which wives are infected with gonorrhoea by their husbands, who perhaps regarded themselves as cured. So that, instead of being a trifling affair, gonorrhoea is in many cases really a very serious disease, and it constitutes a grave social danger. In some cases — not very common ones, however — the bladder becomes infected by extension from the urethra, and from there, creeping up the ureters, the disease settles in the kidneys, producing pyelitis and pyelo- nephritis. In these cases of ascending gonorrhoea in women the symptom- complex is very similar to that observed in men. It is very difficult, and even impossible, to get reliable statistics as to the frequency of occurrence of acute gonorrhoea in women. It of course exists largely in prostitutes, particularly in quite young ones and those of the lower walks of life, and it is not uncommon in shop-girls and others who for various reasons leave their homes and cease to be under parental and family restraint. Fournier's statistics as to the class of women from whom gonorrhoea is most frequently derived are interesting : Public prostitutes 12 Clandestine prostitutes 44 Kept women, actresses 138 Shop-girls • 126 Domestics 41 Married women 26 ^87 GONORRHCEA IN THE FEMALE. 281 The word "actress" used in these statistics is rather misleading. There is no doubt whatever that gonorrhoea exists in full-fledged actresses, but not to the extent implied by this table. These figures refer to young women in general, usually under and not much over twenty years of age, who are employed in various capacities in theatres, music-halls, and "dives." They dance in the ballet, sing in the chorus, and are other- wise employed in these places. Usually these girls have but indifferent notions as to personal cleanliness. They are unsophisticated and not sus- picious of men, and thus fall victims of gonorrhoea. Carelessness of person and indifference to discharges from the genitalia cause them often to allow their disease to run on, while at the same time they accord favors to many men. Thus it is that these women so frequently give gonorrhoea to men. There are several reasons why gonorrhoea in women not infrequently passes unrecognized. In many cases when the urethra is involved the acuteness of the symptoms cease rather promptly, and the woman simply thinks that something is mildly amiss or that she has taken cold. Then, again, invasion of the cervix uteri may be attended with mild symptoms which do not alarm the patient, and which may exist for a time, long or short, without the knowledge of the patient. In other cases many women have suffered so long from vaginal discharges, muco-purulent and puru- lent, that they become quite indifferent to them, and any increase of their quantity does not in many instances cause them to seek medical advice. As regards the frequency of gonorrhoea as found in patients who seek relief at the hands of gynecologists, we have considerable quite accurate information. Thus, Schwartz * in 617 cases found 112 in Avhich gonor- rhoea! infection was the probable causative factor. Of these 112 cases, 33 (5.3 per cent.) suffered from acute gonorrhoea (the gonococcus having been found), and of these 19 Avere either unmarried or widows. Of the remaining 79 cases, the gonococcus was found in 44, and, though absent when looked for, Schwartz thinks from their clinical histories it had been present in the remaining 35 cases. Taking, therefore, only the 77 cases in Avhich the gonococcus was found, out of the 617 cases gonorrhoea was proved to exist in 12.4 per cent. Sanger^ in 1930 gynecological cases in private and hospital practice found 230 of gonorrhoeal origin, being 12 per cent., or one-eighth of all the cases. In 161 later cases there were 29 of gonorrhoeal origin, which would be 18 per cent. As a general statement, he thinks that in one- eighth of all gynecological cases gonorrhoea is the underlying cause. Steinschneider^ examined 55 prostitutes in the venereal hospital of Breslau, and of these 20 presented no symptoms of gonorrhoea. But of the remaining 37 cases, in 34 there was recent gonorrhoea, and in 3 the infection had existed three, four, and five months. In the urethral secre- tion of the 34 cases the gonococcus was found, but it was absent in the urethral secretions of the 3 chronic cases. Laser* examined 198 prostitutes, and from their secretions 600 speci- mens were examined. Of these, 353 were from the urethra, 180 from ^ " Die Gonorrhoische Infektion beim Weibe," Volkmann's Sammlung kltn. Vortrage, No. 279, 1886. ^ Die Tripperansieckung beim Weihlichen Geschlecht, Leipzig, 1889. ^ " Ueber ilen Sitz der Gonorrhoischen Infektion beim Weibe," Beii. klin. Wochenschr., No. 17, 1887, p. 301. * "Gonococcen befund bei 600 Prostituirten," Deut.med. Wochenschr., No. 37, 1893, p. 892. 282 GONOBBHCEA AND ITS COMPLICATIONS. the vagina, and 67 from the cervix uteri. Of the 67 cases, in 21 the gonococcus was found, that being 30.3 per cent. In these 21 cases there were clinical symptoms present in only 4. In the 180 cases of vaginal discharge gonococci were found in only 7, and in 5 of these cases the cervical discharge contained gonococci. In only 1 case was it evident that the microbe grew in the vagina. Of the 353 specimens of urethral pus, the gonococcus was found in 112 cases, which is 31.7 per cent. The result of the 353 examinations of the urethra gives gonococci in 112 cases, in 61 cases of which there was no symptomatic evidence of gonorrhoea. The gonococci were alone in but few cases ; leptothrix was present in 6 cases. Among the 241 cases in which no gonococci were found, follicular catarrh was present in 17 ; the mucous membrane was red and swollen in 19. In 31 cases there were signs that would lead one to suspect gonor- rhoea. In 8 of these cases a thick purulent discharge could be squeezed out of the urethra, and in the other 23 cases a more mucoid discharge was present. From his studies Laser has convinced himself that other micro-organisms besides the gonococcus may produce purulent discharge in the female genital tract. In the light of recent investigations and studies it is clearly proved that in women over twenty years of age the urethra and the cervix uteri are the parts most commonly attacked by gonorrhoea. There is some dis- cordance in opinion as to the relative frequency of these two forms of gonorrhoea, but a conservative estimate, I think, will place the urethral trouble as a little more frequent than that of the os uteri. There can be no doubt of the existence of a true gonorrhoeal inflammation of the vulva, but it is not very common. It is sometimes seen in young girls over fif- teen and less than twenty years of age, usually as a result of their first infection and of their earlier attempts at intercourse. Though the existence of a gonorrhoeal vaginitis has been denied, there can be no doubt that in a restricted number of cases gonorrhoea primarily attacking this tube does occur. It is also not infrequently observed to become secondarily infected by the gonorrhoeal secretion from the os uteri. Most commonly, therefore, gonorrhoea is found in the urethra, cervix uteri, vulva, and vagina. These are the four principal forms of gonorrhoea in women, and from them the many complications of the genital and urinary parts above may develop. One or more, and perhaps all, of these forms may exist in a given case. Sometimes we find simply gonorrhoeal urethritis, or coexist- ent with it may be vulvitis and even endocervicitis. Then, again, we find inflammation of the uterine neck as the sole trouble, or it may be attended with vaginitis and urethritis. In other words, while the urethra and cervix uteri are the parts most commonly attacked, other parts may severally or in totality be coincidently involved. In some cases follicular and glandular inflammation may be present with any of the foregoing inflammations or combinations. There are also certain minor forms of gonorrhoea which are localized in the peri-urethral and intra-urethral follicles and in Bartholin's glands. The essential gonorrhoeal process in women has been carefully studied by Bumm,^ both microscopically and clinically, in 132 cases, and it is ^ " Ueber die Tripperansteckung beira "Weibliclien Geschlecht und ihre Folgen," Munch, med. Wochenschr., 1891, pp. 853 et seq. GONORRHCEA IN THE FEMALE. 283 from his essay that I take the facts of pathological histology. The mor- bid process is similar to that of the male. (See p. 78.) It has a period of incubation of two or three, perhaps even more, days. The microbes, being deposited on the mucous membrane, luxuriate and greatly increase in numbers. Then they, as already described, pass through the mucous membrane in the clefts between the cells and reach the papillary bodies. The result is an acute exudative inflammation with an abundant secretion of pus. When in favorable cases the morbid process ceases, the epithelium is restored and a cure is produced. There is a tendency, according to Bumm, for the microbes to remain in an indolent state in the sticky mucous secretion of the parts previously inflamed. It has long been con- tended by Bumm that parts covered with flat pavement epithelium are very resistant, and even impregnable, to the invasion of the gonococcus, and that where cylindrical epithelium covers parts they are readily sus- ceptible to invasion. The consensus of opinion of a number of later observers goes to show that parts covered with flat pavement epithelium are more resistant to the action of the gonococcus than are those covered by cylindrical epithelium, but that they both are susceptible, though in varying degrees. It is therefore important in the study of gonorrhoea in women to con- sider the kind of mucous membrane which covers a part. Thus, the vulva, vagina, and the vaginal portion of the external surface of the os uteri are covered with pavement epithelium, which in early life is soft in structure and becomes harder toward puberty. In the vulva, on each side of the introitus vaginae, in the depression between the nymphae and the remains of the hymen, Bartholin's or the vulvo-vaginal glands open by means of a long single duct. These ducts become infected in gonor- rhoea, which may extend deeper and invade the glands. The urethra also opens into the vulva. The female urethra is a dense structure composed of yellow and white elastic fibrous tissue in which involuntary muscular fibres are inextricably interwoven. The mucous lining is firmly adherent to the tissue of the canal, and is of the squamous variety in nearly its whole length, while that nearest the bladder is of the transitional type. In the intervals of urination the mucous membrane is thrown into longitudinal folds. There are many mucous crypts, called, as in the male, Littre's glands, lined with columnar epithelium, seated along the course of the canal. Besides the deep-seated follicles, there are two large racemose glands seated near the meatus, w^hich have been described by Dr. Skene,^ and are called Skene's glands. He describes them as folloAvs : " Upon each side near the floor of the female urethra there are two tubules large enough to admit a No. 1 pi'obe of the French scale. " They extend from the meatus urinarius upw'ard from three-eighths to three-quarters of an inch. " They are located beneath the mucous membrane, in the muscular walls of the urethra. " The mouths of these tubules are found upon the free surface of the mucous membrane of the urethra, within the labia of the meatus urinarius. The location of the opening is subject to slight variation, according to ^ "The Anatomy and Pathology of Two Important Glands of the Female Urethra." Am. Journ. Obstetrics, etc., vol. xiii., 1880, p. 265. 284 QONOBBHCEA AND ITS COMPLICATIONS. the condition and location of the meatus. In some subjects, especially the young and very aged, and in those in whom the meatus is small and does not project above the plane of the vestibule, the orifices are found about an eighth of an inch within the outer border of the meatus. When the mucous membrane of the urethra is thickened and relaxed so as to become slightly prolapsed, or when the meatus is everted — conditions not uncommon amongst those Avho have borne children — the openings are exposed to view upon each side of the entrance to the urethra. " The upper ends of the tubules terminate in a number of divisions, which branch off into the muscular walls of the urethra. By injecting the tubules with mercury and then laying them open the openings of the branches can be easily seen. " I have called them glands, because they differ in size and structure from the simple follicles that are found in abundance in the mucous mem- brane." Besides Skene's glands, there are certain peri-urethral follicles seated around the urethra one-third or one-half an inch from the meatus. In the third order of glands belong the vestibulo-vaginal glands or bulbs, which are seated on each side of the meatus on its lower part near the vagina. There are also certain para-urethral follicles, which are sparsely scattered over the vestibule in the vicinity of the urethra. All these fol- licles and glands may play a prominent part in the gonorrhoeal process. There are also a number of large-sized follicles which open upon the fourchette or on the anfractuous surface of the hymen left after its rupture in childbirth, which may be attacked by simple catarrhal processes and bv gonorrhoea.- The vagina is covered with a thick, hard, and horny epithelial layer of the flat variety, and into it no glands open. It is the habitat of myriads of various forms of micro-organisms. From the external os uteri to the abdominal openings of the tubes the genital canal is covered by a simple layer of ciliated cylindrical epithelium. In the cervix the acinous glands of Naboth penetrate deep down in the tissues and open on the surface of the mucous membrane. They offer a peculiarly deep and almost impreg- nable nidus for microbic invasion. Indifferent microbes are found in this part in healthy subjects. In the body of the uterus the mucous membrane is supplied with tub- ular glands and lies directly on the muscle without the intervention of any submucous connective tissue. According to Winter,^ neither the nor- mal uterine cavity nor the tubes contain any micro-organisms or contents of any kind. The tubes possess no glands, and are of succulent structure which will admit of much swelling and distention. In the course of the tubes there are many folds which make of the canal an irregular cavity with many depressions and nooks which are favorable to the long exist- ence of an inflammatory process. The structure and relations of the ovaries are described in works on anatomy and gynecology. In the lisht of the foreffoins; statements, when we take into considera- tion the facts that gonorrhoea in women, as in men, consists of an exudative inflammation of the submucous connective tissue, and that the genital organs of women are so extensive, complex, and involuted, and so profusely ^ "Die Microorganismen im Genitalcanal der Gesundenfrau," Zeitschr.filr Geburtsch. und Gyndk, Stuttgart, 1888, vol. xiv. pp. 443 et seq. GONORRHCEA IN THE FEMALE. 285 supplied by blood-vessels which frequently undergo normal engorgement, it can readily be understood why the morbid process may show a tendency to become chronic and to lurk and to hide in them. Although gonorrhoea in women in many cases is a very persistent and chronic aifection, it certainly must not be pronounced an incurable one. The So-called Latent Gonorrhoea. There has been a tendency developed within the past ten years to refer in a loose and unscientific manner nearly all female ailments to gonorrhoea, and attribute to many husbands who in earlier days had gonorrhoea a gonorrhoeal infection of their wives, which produced serious pelvic inflam- mations which, besides causing sterility, often entailed lifelong suiferina; and invalidism, and frequently ended in death. In the year 1872, Dr. E. Noeggerath ^ made the bold statement that, as claimed by Ricord, 800 out of every 1000 men living in large cities had gonorrhoea, from which he, Noeggerath, claimed they never recovered. On marrying, these men earlier or later infected their wives, 90 per cent, of whom then suff'ered from the ravages of gonorrhoeal infection. Though these views were vehemently combated by many and were accepted by only a few, Noeggerath ^ still clung to them, and in a paper read in 1876 he formulated the following conclusions : 1. Gonorrhoea in the male, as well as in the female, persists for life in certain sections of the organs of generation, notwithstanding its apparent cure in a great many instances. 2. There is a form of gonorrhoea, which may be called latent gonor- rhoea, in the male as well as in the female. 3. Latent gonorrhoea in the male, as well as in the female, may infect a healthy person either Avith acute gonorrhoea or gleet. 4. Latent gonorrhoea in the female, either the consequence of an acute gonorrhoeal invasion or not, if it pass from the latent into the apparent condition, manifests itself as acute, chronic, recurrent perimetritis or ovaritis, or as catarrh of certain sections of the genitaL organs. 5. Latent gonorrhoea on becoming apparent in the male does so by attacks of gleet or epididymitis. 6. About 90 per cent, of sterile women are married to husbands who have suffered from gonorrhoea, either previous to or during married life. These extreme and exaggerated views of the result of generalization and deductions based on faulty diagnosis and false premises are not quoted here with approval, but simply as a matter of medical history. Since the discovery of the gonococcus Noeggerath's views have attracted wide attention, and they certainly have been of great benefit in causing gynecologists, syphilographers, and bacteriologists to study gonorrhoea in women from all standpoints. L^nfortunately, gynecologists, as a rule, know little, if anything, of gonorrhoea in men, and many of them, not having gone into its study carefully, think that the gonococcus hides, but never dies, and that a husband, once having had gonorrhoea, must of necessity be the cause of nearly every pelvic inflammation his wife may ^ Die Latente Gonnrrhoe im Weibllehen Geschlecht, Bonn, 1872. ^ "Latent Gonorrhoea in the Female, etc.," reprint from the Transactions of the Ameri- can Gynecological Society, 1876. 286 GONORBHCEA AND ITS COMPLICATIONS. suffer from. Sypliilographers may see the early gonorrhoeas in women, but they rarely see these cases when they become gynecological. Hence the present unsettled condition of our knowledge as to just what gonor- rhoea is responsible for in female uterine and pelvic inflammations. The views of many gynecologists concerning gonorrhoea may be stated about as follows: Some of them, with propriety, claim that there is first an acute attack, and that this becomes subacute and then chronic. In the chronic form it may cease or may lurk indefinitely, and may then undergo exacerbations which may lead to grave pelvic trouble. On the other hand, according to many observers, the acute form of the disease in women is rare, but a latent form of the whole genital tract is very fre^ quent. Gonorrhoea in men is thought to exist in a low, smouldering form for years without producing any symptoms, and this latent form may be transmitted in coitus to the wife, who will only receive latent gonorrhoea, which for a long or short time may cause no symptoms, and of the exist- ence of which the woman may be ignorant. The explanation of this curious mode of infection is that the infecting secretion of the male is deposited in the female genitals, and there lies dormant until some cause like menstruation, pregnancy, or instrumental manipulation produces con- ditions favorable to its resuscitation, when it again becomes hostile and produces disease. One gentleman very naively states that " the gonococci are few and decrepit, probably altogether absent from the periodic emissions of a con- tinent man. It is onl}'- the post-nuptial sexual excess that rouses them into sufficient vigor to be harmful." Of this vague form of gonorrhoea Feliki ^ very pertinently remarks : " According to this theory, the gonococci, having penetrated into the female genital tract, coming as they do from a latent gonorrhoea in the male, do not cause the well-known typical gonorrhoea, but a morbid pro- cess whose beginning we cannot observe, and whose later stage would cor- respond to the well-known complications of a typical gonorrhoea. It is remarkable that according to these observers it is not possible in gonor- rhoeas to discover the gonococcus — first, because these microbes disappear among the bacteria that thrive in the female genital tract; and, secondly, because it is impossible to obtain any secretion from the nooks and corners in which they may hide. Thus in the latent gonorrhoea of the female both clinical symptoms and the bacteriological criterion, the gonococcus, are wanting." As an example of the easy-going manner in which a diagnosis of latent gonorrhoea in women has been arrived at, I will quote from the work of Sinclair,^ who says that he will " mention in somewhat general terms a few fairly typical cases." Case I. was that of a married woman, aged twenty years, who had been married a year and had not become pregnant. Three months after marriage she complained of inguinal and hypogastric pains, and suffered from menstrual disturbances. She failed in health and strength, and became a dysmenorrhoeal invalid, in all probability per- manently sterile. The gonococcus was not found in her genital secretions, ^ "Ueber Sogenannte latente Gonorrhoe und die Dauer der InfektiositJit der Gonor- rhoischen Urethritis," Internal. Centrulblatt der Ham und Sexualorgane, vol. iv., 1893, pp. 15-22 and 60-77. ''' On Qonorrhozal Injection in Women, London, 1888, pp. 6 et seq. GONORRHCEA IN THE FEMALE. 287 and the only evidence of her having had gonorrhoea was that her husband had that disease a year before his marriage, since which he had no signs of it. Other cases in a similar vein are reported. Now, it certainly will strike a critical reader that such loosely-observed cases, in which the clinical history and the most essential facts are not scientifically ascertained and brought out, but in which almost everything is assumed, are entirely valueless for purposes of study and statistics. Unfortunately, this easy-going method of arriving at a diagnosis has been employed very generally, and as a result gonorrhoea is considered by many as the prime cause of all pelvic inflammations. It is so easy and con- vincing in the case of a wife suffering from pelvic disease to ascertain that at a more or less remote period the husband has had gonorrhoea, and to fix upon that infection as the origin of the wife's trouble, that some men by routine come to make these diagnoses. As has been shown elsewhere (see page 72), the gonorrhoeal process runs its course, and when not cured a chronic inflammation is left with Avhich microbes have no relation whatever, since they have played their part and disappeared from the scene. In very many cases of chronic urethritis in the male there is simply submucous thickening with purulent secretion, in which no microbes, or at best only indiff"erent ones, are found. These men cohabit for years regularly with their wives and mistresses, and at intervals with other consorts, and never do them any harm. The reason is that they simply have a low grade of urethral inflammation which has resulted from the initial virulent inflammation. There is a tendency now-a-days to harp upon the longevity of the gonococcus, on its phoenix-like power of resus- citation, and on its relentless virulence. This idea, put forth by some syphilographers, has had undue weight with many gynecologists, who under its influence are led to think that the gonococcus in male and female never dies, but that it is ever ready to produce pelvic mischief. I have seen many cases of young women who have suff'ered from uterine and pelvic diseases after marriage whose trouble Avas induced by instrumental manip- ulation at the hands of energetic young men possessed of an ambition to be known as gynecologists. Minor surgical gynecology is certainly the cause of a great many cases of uterine and pelvic disease. But it is gen- erally so easy to get the husband to acknowledge to having had a previous gonorrhoea, and then to confidentially inform him that he is the cause of his wife's sickness. In estimating the importance of gonorrhoeal infection as the cause of female pelvic trouble we must individualize rather than generalize. Some women having gonorrhoea are not cured, for the reason that their condi- tions and surroundings are bad, and that they cannot or will not take the trouble to undero;o treatment. Some suffer on in sheer ignorance of their peril. But, on the other hand, there are women of the higher walks of life who, having been infected with gonorrhoea, take every means and care to rid themselves of it, and they succeed in many instances. Gonorrhoea of the urethra is pertinacious, but in the majority of cases it is curable if the patient seeks and follows good advice. Gonorrhoea of the cervix uteri is also very persistent and a menace to the woman's health, but it would be rash to say that it is incurable. In clinics and hospitals large numbers of cases of gonorrhoeal pelvic diseases are found, and the}^, when sub- mitted to statistical study, make a formidable showing. But such statistics 288 GONORBHCEA AND ITS COMPLICATIONS. should only be taken for what they are worth. I have for more than a quarter of a century treated men and women for gonorrhoea, and in that time have been able to observe a large number of patients during a period of many years. Many young Avomen had gonorrhoea and recovered. They married, bore children, and were healthy and happy. Some few suffered from chronic gonorrhoea, and later developed pelvic trouble. I have the evidence of scores of men, some of whom had gonorrhoea and were cured, others who had chronic urethral discharge from localized patches of thick- ening or from strictures, who have lived with their Avives for years, have cohabited with them without the least injury and without the production of a single symptom referable to gonorrhoea. On this subject the statistics of the late Dr. Thorburn^ of Manchester are of interest. Thorburn denied the correctness of Noeggerath's conclusions, and appealed to the statistics of 81 families carefully collected by him. He showed that there had been 33 per cent, of male gonorrhoeic infections previous to marriage, 26 in all, and, taking all cases of abortion, sterility, uterine and pelvic inflammations, and living births that had occurred in these 81 families, he showed conclusively that there had been the merest fractional difference in their proportion between the previously healthy and not previously infected classes. As regards inflammatory pelvic afiections, the balance was fractional in favor of the free-gonorrhoeic cases, in other respects equally fractional in favor of the non-gonorrhoeic. As bearing upon Dr. Thorburn's evidence the remarks of Dr. Chadwick, made at the time of the discussion of Noeggarath's second paper, are interesting. Chadwick said that he "had ascertained in conversation with twenty difi"erent physi- cians who acknowledged having had gonorrhoea in early life that in no single case had any such symptoms as had been referred to been devel- oped in their wives, and all had had large families of children." It should be borne in mind, in considering these conspicuously favor- able statistics of Chadwick, that the gonorrhoeics were physicians who naturally would follow treatment and become cured. The statistics would not show up as favorably if the twenty men were 'longshoremen or com- mercial travellers. Intelligence, pecuniary resources, and a life of com- parative leisure have much to do with lessening the proportion of gonor- rhoeal pelvic diseases in the better classes of patients. Ignorance, poverty, and unhygienic surroundings are the underlying causes of so many cases in the lower walks of life. It is well known that among the myriads of microbes which thrive in the female genitals — the vagina and os uteri especially — the streptococcus and the staphylococcus are frequently found. Doederlein^ has clearly shown that in the genitals of married women a secretion is found which contains pyogenic microbes. Seeing that these morbific agents infest the normal female genital tract, is it not warrantable to assume that these microbes may become hostile when the condition of the tissues as a result of engorge- ment, of operations, of examinations, of instrumental manipulations, and of pregnancy becomes favorable to their vital activity ? In confirmation ^ "Latent Gonorrhoea as an Impediment to Marriage," British Medical Journal, Aug. 25, 1877. '■^ Das Scheidensecret und Seine Bedeatung fiir das Puerperalfieber, Leipzig, 1892, and "Ueber Scheidenabsonderungen und Scheidenkeime," Arch, fiir Gynaek. 1891, xl., pp. 306 et seq. GOXORRHCEA IN THE FEMALE. 289 of this view we have the evidence of many microscopical demonstrations of pyogenic bacteria which have been found in diseased tubes and ovaries. Menge^ found in 26 cases of tubal disease the streptococcus pyogenes twice and the staphylococcus albus once, and thinks that he found the gonococcus once. It has struck me as being very singular that so very much insist- ence is made upon the presence of the gonococcus in the female genital tract (where it is most difficult to find it), and so little is said of the existence of pyogenic microbes which abound there so plentifully and are so easy of detection. From the foregoing survey of the subject I think we are warranted in throwing out of consideration the mythical and fanciful latent gonorrhoea in women. We shall see a little farther on that gonorrhoea may remain in an indolent condition, either in the urethra, the cervix uteri, or the parts higher up, but in these cases it is a gonorrhoea with distinct tissue- changes. These gonorrhoeas are not myths, since they present determinate symptoms, which may, however, be very mild, and in very many cases their secretions will reveal the gonococcus if it is properly and persistently looked for. I am disposed to think that Sanger's estimate that one-eighth of all gynecological cases is due to gonorrhoea! infection is conservative and probably nearly correct. But we need further light. Instead of assump- tions and generalizations, close observations and study of cases are needed in order that we may have unimpeachable scientific knowledge. We now come to the consideration of the various forms of gonorrhoea in women. In many cases of gonorrhoea in women the history of the period of invasion is very obscure. In some the sudden onset of the affection in a previously healthy woman, in a Avoman recently married, or in a woman having had but a single intercourse may give positive clues as to the early stage of the disease. In very many cases, however, the patient gives the history of having suffered for a long period with chronic leucorrhoea, and of having experienced an exacerbation, and then examination reverJs acute inflammation of the external and perhaps internal genitalia. Gonorrhoea of the Urethra. Gonorrhoea of the urethral canal is the most common form observed in women. Formerly gonorrhoea of the vagina ranked first in importance and frequency, but recent observations and studies, particularly those of Steinschneider,^ Horand,^ Aubert,^ and firaud,^ have conclusively proved that the virulent suppuration caused by the gonococcus is most frequently found in the urethra. The disease may be limited to the urethra, and it may exist at the same time with gonorrhoea of the os uteri. In some ^ " Ueber die Gonorrlioische Erkrnnknng der Tiiben und des Bauchfells," Ztschr. fur Geburfsh. und GynakoL, 1891, vol. xxi. pp. IIU et seq. '■' "Ueber den Sitz der gonorrhoischen Infection beim Weibe," Beii. klin. Woehensckr., 1887, No. 17, p. 301. ^"Note pour servir a I'Etnde de la Blennorrhagie cbez la Femme," iyow 3Iedical, No. 43, 1888. * "Localisation de la RIennorihagie chez la Femnie," Annales des Mai. des Org. Gcn.- urin., 1888, vol vi. pp. SOI et scq. ^ "De la Blennorrhagie chez la Femme," Annides de Derm, et de Syph., 1890, vol. i. p. 57. 19 290 GONOBBHCEA AND ITS COMPLICATIONS. cases there is a coexistent vulvitis, and, particularly in young subjects, the vagina may also be involved, either as a whole or in part. Urethral gonorrhoea in the female resembles in some particulars the same form in the male. It has a period of incubation, as shown by ex- perimental inoculations both with virulent pus and the cultivated gono- coccus, of about two days, which may, according to Martineau, be pro- tracted to five days. As a rule, the invasion of the urethra in the female is much the same as in the male. There is the slight tickling and burning sensation, and the same sero-mucous secretion in which little whitish particles may be seen suspended, which under the microscope are shown to be epithelial cells and gonococci. Then, after a prodromal period of a few hours or a day or two, the acute stage develops, with more or less severe burning in the urethra, rendered worse on urination, which soon becomes quite fre- quent. Examination of the parts shows the urethral orifice to be very red and swollen, with perhaps a pouting prominence of its lips. A green- ish-yellow discharge escapes in considerable quantity, and may cause red- ness and swelling of the parts around and beneath. The presence of the finger-tip inserted in the vagina shows that the urethra is swollen and tender, and pressure from behind forward causes pus to exude from the meatus. The urethra being such a short, nearly straight tube, ending directly in the bladder, that viscus may be early involved in the inflam- mation. Examination of the urine by the two-glass test will always show how deeply the morbid process has travelled. If the first specimen is cloudy and the second clear, it is certain that the bladder is not involved. If the second specimen is turbid, then it is certain that the bladder has been infected. In some 'cases of acute urethral gonorrhoea in women there may be mild febrile movement and malaise. As a rule, their local sufferings are quite acute at this time, and they usually become worse when the bladder is involved. Then in bad cases there is constant tenesmus, and as a result the frequent urinations cause great agony : not infrequently the patient's sufferings are increased by the urine scalding the inflamed contiguous parts. In the majority of cases of the acute stage of urethral gonorrhoea in the female amelioration of the symptoms begins in about a week or ten days, and even sooner. The burning and scalding become less and less severe, the tenesmus is less imperative, and the urinations become less frequent and painful. The redness and swelling of the meatus subside slowly, and the pus becomes whitish and mucoid. In this way matters grow progressively better until the chronic stage may be reached. Then we commonly see a normal or only slightly red meatus, from which, by intravaginal pressure on the urethra, a drop or two of viscid muco-pus or a thinner milky-looking fluid may escape. In this condition the woman may suffer no discomfort whatever, or she may have a very slight smarting or a sensation of heat on urination. Microscopical examination of the pus in the florid stage shows pus- cells with many gonococci. As the secretion becomes more mucoid, epi- thelial cells show prominently in the field, with a diminished number of gonococci. In the chronic stage there are usually found some pus-cells, epithelial cells, a few gonococci, and the usual indifferent microbes. Later GONORRHCEA IN THE FEMALE. 291 on no gonococci can be seen. In this chronic stage, when the bladder has remained intact, the first ounce of water passed into the first vessel will contain some clumps and filaments of pus and epithelium, while the urine in the second vessel will be clear. When there is a complicating cystitis the urine in the second glass will be nearly as turbid as that in the first glass. Many women have this chronic form of urethral inflammation for a long time, even for years. Its secretion in the early months is infectious. Later on the process is simply a post-gonorrhoeal urethritis, and the pus then is harmless. As a rule, the urethral secretion becomes innocuous in about six months or a year after the date of infection, as I have myself many times seen. This is shown by the impunity with which men co- habit with women who have this emasculated secretion. In its active stages, however, the pus of gonorrhoeal urethritis of women is equally as virulent as that of men simiharly afflicted. In the declining and chronic stage of urethral gonorrhoea, in the absence of symptoms and of swelling and redness of the urethral orifice, the way to diagnosticate the trouble is by intravaginal pressure on the urethra from behind forward, or by the examination of the urine which is passed several hours after a previous urination which has cleansed the canal. Women very frequently urinate just before presenting themselves to the surgeon, who then fails to obtain a secretion in the meatus by pres- sure on the urethra. The woman under suspicion should not be allowed to urinate or use injections on the same day that she applies for examination, and the surgeon should decline to give an opinion if she does. In chronic urethritis in women it is not common to see the exacerba- tions of the trouble Avhich are so frequent in men. In the majority of cases the intra-urethral and peri-urethral glands only become infected in the declining stage of the urethritis. Therefore these forms of inflamma- tion will be considered farther on separately. Since there are no mucous follicles along the course of the female urethra beyond the first half inch, as there are in man, we do not, as a rule, find those deep-seated follicular abscesses which are almost peculiar to men. The morbid appearances of the female urethra affected by gonorrhoea have been studied by Janovsky.^ In the acute stage the parts are red, swollen, and succulent, and erosions are seen over the surface. Much swelling is seen around Skene's glands. Minute polypoid growths were seen along the canal, and in one case there was distinct membranous des- quamation. In the chronic stage a granular appearance was noted as a result of the submucous infiltration. There was also epithelial thickening in localized and diffuse form, and decided prominence to Skene's glands. Chronic urethritis in women results in some instances in stricture of the urethra,^ which makes itself evident by increasing difficulty in uri- nation, and sometimes by retention. In women, as in men, urethral stric- ture may lead to cystitis and to pyelo-nephritis. ' " Endoscopische Beitrlige zur Lehre von der Gonorrhoe des Weibes," Archiv filr Derm, unci Sijphilis, 1891, pp. 911 et seq. '*' The reader is referred to an elaborate essay on urethral stricture in women and its treatment by Genouville, entitled " Du Retrecissement blennorrhagicjue de I'Ur^thre chez la Femme, etc.," Annales des Mai. des Org. Gen.-urin., 1892, pp. 832 and 925 et seq. 292 GONOBBHCEA AND ITS COMPLICATIONS. Gonorrhoea of the Os Uteri and Uterus. The frequency and importance of gonorrhoeal infection of the os uteri and uterus were really not fully appreciated until within recent times. Though many years ago Rollet^ published an admirable paper on the sub- ject, gonorrhoea of the os uteri remained obscure among the catarrhal inflammations of this part, and was not accorded a prominent place as a distinct morbid condition.^ As claimed by Bumm ^ and Steinschneider,* this form of gonorrhoea ranks second to urethritis, which is the most common form of the disease in the adult female. The chief importance of gonorrhoea of the os uteri resides in the fact that from this focus the uterus itself and the parts above in direct anato- mical connection may be invaded early or late by the infection. Gonorrhoea of the os uteri is very probably contracted in intercourse with men who are in the declining stage of acute gonorrhoea. During the acute stage men, by reason of the pain, swelling, and discharge, refrain from coitus, but as the trouble subsides they often weary of continence, have intercourse, and infect their consorts. The anatomical position of the os is such that in coitus it generally comes in contact with the apex of the glans penis, and then becomes bathed with the ejaculation which carries with it pus from the still inflamed urethra, unless the latter tube has been thoroughly flushed by recent urination. When the vagina is short, and when the uterus rests low in the pelvis, the chances of infection are great. Consequently, when the uterus is placed high up the os may escape infection. The length of the penis and the duration of the sexual act also have bearing upon the infection of the os. Gonorrhoea of the os uteri may be the sole evidence of a given infec- tion, which may begin in this part, and there remain until cured. It also coexists in many cases with a urethritis of similar origin. Then, again, the pus escaping from the uterine orifice not infrequently infects the vagina, usually in a localized manner, and rarely in the totality of the tube. In only acute and very severe cases is the os infected by extension of the disease from the urethra up the vagina. According to Martineau,^ the onset of gonorrhoea of the os uteri may be brusque and accompanied by dull pain and weight in the hypogastrium, with radiating pains over the abdomen, lumbar region, and thighs. With this evidence of local trouble there is fever and all its attendant symp- toms. Martineau seems to be alone in the observation of such severe initial symptoms, and probably based his description on cases in which there was extension of the gonorrhoeal process from the os to the body of the uterus. Verch^re,^ while he quotes Martineau's description of symptoms, dis- ^"Des Maladies veneriennes et syphilitiques de I'Uterus," Annates de Derm, et de Syph., vol. i., 1869, pp. 100 et seq. ^ Audry {Preck des Maladies blennorrhagiques, Paris, 1894, p. 183), speakins: of sjonor- rhoea of the uterns, says that prior to 1884 an experienced clinician had no hesitation in stating that in 4000 women (venereal cases) treated at the Lourcine Hospital he had ob- served this affection only in 10 cases. =* Op. cit. ■* Op. cit. * Lemons cliniques sur la Blennorrhagie chez la Femme, Paris, 1885, p. 90. ^ La Blennorrhagie chez la Femme, vol. i. p. 87, Paris, 1894. GONOBRHCEA IN THE FEMALE. 293 tinctly states that he never observed such a mode of evolution in his experience at the St. Lazare Hospital. In the majority of cases gonorrhoea of the os uteri begins in an insidi- ous manner unattended with marked symptoms. The external and inter- nal surfaces of the os become red and swollen, and they give forth a muco-purulent secretion. Some women will complain of excessive dis- charge, while others, who have long had vaginal secretions, may pay no attention to an increase, even if it is decidedly copious. Thus it is that this affection is seldom seen in its very early days. When a woman suffering from gonorrhoea of the os uteri is examined by means of the speculum, nothing absolutely characteristic or diagnostic can be seen. The os is swollen, is more or less red, even to a purplish tint. At first the mucous membrane is swollen and has a velvety appear- ance. From the os a purulent or muco-purulent discharge escapes in large drops, and around the os is a narrow collarette of redness and erosion. Then, when the os is much enlarged, it may be eroded in totality or in part. Sometimes there are many small erosions, and again there may be several quite large ones. Though these erosions are sometimes called ulcerations, they are simply local losses of epithelium, such as we see in tolerably well-marked cases of erosive balanitis. When the inflammatory process runs higher and there is much exudative inflammation, the outer surface of the os presents a mammillated appearance, probably from the swelling and prominence of the muciparous glands. This condition may become so well marked that the appearances of the os resemble those of a very rough orange. Then, again, the surface of the os, in cases of a severe course, may become quite deeply eroded and present, as pointed out by Rollet, the appearance of a deep-red cherry, from which its rind has been peeled off". With a still greater increase in the morbid process, granulations, perhaps a few and perhaps in abundance, may develop on the external surface of the uterine neck and on the contiguous mucous membrane, particularly that part below the posterior lip of the os uteri. These granulations may be of millet-seed size, and they may resemble the papillae of raspberries and strawberries. In the course of time these granulations may go on and develop into true warty growths, which may further become epitheliomatous. Over the morbid surface we frequently find a film or membrane of thick greenish pus, and from the os a purulent fluid escapes. In many of these cases, Avhen fully developed, the patients complain of dysmenorrhoea and too frequent and too copious menstruation. It is these menstrual symptoms which often cause the patients to seek medical advice, and then a correct diagnosis may be made. In a goodly number of cases the tissue-changes of the external surface of the OS are yqtj slight, consisting of a mild increase of redness with or without moderate erosion. Even when there is a marked condition of erosion the external epithe- lium may be restored, while at the same time the morbid process persists in the lumen of the os. The main cause of the chronicity of gonorrhoea of the uterine neck is the localization of the process in the numerous and deeply-seated glands of Naboth with their plentiful blood-supply. As the aff'ection grows old, even if little or indifferent treatment is followed, the discharge in many cases becomes less purulent and more mucoid, so that in its chronic stage this form of gonorrhoea may only give as an objective 294 GONORRHCEA AND ITS COMPLICATIONS. symptom the well-known glassy-white mucous plug which hangs from the OS so constantly. This plug resembles those of the ordinary simple in- flammations of these parts, and, while it frequently contains gonococci in its meshes, there is no visible sign present to denote its virulent character. In many cases the only means of determining the presence of gonococci in the os is to gently curette it, and then examine the detritus micro- scopically. Throughout the whole course of gonorrhoea of the os this segment may not be the seat of pain, and its examination by bimanual manipulation may give rise to little if any unpleasant sensation. Pain, however, is quite exceptionally felt, either spontaneously or as a result of physical examination. Now, it must be confessed that with all the objective phenomena just presented there are no appearances which may not be found in simple troubles of the uterine neck. How, then, can we establish a diagnosis of gonorrhoea ? In some cases the facts of an infecting coitus may be estab- lished. In others (when the trouble is known or found out) the onset of an endocervicitis in a healthy young woman, who has not been tampered with to produce abortion, who has not undergone any form of minor gyne- cological treatment, and who has not had any disturbance of menstruation, may cause the suspicion of gonorrhoeal infection in coitus. In many cases early in their course it is very easy to find the gonococcus in the pus, which must be taken by means of a platinum loop from within the cervical cavity, the orifice of which has been rendered clean and sterile. Then, again, we frequently meet with cases in which a profuse, very yellow, purulent discharge escapes from the os, in which discharge the most scrutinizing examination fails to reveal the gonococcus and perhaps any hostile microbe. A further surprise often awaits us. From a SAvollen and eroded or only a mildly-reddened os a glairy mucous plug hangs, which looks so innocent that a diagnosis of gonorrhoea seems unwarrantable. But perhaps the woman may be under suspicion of having given gonor- rhoea to a man, and further examination is necessary. Then, the secre- tion having been gathered and prepared, great is one's surprise to see typical gonococci in large or small numbers. Then, again, in very many of these mucous plugs nothing but a few pus-cells and indifferent microbes are found. The conclusion warranted by all these facts is, that while it is certain that gonorrhoeal infection of the os uteri is of very frequent occurrence, it is often overlooked. It may present no objective or subjective symp- toms which distinguish it from simple processes, while the facts of the case may occasionally point to gonorrhoeal infection in coitus. In these cases, when recent, the microscope may reveal the gonococcus, and thus dispel all doubt. Then, again, as the morbid process grows old, even the micro- scopic evidence may grow less and less striking and certain, so that in many cases, in the absence of the gonococcus, it having played its part and disappeared, there is no diagnostic evidence of any kind to prove that the case started out by gonorrhoeal infection. On this subject the words of Ricord ^ deserve to be quoted and em- phasized. He says : " Whatever uterine catarrh may be, an experience of more than twenty years has taught me that it is the most common ^ Clinique iconogmphique de I'Hdpital des Veneriens, Paris, 1862, p. 8. GONOBRHCEA IN THE FEMALE. 295 source of gonorrhoea in men, even when we have not the right to attribute it to a venereal cause." Gonorrhoea of the os uteri very often presents in a clear manner the fallibility of the doctrine of the gonococcus. In many cases gonorrhoea in men can be traced to gonococci-containing pus or muco-pus from the OS uteri of an infected woman. In many other cases, where this is the only segment of the genital tract that is the seat of inflammation, the most elaborately careful examination of the secretion, even when pro- cured by scraping, fails utterly to show any gonococci, while other microbes may be seen. Yet the men who have cohabited Avith these women may have florid gonorrhoea, with gonococci-containing pus. In the larger number of cases the gonorrhoeal process ceases at the os internum. Whether this normal constriction of the parts has, as claimed by some, any tendency to act as a barrier to the infection, we cannot positively say. GoNORRHCEAL ENDOMETRITIS. — By the extension of the gonorrhoeal process beyond the os internum the mucous membrane of the body of the uterus is attacked by its characteristic inflammation. When the uterus is attacked, there may be fever, a sensation of heat, and bearing-down pains in the pelvis which radiate to the back. There may also be nausea and vomiting. In this acute form the uterus is tender on pressure, and Avhen practicable bimanual palpation shows that the organ is much swollen in all directions. There may be suppression of the menses or monorrhagia. The uterine secretion is abundant, purulent, or muco-purulent in charac- ter, and perhaps mixed with blood, and in it the gonococcus can readily be demonstrated. The vagina is hot and the cervix is red, swollen, and eroded. Where the history of the case points to gonorrhoea, the diagnosis may be made with the aid of the microscope. There are no pathogno- monic symptoms whatever, either objective or subjective, by which a posi- tive diagnosis of gonorrhoea can be arrived at. In some cases acute recent gonorrhoea of the husband, followed by symptoms of acute infec- tion in the wife, clearly points to the virulent origin of the process, which may be confirmed by the aid of the microscope. Acute gonorrhoeal metritis passes into the chronic form, in which the diagnosis becomes more and more difficult, since in the absence of a clear history the gonococcus is the only criterion, and this microbe grows less numerous, and even disappears, in proportion as the process grows old. In the chronic stage the case belongs to the domain of the gyne- cologist (and it is to be hoped that the one consulted is a cool and con- servative man), whose advice should be sought unless the attendant is especially skilled in women's diseases. Gonorrhoea of the Vagina. In former years the vagina was looked upon as the stronghold of gonorrhoea in the female, but to-day there are observers who claim that there is no such afl'ection as true gonorrhoea of this part, and that, if this tube is gonorrhoeically aff'ected, its infection has been caused by the virulent pus pouring down from the os or the uterus. The reason as- signed by Bumm^ and Steinschneider^ is that the epithelium of the ^ Op. cit. ^ Op. cit. 296 GONORRHCEA AND ITS COMPLICATIONS. vagina is of the pavement variety, which is tough and horny, and fully capable of resisting the invasion of the gonococcus. Bumm says that he kept gonorrhoeal pus in contact with the vagina for twelve hours and failed to produce any inflammatory reaction. It is further — and truth- fully — claimed that gonococci do not thrive exuberantly in the vagina. Bumm, however, does admit that the mucous membrane of the vagina is soft and susceptible before the age of sexual maturity, and that during that period the parts may be successfully attacked by the gonococcus. Schwartz ^ denies Bumm's contention, and claims that the gonococcus does thrive in the deep parts of the epithelium, and that there may be true gonorrhoeal vaginitis without the infection of the uterus. This position of the ardent advocates of the virulency of the gono- coccus is in keeping with many of their attempts to formulate laws based on microscopic and bacteriological investigations. In a measure, they are correct in their claim, but clinical facts must not be utterly subordinated to conclusions reached by study with the microscope. Speaking from the standpoint of both microscopists and clinical observers, the matter may be summed up as follows : True gonorrhoea of the vagina may be found in young girls Avhose vaginal mucous membrane is yet succulent, and who have not been accustomed to sexual intercourse, which tends to the corni- fication of its epithelium. In some rather older girls or women, in whom the mucous membrane is still soft and normally quite hypergemic, gonor- rhoeal infection may occur. Then, again, in women whose vaginae possess the normal resistance the continued contact of the gonorrhoeal pus from the cervix or uterus produces a localized vaginal gonorrhoea. In the foregoing considerations Ave have kept strictly in the line of true gonococcus infections, but clinically Ave must not be thus hampered, but must go farther. Any one Avho has seen in a long stretch of years large numbers of Avomen suffering from various venereal diseases, and has observed and studied them carefully, wull call to mind many women with chronic purulent vaginitis in the secretion of whom no gonococci could be found, but who in coitus Avith men communicated to them florid gonor- rhoea, in the pus of Avhich gonococci could be found. Gonorrhoea of the vagina may be local or general, acute or chronic. Very commonly, little can be learned of its onset, since it is liable to occur in Avomen the subjects of uterine or vaginal leucorrhoea. Then, again, women, as a rule, are less communicative and truthful regarding their amours than men are ; consequently, the date and source of conta- gion are always with difficulty, and many times are never, ascertained. Carelessness of the person, and the indifference Avhich comes to many Avomen about vaginal discharges, very frequently tend to prevent the surgeon obtaining a satisfactory history of the case. When seen early the vagina affected Avith gonorrhoea presents a dry red surface, which is the seat of a sensation of heat. Very soon a mucoid fluid is seen, which soon becomes muco-purulent. In its fully-developed stage the secretion of vaginal gonorrhoea is a pus of considerable consist- ence and of a milky color, due to the admixture of large quantities of epithelial scales. When gonorrhoea of the vagina is due to the extension of the inflam- mation from the external genitalia, it is attended with all the symptoms 1 Op. cit. GONORRHCEA IN THE FEMALE. 297 incident to the latter, together with a sense of burning heat which is referred by patients as deep down in the pelvis. The vaginal orifice and caruncLilfe myrtiformes are reddened, swollen, and eroded, and constantly bathed with pus. In the cases under consideration, if treatment is adopted promptly, only a small portion of the lower vagina may be involved. Untreated, however, the tendency of the disease is to become firmly fixed and chronic, and to localize itself in the upper parts of the vagina, par- ticularly in its posterior fornix or Douglas's cul-de-sac. In some cases it is found to attack the anterior fornix, and in others both recesses, anterior and posterior to the uterus. Acute gonorrhoea originating in the vagina proper is sometimes seen to involve its lower third, but may occur at any part, particularly on its posterior aspect. When severe and extensive, it gives rise to great sufi'er- ing in the form of a continuous burning pain in the pelvis, which is much aggravated by motion, walking, and even by sitting down. So great is the swelling of the vaginal orifice, and such is the tenderness, that the introduction of the finger or of an instrument is impossible, and patients beg that the nozzle of the syringe shall not be inserted, and if at all a very small one. When the acute stage is fully developed, the sufferings of the patient are often further increased by the extension of the disease to the urethra and vulva. Under these circumstances her condition is often pitiable, as may well be imagined from the extent of surface in- volved. The duration of the acute stage is very variable, and depends largely upon the efficacy of treatment and upon the regularity with which it is followed. In general, a week or ten days elapse before topical treat- ment can be instituted in the vaginal canal. Then much can be done, provided the woman can be kept in bed and properly attended to. But women thus afflicted are, as a rule, careless patients, and, though the gravity of their case be pictured to them in the clearest manner, they in very many instances backslide. Then, again, the recurrence of the menstrual epoch, with its engorgement of the genito-urinary tract and sometimes its irritating secretion, is often a very serious setback. In private and dispensary practice we constantly see these patients reach a subacute condition, and then they disappear, and even in the hospital they often consider themselves well and demand their discharge long before the surgeon deems it prudent. Subacute gonorrhoeal vaginitis is seen in two principal forms — the one limited to the lower segment of the tube, and usually rather more severe on its posterior wall ; the other and more frequent one in the cul-de-sac behind the uterus. Besides these, the affection may be seen to be seated anterior to the uterus and in the middle third of the vagina. When occurring in the lower two-thirds of the vagina, the membrane is found to be red, swollen, in places eroded, thrown into large folds, and bathed with pus. When the inflammation is seated low down, the introitus vaginae and the tissues immediately around it are more or less inflamed. Gonorrhoea of the posterior vagina or Douglas's cul-de-sac is of not infrequent occurrence. In this position it is very liable to escape detec- tion unless carefully looked for. To this end, the best opportunity for a thorough examination is offered by the genu-pectoral position, though very often, from feelings of delicacy, we cannot insist upon it. The next best position is that of Sims with his own speculum, but it is inferior, in 298 GOXOREHCEA ASD ITS COMPLICATIONS. my experience, to the genu-pectoral position. In the latter Sims' spec- ulum may be used or one made of thin nickel-plated wire, such as is found in the shops. Thus exposed, the mucous membrane is seen to be deep red, cedematous, and more or less excoriated and covered with copious creamy greenish pus mixed with glairy mucus. In most cases there is coexistent inflammation of the os uteri in the form of a deep-red, easily- bleeding, inflammatory areola, and from it a muco-purulent plug may hang. In some cases the gonorrhoeal inflammation extends only as far as the OS internum, but in others the uterine cavity is aff"ected. Besides the cases of gonorrhoea of the vagina which, from the sudden onset of the affection and from its violent nature, are regarded as due to direct contagion, we frequently see vaginitis — or, as it is of late years termed, elytritis — develop in persons subject to cervical and corporeal endometritis and chronic subacute inflammation of the vagina. The history of the beginning of the trouble is usually very vague, though in some cases excessive and unnatural coitus and uncleanliness seem to be the exciting causes. Morbid constitutional conditions may tend to inten- sify this inflammation. Vaginitis or elytritis of more or less severity occurs in the young, middle-aged, and old in less severe form than that alreadv described. This variety is termed by authors simple vaginitis, and Martineau says that it can be difi"erentiated from the severe forms by the fact that in the latter the secretion is acid in reaction, while in the former it is alkaline. The clinical description of the severe form has been given, and it is only necessary to say that in every feature the mild aff"ection is much less severe. In these mild cases, however, exacerbations may be observed, and the affection may become as severe as those of gonorrhoeal origin. Verchere ^ describes a rare form of diphtheroid or croupal vaginitis which he observed in two cases of young girls suffering from acute gonor- rhoea. The vaginal mucous membrane was red and swollen, and scattered over it in small and large areas were yelloAvish-white patches of false membrane which were very adherent to the vagina. They showed a decided tendency to reappear after removal. The mucous membrane under these plaques gave the appearance of hospital gangrene. There was an abundant flow of pus of bad odor, and the parts were the seat of heat and pain. In spite of an energetic treatment, the affection, which was strictl}'' limited to the vagina, lasted about three weeks. As a result of gonorrhoeal vaginitis, the mucous membrane is some- times found to be thickened and granular. These granulations are due to exuberant epithelial proliferation and new vessel-formation, and may be scattered over the whole tube, or may be localized particularly in its posterior Avail. Some observers, notably gynecologists, claim that simple vegetations or warts are symptomatic of gonorrhoeal inflammation. This state- ment is incorrect and misleading. Vegetations result from any chronic irritative process by which the parts are kept hot and moist. They are frequently seen in women Avho never had connection and Avere uncleanly. They may occur during the course of any catarrhal process of the vagina or vulva, and may develop in the course of gonorrhoea. In the study of gonorrhoea in the female Ave must not alloAv ourselves ^ Op. cit., vol. i. pp. 82 et seq. GONORRHCEA IN THE FEMALE. 299 to be fettered with too sharply-drawn laws based on the infallibility of the gonococcus,^ since at almost every step we find that clinical facts are at variance with microscopical deductions, or at least not in direct con- formity with them. It is these considerations, which have for years been forcing themselves on my mind, which cause me to give myself more lati- tude in describing gonorrhoeal vaginitis than the followers of Neisser are willing to accord to themselves and to others. As an instance of the susceptibility of the vagina the following striking case, reported by Welander,^ is of great interest : A man having gonor- rhoea attempted coitus, without successful intromission, during two days with his newly-married wife. Violent inflammation of the vulva, urethra, and introitus vaginae was soon set up. In the profuse purulent secretion many gonococci were found. The infection travelled upward and involved the vagina, but not the cervix uteri. Hardy, quoted by Verchere,^ also reported an interesting case. It was that of a young girl who, having no trouble previously, had a single and only connection with a man. A few days later there was a purulent discharge from the cervix uteri, which ran down and infected the vagina. The whole morbid process was carefully watched by Hardy. 1 Conrad of Berne {British Med. Journal, Oct. 17, 1887, p. 854) has tried to solve the question as to whether it is possible to differentiate a gonorrhoeal affection of the female genitals from a non-gonorrhoeal one by means of the microscopic examination of secre- tions and cultivation-experiments. He gathered with much care and at different times the secretions of acute purulent and mucoid catarrh of the vagina, womb, and urethra from cases which had from time to time recurred with exacerbations, and submitted them to bacterioscopic examinations with the assistance of three experienced bacteriologists. Sixty cases of supposed gonorrhoea were thus studied, and only in five recent and two chronic cases was the gonococcus found, though numerous bacilli and cocci were seen. Conrad reaches the following conclusions : 1. The detection of the gonococcus succeeds more easily in men than in women. It is so because the latter (a) experience compara- tively less discomfort from acute gonorrhoea where the microbe is most frequently demon- strated ; (6) they generally seek medical advice and help later than men; (c) as a rule, they pass water before undergoing a gynecological examination, and thus wash away or dilute their urethral discharge; [d) they sometimes come to be examined only after treatment by injections or other local means. It is possible also that detection becomes more difficult in consequence of gonococci being destroyed by micro-organisms of other species, which often grow luxuriantly in discharges of genital mucous membranes. 2. While in recent cases of female gonorrhoea Neisser's gonococcus may be almost always detected, it cannot possibly be found in many chronic cases. 3. Hence both acute and chronic gonorrhoeal affections may be present in women in spite of our inability to demon- strate the pathogenic microbe in a given case. If so, the gonococcus may have merely a limited diagnostic value, the practitioner being often compelled to rely on etiological and clinical facts. Emmert, a colleague of Conrad, drew attention to the fact that the genuine habitat of the gonococcus appeared to be the discharge of the urethra, and not of the vagina, since, when the microbe was found in the former, artificial inoculation of the vaginal mucous membrane almost invariably produced gonorrhceal vaginitis, while inoculation of the vaginal discharge from a gonorrhoeal woman in the vagina of a healthy one had no effect. Sahli, another of Conrad's colleagues, also thought that the gonococcus very often could not be demonstrated in the gonorrhoeal pus of women, and states that he was unable to detect it in a patient with a profuse purulent vaginal discharge who had recently been infected by a man with typical gonorrhoea and with masses of cocci in his urethral discharge. Only some extracellular diplococci were discovered in tiie woman. Sahli ascribes the difliculties in finding the gonococci in the female to the possibility of their being crowded out by other vaginal micro-organisms of non-pathogenic and iialf-patho- genic varieties ; by which he means microbes which give rise to pathological processes only when they are present in considerable numbers or when the system is already weak- ened by any cause. '■^"Gibt es eine Vaginitis gonorrhoica bei erwachsenen Frauen?" Jre/«t' /«>• Derm, und Sijph., 1892, pp. 78 et seq. ^ Op. cit. 300 GONORBHCEA AND ITS COMPLICATIONS. Gonorrhoea of the vagina, therefore, may be caused by the extension upward of the infection from the vulva, and it may also result from infection by virulent pus from the cervix uteri. True gonorrhoea, limited to the vao-ina proper, may be seen rather exceptionally in quite young women. Gonorrhoea of the Vulva. Gonorrhoea may originate primarily in the vulva, or it maybe caused by contact with gonorrhoeal pus from the vagina and parts above. As a primary affection it is not very common, and is usually seen in young girls of from fifteen to twenty years of age as a result of rape or coitus which is difficult of accomplishment, owing to the then compact and unstretched condition of the parts. It is this natural impediment to intromission which causes the external infection by the gonorrhoeal pus from men. Gonorrhoea of the vulva begins with a sensation of itching, soon fol- lowed by intense burning. At first the secretion is mucoid and in excess of the normal fluid of the parts ; it then becomes muco-purulent, and finally of a glairy, purulent character. Examination usually shows, par- ticularly in hospitals and dispensaries, and often in private practice, matting of the hairs on the mons Veneris and of the hairs of the labia majora in the form of little tufts. Upon separation the greater and lesser labia are seen to be very red, much swollen, with more or less superficially eroded areas, and in the reflections of the mucous mem- brane. The whole surface is bathed with a creamy pus which stains and stiffens the drawers and back portion of the chemise in spots. Per- haps there may be erythematous or even eczematous patches on the upper and inner coapted surfaces of the thighs from the irritation of the discharge which has flowed over them, and which may even severely irritate the anus. In uncleanly subjects the retention and decomposition of the discharge give rise to a characteristic nauseating and disgusting odor. When the inflamed surfaces have been carefully bathed, numerous minute follicular elevations, many perhaps superficially eroded, may be seen, mostly on the labia minora, but also on the labia majora. Unless appropriate treatment is instituted, the swelling becomes very great, the eroded surfaces become larger and coalesce, and in consequence of the swollen condition examination of the urethra and vulva is very difficult and painful. In cases of long labia minora the swelling is sometimes so great, and the constriction offered by the labia majora is so firm, that strangulation seems imminent. This condition has been considered by some authors as analogous to paraphimosis in the male, while others think that acute vulvitis is the analogue of balanitis and balano-posthitis. The inflammatory process may be thus intense, and yet limited to the vulva ; and, although the urethral and vaginal orifices are red and inflamed, these canals may yet remain unaffected. Thus it is that urina- tion is excruciatingly painful, particularly when the urine runs over the vestibule, vaginal orifice, and fourchette, and that digital or instrumental examination is rendered impossible. Taking all its features into consideration, gonorrhoea of the vulva of the severe form is a distressingly painful affection. Its heat, attendant itching, and burning give rise to erotic desires, even to nymphomania, GONORRHCEA IX THE FEMALE. 301 while handling or manipulation of the parts or sexual intercourse is utterly impossible. Not uncommonly, the irritation of the anal orifice by the escaping discharge gives rise to tenesmus, diarrhoea, and even incontinence of the rectum. Such patients are frequently forced to assume the recumbent position, since sitting and walking are attended by increased pain. Occasionally malaise with mild fever is noticed. Arising as it does from aborted and perhaps violent attempts at coitus in rape, in mediate contagion from gonorrhoeal pus, the date of the onset of vulvar gonorrhoea is very often clearly marked. The evolution of the affection is prompt and rapid, and but one or two days may elapse from the time of the commencement of the premonitory pruritic burning sensation to its full development. The course is entirely dependent upon the efficiency and vigor of treatment. In dispensary practice it is often very difficult to make these girls give themselves proper care. Hence this affection in the lower classes often runs on into a chronic condition. In many of these cases the inflammation settles itself in the cleft between the large and small labia and around the introitus vaginas. In private practice patients are more attentive to treatment, and then the severity of the trouble subsides in about a week or ten days. Becoming sub- acute, it then may rapidly subside and disappear. In acute gonorrhoea of the vulva there is frequently invasion of the urethra, and in some cases the infection extends into the vagina. Not uncommonly Bartholin's glands are attacked, and rather less frequently Skene's glands and the periurethral glands may become implicated. These complications naturally prolong the course of the inflammation. There is a chronic form of vulvitis, which consists in an inflammation of the sebaceous and mucous follicles, which may or may not be of gon- orrhoea! origin. Examination of the parts shows a large or small num- ber of minute red follicular elevations seated on the inner surface of the labia majora and minora. This is the " sebaceous " or follicular vulvitis described by Huguier.^ If properly treated, it is an ephemeral affection. The vulvo-vaginitis of children is described in the following chapter. Inflammation of the Periurethral and Para-urethral Follicles and Glands. IXFLAMMATIOX OF SkENE'S UrETHKAL GlA?s^DS. Skene's glands, which open a little Avithin the orifice of the urethra, may be the seat of a mild form of inflammation Avhich causes the patient very little discomfort. The orifices are seen to be enlarged, and around them is a thin rim of redness. A more severe condition is sometimes seen in which there is active inflammation of the ducts and the surround- ing tissues and the escape of a purulent fluid. In this condition the meatus is so swollen that it is somewhat prolapsed and everted, and thus it happens that the orifices of the ducts are rendered visible and look like little A^ello wish-gray ulcers seated on a deep-red papillomatous base. Skene "^ says that the appearance of the parts reseiubles caruncle or papilloma, and he records a case under his own care in which the diag- ^ Memoires de I' Academic de Med., 1850, p. 529. ''' Op. cit. 302 GOyOBEHCEA AXD ITS COMPLICATIONS. nosis was not made for many months. The patient suffered from pain on sitting and walking, and was debarred from sexual intercourse. A probe could be passed into the orifices of the glands for more than half an inch, and on withdrawal and by downward pressure on the urethra pus escaped. This patient under a false diagnosis was treated twenty- one months with no relief, but was promptly cured in two months after a correct diagnosis had been made. These glands may be affected during and after acute gouorrhoeal inflammation. This affection, however, is not of frequent occurrence. G0X0RRH(EAL FOLLICULITIS. Around the urethra for a distance of a third or half of an inch a number of small follicles open by means of very minute ducts. These follicles may become inflamed during acute or chronic gonorrhoea and in women with simple vaginal discharges. These little foci of inflam- mation, of which there may be as few as two and as many as ten, called by French authors foHiculite hlennorrJiagique, are very apt to escape observation, for the reason that they do not present a strjking appearance. They simply look like inflamed pinhead-sized elevations, on which per- haps there may be a small pus crust. They cause the patient very little trouble beyond a very slight sensation of heat and pricking. Pressure on the parts will usually cause a small quantity of pus to exude. Then a very fine probe may be inserted into the orifice thus revealed for a quarter of an inch or even deeper. Unless properly treated, these peri- urethral folliculites of women may persist indefinitely. Martineau is the only author Avho claims the frequency of occurrence of these lesions. Under the title urethrite externe Guerin^ described a gonorrhoeal pro- cess involving two goodly-sized glands, to-day known as the vestibulo- vaginal bulbs, the orifices of which open on each side of the meatus, and perhaps a little distance from it, but on its lower border near the vagina. This affection rapidly passes from the acute to the chronic stage, in which it may linger for long periods. This variety of gonorrhoea m women is considered by Guerin, owing to its chronicity, analogous to the goutte militaire of men. On examination we find a red elevation, which may be covered with pus or from which on pressure a little pus may exude. This lesion may escape detection unless very scrutinizing search is made for it. Women frequently, before coming to the surgeon, wash the parts or in urination the secretion is carried away. When by careful pressure the orifice of the gland is detected, the passage of a fine probe to the depth of half an inch or more will show the source from which the suppuration comes. It can readily be understood that such a chronic lesion might be a persistent source of infection in men, since it is not uncommon for it to undergo exacerbations. These glands may rather rarely become the seat of abscess. Gobel ^ reports the case of a young girl suffering with gonorrhoea who had a pain- ful abscess of the size of a pigeon's egg which bulged into the vaginal canal. The microscopical examination of the pus evacuated by incision ^ Maladies des Organes f/enitaiix externes de la Femme. Paris. 1864, p. 307. ^ " Gonorrhoische urethritis beim "Weibe mit Periurethralem Abscess," Inauq. Dissert., Erlangen, 1889. OONORRHCEA IN THE FEMALE. 303 was negative. Cory ^ also reports a similar case, in which the history of gonorrhoea is not clear, but in which there was much local inflammation, together with severe febrile symptoms. Inflammation of these glands may be cured by treatment, but it may result in sinuses and fistulse. Lormand ^ reports an interesting case. It was that of a young woman suff'ering from gonorrhoea who had a swelling of the size of a small nut to the left of the urethral orifice. Pressure on the swelling caused pus to exude from the meatus, and Avhen a solution of permanganate of potassa was injected into its ducts, then fluid ran from the meatus. A probe passed into the fistula could be felt in the urethra. Harmonic ^ also reports a case in which to the right and a little below the meatus was a small red warty or papillomatous elevation through which a fine probe could be passed into the urethra. In this case lanci- nating pains in the vulva were complained of. Para-urethral Folliculitis. Scattered over the vestibule, at a distance of half an inch or a little more from the meatus (according to the natural size of the parts), is a number of mucous follicles which may be affected by gonorrhoea of the urethra, vulva, and vagina. These follicles, when inflamed, look like small red papillas, from which, upon pressure, a little muco-pus or pus Avill exude. Unless cured, these lesions may remain in a chronic and indo- lent condition, and they may end in sinuses or in true fistulae. These fistulse may end in the urethra near the meatus or farther down the urethral canal. They also may extend toward the vagina in an incom- plete form, or they may open into that tube. On this subject Marti- neau's^ brochure may be consulted. Around the fourchette and near the posterior wall of the vagina a number of mucous follicles are seated, and they are sometimes invaded by the gonorrhoea! process. These lesions look like small red swellings, from Avhich, on pressure, a little pus may exude. These follicular inflam- mations ai'e very chronic in character and rebellious to treatment. They may result in sinuses and fistulge. In some cases the sinus or fistula extends toward the vagina, and in others toward the rectum. As a result, therefore, there may be vulvo-vaginal or vulvo-rectal fistulse. These fistulne are usually very small, they cause little trouble during long periods of time, and frequently they pass unrecognized for years. Many cases of genital folliculitis in Avomen will be met in which abso- lutely no history of gonorrhoea can be obtained. Inflammation of Bartholin's Glands. Bartholin's or the vulvo-vaginal glands are situated one on either side of the entrance to the vagina, in the triangular space bounded by ^ "Abscess of the Female Urethra," Transact, of Obstet. Society of London, 1870, vol. xi. pp. 65 et seq. '■* " Note sur un Cas de Fistule vestibulo-nrethrale d'Origine blennorrliagique," La France medicale, Sept. 27, 1883, pp. 433 et seq. ^ " Fistule vestibulo-iir^thrale consecutive a une Folliculite bleunorrhagique pr^- urethrale," Annales de Derm, el de Syph., 1884, pp. 344 et seq. * Op. cit., pp. 61 et seq. 304 GONOBRHCEA AND ITS COMPLICATIONS. the ascending ramus of the ischium, the vaginal orifice, and the trans- versus perinsei muscle, and are covered by the superficial perineal fascia and some fibres of the constrictor vaginae. They are conglomerate glands, having, when fully developed, a diameter of six-tenths of an inch. The ducts of these glands are about six lines in length, and they open just in front of the hymen near the lateral and posterior carunculge myrtiformes. These glands pour out in coitus and in genital excitation a copious secretion of albuminous fluid, which lubricates the vulva and the vagina. The vulvo-vaginal glands may be the seat of two forms of inflammation, the one simple, and the other gonorrhoea!. Simple acute Bartholinitis is mostly seen in young girls, married or single, and generally follows early eff"orts at coitus. In many cases it results from the violence attendant upon rape. In some cases the simple rupture of the hymen causes local irritation, and as a result one or both vulvo-vaginal glands become inflamed. Its frequence in very young married women has caused it to be called "the bride's abscess." It is particularly liable to develop in girls who have leucorrhoea and who are not careful as to the cleanliness of the genital parts. It some- times results from excessive coitus and also from masturbation. The symptoms are usually quite strongly marked. The patient com- plains of pain or soreness in the vulva, and inspection reveals a small Fig. 89. Abscess of vulvo-vasrinal a-land. rounded swelling at the lower or posterior third of the vaginal orifice. This swelling rapidly increases until it may reach the size of a quite small egg. Then the labium major becomes pear-shaped and is pushed outward, and we see a deep-red, rounded, fluctuating swelling, which may extend an inch and even more from the level of the vaginal orifice. The parts are the seat of throbbing, dragging pain, and are exquis- itely sensitive to the touch. In this condition, in severe cases, the patients can neither walk, stand, nor sit. They have chills, malaise, GONORRHOEA IN THE FEMALE. 305 and febrile movement. In some cases there is spontaneous rupture through the duct, but in most cases it is necessary to incise the abscess. Sometimes it bursts spontaneously, most commonly near the glandular outlet, and rarely over the convexity of the tumor. The pus is usually thick and yellow, but it may be thin and serous. Exceptionally, it has a fetid odor. In most cases, after incision into or bursting of the abscess, the parts heal and the gland seems to return to its natural condition. In several cases I have observed that the abscess was periglandular, and that the suppuration left the gland itself and developed itself in the connective tissue outside of it. This condition is the same as that which we sometimes observe in abscess of follicles of the male urethra. With the discharge of the pus the gland promptly becomes normal and the surrounding inflammation ceases. In many cases, however, after abscess-formation and pus-extrusion have taken place, the gland seem- ingly returns to its normal state, yet exacerbations and relapses are liable to occur. Thus, after menstruation the gland may swell and become painful, and in this condition it may remain a little time, and then subside. Such exacerbations as these may be very frequent, and they keep the patients in a continuous state of dread. Excessive venery, masturbation, and leucorrhoeal discharges may also light up the suppu- rative process, with all its local and general disturbances. As the inter- val of time between exacerbations becomes longer the tendency to them seems to lessen, and generally it dies out. But it is not uncommon to see a Avoman suffer from acute Bartholinitis several years after her first, second, or third experience. In most cases of simple acute Bartholinitis the parts heal and appear normal. In some cases a sinus is left, and in very exceptional cases a vulvo- or vagino-rectal fistula is formed. Usually but one gland is affected, and most commonly it is the left one. The affection may, however, occur bilaterally. In all probability the simple form of Bartholinitis is caused by pus-cocci acting upon a bruised or hyperaemic part thus rendered susceptible to infection. During the course of gonorrhoea, acute or chronic, the ducts of Bar- tholin's glands, or the glands themselves, may be the seat of a suppu- rating inflammation. Of late years there has been a tendency to mag- nify the frequency of occurrence of these complications of gonorrhoea in women. In acute gonorrhoea the duct and the gland itself are sometimes the seat of inflammation. In chronic gonorrhoea it is more common to find only the duct or the ducts involved. Gonorrhoeal inflammation of the duct of the vulvo-vaginal glands may be attended with very mild symptoms of heat and pricking, and these may be wholly absent. On inspection we find the opening of these ducts red and a little swollen ; the red spots thus produced are called by Sanger " macul?e gonorrhoeica." Pressure on the parts against the ramus of the ischium causes a drop of milky or greenish pus to exude. In some cases this localized inflammation is the only remnant of the gonorrhoeal process. It causes little or no discomfort, so that frequently the patient does not know that she has such a trouble. In this indolent condition it may remain for long periods, or it may, as a result of exciting and irritating causes, become acute. The body of the gland may become infected, in which event there may be an 20 306 QONOBRHCEA AND ITS COMPLICATIONS. acute suppuration, but usually the condition is rather indolent and sub- acute. The gland swells to the size of a nutmeg or walnut, and may be grasped and its contour clearly made out between the finger-tips. The swelling presents a smooth, quite firm structure of roundish or oval out- line. Not infrequently the duct of the gland can be felt like a firm round cord. Pressure causes a whitish pus to exude. This condition of affairs is found in prostitutes, particularly in old ones. It is the cause of much trouble and worry to them, since they are always in dread of a recrudescence of the acute inflammation, which may result from sexual excess or any inflammation about the genitals or in the pelvic cavity. Very exceptionally I have seen chronic gonorrhoeal inflammation of Bartholin's glands take on the characters of a simple acute affection, develop into an abscess, and burst. The usual tend- ency is for the glands to become hard and swollen, and to remain unin- fluenced by any treatment, except surgical. The infectiousness of the pus of specifiic Bartholinitis is now generally conceded. In 1877, prior to the era of the gonococcus, Le Pileur ^ traced an acute gonorrhoea of a medical friend to the pus of a discharging vulvo- vaginal gland, there being absolutely no other seat of gonorrhoeal infec- tion in the woman with whom the medical man had cohabited. Owing to the mild chronicity of the morbid process and to the hidden condition of the orifice of the duct, gonorrhoeal Bartholinitis may very readily escape recognition unless carefully looked for. Women coming for examination and public prostitutes become aware of this focus of in- flammation in their genitals, and take pains to deceive the examining physician. They squeeze out the contents of the glands and wash and syringe their genitals, thus frequently removing for a time all traces of the inflammation. This point must be borne in. mind when examining women under suspicion of having gonorrhoea. They must be compelled to present themselves without any preliminary preparation. Arning ^ placed gonorrhoeal vulvo-vaginitis on a scientific basis when he clearly demonstrated the presence of the gonococcus in the pus of seven inflamed vulvo-vaginal glands. Teuton^ has recently submitted an excised vulvo-vaginal gland and its duct to an elaborate and interesting microscopical examination and study, and has clearly shown that the micro-organism attacks the pavement epi- thelium of the duct and produces typical inflammation, and by extension attacks the gland itself. Gonorrhoea of the Tubes, Ovaries, and Peritoneum. — When gonorrhoea ascends and passes from the uterus to the tubes and beyond, the case then enters the domain of the gynecologist. I shall not attempt to give a detailed description of the pelvic troubles in women caused by gonorrhoea, but shall confine myself to a general consideration of the subject, leaving it to the reader to fully inform himself from the various works on gyn- ecology. We have already seen that there is at present a tendency to exaggerate ' " Blennorrhagie ur^thrale ayant pour origine I'inoculation de Pus d'une Glande de Bartholin abcedee, etc.," Annales de Derm, et de Syph., vol. ix., 1878, pp. 374 et seq. ^ "Ueber das Vorkommen von Gonococcen bei Bartholinitis," Vierteljahresschr. fur Derm, vnd Syph., 1883, pp. 371 et seq. ^ " Die Gonococcen im Gewebe der Bartholini'schen Driise," Archiv fur Derm, und Syph., 1893, pp. 181 et seq. GONORRHCEA IN THE FEMALE. 307 the frequency of gonorrhoeal pelvic disease and to make such a diagnosis oft-hand on very insufiicient data. That the tissues around the uterus, the tubes, the ovaries, and peritoneum may be attacked by the gonorrhoeal process is undeniably true, but it does not occur in. the majority of cases. In reporting cases it is necessary first to establish the facts of a gonorrhoeal infection beginning in some part, such as the urethra, vulva, uterine neck, and vagina, and if possible to find out from Avhom the infection Avas derived. Then the symptoms and course of the disease must be such as will accord Avith the clinical history of gonorrhoea. Then it is necessary to establish the fact that the cervix uteri has been infected primarily or secondarily, and, if this is done, there can be no doubt whatever as to the gonorrhoeal origin of any pyosalpinx, oophoritis, perimetritis, and peri- tonitis. These requirements may be difficult of fulfilment, but accurate knowledge of the subject can only be obtained as a result of painstaking observation and examination, which will generally warrant a correct diagnosis. There is no such thing as a latent gonorrhoea without well- defined pathological conditions. Gonorrhoea may lurk in a latent or dormant condition in some part of the genito-urinary tract of the woman, but it is always a well-defined pathological process, and it may be clearly established if we take the pains to search for it clinically and micro- scopically. V. Rosthorn^ gives a very clear general clinical history of a case of severe gonorrhoeal infection in a woman. " Having been infected by her husband, a previously healthy Avoman shortly after marriage begins to feel poorly and becomes tired easily. Menstruation becomes profuse, and there is dysmenorrhoea and leucorrhoea. She has severe colicky pains resembling those of labor, and constant pains in the groins and back, which interfere with locomotion and the pleasures of life. She has mental depression, and even may become melancholy. Suddenly an acute attack of peritonitis^ comes on, from Avhich she partly recovers, and can Avalk around, but is forced to avoid all exertion, and particularly jolting in cars or carriages. Coitus may bring on another attack. Indeed, throughout her life, until after the menopause, she is liable to relapses from slight causes. The uterus is enlarged and tender. The tubes are dilated to the size of a finger or a sausage, and the ovaries are enlarged, suppura- ting, and perhaps cystic, covered with inflammatory products, and per- haps displaced and bound down by adhesions in Douglas's cul-de-sac. The peritoneum is thickened, hypersemic, and produces displacements of the uterus. Sterility is observed in the majority of these cases." In some cases it is very difficult, and even impossible, to get a clear consecutive history of gonorrhoeal inflammation and invasion, and in these the microscope may or may not be of assistance. In the examination of ^ " Ueber die Folgen der Gonorrhoischen Infection bei der Frau," Prag. med. Woclien- ■schr., vol. xvii., 1S92, IS'os. 2 and 3. ^ The usual mode of invasion of pelvic organs of the female by gonorrhoea is slow and insidious, sometimes developing suddenly into an acute condition. In a case, how- ever, reported by Penrose ("Acute Peritonitis from Gonorrhoea," ]\[ed. Neirs, July 5, 1890, pp. 16 and 17), only six days elapsed between the sexual act in man and wife and the development in the latter of an intense and threatenina; i)eritonitis which required opera- tive relief. The peritoneum was characteristically intiamed and the tubes were the seat of an exudative purulent inflammation. The husband at the time suffered from very severe gonorrhoea with epididymitis. The microbes found in the tubal pus had the .appearance of some of the staphylococci of suppuration. 308 GONOBBHCEA AND ITS COMPLICATIONS. pus from the uterus and tubes the finding of the gonococcus is not at all frequent or constant, and the supposition is warranted that other micro- organisms take part in the morbid process. Bumm ^ has advanced the theory of mixed or compound infections in women. Reasoning on the hypothesis that the bacteria of pneumonia destroy the epithelial lining of the pulmonary alveoli, and cause an exu- dation which forms a cultivating medium for the bacillus tuberculosis and pyogenic micro-organisms Avhich result in phthisis and abscess of the lungs, he thinks that the gonococcus likewise acts upon the female geni- tal mucous membranes, and produces a suitable culture-ground for other organisms which do not attack them in the healthy state. Bumm is con- vinced that the gonococcus only involves mucous membranes, and that for this reason women suffering from gonorrhoea are not attacked by pelvic cellulitis. The latter, he thinks, is due to compound infection, since in two cases of the trouble complicated by abscess he found large quantities of the staphylococcus aureus in the pus. He thinks that the micro-organisms penetrated the erosions in the cervix, and were carried by the lymphatics into the connective tissue of the pelvis. Bumm also states that the further the inflammation extends from the vagina, the less are the chances for compound infection, and that in gonorrhoea of the uterus there are usually feAv germs besides the gono- coccus, and that in the tubes the latter alone is usually found. In the tubes the specific action of this microbe may be seen in the form of puru- lent inflammation of the mucous membrane only, the connective tissue not being invaded. He is under the impression that the escape of gonor- rhoeal pus from the tubes into the peritoneal cavity is not followed by suppurative peritonitis, but that a circumscribed adhesive inflammation is set up which seals up the tube, and that the woman may suffer afterward from chronic pyosalpinx. Should pyogenic micrococci be present in the pus, Bumm thinks that purulent peritonitis and death might ensue. As in man gonorrhoeal epididymitis may be followed by tuberculosis of the organ, so in the woman, according to Bumm, may the tubes the seat of gonorrhoea be attacked by tuberculosis, both cases being instances of "mixed gonorrhoeal infections." Later observations by Wertheim ^ have shown that Bumm too narrowly restricts the pathological action of the gonococcus. AVertheim clearly shows that the gonococcus can invade the connective tissues like ordinary pus-microbes. Thus, he shows that the deeper inflammations, other than those of the mucous membrane, in the female may be caused by the gono- coccus, such as parametritic infiltrations, perimetritic exudations, and plastic adhesions and inflammatory changes in the ovaries. Wertheim shows that the gonococcus can penetrate the walls of the tubes into the peritoneum, and there produce inflammation. Peritonitis is also caused by the escape of gonorrhoeal pus through the tubal orifices into the peri- toneum. The tendency of peritonitis produced by the gonococcus is to be- ^ "Ueber Gonorrhoische Mischinfectionen beim Weibe," Deutsche med. Wochenschrift, Dec. 8, 1887, pp. 1057 et seq. ^ Op. cit. In Wertheim's two essays the bibliography of tlie observations (all foreign) of the gonococcus in the tubes is given. In this country Dr. Howard A. Kelly ("The Gonococcus in Pyosalpinx," TJie Johns Hopkins Hospital Reports, vol. ii., Isos. 3 and 4, 1890) reports finding a diplococcus characteristically grouped within the pus-cells from the tube least affected in a case of double pyosalpinx. GONOBRHCEA IN THE FEMALE. 309 come walled in by adhesions and to run a less severe and prolonged course than other forms. From what has already been published it seems conclusive that the gonococcus may in some cases live and thrive in the tubes, and from these invade the neighboring parts. It also seems clear that in some cases the microbes die in the tubal pus, perhaps, as is claimed, as a result of the poisons they secrete. There can be no doubt of the presence of the pyo- genic micro-organisms in the majority of cases of tubal disease. Wertheim's observations certainly restrict the scope of Bumm's mixed-infection theory, but they do not absolutely invalidate it, since he has not by any means proved that the gonococcus is uniformly found in the pus of tubes the seat of gonorrhoeal inflammation. This subject needs further elucidation and elaboration. Prophylaxis. — The question of the prevention of gonorrhoea in women is one of great gravity, and should attract more attention than it does, particu- larly in this country. Much can be done by physicians in lessening the num- ber of cases of gonorrhoea in men by impressing on kept-women and prosti- tutes, who so numerously come under our care, the necessity of absolute cleanliness and of the use of antiseptic (bichloride) injections and douches. While Ave can hardly agree with Broese,^ Avho says that " one can scarcely err if he assumes that all prostitutes are infected with gonorrhoea, espe- cially if they have exercised their profession for any length of time," we can look upon them as a dangerous class, and should treat them as such. There being no registration of prostitutes in this country, the physician's influence over them is very limited. When, however, they do come under medical care in hospitals, dispensaries, and in private practice, we should endeavor to follow as far as we can the requirements laid down by Sanger and V. Rosthorn, which, though some of them are impracticable with us, are deserving of being emphasized. They are — 1. A careful watch over registered prostitutes and relentless efforts directed against the unregistered class. (We can do nothing in this direction.) 2. Pi'olonged treatment of infected prostitutes by physicians having special training. , 3. The compul- sory use of bichloride douches for the vagina and vulva. Care should be taken by the physicians to teach these women how to use these douches eff'ectively. 4. Have the male wash the penis with bichloride solution after each coitus. 5. Rational and prolonged treatment of men having the disease, and forbidding marriage until the gonorrhoea is cured. Broese lays great stress on the danger of reinfection of the Avife, after having been cured of one attack of gonorrhoea, by her husband, in whom the disease remains in an infectious condition. This is a very im- portant subject. The surgeon, having satisfied himself that the woman has gonorrhoea, has the double duty on his hands of curing the Avoman and of seeing to it that she is not again infected. To this end he must consult the husband (using all tact and prudence) and impress upon him the necessity of being absolutely cured of his trouble. Much good can be done in hospitals and maternity institutions by the examination of the secretions of the genitals of pregnant Avomen, and by instituting an in- telligent and vigorous treatment which will benefit the woman and perhaps prevent the gonorrhoeal infection of the eyes of her infant Avhen it arrives. ^"Zur Aetiologie Diagnose, und Tiierapie der Weiblichen Gonorrhoe," Deut. med. Wochenschr., 1892, pp. 370, 398, and 419. 310 60N0RRHCEA AND ITS COMPLICATIONS. Treatment of Gonorrhoea in the Female. — In the treatment of gonor- rhoea in the female the prime essentials are scrupulous cleanliness, copious antiseptic injections and flushings, and constant care as to details. The patient should be made to clearly understand the gravity of the disease and its tendency to further ^upward extension and to localize itself in the recesses and crypts of the genitalia ; and she should be urged to continue under observation until she is pronounced cured by the surgeon. It is the duty of the latter to make thorough and painstaking examinations of the whole genito-urinary tract, and to acquaint himself with the full extent of the disease. The various mor- bid secretions should be examined by means of the microscope with a high-power lens and oil-immersion. In acute cases the recumbent position should be insisted upon. The diet should be of the simplest character, and preferably of milk. A brisk cathartic may be given, and throughout the course of the disease one or more full movements of the bowels should occur each day. For the purpose of lucidity of description and orderly arrangement the treatment of gonorrhoea will be given on the lines of the anatomical situation of the parts and regions involved, rather than on the clinical basis and the relative frequency of the various forms of gonorrhoea in the female. For gonorrhoea of the vulva, with all its painful accompaniments in the acute stage, very hot sitz-baths, repeated four or more times daily if possible, should be used, taking care that the water is brought into free contact with the whole surface affected. Very often the itching and burning are much allayed by affusions of hot alkaline solutions (powdered borax or supercarbonate of soda, 3ij to water gxxxij), to which may be added two to four drachms of wine of opium or lauda- num. Then a lotion as follows may be employed: I^. Pulv. boracis, 5j ; Liq. plumbi subacetatis, giss ; Ext. opii aquos, 3j ; Aquae, §vj._M. With this may be saturated pledgets of lint or of absorbent gauze, which should be carefully and thoroughly applied to the surfaces in order to keep them apart, and renewed very frequently, since they soon become saturated with pus. So soon as the vulvar orifice will permit a soft catheter. No. 15 F., or the long tube of a Davidson's or fountain syringe, should be introduced as far as it will go, and several copious injections of very hot alkaline water should be made every day. As the inflam- mation declines it may be necessary to paint the parts to their smallest recesses with a solution of nitrate of silver, thirty grains to the ounce of water, followed by hot ablutions with a solution of common salt. After a very hot sitz-bath the lead-opium-and-borax lotion may again be ap- plied. In twenty-four hours after this application to the old or the young much improvement will be noted in the lessened oedema and red- ness and in a less painful condition. Then a 1 per cent, solution of alum, with laudanum, may be used, and later on the parts may be dusted with subnitrate of bismuth or powdered boracic acid on a pledget of lint or absorbent gauze. GONOBBHCEA IN THE FEMALE. 311 GoNoRRHCEA OF THE Urethra. — Vulvar gonorrhoea is very fre- quently, sooner or later, accompanied "with implication of the urethra and increase in the patient's sufferings. The solution of bicarbonate of potassa with hyoscyamus recommended for acute gonorrhoea of the male may be given in order to relieve the urine of its acidity, and diluent drinks, such as flaxseed and slippery-elm teas and barley-water, may be taken ad libitum. As soon as the inflammation in the urethra has somewhat subsided by use of the foregoing measures suitable for the acute stage of vulvitis, intra-urethral injections of very hot Avater with borax or boracic acid, siij to sxxxij, frequently made by means of any recurrent syringe or catheter, or preferably by means of Skene's reflux catheter, may be used. As the inflammation subsides, intra-urethral injections of hot water, containing carbolic acid in the proportion of J of 1 per cent., are very beneficial. In many instances where the pain on urination is very great the instillation into the urethra by means of a small cylindrical dropping-pipe of a solution of opium in glycerin, or of cocaine muriate in glycerin and water, is followed by marked relief. As the urethral lesion further declines, a 2 per cent, solution of nitrate of silver may be injected as far down the urethra as possible, since it is commonly involved in its whole length ; or a thirty -grain-to-the-ounce solution of nitrate of silver may be carefully and sparingly applied by Sims's urethral forceps. means of a cotton-holder, facilitated either by the endoscope or by the fenestrated forceps of Dr. H. M. Sims. An essentially antiseptic treatment is used at the Antiquaille Hos- pital by Rollet.^ A catheter like that of Mitchell's reflux form is intro- duced into the urethra as far as its vesical neck ; then the canal is irri- gated with solutions of sublimate, 1 : 2000, or permanganate of potassa, 1 : 250. An antiseptic pencil (see Medicated Bougies, p. 152) may be inserted into the urethra, which is washed with a solution of resorcin, 1 : 10 or 30. Antiseptic irrigations of the vagina are used to prevent the ascent of the disease. Vigneron,^ in Chdron's service, used injections of a saturated solution of picric acid. The urethra was first irrigated wnth boric-acid water, and then by means of a uterine syringe ten cubic centimetres of the solu- tion were thrown into the bladder. The vulva was carefully cleansed. A cure is said to follow a few injections in from ten to twenty days. It is only in the subacute and chronic stages that antiblennorrhagics are to be used, and then in rather smaller doses than in the male. (See section on Gonorrhoea in the Male.) In some cases these agents produce marked relief in the symptoms and a lessening of the discharge, and, 1 Gazette de Gynecol, 1894, vol. ix. pp. IS et seq. ^ Tlihe de Partis, 1894. 312 GONORBHCEA AND ITS COMPLICATIONS. again, they seem to be of no benefit at all ; from which it follows that local measures are always the most certain. It is necessary to repeat that in chronic urethral and vulvar gonor- rhoea in women the patients are apt to be careless and indifferent in the stage of decline, which, added to the setbacks incident to menstruation, tends to perpetuate their trouble. At this time the surgeon should accentuate his injunctions to follow treatment, to be as quiet as possible in every Avay, and to abstain from any errors in eating or drinking. GoNORRHCEA OF THE Vagina. — Gonorrhoea of the lower part of the vagina, which is commonly accompanied with the same affection of the vulva and perhaps of the urethra, should be treated on the principles already given. As soon as the acute symptoms subside, copious irriga- tions of very hot water well into the canal should be made. Then, as soon as the irritability of the parts will permit, the surgeon should make a thorough examination, having at his command a perfect light, natural or artificial. In my judgment, the genu-pectoral position, though objec- tionable to patients by reasons of delicacy of feeling and of its uncom- fortableness, is by far the best to obtain a thorough view of the whole vagina, including the cervix uteri and the posterior and the anterior fornix vaginae. The blade of a Sims speculum carefully introduced ele- vates the posterior vaginal wall, and free inspection is possible. Where the surgeon works without the aid of an assistant the adjustment to the Sims speculum devised by Dr. Cleveland may be used, Avith much help. When the very acute symptoms of gonorrhoeal vaginitis have begun to subside, the inflamed surfaces may be carefully and thoroughly cleansed by means of a cotton-holder. Then the whole surface may be exposed by the wire speculum, and then gently and sparingly touched with a thirty-grain-to-the-ounce solution of nitrate of silver, after which the canal should be thoroughly irrigated with hot water to Avhich a little common salt has been added. Another and less commendable and pre- cise way of applying the nitrate-of-silver solution is to pass a Ferguson's speculum so as to encircle the cervix uteri, which is touched with the solution on a cotton-holder. Then one or two drachms of it are poured into the speculum, when, on withdrawal with a rotary motion, the solu- tion will come in contact with the vaginal walls. After this application, which should be thoroughly made in the posterior and in the anterior fornix, and also to the uterus, usually as far as the os internum, the vagina should be thoroughly tamponed with iodoform gauze. Currier ^ claims that benefit will sometimes follow the application by means of the tampon of a mixture of subnitrate of bismuth and glycerin, one drachm to the ounce. In this I think, from experience, that as regards many cases he is perfectly right, though my preference is for a mixture con- taining double the quantity of bismuth. In my experience, tampons made of absorbent gauze are preferable to those of absorbent cotton, since they absorb more freely and do not give rise to the unpleasant and sometimes painful sensations caused by the bolus of cotton. In many cases, the nitrate-of-silver solution having been applied once or twice, much benefit will follow the deposition deep into the vagina of a considerable amount of powdered boracic acid, which must be retained by the gauze tampon. Whatever form of tampon is used, it should be 1 N. Y. Med. Journ., Oct. 24, 1885, p. 454. GONORRHCEA IN THE FEMALE. 313 removed with great care every twenty-four or forty-eight hours, and then copious hot-water injections should be made. The frequency and strength of the nitrate-of-silver applications should be determined by the Fig. 91. Wire speculum for applications to the vagina. progress of the case. Usually, several days should elapse before a sec- ond is made, and if the patient is under control two or three are enough. It is well to bear in mind that vaginal injections may be given, the patient lying on her back with her hips elevated, either by means of a Davidson or a fountain syringe, or by Dr. Foster's excellent vaginal douche. In chronic vaginitis extract of Pinus canadensis may be used on tampons. Bichloride-of-mercury irrigations may in a measure allay the irritation, but they generally fail to produce a cure. Schwartz ^ of Halle, believing that the annihilation of the gonococcus means the cure of gonorrhoea, recommends the following heroic anti- parasiticide treatment : The vagina and vulva are thoroughly cleansed with a 1 : 1000 solution of the bichloride. Then by means of a Sims or Bozeman speculum all the parts are swabbed, with the utmost care, with cotton-Avool saturated with a 1 per cent, bichloride solution, taking care to rub off the superficial layers of the epithelium and to reach the folds of the introitus vaginae. Then the vulva and vagina are dusted with iodoform, which to be effective should be rubbed in, and then the vagina must be packed with iodoform gauze, which should remain three days, at the end of which the process should be repeated. Another tampon of iodoform gauze is then inserted and allowed to remain five days, upon the removal of which, during eight or fourteen days, copious irrigations of the vagina with sublimate solution, 1 : 2000, should be employed. It is stated that after the second tampon the vagina is red and raw and the seat of a copious purulent discharge. While it is claimed that in Germany marked benefit has followed this method of treatment, I think that its employment should be much modified in the reduction of the solutions of the sublimate. It is well known that con- tinuous irrigation of the vagina with a solution 1 : 5000 is commonly attended in a short time with irritation, which also sometimes affects 1 Op. cit. 314 OONORRHCEA AND ITS COMPLICATIONS. the hands of the nurse or surgeon. Then, again, many persons are subject to the iodoform idiosyncrasy, and the application of the drug causes violent local reaction and sometimes systemic poisoning. There- fore it should never be put recklessly in large quantities into any cavity, natural or artificial. I think, however, that with modifications and toning down Schwartz's treatment may be of benefit. A number of new drugs have been used in the form of injections in the treatment of gonorrhoeal vaginitis. D'Aulnay^ first thoroughly swabs the vagina with a 1 per cent, sub- limate solution, and then tampons the cavity with absorbent cotton or gauze moistened with a solution composed of methyl blue 10, alcohol 15, caustic potassa 0.2, and water 200. The application is left in the vagina for two days ; then a copious irrigation is given and the remedy applied in the same manner again. It is claimed that this treatment soon pro- duces a cure. Retinol is well spoken of by Barbier,^ who used it in Balzer's ser- vice. The parts are first freely irrigated, then gauze or cotton tampons moistened with the balsam are inserted in the vagina. A cure is said to be produced in from twelve to fifteen days. Subacute and chronic gonorrhoeal vaginitis may, according to Schwimmer,^ be cured by the use of alumnol, by insufflation or irriga- tion of the canal, in two to eight weeks. In Hirtz's service at the Lourcine Hospital, Dubard* used on tam- pons and by smearing a solution consisting of 12 per cent, of resorcin in glycerin. If the application caused pain, cocaine was used locally. Treatment of Gonorrhoea of the Os and Uterine Cavity. — There is no form of gonorrhoea in women that demands greater skill, judgment, and conservatism than gonorrhoeal infections of the os and uterine cavity. In these delicate parts energetic treatment should be promptly insti- tuted in order to prevent, if possible, the further upward spread of the infection. Unfortunately, the general practitioner is, as a rule, not sufficiently versed in the course of the disease and skilled in its handling to warrant his active intervention in these cases, and my ad- vice to any one not thus equipped is, when he has these cases under his care, to promptly call in the aid of a wide-awake but conservative gynecologist. Tixeron ^ has shown that intra-uterine irrigations with solution of permanganate of potassa, 1 : 1000 and 1 : 500, may be of benefit. It is well for the surgeon to bear in mind these facts : In these cases the disease quickly localizes itself deeply in the mucous membrane of the cervix, and there assumes a chronic condition which at any time under stimulation may become acute. To treat these cases properly the OS must be dilated, and then the mucous membrane must either be curetted or to it must be applied quite strong caustic solutions (chloride of zinc, Lugol's solution, etc.). These operations should be done with special skill and good judgment under favorable home or hospital con- ^ Bull. qen. de Therapeut., 1893, vol. cxxiv. pp. 396 et seq. . '^ These de Paris, 1890. ^ Archiv fur Derm, und Syph., vol. xxix., 1894, p. 157. * These de Paris, 1889. * Annates des Mai. des Org. Gen.-urin., vol. xi., 1893, pp. 47 et seq. VULVO-VAGINITIS IN INFANTS AND YOUNG CHILDREN. 315 ditions and with the utmost regard for asepsis and antisepsis. Therefore I say that, as a rule, these cases do not belong to the genito-urinary sur- geon, but should be treated by men well versed in women's diseases. In the treatment of abscess of Bartholin's glands general surgical principles should prevail. If an incision is necessary, it should be freely made over the most fluctuating part of the tumor. Then, after thorough antiseptic irrigation, the parts should be well packed with iodoform gauze, which when the inflammatory symptoms have subsided may be replaced by balsam-of-Peru gauze. These packings should be carefully applied until full healing has been produced. In chronic cases it is good surgery to extirpate the gland as soon as possible, since it is almost certain that exacerbations will occur sooner or later. Whenever the anatomical arrangement of the parts will allow of the slitting up of the various follicles in the vulva and urethra when the seat of chronic gonorrhoea, this little operation should be performed with all antiseptic care. Then, after cauterization with a solution of nitrate of silver (3ss to 5j water), the little cavity should be packed and caused to heal from the bottom. Sometimes these little inflammatory foci cause much trouble to the surgeon, and ultimately it is necessary to extirpate them. CHAPTEK XXXI. VULVO-VAGINITIS IN INFANTS AND YOUNG CHILDREN. Within the last twelve years much light has been thrown on the subject of inflammation of the vulva and vagina of young children by a number of essays which contain important information as to its clinical history, etiology, and bacteriology. Prior to the year 1879 little of a definite character was known concerning this affection : to-day our knowledge is greater and clearer. Yet even now there are many ob- scure points which the future may perhaps clear up. Yulvo-vaginitis may occur in the newly-born infant shortly after birth and during its first half year of life, and it has been observed in the latter part of the first and in the second year. There is, however, a remarkable unanimity of statement that it occurs most frequently be- tween the ages of two and ten or twelve years. In other Avords, when the child is cared for by its mother or nurse it is usually less likely to become aff'ected with vulvo-vaginitis. When, however, it begins to mingle with other children or to sleep with older persons, then it be- comes more liable to the aff"ection. This fact is well brought out by Comby,^ who found in 151 cases of vulvo-vaginitis that in 84 the chil- dren were over two and under ten years of age. Yulvo-vaginitis — or urogenital blennorrhoea, as Cahen-Brach ^ pro- ^ " Etude sur la Vulvo-vaginite des Petites filles," Bidl. et Mem. cle la Soc. med. des Hopit. de Paris, 3d Series, 1891, vol. viii., pp. 395 et seq. '^ " Die Urogenitalblcnorrhoe (gonorrhoe) der kleinen Mildchen," X>eM<. med Wochen- schr., 1892, vol. xviii. pp. 724: et seq. 316 GONOBBHCEA AND ITS COMPLICATIONS. poses to call it, being more precise and anatomically correct — occurs in an epidemic, an endemic, and a sporadic form. A number of classifica- tions of this affection have been offered, but for purposes of clearness and simplicity of description it is only necessary to consider the simple or catarrhal and the severe or so-called gonorrhoeal varieties. The so- called phlegmonous vulvitis is simply one or the other of these forms complicated by abscess-formation, and is sometimes the result of trau- matism, while aphthous or diphtheritic vulvitis is an accident — an acute infective process occurring usually, and complicating a simple vulvo- vaginitis in subjects suffering from diphtheria, the exanthemata, and typhoid fever. In like manner a gangrenous form has been spoken of, but it has not a distinct entity, for the gangrene develops as an accident in poorly-nourished, sickly children usually suffering from an infectious disease. Vulvo-vaginitis in infants and children is mostly seen among poor, ignorant, careless, and dirty people, and therefore is found, for the most part, at dispensaries, hospitals, and maternities. Before considering the disease it is well to think of the structures and tissues attacked by it. The external genitals of the young female differ from those of girls approaching maturity. In the young child the nymphse are commonly more prominent than the labia majora and the vulva; the urethra and the hymen are comparatively prominent, even protuberant. Further, there are no pudendal hairs to serve as a protection to the parts. All the structures are therefore much exposed and liable to traumatisms of all kinds and to irritation from secretions of the vagina and rectum, and to dirt and general uncleanliness. Further, the tegumentary tissues are soft, very vascular, and prone to become hypersemic. In fact, everything about the female genitals in early life tends to offer a favorable soil to any infective process, mild or severe. In this connection it is well to bear in mind the facts stated by Epstein,^ based on careful observation. He says that we often see in new-born girls a more or less abundant secretion in the form of a viscid, gelatinous, glassy, milk-like mass lying in the vulva. This mass may be continuous with an extension or plug of similar nature seated in the vagina, and is composed mostly of flat epithelium. In a few days the mass breaks up into a paste-like or creamy secretion, which may look like pus and in which large quantities of round cocci are found. This condition, which Epstein calls the " desquamative catarrh of the new- born," may last two or three weeks, and on disappearing may leave the parts in a healthy condition. Further, Epstein remarks that a catarrhal vulvo-vaginitis may be added to this normal desquamative process ; the mucous membrane may become hyper^mic, then inflamed, and the secre- tion may become muco-purulent and then purulent. All this may occur from uncleanliness, dirt, decomposition of urine, and lodgement of faeces. A low and depraved condition of the system renders the infant very susceptible to this purulent form of inflammation. Thus we see at the very outset that the topography of the parts and the conditions to which they are subjected all tend to render them vul- nerable to irritations inherent in them and to invasion from without. 1 " Ueber Vulvo-vaginitis gonorrhoica bei Kleinen Miidchen," Archiv fur Derm, und Syphilis, 1891, vol. xxiii., Erganzungsheft 2, pp. 3 et seq. VULVO-VAGINITIS IN INFANTS AND YOUNG CHILDREN. 317 Further than this, it must be remembered that the urethra, the vulva, and the vagina harbor as hosts innumerable and varied micro-organisms, many of Avhich under all circumstances are harmless, but some of Avhich in altered conditions of the tissues may become active and harmful. Simple Vulvitis. — This form may be found in very young infants and in children from two years onward, and exceptionally even up to puberty. The attention of the mother is first called to the trouble by the cries of the child on urination and by the frequency of the act. Examination shows the vulva alone to be involved, or this part and the urethra together, or these external parts and the vagina are found affected. If there is simple vulvitis, we find redness and swelling of the nymphre and the labia majora (as much of them as is developed), and at first a sero-epithelial secretion looking like milk, then later on a muco- purulent discharge. The surface of the mucous membrane is eroded in minute spots and goodly-sized patches. The child's pain is then mainly caused by the scalding sensations caused by the urine lodging on the excoriated surface. Spontaneous pain may result from the vulvar in- flammation. A further form of simple vulvitis consists in moderate heat, redness, and swelling of the parts, from which pus or muco-pus exudes. Thus there are in these young infants two forms of vulvitis — the one mild and ephemeral, with a sero-epithelial discharge moderate in quantity, and the other more severe and attended with greater inflammation and a muco-purulent discharge. Care and proper medication will soon cure these conditions. When, however, cases are neglected the morbid process extends to the con- tiguous parts. VuLVO-VAGiNiTis. — This affection is found in very young infants and in children from two to thirteen years old. In infants vulvo-vaginitis usually begins as a vulvitis, ■which, being uncared for, becomes more intense and spreads either to the vagina or to the urethra, or to both. As a result there is produced a very formid- able aff'ection for such a young subject. In many cases the urethra is not infected, but there seems to be a tendency for the morbid process to extend through the hymeneal introitus and to involve the vagina and perhaps the cervix uteri. Examination shows a reddened, eroded surface of the vulva, hymen, and vagina. A copious purulent or muco-purulent secretion escapes from the parts, and it may dry in crusts on the labia majora or even on the thighs. The pus may k.. thin, and again thick, even to being so gelatinous that it can be taken up by the forceps. In this condition the infant's suff'erings are quite severe. The tendency of the disease is to persist unless proper treatment is adopted, and even then it may run on for months and end in a mild and chronic catarrhal process. When the urethra is involved the child's suff'erings are much increased. When simple vulvo-vaginitis attains a very severe grade of intensity, it is practically impossible to diagnosticate it from the so-called gonor- rhoeal form. It will be seen later that the microscope often gives us very little aid. 318 GONOBBHCEA AND ITS COMPLICATIONS. The statement has been made that the pus of simple vulvo-vaginitis is not infectious, but there are many facts in existence to prove that it is often highly infectious. It is sometimes noted that an infant becomes affected with this disease, and soon after the other children are attacked by it or by purulent ophthalmia. I saw a severe epidemic of vulvo- vaginitis in Charity Hospital which was traced to a child suffering from the simple form of the affection. This fact has been observed in other epidemics. The clinical features of phlegmonous vulvitis are those of follicular abscesses or even abscess-formations usually involving a labium, in addition to the vulvar inflammation. In the aphthous or diphtheritic variety there are present, besides the severe catarrhal process, patches of false membrane of a dirty-white or brownish color seated on an ex- coriated surface. Gangrenous vulvitis is an analogous condition to noma as seen in the mouth. It occurs in poorly-nourished and uncared-for infants. More or less tissue sloughs away, but it is astonishing how thoroughly Nature repairs the injury, so that in some cases little trace of the destructive process is left. Diphtheritic and gangrenous vulvitis is usually a con- comitant of some general infective process. The So-called Gonorrhceal Vulvo-vaginitis. It must be distinctly understood that vulvo-vaginitis is very rarely of venereal origin, and that, if the suppuration does originate in gonor- rhceal pus, the infection in most cases takes place in an indirect manner through some medium or agent. Since so little is really known as to the mode, of origin of this form of vaginitis, and as its onset is unlooked for and insidious, the affection is well on in its course before it is seen by the surgeon. We have no precise data as to the period of incubation, but we are warranted in assuming that the morbid process begins in mild and localized hyper- semia. When first seen these children present the evidence of suffering in their uneasiness and their cries. When the cervix uteri is involved they also suffer from bellyache. We find an intensely red and tumefied, superficially eroded, and even bleeding condition of the vulvar struc- tures of the introitus vaginae, of the vagina itself, and also of the cervix uteri, from which pus may drip. A profuse yellowish-green discharge escapes from the hymeneal orifice and is found smeared over the vulva. Very often this pus dries into crusts upon the labia majora and upon the inner surface of the thighs. There is very often intertrigo, even of a severe type, on the latter regions. When the urethra is involved urination is frequent and painful. Then when the urine flows over the inflamed vulva the child's sufferings are great. The course of the affection is dependent upon the care given the child and the nature of the treatment adopted. Under the most favor- able conditions the affection is often very obstinate, and in neglected or insufiiciently cared-for infants it runs on indefinitely unchecked. If a child afl[licted with this disease is cured in two or three months, the result may be pronounced to be brilliant. In very many cases the dis- ease runs on and ends in a chronic catarrhal condition. VULVO- VAGINITIS IN INFANTS AND YOUNG CHILDREN. 319 In some cases the inguinal ganglia become swollen and painful. There are well-attested cases on record in which peritonitis resulted from this form of vulvo-vaginitis. Those reported by Hatfield,' Loren,^ and Huber^ are of much interest. As stated by Martin, Dr. R. Curtin has seen endometritis as a complication of this affection. Currier* says that it seems to him very probable that many of the deformed and unde- veloped uteri, with which are associated so much dysmenorrhoea and anguish, sterility, and domestic unhappiness, are the legitimate conse- quence of vulvo-vaginitis which had travelled from the vagina to the uterus and tubes in early life. There can be no question as to the infectious quality of pus derived from this disease, since there are many cases on record in which it has produced severe vulvo-vaginitis and also intense purulent ophthalmia, which as a complication of the disease stands first. This form of the affection is seen in babes in the arms and in young children from two to ten years old. In families we see sporadic outbreaks, and in hospi- tals and maternities more or less severe and extensive epidemics. Gonorrhoeal rheumatism is, according to statistics, a rather rare complication of purulent vulvo-vaginitis. Hartley^ reported a case of joint-swelling in a child, in whom it appeared that the infection origi- nated in rape. Two other cases are also reported by Koplik,^ and a fourth by Goldenberg." Etiology. — In the cases of young infants it is often impossible to learn any facts as to the source of infection. It is claimed by Pott^ that he has seen specific vulvo-vaginitis in the child contracted from its mother (who suffered from gonorrhoea) during the process of delivery. Such a mode of infection is certainly possible, but before it is accepted in an unqualified manner we must have the facts concerning it clearly proved in a number of cases, and fortified with an entire concordance in the microscopical findings in mother and infant. Usually infants are brought suffering from vulvo-vaginitis when they are some weeks or months old. In very many instances the only assump- tion warranted is that the more or less severe process began in the phys- iological hypergemia which is constantly present in young children. In absence of negative proof it may be confidently asserted that many cases of this affection originate de novo, without the implantation of an infectious secretion. Undoubtedly, many infants are infected by some means from pus from the vaginae of their mothers or nurses. I have heard of mothers and nurses who quieted their infants and charges by placing a finger in the vulva, and I can understand that a soiled finger might carry infec- tion. Then, again, sponges used by mothers suffering from leucorrhoea ^ Archives of Pediatric^:, 1886, p. 641. ^ Higiea, vol. xlviii. p. 607 ; and Jahr.fur Kinderheilkunde, vol. xxvi. p. 410. 3 Archives of Fediatries, Dec, 1889, p. 887. * " Vulvo-vaginitis in Children," 3Ied. News, July 6, 1889. ^ " Gonorrhceal Rheumatism, especially in the Female," N. Y. Med. Journ., April 2, 1887. * "Arthritis complicating Vulvo-vaginal Inflammation in Children," ibid., 3m\e 21, 1890. ' "Gonorrhoeal Rheumatism in Early Childhood," ibid., July 23, 1892. * " Zur Aetiologie der Vulvo-vaginitis im Kindesalter und ihre Behandlung," Jahr, fiir Kinderheilkunde, vol. xix., 1883, pp. 71 et seq. 320 GOyOERHCEA AND ITS COMPLICATIONS. have been also used upon their infants, who became affected -with vulvo- vaginitis. It is claimed that pieces of soap used on infected infants have conveyed the disease to the healthy. The details of Hatfield's case war- rant the suspicion that infection of the child resulted from use of a syringe used by its father, who suffered from gonorrhoea. It sometimes happens that excited mothers bring children thus affected, claiming that they have been tampered with and infected by a man. Such, certainly, may be the case, but most commonly older children are selected for pur- poses of rape. Walker' reports 21 cases in which there was a history of contact with parents who had the disease or with other infected per- sons who had committed assault and rape. When the child of poverty and squalor gets out of arms and sleeps and mingles with older girls and women, it is liable to contract vulvo- vaginitis accidentally, conveyed by means of infected fingers, and mainly by soiled under-wear, sponges, and towels. From one suffering child other members of the family or its playmates may be infected in the vulva or the eyes by either the simple catarrhal or the so-called gon- orrhoeal form of the disease. Among older girls direct gonorrhoea! infection may occur as a result of attempted or complete coitus with young boys. There are many such instances in medical literature. Then, again, infection may occur among several or many young girls through their own bad habits. Atkinson^ relates the facts of a small epidemic of purulent vulvo-vaginitis in young girls at a boarding-school, by which it appears that they crept into each other's beds and titillated each other's genitals. In this epidemic puru- lent ophthalmia and stomatitis Avere also prevalent. The records of a number of epidemics bring out many interesting and important facts, and unfortunately leave many in doubt and uncertainty. Ollivier^ states that in his asvlum there were three voung children suffering from this disease, and that within three Aveeks twelve others Avere attacked. It Avas found that after caring for the original three infected children the nurses did not wash their hands before attending to the uninfected, and that they used on the healthy the same sponges Avith which they Avashed the infected children. They passed presumably pus-soiled chambers from infected to healthy children, and alloAA-ed all to sit on the same wooden seat of the water-closet, Avhich was no doubt smeared Avith infecting pus. These facts throw a flood of light upon the matter of prophylaxis. The details of the great epidemic of Posen, recorded by Skutsch,^ carry with them an awful lesson. In an institution for children within fourteen days 236 female children became affected Avith purulent vulvo- vaginitis. The origin of the infection, Avhether from one child or several children, is not known, but it is very evident that the massing together ^ Archives of Peiliatrics, 1886, p. 269. ^ "Keport of Six Cases of Contagious Vulvitis in Children," Am. Jour }i. Med. Sciences, vol. xcv., 1878, pp. 444 et seq. ^ " Note sur la Contagiosite de la Vaginite des petites Filles," Bull, de I'Acad. de Med., 3d Series, vol. xix., 1888, p. 56. * " Ueber Vulvo-vaginitis Gonorrhoica bei Kleinen Miidchen," Inavg. Dissert., Jena, 1891. Other interesting essays, giving histories of epidemics, are as follows : Cs^ri, Wien. med. Wochenschr., vol. xxxv., 1885, pp. 703-739; Friinkel, ArchivfUr Path. .Anatomie, vol. xcix., 1885, pp. 276 et seq. ; Von Dusch, Deut. med. Worhen.'ichr., vol. xiv., 1888, pp. 831 et seq. ; and Martin, Journal of Cutaneous and Gen.-urin. Diseases, 1892, pp. 415 et seq. VULVO-VAGINITIS IN INFANTS AND YOUNG CHILDREN. 321 of large numbers of children in brine-baths afforded the opportunity for the dissemination of the disease. Basing their opinion on microscopical findings, many authors to-day, following the lead of Pott, unreservedly consider the majority of cases of vulvo-vaginitis as of gonorrhoea! origin, the infection having taken place in an indirect and often unknown manner. We find that in this affection also many authors claim that they have found the gonococcus, when it is evident from their writings that their examinations have been superficially made. In some cases of the simple variety the microscope affords definite aid. Thus, as has been well shown by Koplik in a valuable essay,^ in the pus of simple vaginitis there are found rods, cocci, and diplococci in the leucocytes, and besides a pseudo-gonococcus, somewhat similar to the gonococcus, seated on epithelial cells. The Avhole microscopic picture is so difi"erent from that presented by true gonorrhoeal pus that even with a limited experience the surgeon will readily recognize its simple nature. It is true also, as claimed by Berggriin,^ that in these mild cases we find staphylococci and streptococci. On the other hand, in severe cases of vulvo-vaginitis the microscopic picture of the secretion is strikingly similar to that of gonorrhoea of the adult male or female. Thus it would seem to be very easy to determine the character of a uro-genital discharge of a young child, but, really, such is not very often the case. Thus we frequently see a child with a profuse purulent discharge from very much inflamed genitals which under the microscope presents a micro-organism answering in every Avay to the description of the gonococcus. Yet an exhaustive and critical study of the case and its environments may show that there is no basis whatever upon which to fix a diagnosis of gonorrhoea. Even so eminent a bacteriologist as Frankel had his misgivings as to the nature of the micro-organisms he found in the pus of the Hamburg epidemic. It seemed to him to be the gonococcus, but the histories of his cases would not warrant an unequivocal diagnosis of gonorrhoea. I have seen cases in which no history of gonorrhoea could be obtained, yet the microscopical picture of the secretion seemed that of gonorrhoea. This being the state of affairs, we certainly cannot from microscopic findings alone unequivocally pronounce a case to be of gonorrhoeal nature unless its history in all its details is in accord with that view. This, to my mind, clearly shows that from a medico-legal standpoint the mere finding of the gonococcus or the supposed gonococcus in the uro-genital secretion of a child only proves that the disease possibly originated in gonorrhoea. Succinctly stated, the truth of this question of etiology is this : In many cases the clinical history and microscopic picture establish a diag- nosis of simple catarrhal vulvo-vaginitis ; in other cases the clinical and microscopical evidence points clearly to gonorrhoea ; but in still other cases, though the symptom-complex is complete and the microscopical picture points to gonorrhoea, absolutely no evidence can be obtained to ^ "Uro-genital Blennorrhcea in Children," Journal of Cutaneous and Oen.-urin. Diseases, 1893, pp. 219 and 263 et seq. ^ " Bakteriolngische Untersuchungen bei der Vulvo-vaginitis Kleinen Miidchen," Archivfiir Kinder heilkunde, 1893, vol. xv. pp. 321 et seq. 21 322 GONORRHCEA AND ITS COMPLICATIONS. prove that the disease has had a venereal origin or has originated in gonorrhoea! pus. On the other hand, all facts point to the suppuration having begun in a simple catarrhal form, and by reason of dirt and uncleanliness has assumed all the features of a severe gonorrhoeal inflammation. I am clearlj of the opinion that in many cases which have been regarded as undoubtedly of gonorrhoeal nature the morbid pro- cess originated de novo in a simple catarrhal process. There can be no doubt that onanism, eruptive fevers, seat-worms, pediculi, eczema, and perhaps impetigo and herpes, act simply as con- tributory causes. They establish a low form of irritative process, and thus render the tissues susceptible to microbic invasion and inflamma- tion, while dirt, the exposed condition of the parts, unremoved dis- charges, and general uncleanliness and want of care combined contribute to the production of a very formidable suppurative process. Treatment. — The first duty of the surgeon in all cases of vulvo- vaginitis is to insist upon the observance of absolute cleanliness of the infant, of its clothes, and of its surroundings. The next is the enforce- ment of prophylaxis for the children and adults of the family. These facts must be vividly impressed upon the mother or nurse or upon any one who may temporarily care for the child. In hospitals and nurseries a child should be isolated immediately that it is discovered that it is infected, and if possible it should be cared for by nurses who wait on it alone. A nurse having charge of a child thus affected should not be allowed to care for other, non-infected, children. In the event of necessity, when a special nurse cannot be detailed to the case, she should be thoroughly instructed as to how not to carry infec- tion or allow it to occur in uninfected children. By rigid discipline the spread of the disease (which in some epidemics is like wild-fire) may be limited to the original case or cases. In newly-born children whose mothers have been known to suffer with a vaginal discharge it is well, as suggested by Epstein, to apply to the vulva the prophylactic measure recommended by Crede for the eyes — namely, the careful washing of the part and the'^application of a few drops of a 2 per cent, solution of nitrate of silver. The desquamative catarrhal condition of the genitals of new-born girls may be treated by cleanliness, by free injections into the vagina of warm solutions of boric acid or diluted Goulard's water, followed by cleanliness and dryness of the parts, obtained by means of some dusting powder. "Whenever it is possible in these cases a pledget of absorbent cotton should be placed in the vulva and it should be frequently renewed. Currier speaks well of subnitrate of bismuth in this affection gener- ally, and Comby states that he has seen benefit in vulvar cases by dust- ing the surface with powdered salol and then applying cotton. ' When the vagina also is affected this author advises the insertion into that tube of salol bougies (10 centigrammes of salol to 1 gramme of cocoa- butter). For severe cases of the simple and so-called gonorrhoeal type a care- fully conducted, methodical treatment is necessary. Very thorough irrigation of the parts with a warm bichloride solution (1 : 6000 or 1 : 10,000) may be used several times daily. After this cleansing pro- cess the vagina should be expanded by means of a double-bladed male STRICTURE OF THE URETHRA. 323 urethral speculum or by my own urethral speculum, and the parts made dry by absorbent cotton on an applicator. Then a 10 per cent, nitrate- of-silver solution is carefully applied to the whole inflamed surface. This treatment is mainly that recommended by Koplik, and is usually pro- ductive of good results. The applications should be made by the sur- geon or by an intelligent nurse, and they should be thorough. As Koplik says, infants struggle and resist when any mode of treatment is used, so it is necessary to have a convenient table, good light, and all suitable instruments and appliances ready at hand. This author states that he has refrained from treating the urethra, since the parts are so small, and the pain resulting from interference with this canal by our present methods do not justify persistence in efforts of treatment. Alkaline mixtures containing tincture of hyoscyamus may be given with benefit to relieve the burning on urination. Thallin and iodoform in bougies may be used, but there is no cer- tainty of good resulting from them. Under the application of the solution of nitrate of silver benefit will be noticed in the change in the color of the discharge from a greenish to a grayish milky hue, and the gonococci (if found in the course of the case) will become much less numerous in the specimens examined. In this event the treatment may be continued by means of warm irrigations of nitrate of silver (1 or 2 : 2000), given once or twice a day. In almost every case the cure Avill be slow and exacerbations may be expected, and the patience of the surgeon and fortitude of the mother may be sorely taxed. Still, in any event, care must not be relaxed nor should the treatment be suspended. CHAPTER XXXII. STRICTURE OF THE URETHRA. A FULL knowledge of chronic anterior and posterior urethritis and of their pathological anatomy is absolutely essential to the clear comprehen- sion of the nature and course of stricture of the urethra. While true gonorrhoeal stricture of the urethra is only found in the anterior part of the canal, it is very essential that the inflammatory condition of the pos- terior part which frequently coexists should be well understood. It is necessary to emphasize this point, since nearly all authors concern them-' selves solely with the morbid changes which take place in the anterior urethra. It has already been shown (see page 78) that in chronic anterior ure- thritis the essential lesion is a more or less extensive small-cell infiltra- tion into the submucous connective-tissue layer and a chronic catarrhal condition of the mucous membrane itself. These pathological conditions may disappear, perhaps spontaneously in some cases, but generally as the result of treatment. On the other hand, when this localized inflammatory 324 OONOBBHCEA AND ITS COMPLICATIONS. process persists for a very long time, it leads to certain permanent cell- changes which materially lessen the calibre and impair the dilatability of the urethra and interfere with its function. In previous years, when our knowledge of urethral pathology was quite limited and far from clear, stricture of the urethra was defined in the following terms : Any loss of dilatability of the urethra ; all encroach- ments on the average normal urethral calibre; any abnormal lessening of the calibre and dilatability of the canal. To one familiar with the subject all of these definitions will appear to be unsatisfactory and incor- rect. Thus, in primary acute gonorrhoea the dilatability of the urethra is more or less impaired, yet there is no stricture. A papillomatous growth or an inflamed follicle may encroach on the urethral calibre, yet neither one constitutes what we know as stricture. In chronic anterior urethritis the calibre of the canal may be narrowed by submucous exuda- tion and epithelial hyperplasia in patches and areas, both of which impair its dilatability, yet it would be rash to say that a man thus afi"ected had stricture of the urethra until the morbid process had become so chronic and inveterate that true structural constringing change had taken place in the urethral walls. With these exclusions and in the light of our present knowledge we may define stricture of the urethra to be a condi- tion of the canal attended by decidedly well-marked contraction or ste- nosis, and an utter loss of normal dilatability caused by an inflammatory process which produces a sclerosis of greater or less density and contract- ile power. In most cases of chronic anterior urethritis the submucous exudation remains in the small round cellular condition for varying periods, in some cases short, and in others long. There is present in all such cases the leaven of stricture of the urethra. When this infiltration is quite dense it constitutes what is known as soft stricture. When these round-cells begin to change into fusiform cells and to form fibrous or cicatricial tissue, a true incipient stricture begins to form which may then be called semi- fibrous stricture. As we shall see later on, we have means at our com- mand to determine quite accurately the stage and character of a urethral infiltration and whether it constitutes a soft or a semi-fibrous stricture. There is great diversity in the extent and depth of stricture-formation, which should be clearly understood. In some cases the sclerosis is soft and yielding, and in others it has more density and resistance. In some patients the cell-changes incident to the production of a true sclerotic condition take place very slowly, and in others more rapidly, while in some exceptional cases the development is very rapid indeed. In very many cases the morbid process is sharply limited to the submucous con- nective-tissue coat, which may be involved to a greater or less extent. Thus there may be a simple narrow band of stricture-tissue, which may occupy only a small part of the circumference of the tube, or it may be more extensive, even to the formation of a ring. (See Fig. 118.) Per- haps an inch or two of the canal may be the seat of morbid change, and, again, a larger segment may be involved. In the pendulous urethra we not uncommonly find three, four, and even five inches of the canal the seat of true stricture-formation. Then in the subpubic curve a part of the canal may be found stenosed, and in somewhat rare and old cases the bulbous part" in its totality is involved. These sharply-limited submucous STRICTURE OF THE URETHRA. 325 strictures therefore may be simply thread-like, and may form incomplete or complete rings. They may involve less than an inch or more of the canal, or they may convert a large portion of it into a distinct pathological tube. As to density, these strictures may remain tolerably soft for long periods. Then, again, as they grow older, they become more or less firm, and later on even fibrous. Clinical history and pathological anatomy show that the morbid process may remain limited for years in the submucous coat. In the cases just considered, therefore, the morbid process has not extended beyond the submucous layer, the corpus spongiosum remaining intact. In a severe class of cases, however, there is a greater or less invasion of the corpus spongiosum. The lesion in these cases is the same small round-cell infiltration which is exuded into the superficial meshes of the erectile tissue. This condition may be properly termed " peri- urethritis." The infiltration into the spongy tissue may not only be scant and superficial, but it may also be copious, dense, and more deeply penetrating, even to the localized or extended involvement of the whole thickness of the spongy body. In some cases the corpus spongiosum becomes aifected by means of the crypts and follicles imbedded in it. These structures become the seat of an infiltration which may become perifollicular, in which case a nodule is produced, and from this focus more or less of the spongy tissue may be invaded. These little nodular masses may not uncommonly be felt in the pendulous urethra. In the great majority of cases, particularly in men up to forty-five years of age, the corpus spongiosum of the pendulous urethra is only super- ficially infiltrated, and its distensibility and extensibility are not much, if at all, impaired. When such a urethra, involved for several inches, is carefully palpated, it will be found that the canal is distinctly round,, tense, and dense in structure. If three or more inches are affected, it can be ascertained that the normal extensibility is somewhat impaired. Yet in these cases, though there may be more or less impediment to mic- turition, there is usually not much impairment of the parts when the penis becomes erect. It is quite rare to find extensive, deep, and total infiltra- tion of this tissue in these parts. In the subpubic curve, particularly in the bulbous portion of the urethra, there seems to be a marked tendency to extensive, and often total, involvement of the spongy tissue. This deep-seated infiltration may be found as far forward as the peno-scrotal angle. The cell-infiltra- tion, however, shows a tendency to become more extensive as it passes down the canal and reaches the height of its development in the bulbous urethra at its junction with the membranous segment. Total infiltration of the corpus spongiosum, or cavernitis, is not very infrequently met with in the form of a hard, round, cord-like mass at the peno-scrotal angle and extending for an inch or more down the canal. At the bulbous portion of the urethra, with the expanded and much thicker spongy body encircling it, the round-cell infiltration becomes more exuberant than elsewhere. Here the tissues are soft and succulent, and the blood-supply is copious. Here also there is no firm, fibrous cap- sule around the bulb ; therefore there is not that hindrance to profuse hypersemia and inflammation that there would be if the parts were quite firmly invested in dense tissue. For these reasons the post-gonorrhoeal 326 GONORBHCEA AND ITS COMPLICATIONS. inflammatory process is severe and long-lasting, and its resulting cell- infiltration exuberant and extensive. In the bulb, therefore, the infiltra- tion is at first inextricably mixed with muscular and elastic fibres and vessels, and the condition called soft stricture then exists. The morbid condition then consists of round-cell infiltration with a tendency to the development of fibrous tissue. When this fibrous tissue is tolerably copious and intermixed with the round-cell infiltration, the resulting con- traction is of semi-fibrous structure. Then, as time goes on and the mor- bid process increases very decidedly in extent and depth, the newly- formed fibrous tissue takes the place of the erectile and vascular tissues, the areolae are obliterated, and the normal structure of the parts becomes wholly lost and replaced by a uniform sclerotic and atrophic fibrous tissue, white, firm, and homogeneous in structure, which constitutes what is called inodular stricture. This division of strictures into soft, semi-fibrous, and inodular and densely fibrous strictures is based on well-attested pathological facts, and is worthy of acceptance, since it conforms accurately to the clinical history of these coarctations. In the early stage of the stricture-formation the mucous membrane rests on the infiltrated submucous connective-tissue layer, but when the process reaches the inodular stage, either in the pendulous or the bulbous urethra, the mucous layer then rests directly on the fibrous tissue. Recent pathological and clinical studies have thrown a flood of light upon the course and development of urethral strictures. In olden times it was thought that strictures always began in a ring of infiltration, and that, if there were several of them, they were each a separate morbid entity. This idea, in the main, is incorrect. In somewhat exceptional cases in the pendulous urethra we may find what may seem like a large number of distinct tight bands, six to fifteen perhaps in number, yet these are not true strictures. They are simply folds of mucous membrane more densely infiltrated than the tissue on either side of them. They result from the stenosis of more or less of the pendulous urethra. Not infrequently, true stricture begins in a little thickened patch or area of the pendulous urethra, seated perhaps on one side or on the upper or lower wall of the canal. If not dissipated this focus of infiltration be- comes larger as time elapses, and it may lead to a true annular stricture. It may be remarked that almost all old strictures are annular. Baraban ^ has clearly shown that the morbid process may be far from uniform in development, and that patches and small foci of infiltration may be joined together among tissues less affected. Wassermann and Halle ^ in their studies found the sclerosis of the urethra to be present in various degrees of development and severity. In old men the subjects of strictures for many years they saw evidences of a progressive increase and invasion of the infiltrating process. Fully-formed stricture-tissue usually increases in thickness, particularly near and in the bulb ; and from such a stricture the infiltration may extend anteriorly to other parts of the canal. I have ^ " Sur les Modifications ^pitheliales de I'Ur^tlire apres Blennorrhagie chez I'Homme," Bevue mkl. de I'lJsL, vol. xxii. June 15, 1890, pp. 3()1 et seq., and Oct., 1890. ^ " Op. cit. Brissaud and Segond ("Etude sur I'Anatomie patholngique des Eetr^- cissements de I'Uretlire," Gaz. Hchdnm. de Med. et de Chir., No 39, 1881, pp. fi2.5 et seq.) in two cases found the upper wall of the spongy urethrn the seat of soft inflammation, while the lower wall was the seat of true sclerotic change. STRICTURE OF THE URETHRA. 327 observed many conspicuous instances of this progressive invasion of the urethra, such as is well shown in the following personal case : A gentle- man at the age of twenty-one had gonorrhoea, and at thirty complained of symptoms of stricture. His urethra (calibre 30 French) was quite firmly contracted at the depth of five and a half inches to No. 7 French. Gradual dilatation during five months restored the canal at the affected part to a calibre of 27 French. He then remained without any discharge and without any instrumentation whatever for seven years. Then exam- ination of the canal showed that from three and a half inches down to the bulb it was quite uniformly and firmly contracted to No. 8 French, the bulb causing some slight bleeding as it passed over several soft-feeling bands. In this case, therefore, the exudative process in seven years crept up the urethra toward the meatus, a distance of two inches. In many cases, however, the process remains limited for years, but even when it has thus remained dormant it may later on become active and involve more tissue. This is the underlying cause of the extensive and deeply invading strictures which are not uncommonly found in old men. In some very exceptional cases a peculiar form of stricture is found in the pendulous, and also in the bulbous, urethra. The cell-infiltration is quite copious and compact, and it converts the urethra, for a distance of several lines to perhaps more than an inch, into a firm fibrous tube lined with granulations or rugosities. In these cases the submucous tissue alone, or perhaps a little of the corpus spongiosum, is involved. The calibre of the canal may be reduced to 20 F., and there it will remain year after year with no tendency whatever to contract, and causing no symptoms other than slight dribbling at the end of urination. These cases prove obstinate to dilatation and all treatment, and in general they get along best when they are let alone. It is important that clear ideas should be entertained as to the condi- tion of the membranous urethra. There is a vagueness, almost amount- ing to ignorance, displayed by many writers, who speak of stricture of the membranous urethra and of " strictures six and a half inches down the canal in the membranous urethra." As a result of the study of 270 museum preparations, Sir Henry Thompson ^ concludes that stricture never exists beyond the bulbo-membranous junction, except as a result of traumatism. In an oral communication Dr. Gouley informed me that he sought for evidence of stricture of the membranous urethra in more than 500 dead-house specimens of urethral stricture, and had not found it in a single instance. I have carefully looked for this form of stricture in the living and in the dead, and have never found it. The studies of Wassermann and Hall^, however, show that synchronously with stricture in the pendulous urethra the membranous segment undergoes a number of changes. The most common change is dilatation of this part of the canal, and perhaps also of the prostatic urethra, in cases of chronic tight anterior stricture. The submucous connective tissue is sometimes the seat of a mild small-cell infiltration, but it never goes on to the produc- tion of stricture. Epithelial thickening is not uncommon, and little papillomatous tufts and masses are prone to form in this situation. These consist of enlarged vessels, embryonic tissue, and epithelial hyperplasia. ' The Pathology and Treatment of Stricture of the Urethra, etc., 4th ed., London, 1S85, p. 50. 328 OONOBBHCEA AND ITS COMPLICATIONS. Cystic degeneration of crypts and follicles may also be found in this region. When the normal urethra is cut across at right angles to the axis of the penis, it presents a sta.r-shaped appearance or it may be likened to a festooned slit. It is elastic and very compressible, and surrounded by the loose erectile tissue of the corpus spongiosum. When the seat of stricture, the urethra presents a variety of appearances when cut trans- versely to its long axis. Its tissue is whitish, hard, and inelastic. In the pendulous urethra the canal has a round or oval shape ; it sometimes looks like a straight, transverse, or bow-shaped slit. In the region of the bulb it has an elliptical, triangular, and even quadrangular shape. All these distortions are due to the submucous cellular changes. Gonorrhoeal stricture of the prostatic urethra has never been found. While the whole anterior urethra may be the seat of stricture, there are certain parts where it occurs more frequently. For convenience of description, Sir Henry Thompson divides the urethra into three parts, called the subpubic curvature, the centre of the spongy portion, and the distal portion. The first division includes the membranous urethra, which is never the seat of stricture. It is this inclusion of the membranous ure- thra in the stricture field that leads readers into error. Consequently, I will modify Thompson's division as follows : Region No. 1, which begins at the bulbo-membranous junction, and includes one inch and a half of the canal up to the peno-scrotal angle, and which constitutes the greater part of the subpubic curve. Region No. 2 begins at the anterior limit of the preceding, includes three inches of the canal, and ends within two and a half inches of the meatus. Region No. 3 begins at the external orifice, and includes a distance of two and a half inches beyond it. (See Figs. 2 and 11.) If this division be followed, we should hear no more of these putative strictures of the membranous urethra. As to the frequency of occurrence of stricture in these three regions, the analysis of the findings of Sir Henry Thompson in the 270 museum specimens is very important. In these 270 specimens 310 distinct strictures were found, and were seated as follows : In Region No. 1, 215, or 67 per cent, of the entire number. " " " 2, 51, or 16 " " " " " " " " 3, 54, or 17 " " " " " These statistics of post-mortem examinations are in accord with my own statistics in 250 personal hospital and clinic cases very carefully examined and recorded : In 155 cases, or 62 per cent., the stricture was found in Region No. 1. " 50 " " 20 " " " "■ " " " " 2. « ^5 u tt jg il i( « (1 « « ii, (( g Total, "250 " In most cases only one region (No. 1) was involved ; in some cases Regions 1 and 2, and exceptionally Regions 1 and 3, Avere the seat of coincident strictures. The records show that in the great majority of cases there was but one stricture, and that less commonly two, three, and four were found. Under the influence of the old conception of a stricture we understood STRICTURE OF THE URETHRA. 329 and spoke of a band, a ring, or a callous mass tunnelled by a small chan- nel. In the light of recent pathological studies we know that gonorrhoeal stricture of the urethra really means a stenosis of greater or less length of the canal, and that the infiltrating process is not uniformly developed, it being more advanced in some parts than in others. The urethral mucous membrane in the quiescent state of the penis and in the intervals of urination, besides being folded longitudinally, is also thrown in smaller transverse folds. Now, it seems that these transverse folds become infil- trated, and are thus rendered prominent and impinge on the calibre of the canal, and they constitute what we know as stricture bands or rings. Therefore, when we speak of these bands or rings we simply specify those portions of the urethral sclerosis which jut toward the axis of the canal most prominently. These bands and rings, however, are usually the surface indications of the underlying cellular infiltration, which is really the essential lesion. In some cases of nearly total invasion of the pen- dulous urethra, when the bougie a houle is gently pushed down to the bulb and withdrawn a jumping or bumping sensation is conveyed to the hand as the head of the instrument passes over thickened ridges. I have encountered as many as fifteen of these ridges or rings in a space of three or four inches. Patients presenting this condition cannot, correctly, be said to have fifteen strictures, since, in truth, they have a decidedly stenosed urethra with fifteen transverse thickened folds. The same re- marks apply to cases in which we find several bands near the meatus or at any part down the canal. In somewhat exceptional cases Regions Nos. 1 and 3 are synchronously affected with stenosis, while Region No. 2 is intact. In such cases there may be separate strictures. To sum the matter up, therefore, we may say that exceptionally in gonorrhoeal steno- sis of the urethra the lesion consists of a firm, strongly-marked ring-like band, but that, as a general rule, a greater or less segment of the canal is involved, in which case there may be several constricting bands felt when sought for by means of instruments. There is an erroneous impression entertained by many that gonorrhoea promptly causes stricture, and many young men are said to be thus affected who are then only suff"ering from chronic urethritis. As a broad general rule it may be stated that unless gonorrhoea is acquired in early youth true stricture is not common in persons under twenty-five, and even twenty-eight, years. In the following table of the 250 cases already spoken of, the dates at which patients presented themselves for relief of true strictures are given, as well as the number of patients : From 10 to 15 years of a.e;e in 1 case. (1 15 " 20 " " 11 4 cases. (( 20 " 25 " (1 " 25 (1 « 25 " 30 " li u 35 II a 30 " 35 " a (I 49 u (f 35 " 40 " u " 46 li (( 40 " 45 " " " 31 tl (> 45 " 50 " (( (1 26