UROLOGY PLATE I B. S. Barringer. PLATE I Cystoscopic Views of Various Abnormal Conditions Within the Bladder. Fig. 1.—Cystocele. The ureter orifice is in a depression. All trigonal landmarks lost. Fig. 2.—Stone of uric acid covered with xanthin (which could not be radiographed) lying near the ureter orifice. Fig. 3.—Orifice of a saccule in a chronically inflamed and trabeculated bladder. Fig. 4.—Depression of the fundus by extra vesical carcinoma (of uterus); cystitis. Fig. 5.—Invasion of bladder wall by uterine carcinoma; no cystitis. Fig. 6.—Carcinoma of both lateral lobes of a hypertrophied prostate. Fig. 7.—Diverticulum produced by adhesion of the bladder wall to uterine carcinoma. Figs. 8 and 9.—Right and left ureters of a patient with left renal tuberculosis of seven years’ duration. The right ureter (Fig. 8) is normal; the trigone and bladder wall on the edge of the field are congested. The left ureter (Fig. 9) is only slightly deformed and the surrounding area is congested. Fig. 10.—Tuberculous ulceration of ureter orifice. Fig. 11.—The same, six weeks after nephrectomy. Fig. 12.—Tuberculous ulceration of ureter orifice. Fig. 13.—Varicose veins of the bladder. Fig. 14.—Intravesical ureteral cyst. Fig. 15.—Papilloma growing near the ureter orifice. It is ulcerated and a long, narrow clot of blood is adherent to it. UROLOGY BY - EDWARD L. KEYES; M.D., Ph.D. PROFESSOR OF UROLOGY, CORNELL UNIVERSITY MEDICAL COLLEGE; UROLOGIST TO ST. VINCENT’S AND TO BELLEVUE HOSPITALS WITH ONE HUNDRED AND NINETY ILLUSTRATIONS IN THE TEXT AND t EIGHTEEN PLATES, FOUR OF WHICH ARE COLORED D. APPLETON AND COMPANY NEW YORK LONDON 1923 COPYRIGHT, 1917, 1923, BY D. APPLETON AND COMPANY Van Buren and Keyes’ Text-Book Copyright, 1874, 1888, by D. Appleton and Company The Surgical, Diseases of the Genito-Urinary Organs, including Syphilis Copyright, 1892, 1900, by D. Appleton and Company The Surgical Diseases of the Genito-Urinary Organs Copyright, 1903, 1905, by D. Appleton and Company Diseases of the Genito-Urinary Organs Copyright, 1910, 1911, 1912, by D. Appleton and Company PRINTED IN THE UNITED STATES OF AMERICA TO MY BELOVED FATHER THIS BOOK IS AFFECTIONATELY DEDICATED PREFACE Only by incessantly sacrificing the deadwood for the green may a textbook, with each succeeding revision, hope to become more mellow as it certainly becomes more personal. In this, the fourth revision by the present author, Gonorrhea in the Female and Syphilis have been dropped as having no place in Urology. Yet a textbook is not an encyclopedia. It cannot hail each new-found comrade with quite the enthusiasm of the current press. Hence only those novelties have been included that bid fair to prove sound. Notable among these are Hun- ner’s theories concerning the pathogenesis and therapy of cystitis, hydronephrosis and renal infection; radiotherapy for the control of malignant growths; the straight tube urethroscope for diagnosis and treatment of bladder and posterior urethral lesions; the principles governing the treatment of chronic urethritis; and the newer developments in operative technic. Many other items have been re- vised and a few topics, such as Suppurative Inguinal Adenitis and Granuloma Inguinale, added. The author despairs of thanking by name the many to whom he is indebted for criticism and suggestions. Let each accept the sincere compliment that imitation implies. To drop the Jr. from the author’s name has not seemed unwar- ranted, though happily the smile of that great gentleman to whom this volume is dedicated still sheds its radiance upon a naughty world. Edward L. Keyes New York City VII CONTENTS THE PRINCIPLES OF UROLOGY CHAPTER PAGE I.—Physical Examination ........ 1 II.—Urinalysis . . . . . . . . . .11 III. —Urethral Instruments: Their Asepsis ..... 19 IV. —The Passage of Urethral Instruments ..... 32 V.—Cystoscopy . . . . . . . . .47 VI.—Cystoscopy of the Diseased Bladder ..... 59 VII. —Ureter Catheterism ......... 67 VIII. —Estimation of the Renal Function ...... 75 IX.—Radiography 87 GONORRHEA X.—Gonorrhea: Its Social Aspects and Prevention . . . 100 XI.—The Gonococcus ......... 108 XII.—Gonorrhea: The Extragenital Types of Inoculation; The Systemic Manifestations . . . . . . .118 XIII. —Gonorrheal Urethritis in the Male ...... 125 XIV. —Symptoms, Course and Complications of Acute Urethral Gon- orrhea in the Male ........ 136 XV.—Course and Complications of Chronic Urethral Gonorrhea . 146 XVI.—Nongonorrheal Urethritis ....... 153 XVII.—Diagnosis of Gonorrheal Urethritis ..... 159 XVIII.—Urethroscopy .......... 167 XIX.—Methods and Drugs Employed for the Local Treatment of Urethritis .......... 173 XX.—Systemic Treatment of Urethral Gonorrhea .... 184 XXI.—Local Treatment of Acute Gonorrhea ..... 192 XXII.—Local Treatment of Chronic Urethritis 201 DISEASES OF THE URINARY ORGANS XXIII.—Spasmodic and Congenital Stricture ...... 211 XXIV.—Organic Stricture of the Urethra—Etiology, Pathology, Symptoms, Results, Diagnosis ...... 215 XXV.—Stricture of the Urethra; Prognosis and Treatment . . 230 XXVI.—The Prostate: Anatomy, Physiology—Prostatism . . . 241 XXVII.—Symptoms, Diagnosis and Prognosis of Prostatism . . . 255 XXVIII.—Treatment of Prostatism ........ 266 XXIX. —Malignant Neoplasms of the Prostate ..... 273 XXX. —Etiology of Infection of the Upper Urinary Tract . . . 280 XXXI.—Pathology of Renal Infection ....... 293 XXXII.—The Clinical Picture of Renal Infection ..... 301 IX X CONTENTS CHAPTER PACE XXXIII.—Diagnosis op Renal Infection . . . . . .314 XXXIV.'—Treatment of Renal Infection ...... 317 XXXV.—Cystitis ........... 328 XXXVI.—Urinary Calculus: Varieties—Etiology—Treatment Other than Radical ......... 339 XXXVII.—Renal and Ureteral Calculus ...... 346 XXXVIII.—Calculi and Foreign Bodies of Bladder and Urethra . . 367 XXXIX.—Genito-urinary Tuberculosis ....... 378 XL.—Tuberculosis of the Kidney ....... 380 XLI.—Tuberculosis of the Bladder—Tuberculosis of the Prostate and Seminal Vesicles ....... 396 XLII.—Movable Kidney ......... 405 XLIII.—The Ureters and Their Diseases ...... 415 XLIV.—Hydronephrosis ......... 420 XLV.—Physiology and Various Diseases of the Bladder . . . 429 XLVI.—Diseases Peculiar to the Female Bladder .... 438 XLVII.—Idiopathic Renal Hematuria—Varicose Veins of the Bladder. 442 XLVIII.—Cysts and Tumors of the Kidney ...... 445 XLIX.—Tumors of the Bladder and Urethra ..... 459 L.—Injuries to the Kidney and Ureter—Aneurysm of the Renal Artery ......... 475 LI.—Wounds and Ruptures of the Bladder and Urethra . . 484 LII.—Malformations of the Kidney and Ureter .... 494 LIII.—Malformations of the Bladder and Urethra .... 502 DISEASES OF THE GENITAL ORGANS LIV.—Diseases of the Scrotum ........ 513 LV.—Anatomy, Physiology, Embryology, and Anomalies of the Testicle .......... 521 LVI.—Inflammations of the Testicle and Epididymis . . . 530 LVII.—Tuberculosis of the Epididymis ...... 544 LVIII.—Diseases of the Testicle ....... 552 LIX.—Hydrocele, Hematocele, Spermatocele, Chylocele . . 562 LX.—Diseases of the Vas Deferens and Spermatic Cord . . 574 LXI.-—Diseases of the Seminal Vesicle ...... 580 LXII.—Derangements of the Genital Function .... 585 LXIII.—Diseases of the Penis—Anatomy—Injuries—Inflammations . 601 LXIV.—Phimosis—Paraphimosis—Tumors of the Penis . . . 615 LXV.—Chancroid—Suppurating Bubo . . . ’ . . . 626 LXVI.—The Initial Lesion of Syphilis ...... 635 OPERATIVE SURGERY LXVII.—General Considerations in Operating on the Urinary Organs 642 LXVIII.—Operations upon the Kidney ....... 651 LXIX.—Operations upon the Kidney (Continued) .... 662 LXX.—Operations upon the Ureters ...... 674 LXXI.—Anatomy of the Bladder—Suprapubic Operations . . . 684 LXXII.—Median Perineal Section ....... 699 LXXIII.—Operations upon the Prostate and Seminal Vesicles . . 710 CONTENTS XI CHAPTER PAGE LXXIV.—Intravesical Operations ........ 726 LXXV.—Operations for the Cure of Urinary Fistula .... 735 LXXVI.-—Operations for Malformations of the Urethra and Bladder . 741 LXXVII.—Operations upon the Scrotum and Its Contents . . . 749 LXXVIII.—Operations upon the Penis ....... 760 Index ............. 764 LIST OF PLATES FACING PLATE PAGE I. Cystoscopic Views of Various Abnormal Conditions Within the Bladder ........ Frontispiece II. Cystoscopic Interpretation of the Appearance of the Bladder Neck in Prostatism ........ 62 III. Radiograms of Prostatic Calculi and Calcified Iliac Arteries . 86 IV. Pyelography in the Diagnosis of Ureteral Calculus . . ..88 V. Pyelography in the Diagnosis of Ureteral Calculus ... 90 VI. Bilateral Silent Renal Calculi ....... 92 VII. Radiograms of Gall-stones ........ 94 VIII. Pyelography in the Diagnosis of Ureteral Calculus ... 96 IX. Microphotographs of Gonococci and Tubercle Bacilli . . 108 X. The Usual Type of Prostatism ....... 248 XI. Focal Suppuratave Nephritis ....... 294 XII. The Tongue of Urinary Septicemia ...... 298 XIII. The Urine of Pyonephrosis ........ 316 XIV. Renal Tuberculosis ......... 380 XV. Renal Tuberculosis ......... 382 XVI. Radiograms of Renal Tuberculosis and Hydronephrosis . . 392 XVII. Pyelogram of Hydronephrosis ....... 426 XVIII. Stereoscopic Cystography of Diverticula ..... 506 LIST OF ILLUSTRATIONS IN TEXT FIGURE PAGE 1. —Double taper sound . . . . . . . . . .21 2. —Olivary bougie . . . . . . . . . . .21 3. —Bulbous bougie ........... 21 4. —Kollmann dilators . . . . . . . . . .21 5. —Whalebone filiform and tunneled sound ....... 22 6. —Woven filiform and Janet sound ........ 22 7. —Woven olivary catheters ......... 23 8. —Double-elbowed catheter ......... 23 9. —Natural curve catheter ......... 24 10. —Guyon obturator .......... 24 11. —Janet syringe ........... 25 12. —Keyes instillator ........... 26 13. Sagittal section through glass and fossa navicularis .... 32 14. —Transverse section of the penis ........ 32 15. —Lacuna magna ........... 33 16. —Lower part of the male bladder with the beginning of the urethra . . 35 17. —Sagittal section of a frozen male subject . . . . . .36 18. Longitudinal section of urethra ........ 37 19. —Introduction of sound .......... 42 20. —Introduction of sound .......... 43 21. —Introduction of sound .......... 44 XIII XIV LIST OF ILLUSTRATIONS IN TEXT FIGURE PAGE 22. —The Brown-Buerger cystoscope . . . . . . . .48 23. —Lenses of prismatic cystoscope ........ 49 24. —Lenses of direct vision cystoscope ........ 49 25. Flute-tipped catheter .......... 50 26. —Maneuvers in catheterizing right ureter . . . . . . 57 27. Radiogram showing bladder and prostatic calculi ..... 86 28. —Vesical calculus: phlebolith in region of pelvic ureter .... 87 29. —Vesical calculi ........... 87 30. —The stone-bearing area ......... 89 31. —Phleboliths ........... 90 32. —Calculus in seminal vesicle . . . . . . . . .91 33-.—Urate stone at end of lower ureter. ....... 92 34. Renal calculi ........... 93 35. —Silent calculus filling the renal pelvis ....... 93 36. —Normal kidney pelvis (pyelogram) ....... 94 37. —Normal kidney pelvis (pyelogram) ....... 95 38. Damage done by pyelography ........ 96 39. Damage done by pyelography ........ 96 40. —Chetwood irrigation. Filling the nozzle ...... 174 41. —Chetwood irrigation. Inserting the nozzle ...... 175 42. Tip of instillator in bulbous urethra ....... 176 43. —Tip of instillator in posterior urethra ....... 176 44. —Chetwood’s tube for rectal irrigation ....... 178 45. —Injection of urethral fistula ......... 199 46. —Congenital stricture of the meatus ....... 213 47. —Stricture of anterior urethra ........ 219 48. —Stricture of membranous urethra ........ 220 49. —Results of stricture . . . . . . . . . .221 50. —False passage . . . . . . . . . . . 224 51. —Introduction of filiforms ......... 237 52. —Sagittal section of prostate, bladder neck and membranous urethra . . 241 53. —Adenoma enucleated from a hypertrophied prostate .... 247 54. —Section of a large prostatic adenoma, showing its composite character . 247 55. —Prostatism; transverse section showing enlargement of lateral lobes . . 248 56. —Bilateral prostatic enlargement ....... 249 57. —General sclerosis of the prostate ........ 249 58. —-General enlargement of the prostate with median bar .... 249 59. —Pedunculated median enlargement ....... 249 60. —Sagittal section of Fig. 56 ........ 250 61. —Sagittal section of Fig. 57 ........ 250 62. —Sagittal section of Fig. 58 ........ 250 63. —Sagittal section of Fig. 59 ........ 250 64. —Section of enlarged prostate . . . . . . . . . 251 65. —Section of normal prostate ......... 252 66. —Sagittal section of prostate, illustrating origin of carcinoma . . . 275 67. Focal suppurative nephritis ......... 294 68. —Pyonephrosis ........... 297 69. —Perinephritis ........... 298 70. —Cystitis cystica adjacent to a carcinoma of the bladder .... 334 71. —Section of a phosphatic calculus, showing excentric development . . 339 72. —Uric acid calculus (section) ......... 339 73. —Section of calculus of mixed uric acid and oxalate of lime, coated with phosphates ........... 340 LIST OF ILLUSTRATIONS IN TEXT XV FIGURE PAGE 74. —Multiple phosphatic calculi (natural size) ...... 340 75. —Oxalate (mulberry) calculus . . . . . . . . .341 76. —Multiple small phosphatic calculi (natural size) ..... 341 77. —Large branched renal calculus ........ 346 78. —Kidney destroyed by large branching silent calculus .... 348 79. —Calculous anuria; the congested kidney. ...... 353 80. —Calculous hydronephrosis ......... 354 81. —Calculous pyonephrosis ......... 354 82. —Urate stone, invisible before pyelogram, in lower calyx, stricture of ureter at pelvic brim .......... 355 83. -Large renal calculi .......... 367 84. —Silent vesical calculi .......... 369 85. —Stone on twig ........... 372 86. —Stones formed on hairs of a dermoid cyst ruptured into the bladder . . 373 87. —Renal tuberculosis . . . . . . . . . .381 88. —Renal tuberculosis .......... 381 89. —Renal tuberculosis .......... 382 90. —Renal tuberculosis—Terminal stage ....... 383 91. —Renal tuberculosis .......... 385 92. —Renal tuberculosis .......... 386 93. —Renal tuberculosis .......... 390 94. —Pyelogram of Fig. 93 ......... 391 95. —Pyelogram of Fig. 96—Irregular pelvis ....... 392 96. —Renal tuberculosis (and gonorrhea) after pyelography .... 393 97. —Movable kidney injected with argyrol . . . . . . .411 98. —Hydronephrosis from ureteral compression by a branch of the renal vein . 421 99. —Polycystic kidney .......... 446 100. —Outline of polycystic kidney and spleen ...... 447 101. —Adenocarcinoma of the hypernephroma type ...... 451 102. —Carcinoma of the kidney ......... 452 103. —Sarcoma of kidney invading the vena cava ...... 454 104. —Papilloma of bladder . . . . . . . . . .461 105. —Carcinoma of the bladder ......... 462 106. —Papillary carcinoma .......... 462 107. —Lobulated carcinoma .......... 462 108. —Carcinomatous infiltration beneath apparently normal mucosa . . . 471 109. —Ruptured kidney. .......... 476 110. —Congenital kidney atrophy; stone in pelvis; pyelitis cystica . . . 496 111. —Horseshoe kidney .......... 498 112. —Urinal for exstrophy .......... 503 113. —Sacculated bladder .......... 503 114. —Cystography showing diverticulum ....... 504 115. —Cystography showing large phlebolith near bladder .... 506 116. —Pediculus ............ 515 117. —Epithelioma of the scrotum in a paraffin worker . . . . .519 118. —Scrotal epithelioma .......... 520 119. —Left tunica vaginalis opened, showing testis, epididymis, etc., from outer side ............. 521 120. —Abscess in tail of epididymis; relapsing epididymitis . . . . 535 120A.—The scrotal support .......... 538 120B.—The scrotum supported ......... 538 120 C.—The fortifying straps ......... 538 120D.—The lateral view .......... 538 XVI LIST OF ILLUSTRATIONS IN TEXT FIGURE PAGE 121. —Rubber bandage for strapping ........ 540 122. —The bandage applied .......... 540 123. —Specimens obtained by orchidectomy and epididymectomy for tuberculosis. 546 124. —Section of tuberculous testicle ........ 547 125. —Carcinoma of testicle .......... 560 126. —Usual form of hydrocele ......... 563 127. —Radiogram of calcified tunica vaginalis ....... 564 128. —Hydrocele ............ 566 129. —Congenital hydrocele . . . . . . . . . 567 130. —Infantile hydrocele .......... 568 131. —Hematocele ........... 572 132. —Seminal vesicles ........... 580 133. —Transverse sections of penis ......... 601 134. Paraphimosis ........... 617 135. —Paraphimosis . . . .. . . . . . . . 617 136. —Reduction of paraphimosis ......... 618 137. —Epithelioma of the penis ......... 623 138. Streptobacillus of Ducrey ......... 626 139. —Chancroids of prepuce, preputial frenum, and glans penis in various stages of development .......... 628 Fig. 139A.—Large ulcerated hunterian chancre ...... 637 140. —Pezzer self-retaining catheter ........ 648 141. —Filiform bougie tied on ......... 648 142. —Sinclair’s method of fixing retained catheter ...... 649 143. —Frontal section through the kidney, pelvis and calices .... 652 144. —Diagram showing relation of the viscera to the parietes; posterior view . 653 145. —Situation, direction, form and relations of the kidneys .... 654 146. —Patient lying on side, showing proximity of free border of ribs to crest of ilium ............ 657 147. —Patient as in Fig. 146, but elevated by “kidney support” . . . 657 148. —The oblique “kidney” incision ........ 658 149. —Nephrotomy incision .......... 662 150. Nephrotomy with decapsulation ........ 667 151. liberation of perirenal fat in nephrostomy for pyonephrosis . 667 152. —Nephrectomy ........... 669 153. —Showing how the true pedicle is obscured by the fibrous capsule in sub- capsular nephrectomy . . . . . . . . .670 154. —Ureteroplasty . . . . . . . . . . .676 155. —Ureteroplasty ........... 676 156. —-Ureteroplasty ■. . . . . . . . . . .676 157. End-in-end anastomosis of ureter ........ 677 158. —Oblique end-to-end anastomosis of ureter ...... 677 159. —Lateral anastomosis of ureter ........ 677 160. —Lateral anastomosis of ureter ........ 677 161. —Uretero-intestinal anastomosis ........ 682 162. —Exposure of the bladder ......... 689 163. —Incision of the bladder ......... 690 164. —Inversion of bladder wall about tube . . . . . . . 691 165. —Lithotomy forceps .......... 694 166. —Permanent suprapubic drainage tube . . . . . . 697 167. —Perineal tube ........... 699 168. —Median perineal section under local anesthesia ..... 701 169. —Maisonneuve urethrotome ......... 705 LIST OF ILLUSTRATIONS IN TEXT XVII FIGURE PAGE 170. Otis urethrotome .......... 705 171. —Perineal incisions ......... 714 172. —Chetwood’s prostatic incisor ........ 720 173. —Chetwood’s perineal galvanoprostatotomy ...... 721 174. —Young’s prostatic punch ......... 722 175. —Bigelow lithotrite .......... 727 176. —Keyes lithotrite ........... 727 177. —Bigelow aspirator and washing-tube ....... 728 178. —Showing the manner of holding the lithotrite when opening and shutting in the search for fragments ........ 728 179. Showing the manner of holding the bulb ...... 729 180. Operating cystoscope .......... 732 181. —Cystoscopic forceps .......... 733 182. —Tuberculous fistula following nephrectomy ...... 736 183. —Beck’s operation for balanitic hypospadias . . . . . 742 184. —Beck’s operation for balanitic hypospadias ...... 742 185. —Beck’s operation for balanitic hypospadias ...... 743 186. —Rochet’s modified Nove-Josserand operation for hypospadias . . . 744 187. —Rochet’s modified Nove-Josserand operation for hypospadias . . . 744 188. —Tapping for hydrocele .......... 753 189. —Method of applying circumcision forceps ...... 761 190. —Dressing after circumcision . . . . . . . . .762 UROLOGY CHAPTER I PHYSICAL EXAMINATION The physical examination of a patient cannot he too thorough: errors in diagnosis are more often due to incomplete or careless physical examination than to any other fault. There are in the United States today innumerable victims of renal stone and tuberculosis being treated for an imaginary cystitis. Twice I have seen prostatectomy done for pyelonephritis. Once I have seen a testis removed for syphilis and twice for subacute epididymitis, the diagnosis of tuberculosis having been erroneously made in each instance. Several patients suffering from arteriosclerotic nocturnal polyuria have been referred to me for prostatectomy. I know of a patient who submitted for months to vigorous local treatment for a mild gleet while he was dying of chronic nephritis. Such gross errors are due to careless physical examinations. Yet it would be hard to decide precisely what constitutes a complete and care- ful examination. It is certainly improper, for example, to cystoscope every patient with gonorrhea; yet it is eminently essential for some of them. The expert diagnostician shows his skill not only by basing his diagnosis on the salient points in the history and physical examination, but also and above all by recognizing the doubtful cases and exhausting for them every means of diagnosis at his command. The general rule of physical diagnosis should therefore be this: Examine the patient to obtain a thorough knowledge not only of the disease from which he suffers but also of all possible complications and concomitant maladies that may have a bearing upon the prognosis or the treatment of this disease. Disease of the urinary organs is peculiarly prone to be complex. That a patient has prostatitis is no evidence that he has not pyelone- phritis. That he has a stone in his bladder does not prove that he has not another in his ureter. That he has a tuberculous prostate does not guarantee him against renal tuberculosis. These are but gross exam- ples of the fact that we must be constantly on our guard against com- 1 2 PHYSICAL EXAMINATION plex conditions in the genito-urinary tract of which the more obvious lesion may be the less important. The detail of our physical examination should cover several fields, viz.: General Physical Examination. Urinalysis. External Examination of the Genito-urinary Tract. Internal Examination. GENERAL PHYSICAL EXAMINATION Though by no means always essential, yet it is never a waste of time to note the age, the weight, and the circulatory, pulmonary, and digestive conditions of every patient. That such observation is most important may be demonstrated by the following list of conditions in which data concerning the vital functions are essential: The condition of the circulation must be carefully studied in every renal case. The blood pressure is especially important. The condition of the lungs is preeminently important in tubercu- losis and in operative cases. The condition of the digestion is perhaps the most important of all. It affects the prognosis of even so local a malady as gonorrhea. It determines the dosage of sandalwood oil as well as of hexamethylen- amin. It enters into the diagnosis of certain forms of urinary toxemia. Study of such important factors is therefore not time wasted. Yet the detail of such study is no special province of ours: it belongs to the general education of every qualified practitioner. URINALYSIS Urinalysis, too, belongs to general medicine. Yet certain features of it are of such special importance in disease of the genito-urinary organs that they merit detailed consideration in Chapter II. EXTERNAL EXAMINATION OF THE GENITO URINARY TRACT We may consider— Palpation of the kidneys and ureters. Palpation and percussion of the bladder. Rectal palpation of the prostate and seminal vesicles, etc. Palpation of the penis and urethra. Palpation of the scrotal contents. EXTERNAL EXAMINATION OF GENITO-URINARY TRACT 3 PALPATION OF THE KIDNEYS Position of the Patient.—The patient, with hack and abdomen bared, lies upon his back with his knees drawn up and his hands at his sides, so as to relax the abdominal wall as much as possible. If examination in this position proves unsatisfactory the patient may be turned upon the side opposite to that which is being examined. Lying thus with knees well drawn up, the kidney is sometimes more palpable; but, as a rule, this is not the case. Palpation of the abdomen with the patient erect but bending slightly forward may reveal renal mobility that otherwise escapes ob- servation. But many patients cannot relax the abdominal muscles while in this position, which is therefore but little employed. Position of the Examiner—The examiner sits or stands next to the side to be examined. The Operation—If the kidney is very large its outlines may be de- termined by abdominal palpation. Yet it is almost always necessary, in order to avoid mistakes, to employ lumbo-abdominal palpation. Lumbo-abdominal palpation is performed as follows: To examine the right kidney the patient lies, as above described, at the edge of a couch, beside which, and to the right of the patient, the examiner sits. With the index and middle fingers of the left hand the examiner now identifies and makes pressure upon the triangular depressible spot below the last rib and just at the edge of the thick spinal muscles. The right hand is then placed on the anterolateral abdominal wall (about an inch external to the linea semilunaris) with fingers directed upward, and their tips just below the free border of the ribs (or of the liver if this be enlarged). This hand is pressed down as firmly as possible, taking advantage of the relaxation of the parietes between inspirations. Ballottement.—With the hands thus placed the examiner may or may not feel a mass between them. In either event he gives a quick, sharp tap to the loin with the fingers of the left hand. The result of this is twofold, viz.: 1. It may elicit costovertebral tenderness. Deep tenderness con- fined to the region just below the ribs and external to the erector spinae muscles is almost conclusive evidence of inflammation in or about the kidney. I have never known myositis to cause tenderness in this region. 2. It may elicit renal ballottement. This is the sensation, com- parable to fetal ballottement, imparted to the fingers depressing the anterior parietes when a sharp tap from behind throws an intra-abdom- inal body against them. Ballottement should be attempted first during normal respiration, then with the patient breathing deeply, just as the abdominal wall relaxes at the end of the inspiratory effort. 4 PHYSICAL EXAMINATION Renal ballottement discloses the presence of a movable mass in the loin. It does not prove that mass to be a kidney, nor, if kidney it be, that the organ is diseased. One may obtain ballottement from a mass of tubercular glands and from a neoplasm or “corset lobe” of the liver. Yet as a clinical sign ballottement is most useful. When the kidney is normal in size and position ballottement can be obtained only if the patient is very thin and the abdomen very lax. But when the organ is abnormal in size or mobility and this abnormality is but slight, or when examination is impeded by fat or rigidity, ballottement may he the only clinical evidence of this change. Thus ballottement of the kidney reveals slight enlargement or mobil- ity, though other signs must be depended upon to prove that the mass felt actually is kidney. Palpation.—In many instances the mass, while large enough to be felt very distinctly by ballottement, escapes every other method of lumbo-abdominal palpation except the following: The patient is in- structed to take repeated deep breaths, and as he does so the examiner gradually insinuates the fingers of his right hand deeper and deeper under the ribs, until, at a propitious moment of post-inspiratory relaxa- tion, rather sudden and sustained bimanual pressure distinctly catches the lower pole of the kidney before it slips back under the ribs. Considerable enlargement or mobility of the kidney is better studied by simple bimanual palpation. The mass is readily felt between the hand on the loin and the hand on the abdomen, and palpation and per- cussion are employed to outline its shape, size, and mobility. Percussion.—A dull or flat percussion note is obtained over the kidneys. But the presence of the liver and spleen immediately above the kidneys renders this sign of little value. Differential Diagnosis by Palpation Palpation of tlie unenlarged kidney scarcely ever affords evidence as to the exact nature of disease in it. Nephroptosis is diagnosed by pal- pation (p. 411), and a tender kidney is usually an inflamed kidney. Perirenal exudates are sometimes characteristically diffuse. But with these exceptions palpation usually reveals little more than the fact that a mass in the loin probably is or is not of renal origin. Retroperitoneal and adrenal growths cannot be distinguished from renal enlargement by palpation. The enlarged kidney usually forms an ovoidal movable mass, in part concealed under the ribs, rising and falling with respiration, pal- pable by lumbo-abdominal palpation or ballottement. But when the kidney is greatly enlarged, or displaced and enlarged, it may be a delicate matter to distinguish the resultant tumor from enlargement EXTERNAL EXAMINATION OF GENITO-URINARY TRACT 5 of liver, gall-bladder, spleen, or pancreas. The kidney is more lateral in position than any of these organs and more readily distinguishable by lumbo-abdominal palpation. Insufflation of the colon 1 may be of use in differential diagnosis. On the right side the hepatic flexure covers only the lower pole of the kidney, but is adherent thereto (by the nephrocolic ligament of Longyear). Hence if the kidney is greatly enlarged it carries the hepatic flexure forward in front of it, covering its lower extremity. Most other growths reach the abdominal wall distinctly above and to the inner side of the angle of the colon (e. g., gall-bladder, pancreas, pylorus), but enlargement of the right lobe of the liver descends external to and in front of it. Thus the only tumor whose lower end is likely to be covered by the hepatic flexure of the colon is a renal tumor. On the left side the transverse colon crosses in front of the lower third of the kidney and the descending colon lies external to it. But the lack of any definite attachment between the two organs permits the enlarged kidney to slip out from behind the colon. When the left kidney is sufficiently large to reach the abdominal wall no hollow viscus intervenes. The descending colon borders the inner side of the mass. Enlargements of the spleen, on the other hand, reach the abdominal wall above the transverse colon. The Ureter Catheter—Inasmuch as disease of the kidney either impairs the secretion of that organ or alters the shape of its pelvis long before it produces a palpable tumor, the main dependence in diagnosis is upon the catheterization of the ureters. A study of the urine thus obtained, confirmed if necessary by pyelography and the wax-tipped catheter, affords an accurate diagnosis with which the find- ings of palpation must be made to conform. PALPATION OF THE URETERS The ureters lie upon the posterior abdominal parietes. Their course may be divided into an abdominal and a pelvic portion. In the Abdomen—The course of the ureter through the abdomen be- gins near the outer edge of the psoas magnus muscle opposite the third lumbar vertebra. Thence it runs on the anterior surface of this muscle downward and a little inward to pass over the brim of the pelvis near the bifurcation of the common iliac artery. At their entrance into the pelvis the ureters are about 5 cm. apart. The normal ureter cannot be palpated through the abdominal wall. Even when considerably enlarged it can only be felt if the parietes be 1 The apparatus for this operation is a long rectal tube and the bulb of 3 Paquelin cautery (or an inverted Vichy bottle). 6 PHYSICAL EXAMINATION thin and relaxed. Points of inflammation in its course may be identi- fied as points of tenderness. But palpation cannot distinguish ten- derness in the ureter from tenderness due to other causes. On the right side an inflamed ureter is likely to be mistaken for cholecystitis or appendicitis. In the Pelvis.—The ureters follow the lateral walls of the pelvis in a wide curve whose convexity is outward and backward. As they enter the bladder they are about 4 cm. apart (though the vesical orifices are separated by but 2 cm.). Through the greater part of their pelvic course the ureters are totally impalpable. Just as they enter the bladder they become palpable in the vaginal vault of the female, in the anterior wall of the rectum in the male. In this location the inflamed ureter may sometimes be felt by bimanual (abdominovaginal) palpation in the female. It cannot be felt by abdominorectal examination in the male unless very greatly enlarged. Vaginal Palpation.—The ureter passes behind and below the uterine artery at a point from 0.5 to 1.5 cm. lateral to the uterine cervix. Thence its direction is downward, forward, and inward (almost trans- versely), against and adherent to the anterior vaginal culdesac, to enter the bladder at a point about 2 cm. from the middle line at the junction of the upper and middle third of the vagina. Hence the sensitive or enlarged ureter may be palpated for over 2 cm. of its course as it runs transversely across the anterior vaginal culdesac. As it reaches the lateral culdesac it is so far distant from the vagina (usually about 1.5 cm.) as to be inaccessible unless greatly enlarged. Rectal Palpation.—A large ureteral stone impacted at the entrance of the ureter into the male bladder may be felt by rectal palpation. It may be sought at a point about 1 cm. above the prostate and just internal to the seminal vesicle. The Ureter Catheter.—The ureter catheter, collargol injection, and the wax-tipped catheter give the foundation of diagnosis here, as stated in the preceding section. PALPATION AND PERCUSSION OF THE BLADDER The bladder may be examined by abdominal palpation and per- cussion, by rectal palpation, and by recto-abdominal bimanual pal- pation. Abdominal Palpation and Percussion—The bladder when empty or partially filled can neither be felt nor percussed through the abdominal wall. The bladder of an infant, lying high in the pelvis, must contain at least 150 c.c. before it can be percussed. The bladder of an adult EXTERNAL EXAMINATION OF GENITO-URINARY TRACT 7 must contain 300 c.c. or more. To be palpable it must contain about 1,000 c.c. Percussion of the distended bladder gives a flat note over an area above the pubic bone, the dimensions of which depend upon the disten- tion of the bladder. This area may extend but an inch or two above the pubes or it may rise up to or even above the umbilicus. Palpation is only possible when the bladder is distended at least half way to the umbilicus. The viscus is felt as a tense sphere rising from the pelvis. When the bladder reaches the umbilicus and the abdominal walls are lax the tumor in the hypogastrium may be distinctly visible. Rectal and bimanual palpation.—These methods are described in the following section. RECTAL PALPATION: RECTO-ABDOMINAL PALPATION The prostate and, in most instances, the seminal vesicles may he felt by a finger introduced into the rectum. Preparation of the Examiner.—The examiner may protect his finger by a simple lubrication or by a rubber glove or a specially con- structed rubber shield. The best protector for the finger is a rubber finger cot (a new one for each examination) and a shield for the rest of the hand, made either by winding a gauze bandage about the finger or by tearing a hole in the midst of a small square of absorbent cotton. The finger cot must be lubricated. In his other hand the examiner holds a piece of gauze with which to wipe the grease from the patient’s anus after the examination. Preparation of the Patient.—The patient’s bladder should be moderately distended, preferably with boric acid solution. This is to be urinated out after the examination. Position of the Patient.—Some prefer that the patient should be upon his back with his knees drawn up, others that he should assume the knee-cliest position, others that he should bend over a table with his heels apart, his toes turned in, his knees slightly bent, his back “swayed.” Most patients can be effectively examined in the position last de- scribed. With his left hand upon the patient’s left shoulder the exam- iner may exert counterpressure to drive his finger as far as possible up the rectum. The examiner may steady his right hand by bracing the elbow against his right knee. The Examination.—As the index finger is introduced with its sen- sitive pulp forward toward the anterior rectal wall, it slips through the two sphincters and enters the rectal cavity above. 8 PHYSICAL EXAMINATION Examination of Membranous Urethra and Perineal Body.—With the index finger hooked down and the thumb on the patient’s perineum an examination of this body may be made for indurations (cowperitis, peri-urethritis). Just above this the finger in the rectum feels the membranous urethra, an almost imperceptible cord about 2 cm. long, in the median line. Boggy, lumpy, or tender infiltrations may perhaps be felt about it. Examination of the Prostate.—As the membranous urethra is fol- lowed up the bowel it disappears within the apex of the prostate, which is felt beneath the anterior rectal wall. The normal prostate as felt from the rectum is heart-shaped, with its apex joining the membranous urethra, its base more or less notched in the center, its lateral lobes quite elastic, its central groove between the two lobes more or less marked. The normal prostate does not project into the rectum. Its lateral lobes are flat rather than bulging. Its outline is a little vague. In order to examine it carefully the finger must be swept over its surface and around its borders. Great experience is required to recognize a normal prostate. So varied are the degrees of sensitiveness and of prominence of the organ, so frequently do we find phleboliths or enlarged glands lying upon it or near it, that the specialist is fre- quently compelled to confess that he can find nothing abnormal in a prostate that has been pronounced diseased by a less experienced ex- aminer. The chief signs of a normal prostate are: The lobes are flaccid, flat, insensitive. An exquisitely sensitive prostate (like an exquisitely sensitive urethra) may be anatomically normal. A sensitive and tense prostate usually contains pus. A prostate with rounded, tense insensitive lobes is usually hypertrophied, but may be simply inflamed. The relative roundness of the lobes is appreciated by sweeping the finger across them from side to side. A prostate may be inflamed or enlarged or the seat of neoplasm and yet feel normal to rectal touch. Cystoscopy and rectal palpation upon a sound in the urethra (p. 277) are of great assistance in diagnosis of carcinoma of the prostate. There are no indurations in or about the prostate. Discrete round masses on or near the prostate are usually glands or phleboliths. Indurations within the lateral lobes or projecting toward the seminal vesicles are usually inflammatory; they may be tuberculous or neoplastic. Indurations extending from the prostate into the base of the bladder beyond are invariably neoplastic. Examination of the Vesicles.—The distinction between the seminal vesicle and the ampulla of the vas is not possible by rectal touch. If EXTERNAL EXAMINATION OF GENITO URINARY TRACT 9 the perineum is deep or the prostate enlarged it may be impossible to insert the finger far enough up the rectum to reach the vesicle. The normal seminal vesicle is impalpable. The dilated or inflamed seminal vesicle is felt as an irregular, elongated mass beginning just above the prostate, laterally, and ex- tending upward or upward and outward beyond the reach of the finger. If greatly enlarged the vesicles may meet in the middle line, but usu- ally there is a space about a finger’s breadth in width between them. The inflamed vesicle feels doughy or doughy and lumpy. Examination of the vesicles may sometimes be made easier by coun- terpressure on the hypogastrium. A vesicle may be inflamed and yet feel normal to rectal touch. Examination of the Base of the Bladder—Neoplasms of the bladder and large stones in the lower end of the ureter may sometimes be felt by rectal touch in the space between the vesicles. Counterpressure on the abdomen is of assistance in this examination. Abdominorectal palpation sometimes reveals stones in the bladder, but in this respect the examination is likely to be extremely misleading. PALPATION OF THE PENIS AND URETHRA Palpation of the Penis.—This presents no peculiar difficulty other than that of identifying obscure circumscribed fibroses in the corpora cavernosa. Palpation of the Urethra.—The urethra should be palpated upon a sound just large enough to fill it without distention. Careful palpa- tion upon this reveals even the smallest infiltrations in and about the urethral wall. Only the anterior urethra can be palpated externally. The mem- branous urethra must be palpated from the rectum. The prostatic urethra can scarcely be palpated. PALPATION OF THE SCROTAL CONTENTS Palpation of the Testicle—The testicle should be palpated by slipping it to and fro between the thumb and the index finger. The chief characteristics to be noted are its size and tension as compared with its fellow, the condition of the epididymis, the presence of hydro- cele, and of pathologic conditions in and about the testicle. The normal epididymis must be carefully palpated many times be- fore the examiner’s fingers attain complete familiarity with its usual variations in size, consistence, and attachment to the testicle. The presence of hydrocele is often a confusing element in diagnosis. Here again familiarity with the tension of a normal testicle and with 10 PHYSICAL EXAMINATION the groove that separates it from the epididymis makes the alteration of that tension and the obliteration of that groove by hydrocele imme- diately recognizable. Palpation of the Vas Deferens—The physician should also accus- tom his fingers to follow the vas from its origin at the tail of the epididymis up to and into the inguinal canal, in order to recognize changes in its size or sensitiveness. INTERNAL EXAMINATION The technic of passing urethral instruments and of using the urethroscope, the cystoscope, and the ureter catheter is taken up in the following chapters. CHAPTEK II URINALYSIS Tiie foundation of urology is urinalysis. Without a thorough prac- tical familiarity with this art as practiced in the laboratory and in the clinic, no man may expect to diagnose diseases of the urinary organs. The practice of urinalysis is twofold: laboratory urinalysis and clinical urinalysis. LABORATORY URINALYSIS In the laboratory the urine is subjected to tests for acidity, specific gravity, albumin, sugar, indican, etc.; it is centrifuged and the cel- lular, crystalline, and bacterial content of the sediment noted. Such an analysis every physician must he competent to perform. There is no special need, therefore, to dwell upon it here, except to insist upon certain points of peculiar interest to the urologist. THE SELECTION OF THE SPECIMEN This is of the greatest importance. Unless the patient’s general health and the examination of a single specimen warrant the belief that the kidneys are sound a twenty-four-hour specimen should, of course, be examined. But this is not enough. The urologist is chiefly interested in the bacterial and cellular content of the urine. This he wishes to examine without contamination (if possible) by the secretions of the urethra or of the vagina. Hence the specimen for microscopical examination must he obtained direct from the bladder. To accomplish this it is best to draw the urine by catheter; though sometimes it is sufficient to have the patient urinate into two glasses (as described below) and to ex- amine the contents of the second glass. This precaution is even more useful for the analysis of the urine of women than of men, though this is not generally recognized.1 The two-glass test is misleading in women, as the first urine passed does not necessarily clean out all the vaginal pus. 1 Such special methods of obtaining urine as suprapubic puncture, ureteral cathe- terization, etc., do not enter into the present discussion. 11 12 URINALYSIS The old-fashioned method of examining the “morning” and “night” specimens of urine has been generally discarded in favor of the “twenty-four-hour” specimen. Yet in estimating the cause of nocturnal frequency of urination, especially in persons past middle age, a com- parative quantitative examination of the urine passed between 9 p.m. and 9 a.m. and that passed between 9 a.m. and 9 p.m. is often impera- tive. Without it one cannot decide whether nocturnal frequency of urination is due to the polyuria of arterial disease or to prostatism or some other local irritant. Thus a complete laboratory urinalysis consists of— 1. Chemical and physical examination, qualitative and quantita- tive, of a “twenty-four-hour” specimen. 2. Microscopical (and bacteriological) examination of the centri- fuged sediment of the bladder urine, obtained by catheter or by the two- glass method. 3. In certain cases a comparative examination of “night” and “day” urines. THE ANALYSIS The tests that suffice for most cases are: Physical Tests— Reaction. Specific Gravity. Chemical Tests— Urea. Albumin (quantitative). Sugar (quantitative) (acetone, etc., if sugar is found). Indican. Phosphates. Microscopical Examination— Crystals (differential). Blood and pus cells. Epithelial cells (differential). Casts (differential). Bacteria (differential), especially the gonococcus and the bacil- lus of tuberculosis. Albumin.—Upon the meaning and importance of the physical and chemical tests we need not dwell, except to insist that the statement so commonly made that “albumin is accounted for by pus” is almost in- variably inaccurate, and often fatally misleading. The urine, mixed with about one-fifth of its bulk of normal salt solution and then tested for albumin,1 never shows more than a trace except under three 1 For qualitative analysis the acetic-and-heat and the nitric-ring tests are the best. The former is the more delicate if properly performed, thus: LABORATORY URINALYSIS 13 conditions: (1) Nephritis. (2) Acute prostatitis. (3) Hematuria. So long as there is much blood in the urine, or acute prostatitis, a moderate albuminuria has no great significance, hut in the absence of these, and even in the presence of slight microscopic hemorrhage or of chronic prostatitis, the appearance in the urine of one-tenth of one per cent of albumin (by weight) means nephritis, and if there is pyuria, pyelonephritis. No amount of pus will liberate so much albumin. The importance of this fact is great, for the gravest cases of pyelo- nephritis may evoke no symptoms directly referable to the kidney, and may deliver urine in which the few kidney casts are overwhelmed in pus and may be overlooked by even the most painstaking search. In this event the amount of albumin in the urine is the first hint that the kidney is involved. Epithelial Cells.—The debate as to the ability of the microscopist to identify epithelial cells from the ureter and the renal pelvis has been on for a generation and is still open. The frequent opportunity of ex- amining specimens of urine obtained by the ureteral catheter has of late years educated many men to the point of making this diagnosis with reasonable certainty. A quantity of round and polyhedral cells little larger than a pus cell can only come from the kidney, pelvis, or ureter. A few round, small cells may be desquamated in prostatitis, but these are accompanied by very large round prostatic cells, and usually by squamous bladder cells. Moreover, these prostatic cells may often be eliminated by using the two-glass test or by drawing the urine by catheter. Accuracy in this diagnosis cannot be learned from a text-book, but must be obtained from a study of specimens obtained by the ureteral catheter. Bacteria.—Smear, culture and inoculation are all employed in the differentiation of urinary bacteria. Perhaps the most useful device for immediate diagnosis is Crabtree’s fractional centrifuging1 with the high-speed electric centrifuge. 1. The filtered urine (four parts) and salt solution (one part) mixture in a test-tube is held over a .Bunsen flame so as to boil only its upper 2 cm. 2. To this is added, without shaking, one or two drops of acetic acid. 3. If a cloud of phosphates is thrown down by the boiling and partially re- dissolved by the acid, the test-tube is shaken just enough to dissolve the rest of this. 4. The mixture is once more boiled. 5. The upper portion of the fluid is examined by means of a camera obscura. This step is the most important of all. The camera consists of a small box, black inside, with a vertical slit on one side to admit the light, a round hole in the bottom to admit the test-tube, and a flap fixed like an open cover to conceal the source of light (an incandescent bulb is better than daylight). The light striking the fluid suffuses it and plainly shows against the darkness inside the camera an albuminous cloud that would otherwise elude observation. 1 Surg., Gynec. and Obstet., 1916, xxii, 221. 14 URINALYSIS If the urine contains considerable pus, centrifuge for one to two minutes at the lowest speed. The bulk of the pus and detritus will be thrown down in a heavy sediment leaving a somewhat cloudy urine above containing a few pus- cells and the majority of the bacilli. Decant the urine into a clean tube, discard the sediment, and centrifugalize the urine at high speed until it is clear. This step requires 15 to 30 minutes. The urine may be then decanted and the tube containing the sediment refilled with partly clarified urine and replaced in the centrifuge. In this way the contents of two or more tubes of urine may be concentrated into a single small sediment. Pour off the urine, invert the centrifuge tube on a towel and drain off the last drops. A fairly dry small sediment will be obtained which can be removed with a loop, and cover-glass preparations made, or cultures planted. In those urines which contain but little pus, experience has shown that pre- liminary centrifugalization is unnecessary. The important step in the pro- cedure is to centrifugalize the urine until clear to ensure deposit of the bacilli. Special precautions are required for— 1. Diagnosis of the gonococcus (p. 106), and 2. Diagnosis of the bacillus of tuberculosis (p. 388). CLINICAL URINALYSIS On the score of common knowledge we have skimped the description of laboratory analysis to make room for detailed description of the special knowledge required for a competent clinical urinalysis, without which the urologist is hopelessly at sea. Clinical urinalysis consists in looking at the urine and interpreting what we see therein. It suggests the nature and quantity of substances held in suspension in the urine. It suggests, also, in many instances, the part of the urinary tract from which these substances are derived. But it is by no means infallible, and its findings must always be con- firmed by laboratory urinalysis and by a physical examination of the patient. These propositions are fundamental. They seem to leave a very small place in the diagnosis for this clinical test whose only function is to suggest and not to prove. Yet, practically speaking, clinical urinal- ysis is employed far more constantly than the laboratory tests. At the first examination of a case it often—very often—gives the suggestion that leads ultimately to correct diagnosis, and in subsequent examina- tions it is our chief means of judging the progress of the case. At the patient’s first visit, therefore, the urine should be carefully inspected before it is submitted to laboratory tests, though the infer- ences made from inspection should not he acted upon unless the labora- tory confirms them. At subsequent visits, on the other hand, clinical examination of the urine by inspection is always imperative, while labo- ratory examination is only required from time to time. CLINICAL URINALYSIS 15 TECHNIC OF CLINICAL URINALYSIS It is by no means a waste of time to describe precisely wbat is meant by “looking at the urine.” This does not mean looking at it as it lies in the bottom of an opaque vessel; it does not mean looking at it after it has shaken about in a bottle in the patient’s pocket for hours; it does not even mean glancing at it casually in a dirty glass and by an imperfect light. What it does mean is this: Let the patient present himself for examination at least two, and if possible three or four, hours after his last urination. Let him pass into a large, clean tumbler (a pint glass is the best size) about 50 c.c. of his urine, the rest into a second glass. Now examine the contents of these two glasses against a strong light. No speck or cloud in them is too insignificant to be noticed. View them intently and begin to draw tentative conclusions, recognizing that these conclusions are not final, but only important hints. “This is a foreign body.” “This is a shred which, to judge by its size, comes from the anterior urethra. There is a speck of blood adherent to it.” “This haze is opalescent, and, therefore, probably crystalline or bac- terial.” “This swirl of fresh blood still undistributed is more probably vesical or prostatic.” Such are a few of the thousand and one inferences drawn by the expert examiner. By making such inferences and confirming or refut- ing them in the laboratory or by physical examination, one soon learns to make rapid and accurate inferences from data imperceptible to the inexperienced eye. The accuracy of these inferences may be increased by: 1. The acetic acid test. 2. The comparison of the contents of the first and second glass (for men only). 3. Comparison with these of a third glass of urine (for those cases in which the two-glass test might prove misleading). The Acetic Acid Test.—The substances held in suspension in the urine are organic and crystalline. The former (pus, blood, bacteria, etc.) form the object of the clinical examination, while the latter (crys- tals), though of considerable importance in the general diagnosis, are only confusing here. Their presence simply obscures the undissolved organic content of the urine. Now of the various crystals that may cloud the urine, the earthy phosphates are the commonest and the most important. Urates and uric acid are rarely seen in any quantity in freshly passed urine (and their reddish color distinguishes them), oxalates or cystin scarcely ever 16 URINALYSIS occur in such quantity as to cloud the urine,1 but the phosphates are common and readily soluble by acidulation of the urine. Therefore, if examination of the urine in two glasses shows that both are cloudy (for the phospliatic cloud appears in both urines 2) the glass containing the second urine is held against the light and a few drops of acetic acid poured down its side. If phosphates are present, there follows instant effervescence (from the breaking up of carbon- ates that are always associated with phosphates) and clearing of the urine. This clearing may be interfered with in only two ways, viz.: by the presence in the urine of insoluble substances (crystalline or organ- ized), the nature of which must be determined by microscopic analysis, and by the presence of copaiba in the urine. The urine of a pliospliaturic patient taking copaiba clears only for an instant, and then becomes cloudy again, the copaibal cloud being only a little less opalescent than the pliosphatic cloud which it replaces. When, therefore, we know from previous microscopic analysis the nature of the insoluble substances in a patient’s urine, and know, also, that he is not taking copaiba, the acetic acid test is used as the simplest 11 have several times seen an oxalate cloud, once a cystin cloud. They produce the same opalescent haze as do phosphates or bacteria, and ard distinguishable only by the microscope. 2 When the phosphates are in great excess they are not distributed evenly throughout the urine but, having settled in the bladder, are most concentrated in the last drops. In extreme phospliaturia this concentration of crystals in the last drops is so marked that the patient can occasionally squeeze from the urethra little gritty masses of phosphates left there after urination is complete. The characteristics of this phospliaturia, as it is called, are the following: It occurs almost exclusively in youth, between the age of fifteen and thirty-five. It is apparently due to a functional disturbance in assimilation, and is therefore commonly seen in young persons who work with their heads rather than with their hands, is often associated with functional dyspepsia, and like this is most marked at periods of mental stress. It never causes stone or inflammation of the urinary passages, and its association with pus in the urine is purely accidental. Its chief clinical char- acteristic is its sudden appearance and disappearance; at one micturition the urine is milky with phosphates, at the next absolutely sparkling and clear. Its prognosis is good; it gradually lessens with age; it does no harm. The sexual neurasthenic of course looks upon it with horror, and for the mental relief of such persons treatment of the phosphaturia is required. First, one should insist that the phosphaturia is harmless in itself and only a sign of functional derangement. Secondly, one must insist upon a strict regime of diet and exercise appropriate to the existing nervous or digestive disturbance. Thirdly, one must remember that a direct attack upon the phosphaturia by drugs is usually a failure, and if successful is only of temporary efficacy. Hexamethylenamin, salol, benzoate of soda, and other urinary acidifiers have a reputation beyond their merits. Ten drops of dilute hydrochloric acid before each meal I have found more efficacious than anything else, but our main reliance is hygiene, especially as to diet and exercise. CLINICAL URINALYSIS 17 method of removing a chance phospliatic cloud, as a routine preliminary to the clinical examination of the urine. Comparison of the First and Second Urines.—Having tested for phosphates by the addition of a few drops of acetic acid, and dissolved these, if present, by adding an excess of this acid, the physician holds the two glasses into which the patient has passed his urine against the light and compares their contents.1 The first urine passed is the urine as it lay in the bladder, plus what it has swept from the urethral walls. The second urine passed is the urine as it lay in the bladder, without admixture of anything gathered from the urethra during its exit.2 This rule has but two exceptions, as follows: (1) If the insoluble substances suspended in the bladder urine are very dense they may settle to the bottom as the urine lies in the bladder and come away chiefly with the last drops of urine. The substances which fall within this exception are blood-clots, crystals (usually phosphates), and pus, when present in great quantity (such as usually comes from pyone- phrosis). (2) The second urine may also he contaminated by whatever may he squeezed from the urethral wall during the “piston stroke” muscular spasm that clears the urethra of the last drops of urine. Under this ex- ception come pus squeezed from the prostatic ducts (or from a prostatic abscess) when the prostate is gravely inflamed, and blood squeezed from the bladder neck (or from the adjoining surface of the bladder or urethra) when this is acutely inflamed, ulcerated, or the seat of neo- plasm. These exceptions amount clinically to this: 1 Comparative examination of the two urines is of no interest if the patient is a woman since the differences in them are chiefly accounted for by the vaginal secretion in the first glass. It is scarcely necessary to add that examination of a third glass is equally inapplicable to women. 2 This elementary physical fact that the first fluid flushes the outlet and the second comes clean from the tank w’ould scarcely require explanation were it not for the fact that so many physicians believe that the first urine passed show’s the contents of the anterior urethra, the second those of the posterior urethra. This fundamental error is fostered by the clinical fact that the contents of the posterior urethra are often mingled with those of the bladder before urination. In this event the first urine passed contains what it sweeps from anterior and posterior urethra during the urination, plus what has entered the bladder from the posterior urethra between urinations, while the second urine .contains only what has flow’ed back into the bladder from the posterior urethra, between urinations (supposing the bladder and kidneys add no contamination). Thus the comparison of the two urines may under certain conditions show one the content of the anterior urethra, plus that of the posterior urethra, the second only that of the posterior urethra, and under these special condi- tions the first urine does roughly represent the anterior urethral washings, the second urethra the posterior. But to step from this particular to a broad generalization is inaccurate and misleading both in theory and in practice. 18 URINALYSIS The two-glass test may mislead in the presence of bleeding or of active suppuration in prostate or kidney. The Three-glass Test—For such cases a still further hint (none of these tests is proof) as to the conditions present may be obtained by making the patient pass his urine in three glasses instead of two without interrupting the flow of urine in transferring from one glass to another. The three specimens thus obtained represent: 1. Bladder urine (less sediment), plus washings of urethra. 2. Bladder urine (less sediment). 3. Bladder urine, plus sediment or substances expressed by “pis- ton stroke.” Yet this test is very rarely employed, since its disclosures are con- fusing (failure to determine the derivation of the contents of the third glass), and require verification by other methods of examining prostate, bladder, and kidneys, which methods are themselves far more accurate than this tliree-glass test. Another three-glass test frequently employed as an aid in the diag- nosis of chronic prostatitis or vesiculitis is the following: The patient urinates into two glasses, but retains some urine in the bladder. The physician then massages the prostate or the vesicles (or both), and the patient then passes into a third glass the remaining urine, carrying with it the expressed secretion from the glands massaged. This test is accurate only in case the second urine is quite clear, and is necessary only when it is impossible to squeeze from the suspected gland enough secretion to make it appear at the meatus, and when the instrumentation necessary to fill the bladder with a clean solution before massage is impracticable. Other Tests.—A variety of tests involving the use of a greater number of glasses have been devised for the specific purpose of locating inflammation in the anterior or posterior urethra exclusively. Their complexity is such that they are of no practical value. THE ESSENCE OF CLINICAL URINALYSIS The results to be expected from any of these methods of clinical urinalysis are directly proportionate to the skill of the examiner. The essence of the test is his ability to distinguish at a glance slight varia- tions in the amount and quality of pus, blood, or shreds present. Thus clinical urinalysis is of the greatest use for the prognosis from day to day. As a diagnostic test of the nature of disease it is at its weakest. CHAPTER III URETHRAL INSTRUMENTS: THEIR ASEPSIS URETHRAL INSTRUMENTS The axiom that a good workman does not complain of his tools implies in him appreciation and possession of adequate instruments. The urologist, therefore, must thoroughly understand the nature, the care, and the use of urethral instruments. In the selection of urethral instruments no two authorities can he expected to agree. Thus the specialist can afford to employ many in- struments which would be useless in less expert hands. But certain instruments are required by every man wishing to do good urological work. All of these we believe to be included in the following list. The latter may he enlarged according to the fancy of the physician; on the other hand, it may be diminished by omitting the instruments bracketed. A set of conical sounds. (Ho. 15 to 32 French.) A set of olivary-tipped conical woven bougies. (Ho. 10 to 20 F rench.) [A set of bulbous bougies.] Kollmann dilators. Filiform bougies. [A set of tunneled sounds, catheters and filiforms.] [A set of Janet steel sounds and filiforms.] Soft-rubber catheters. (Ho. 15 to 20 French.) Woven olivary “natural curve” catheters. [Indwelling catheters.] An elbowed obturator. Urethroscopes and attachments. Cystoscopes, ureteral catheters, etc. [Silver catheters.] [Stone searcher.] A 200 c.c. syringe. Urethral injection syringes. An instillator. (Keyes, Bangs or Guyon type.) Hozzles and apparatus for anterior urethral irrigation. 19 20 URETHRAL INSTRUMENTS: THEIR ASEPSIS SCALES The scale for grading the caliber of urethral instruments wTas first accurately fixed in France, where two scales are at present in use—the Charriere (commonly known as the French scale) and the Benique. Other scales are the English and the American. Of late years the tendency in this country, as well as in England, has been to adopt the French scale as the most convenient, while in France itself there is a tendency to replace the old French (Charriere) by the new Benique scale. Although Dr. Van Buren, senior author of the parent edition of this work, was very tenacious of the American scale—which, indeed, was born in his office—the almost universal adop- tion of the French scale since his time has led us to drop the American in favor of the French scale. The French (Charriere) scale indicates diameters in -jj mm. Ho. 1 has a diameter of mm., Ho. 2 a diameter of § mm., and so on. From this scale, therefore, the diamete ' of an instrument may be deter- mined by dividing its number by 3. A Vo. 30 sound has a diameter of 30 mm. 3 = 10 mm. The Benique scale indicates diameters in J mm. It numbers instru- ments twice as high, therefore, as the Criarriere. A Ho. 30 French sound is a Ho. 60 Benique. B. = F. X 2. The American scale indicates diameters in mm. 30. F. = 60 B == 20 A. A. = f F. The English scale follows no rule, but its numbers are generally about 2 less than the American. Thus, 30 E. = 60 B. = 20 A. = 18 E. E. = (A. or § F.) — 2. SOUNDS AND BOUGIES A metal instrument for urethral exploration is commonly termed a sound (though a bulbous bougie may be metallic), while a flexible instrument (made of woven silk and varnished) is called a bougie. The best woven instruments are made in France. In order to spare the patient’s meatus, I have all my sounds above 24 F. size made with double taper (Fig. 1). American custom favors the use of the single-curve sound (Fig. 1), while European custom favors the double-curve or Benique instru- ment (Fig. 6). After many years’ use of the former, I have discarded them in favor of the latter. Conical Woven Bougies (Fig. 2).—These should be olivary tipped. Inasmuch as they are used to dilate strictures up to the point where steel sounds may be used, one should possess a complete set from 10 to 20 French size. The neck of the instrument should be quite flexible. URETHRAL INSTRUMENTS 21 Bulbous Bougies (Fig. 3).—Bulbous bougies may he flexible or metallic. The best French makes of flexible bougies are almost as durable as and more useful than the metallic instruments. Fig. 2.—Olivabt Bougie. Fig. 3.—Bulbous Bougie. Fig. 1—Double Taper Sound. Fig. 4.—Kollmann Dilators Kollmann Dilators (Fig. 4).—These are useful for dilating the urethra while sparing the patient the insignificant operation of meat- otomy, and also to carry dilatation to great lengths. The Oberlaender, Frank, and Thompson dilators are inferior to the Kollmann. 22 URETHRAL INSTRUMENTS: THEIR ASEPSIS The best models of these dilators are made of pure nickel by Gentile in Paris. The nickel does not rust, and the instrument may therefore be sterilized by boiling. This dilator is made in several designs, some of which have irri- gating attachments. The two types illustrated are the ones generally employed. Filiform Bougies (Fig. 5).—Filiform bou- gies are made of whalebone or of woven silk. Fig. 5.—Whalebone Fil- iform and Tunneled Sound Fig. 6.—Woven Filiform and Janet Sound. Tlieir average size is 3 French; they should be olive tipped. The choice between whalebone and woven filiforms is largely a matter of taste. Both are fragile, liable to break off in the urethra, and therefore old, frayed, and ragged filiforms should he instantly discarded. Inasmuch as filiforms are used chiefly as pathfinders for larger URETHRAL INSTRUMENTS 23 instruments, the choice of filiforms depends largely upon the instru- ments which are to follow. Two combinations are possible, viz.: the whalebone filiform and the tunneled sound (Fig. 5), the French woven filiform and the Janet sound (Fig. 6). The excellence of our whalebone instruments and the difficulty of obtaining satisfactory woven filiforms, have made the whalebone-tun- neled-sound combination the popular one in this country, in spite of its mechanical inferiority.1 The combination of a good woven filiform and a Janet sound (a set of these should contain at least every alternate number from 10 to 20 French) is better, both because of its smoothness and because the filiform may be tied into the urethra until, by repeated dilatations, a sufficient size shall have been attained to insure the patency of the stricture. CATHETERS A good catheter must be smooth both inside and out, boilable and durable. Two special features of importance are the “round-edged” or “velvet” eye, now universally employed, and the funnel end, which is universally em- ployed in Europe and conspicuously neglected by American manufactur- ers. Soft-rubber Catheters. — These commend themselves for general use by their flexibility. Of all urethral instruments they can be passed the most gently. The choice of sizes lies between 15 and 20 French. An in- strument larger than the latter size is unnecessary, while most instru- ments of the former size have so small a caliber that they transmit fluids very slowly, and are obstructed by even a small amount of viscid pus or blood clot. Yet these smaller instruments pass more comfortably through a sensitive urethra. Woven Olivary Catheters (Fig. Y).—These are useful to pene- trate a small orifice (stricture, spasm), while woven elbowed catheters introduced with the point directed upward, ride over obstacles on the urethral floor (false passage, hypertrophied prostate). Woven double- Fig. 7. —Woven eteks.RY Ca™' fig. 8—Double-el- bowed Catheteb. 1 The rough eye of the tunneled sound scratches the urethra, slips with difficulty- over the filiform, and bends or even breaks this in the urethra, complicating the already difficult situation by the addition of a false passage or a foreign body. 24 URETHRAL INSTRUMENTS: THEIR ASEPSIS elbowed catheters (Fig. 8) ride over certain prostatic obstacles which, the single-elbowed instruments will not surmount. Woven olive-tipped elbowed catheters (Fig. 7) combine the advantages of the olivary and elbowed instruments, and are more generally useful than either. But sometimes a spasmodic or congested urethra admits a blunt instrument more readily than an olive-tipped one, just as occasionally a straight instrument may pass where an elbowed one will not. "Natural curve” Fig. 9.—Natubal Curve Catheter. Fig. 10.—Guyon Obturator. catheters (Fig. 9) are more generally useful than any other type of woven catheters. I employ them almost exclusively. Since woven in- struments have a relatively larger caliber than soft-rubber ones, they may be employed in rather small size (15 to 17 French), and one should possess very small woven instruments (10 French) to pass a tight stricture or a greatly congested prostate. Indwelling Catheters—These are not necessary instruments, and since they have to be made of a relatively perishable mixture they are URETHRAL INSTRUMENTS 25 usually stiff and useless before the occasion for their use arises. Indeed the indwelling catheter usually irritates the male. It is therefore used almost exclusively in women. For such prostatic obstacles as cannot be surmounted by even the “natural curve” catheter, various ingenious devices have been employed. The silver catheter, with a long, “prostatic” curve, is a dangerous in- strument in inexpert hands, which may rarely be passed with safety, even by an expert, more than once or twice in a given case. A very satisfactory substitute is the elbowed or Benique curved obturator of Guyon (Fig. 10). This, when slipped into a rubber or woven catheter, converts it temporarily into a stiff instrument, with the great advantage that the obturator may be withdrawn, leaving an in- dwelling, soft catheter in the urethra. Silver Catheters.—Silver catheters, tunneled or threaded, for filiforms, are useful in an emergency to relieve stricture retention. The silver catheter curved like a sound, that is found in every pocket case of instru- ments, is inferior in every respect, except that of port- ability, to a woven instrument. SYRINGES AND NOZZLES One of the most difficult to obtain of all urological instruments is a good syringe of large capacity. The Janet Syringe (Fig. 11).—This is an excellent instrument. These syringes hold 125 to 150 c.c. of fluid. When not in constant use, the rubber piston must be kept out of the barrel. Quarter-ounce Blunt-nozzled Glass Syringes.— These are necessary for injections into the anterior urethra. Instillators.—Instillators of the Keyes1 pattern (Fig. 12), as at present constructed, consist essentially of small-caliber, short-curve silver catheters, with the eye in the tip. These are fitted to thread or slip on any hypodermic syringe. The instruments are thus readily sterilized and portable. The straight part of the shaft should be six inches long, in order to keep its outer end clear of the glans penis. Fig. 11.—Janet Syringe. ANTERIOR URETHRAL IRRIGATION The apparatus for anterior urethral irrigation consists of a tank (preferably of glass, and so hung that it may he readily raised and 1 The Ultzmann syringe, of which the Keyes is a modification, is a very clumsy instrument. The Guyon instillator, a capillary woven catheter, has never found favor in this country. Modifications of the Keyes instrument have been made by Cabot, Bangs, and others. 26 URETHRAL INSTRUMENTS: THEIR ASEPSIS lowered), a connecting tube, a nozzle, and means of interrupting the dow of fluid through the tube. The tank forms part of the urological equipment. Of nozzles and interrupters there is a great variety. The simple, blunt-pointed glass Fig. 12.—Keyes Instillator. nozzle and a cut-off with protecting bell, form the most familiar appara- tus. URETHROSCOPES, CYSTOSCOPES, ETC. A description of urethroscopes, cystoscopes, etc., is more appro- priately reserved for a special chapter. The same is true of the opera- tive armamentarium. ASEPSIS IN URETHRAL EXAMINATION However infected the bladder into which a catheter or sound is to enter, that catheter must be scrupulously aseptic. The days when sur- geons may joke about the old gentleman who keeps his catheter inside his hat and spits on it by way of lubrication are past.1 Even when the bladder is infected asepsis is imperative, to prevent an increase of that infection. The asepsis of catheterism, using the term broadly to cover every passage of an instrument into the urethra, implies three requirements, viz.: 1. Asepsis of the physician’s hands. 2. Antisepsis of the patient’s urethra. 3. Asepsis of the instrument introduced. 1 Yet such old gentlemen are still encountered in practice. But the apparent immunity which some of them enjoy is due in part to the fact that their bladders are already so severely infected that a little saliva makes them no worse. And though their immunity may for a time prevail, in the end they become more and more infected and die of sepsis. The need for scrupulous asepsis is not because every dirty catheterism causes infection, but because a single dirty catheterism may cause infection of the gravest sort. ASEPSIS IN URETHRAL EXAMINATION 27 ASEPSIS OF THE PHYSICIAN’S HANDS It is not possible to require of the physician about to pass a catheter that he sterilize his hands as if for a surgical operation, or wear sterile lubber gloves. Such cleanliness is only required for such prolonged and delicate operations as cystoscopy. But the physician’s hands should he well washed with soap and water, and, having washed his hands, the physician should act as though they were still dirty; i. e., he should not touch that part of the instrument that is to enter the deep urethra. This is a simple rule, a necessary rule, a universal rule. The last three inches of the instrument should not he touched hy anything except1 sterilized lubricant from the time it is sterilized until it enters the, urethra. ANTISEPSIS OF THE PATIENT’S URETHRA The Uninflamed Urethra.—It has been amply proven 1 that, though the posterior urethra is sterile, the normal anterior urethra may harbor quite an indefinite number and variety of pathogenic microorganisms. But, on account of the mechanical cleansing of the urinary stream, these are almost exclusively confined to the halanitic portion of the canal. Yet it is not unusual to find bacteria in the bulb of the unin- flamed urethra, though it is most unusual not to find them in the terminal inch (p. 134). Moreover, the preputial cavity swarms with bacteria. Hence has arisen the practice of washing the glans penis and flushing the terminal inch of the urethra with boric acid solution before introducing any in- strument. Though such washing and flushing is scarcely more effective than that of the urinary stream, and might, therefore, be omitted, except in case the danger of infection is unusually great, i. e., in cystoscopy, catheterism for aseptic retention, and tying in an indwelling catheter, perfect technic requires that this washing and flushing always pre- cede introduction of urethral instruments of whatever description. The Inflamed Urethra.—When the urethra is acutely inflamed, the passage of instruments is permissible only for the cure of that inflam- mation, or for the relief of retention of urine. In either event the mechanical damage done by any added manipulations outweighs their virtue. ISTo special effort should therefore be made to clean the canal: the glans and meatus should be well washed. Chronic urethritis is no bar to the passage of instruments. These may be used either for the treatment of urethritis or for the diagnosis or treatment of coexisting conditions. 1 Lustgarten and Mannaberg, Vierteljahresschrift f. J. Berm. u. Syph., 1887; Rovsing, “Die Blasenentziindungen, ’ ’ 1890; Wassermann and Petit, Guy on’s Annalcz 1891, ix, 371; Melchior, “Cystite et infection urinaire, ’ ’ Paris, 1895. 28 URETHRAL INSTRUMENTS: THEIR ASEPSIS In the former case the instrumentation (catheterism) habitually carries with it its own antisepsis (injection). In the latter event (passage of sound, cystoscope, etc.), not only may this instrumentation not directly imply antisepsis, but it may directly imply considerable trauma to an infected canal. Therefore it is neces- sary to precede the instrumentation by a soap-and-water and bichlorid wash of the glans and adjoining tissues, and a thorough irrigation of the meatus, and even, in some cases, of the whole urethra, with silver nitrate 1: 4,000, or oxycyanid of mercury 1: 4,000. But the urologist must not confide too much in what is at best but a superficial and in- complete antisepsis of the anterior urethra. The danger of infection is far more closely related to clumsiness or roughness in passing the in- strument than to preliminary urethral antisepsis. Every surgical opera- tion must be cleanly; but every urethral manipulation must also, and above all, be gentle. The dangers of urethral instrumentation are local (exacerbation of urethritis, prostatic or periurethral abscess), and chiefly to be avoided by discretion in the choice of and gentleness in the passage of the in- strument ; or general (urethral chill, systemic gonorrhea, urinary sep- ticemia), and chiefly to be avoided by antisepsis, to a less degree by gentleness. This antisepsis, of which the principles and practice are discussed in Chapter XXXIV", consists in: Hexamethylenamin before, Gentleness during, and Local antisepsis after instrumentation. The hexamethylenamin may often be omitted with impunity, and, since it implies administration of the drug for forty-eight hours before instrumentation, it is often neglected. But there is no excuse for neg- lecting to be gentle or for omitting some form of antisepsis after instru- mentation. Even when the temper of the urethra is well known the omission of a postinstrumental antisepsis may unexpectedly excite a sharp chill. The usual postinstrumental antisepsis consists of an instillation of nitrate of silver or an irrigation with some silver salt or with perman- ganate of potassium. ASEPSIS OF THE INSTRUMENT In any case, the instrument introduced must be aseptic. By this we mean that the whole instrument must he rendered aseptic,1 and 1 The flaming of a metal instrument whereby the beak and shaft are sterilized, but the dirty handle remains uncleansed would be perfectly permissible were it not a dangerous habit to permit the least relaxation of asepsis. Moreover, the con- venience of flaming compared to boiling is quite imaginary. URETHRAL INSTRUMENTS: THEIR ASEPSIS 29 must so remain except for its contact witli the physician’s hands, which, as already stated, should not touch its terminal three inches. This asepsis implies four conditions: 1. Aseptic lubrication. 2. Antisepsis immediately after using. 3. Aseptic preservation. 4. Antisepsis before using. Lubrication.—The lubricant employed for urethral instruments should be soluble in water. Oily lubricants, such as vaselin or olive oil, may be perfectly sterilized by boiling, but they can only be removed from the instrument with great difficulty, if at all. Hence, an instrument covered by an oily lubricant is much more difficult to resterilize than one which is mechanically clean. Albarran has shown that a clean catheter may be sterilized by boiling for ten minutes, while an oily catheter must be boiled half an hour. Among the substances in common use as lubricants may be men- tioned glycerin and boroglycerid. Guyon uses a mixture of equal parts of water, glycerin, and soap powder. Various combinations of Iceland moss, sterilized in formalin, are sold under different trade names. But the best lubricant I know has the following formula, modified by Dr. E. Wood Buggies: Dissolve 1 cm. of oxycyanid of mercury in 200 c.c. of hot sterile water; add 35 c.c. of glycerin and water enough to make 350 c.c. Let this mixture cool; then add 10 to 15 gm. of powdered gum tragacanth. Let this stand until it becomes a homogeneous mass, a process which takes several days, but may be hastened by occasional stirring to break up the lumps. The amount of tragacanth employed depends upon the consistence of this substance, which varies considerably. This lubricant may be put up in sterile paint tubes. Its quality de- pends upon the employment of precisely the right amount of tragacanth. The Instrument.—The practice of asepsis for urethral instruments is approximately that of general surgery, and requires that: 1. The instrument should be so constructed as to be readily cleansed. It should be as free as possible from joints, crannies, etc. It should be in good condition, free from rust or cracks. 2. It should be sterilized by boiling. Strong (almost saturated) sodium chlorid solution is less destructive than plain water.1 3. It should be washed clean and sterilized immediately after using, kept sterile (if possible), and resterilized immediately before using. 4. Instruments for use in “pus cases” should be kept entirely dis- tinct from those for use upon “clean cases.” 1Krotoszyner (Medical News, 1904, Ixxv, 406) makes this suggestion and also suggests a saturated solution of ammonium sulphate for woven instruments. 30 URETHRAL INSTRUMENTS: THEIR ASEPSIS Unfortunately the one instrument that is the least subject to any of these rules, viz., the cystoscope, is the very instrument that preeminently requires sterilization. The special measures required for sterilization of cystoscopes are, therefore, considered elsewhere (p. 51). All other instruments should be subjected to the following: 1. Soap and water wash, inside and out, immediately after using. Then rinse in water and boil for at least fifteen minutes in strong salt solution. 2. Keep the instruments in an instrument case, the interior of which is kept at least relatively clean by formalin (trioxymethylene) pastilles, or a formalin lamp. 3. Unless the instrument has been recently used and its asepsis assured, always resterilize by boiling for fifteen minutes immediately be- fore using. 4. Use a separate set of catheters at least for gonorrheal cases. The special variations and precautions in the technic of sterilization required by various instruments are the following: Dilators and Other Complex Instruments.—Dilators, urethro- tomes, and such complex instruments should be made of pure nickel; otherwise it is almost impossible to keep them from rusting. If nickel- plated, they must be sterilized like the cystoscope (p. 51). Woven Instruments.—It is the accepted tradition that woven in- struments cannot be boiled, and it is current practice to sterilize them by formalin vapor. But I have for several years been boiling all my woven instruments, and can assert that they stand boiling perfectly well if they are of standard French manufacture (any one of half a dozen firms) and if their sterilization is surrounded with a few simple precautions. When a woven instrument is boiled, its varnish becomes utterly soft, and therefore cracks if any other instrument rests upon it, or if it is bent before it has cooled. Therefore it must lie perfectly straight in the sterilizer, touching neither the sides nor the ends of this, and with no other instrument resting upon it. More important still, after the instrument has been boiled it must not be touched until it has been cooled off, either by lifting it from the water on an automatic platform or by pouring in cold sterilized water. ASEPSIS OF OTHER INSTRUMENTS AND OF SOLUTIONS In order to permit clean urethral work, the wall tanks, syringes, and other containers, as well as the solutions, must be sterilized quite as care- fully as the urethral instruments themselves. Tanks, Syringes, Etc.—All containers are best sterilized by boiling immediately before each clinic or office hour. Wall tanks may, however, be left filled with an antiseptic solution between times. It is necessary URETHRAL INSTRUMENTS: THEIR ASEPSIS 31 to have at band a pan of boric acid solution in which to cool sounds after boiling, and to rinse instruments that have been sterilized by formalin. It is my custom to keep all syringes, hypodermic needles, mixing rods, instillator catheters, in a 10 per cent formalin solution, supersaturated with borax.1 It is peculiarly important that all containers should be kept from any contact with urine. The measuring glass for urine should, there' fore, be of a peculiar shape, readily distinguishable from that employed for the solutions. Solutions.—All solutions should be made up fresh, warm, and asep' tic. The chemicals are kept in a certain stock (preferably solid) form (p. 179), and the water must be both sterile and warm. The urologist should have two boilers, containing a gallon or two apiece, each one of which should be boiled every alternate day, so that hot and cold sterile water are at hand to be mixed in any desired proportion. For him who depends upon a central supply of sterilized water (e. g., a boiler in the operating room), it is more convenient to keep cold sterile water in a glass reservoir and hot water in a metal reservoir, covered with asbestos. SUMMARY OF INSTRUMENTAL ASEPSIS For Cystoscopes.—Cabinet containing formalin lamp and desicca- tion apparatus. Clean well before and after sterilization. For Other Instruments.—Boil for fifteen minutes. Use soluble lubricants, and boil again after use. Keep in formalin cabinet. For Solutions.—Hot and cold boiled water in boilers or tanks. Containers boiled daily. Mixing rods, syringes, etc., boiled and kept in sterile solutions. 1 Steel instruments do not rust in this solution if enough borax is kept in it actually to supersaturate it and leave a little undissolved at the bottom of the jar. As the borax dissolves very slowly what may appear enough when the solution is first made up proves insufficient a day or two later. CHAPTER IV THE PASSAGE OF URETHRAL INSTRUMENTS The successful introduction of an instrument into the urethra de- pends upon the skill of the operator and his comprehension of the obstacles that may defeat the operation. ANATOMY OF THE URETHRA The urethra is the outlet of the bladder. It commences at the blad- der neck, hut embryologically and anatomically that part of the floor of the bladder known as the trigone (i. e., the triangular space between the orifices of the ureters and the urethra) belongs to the urethra, and will be so considered. The urethra tunnels the upper part of the prostate, perforates the triangular ligament, and terminates at the end of the penis. Its outer Fig. 13.—Sagittal Section through Glans and Fossa Navicularis. (Cruveilhier.) Fig. 14.—Transverse Sec- tion of the Penis. (Cru- veilhier.) opening is known as the meatus, or the meatus urinarius. The urethra is divided naturally into two parts, the anterior and the posterior urethra, by the triangular ligament, the anterior urethra lying external to the anterior layer of that structure, and the posterior urethra being the continuation of the canal backward into the bladder. The anterior or spongy portion of the urethra is again subdivided into four parts, the navicular (or the fossa navicularis, Fig. 13), penile (Fig. 14), scrotal, and bulbous or bulboperineal. The posterior urethra is subdivided into the membranous, the prostatic, and the trigonal portions. It is much more accurate to speak of a lesion, such as a foreign body or a 32 ANATOMY OF THE URETHRA 33 stricture, as being at the penoscrotal angle or in the bulb, than to say it lies at a depth of 4 or 6 inches, for not only does the length of the urethra vary according as the penis is erect or flaccid and in disease (hypertrophy of the prostate), but the urethral length, the urinary dis- tance, varies widely in different healthy individuals (p. 37). The urethra is always a closed canal throughout its whole course, except when distended by some foreign substance. The mucous membrane of the urethra consists of a layer of epithe- lium, of which the superficial cells are squamous in the navicular and prostatic regions and columnar elsewhere, on a connective-tissue base- ment substance particularly rich in elastic fibers to allow for the great distensibility of the canal. THE ANTERIOR URETHRA In the anterior urethra the mucous membrane is surrounded, except in the fossa navicularis, by a very thin longitudinal layer of unstriped muscle fibers (in direct continuity with the inner fibers of the prostate), and these are in turn sur- rounded by a circular layer of unstriped muscle. These circular fibers are so few around the spongy urethra that their very existence was denied by Sappey. Finally, the anterior urethra is sur- rounded from triangular ligament to meatus by the corpus spongiosum, except for the half inch nearest the bladder, where the corpus spongiosum fails to cover the roof of the urethra and is enlarged below into the bulb. Crypts and Glands.—In the roof of the fossa navicularis lies the lacuna magna (Fig. 15), a sim- ple pocket in the mucous membrane with its orifice toward the meatus, and consequently open to entrap small instruments. This lacuna varies greatly in size in different persons, being some- times entirely absent, and occasionally running as far back as the triangular ligament, forming the so-called double urethra (q. v.). A few other smaller lacunae lie along the roof of the penile urethra. The glands of the urethra,1 to be distinguished from the lacunae, are of the compound racemose type, of very small caliber, lined with a cylindrical epithelium. They lie chiefly on the roof of the anterior urethra, and are more numerous in its deeper parts. They are also found on the roof of the membranous urethra. In some instances they pierce the sheath of the corpus spongiosum and extend for some Fig.' 15. — Lacuna Magna. (Cru- veilhier.) 1Paschkis, Monatsbericht f. Urol., 1903, No. 6; and Lichtenberg, Beitr. z. Histol., etc., d. Urogenital Kanals, etc., Wiesbaden, 1906. 34 THE PASSAGE OF URETHRAL INSTRUMENTS distance within it—an important fact in relation to organic stricture of the canal, since these glands convey the products of urethral inflam- mation into the corpus spongiosum and so involve it in the subsequent cicatrization. Coivper’s glands are two small, round, lobular bodies, each about the size of a cherry stone, lying just behind the bulb of the urethra in the muscle between the layers of the triangular ligament. Their ducts open on the floor of the bulbous urethra. The color of the membrane is pale pink. In rest its walls are in contact, obliterating the cavity of the canal, so that a cross-section pre- sents a transverse slit instead of an opening (Fig. 18). The anterior urethra is called the external urinary tract, and the canals and reservoirs beyond the internal urinary tract, for the anterior urethra is in free communication with the surface of the body and har- bors all the microorganisms that may lie thereon. As a general thing it does this with perfect impunity. Its flora include the bacteria found upon the skin; notably pseudodiphtheria bacilli and staphylococcus albus (p. 166). Such bacteria as flourish normally in the anterior ure- thra, being constantly washed out by the urine, and entering only through the meatus (except under pathological conditions), are most numerous in the fossa navicularis, and indeed are usually found only in that region. THE POSTERIOR URETHRA The posterior urethra, extending from the anterior layer of the triangular ligament to the bladder, presents many notable points of contrast with the anterior urethra. The canal is no longer surrounded by erectile tissue, and, indeed, it could scarcely become erect, for whereas the anterior urethra is freely movable with the penis, the pos- terior urethra possesses a fixed curve—of which later. Moreover, the posterior urethra is, in its normal state, entirely free from the bacteria harbored by the anterior urethra; it is the lowest section of the aseptic internal urinary tract. The posterior urethra is divided into the membranous and the pros- tatic urethra, and the trigone of the bladder. The Membranous Urethra.—Of all parts of the canal the membra- nous urethra is the most fixed, running, as it does, from the aperture in the anterior layer of the triangular ligament to the aperture in the pos- terior layer. Its mucous membrane, though of a darker color and much more sensitive, does not differ in structure from that of the anterior urethra. This in turn is surrounded by a thin layer of unstriped muscle, but instead of being sheathed in the corpus spongiosum, it is embedded in the voluntary muscle that fills the space between the two layers of the triangular ligament. This muscle has had special names given to different portions of it by Guthrie, Muller, Wilson, and others, but it ANATOMY OF THE URETHRA 35 may be considered clinically as one muscle, the constrictor or compressor urethrae, the cut-off muscle, the external or voluntary sphincter of the bladder. The last term best expresses its function. It is the muscle by which the outflow of urine from the bladder is voluntarily opposed. It may suffer from spasm, and so not only prevent urination, but also present a serious obstacle to the introduction of instruments. This is spasmodic stricture (q. v.). The Prostatic Urethra.—The prostatic urethra tunnels the pros- Fig. 16.—Lower Part op the Male Bladder, with the Beginning of the Urethra. Exposed by incising the anterior wall and laying it open. 3, ureter; 4, opening of the ureter; 2, vas deferens; 9 verumontanum; 7, center of trigone; 8, section of prostate; 10, orifice of the common ejaculatory duct: 11, opening of utricle; 12, mouths of prostatic gland ducts; 1, interureteric fold. (Henle.) tate, sometimes barely covered by that organ above, sometimes deeply embedded in it (Fig. 18). It is fixed only where it joins the mem- branous urethra. It is fusiform in shape, being closed internally by the internal or involuntary sphincter of the bladder. Into it the ducts of the sexual organs empty. It is lined by squamous epithelium like that of the bladder, and is liable to great deformity and obstruction by prostatism. Upon its floor rises a little mass of erectile tissue, the verumontanum, or caput gallinaginis, the anterior slope of which is hollowed out into a little cavity, the sinus pocularis or utricle (Fig. 16). The prostatic ducts open upon the floor of the urethra on each side of the verumontanum. The ejaculatory ducts usually open in the sinus pocularis or on its edges. 36 THE PASSAGE OF URETHRAL INSTRUMENTS Fig. 17.—Sagittal Section of a Frozen Male Subject. The small intestine is removed. 1, peritoneum; 6, opening of the ureters; 8, internal sphincter; 9, external sphincter, with the compressor urethrae muscle; 10, dorsal vein of the penis; 15, bulbocavernosus muscle; 16, bulb of the urethra; 17, sphincter ani; 21, utricle; 24, isthmus of prostate; 29, seminal vesicles. (Henle.) THE SPHINCTERIC MECHANISM The urinary tract, like the intestinal tract, possesses two sphincters, an internal sphincter of unstriped muscle and an external sphincter of striped muscle fiber (Fig. 17). The External or Voluntary Sphincter.—This is the constrictor or compressor urethrae, mentioned above. It surrounds the membranous urethra almost to the apex of the prostate. On the upper surface of the urethra the fibers of the compressor continue back for a centimeter or more over the anterior surface of the prostate. The Internal Sphincter.—The internal sphincter surrounds the neck of the bladder and spreads out fanlike throughout the trigone of ANATOMY OF THE URETHRA 37 the bladder, reaching the ureteral mouths, and thus forming a con- necting band between the ureters and the urethra. THE VESICAL TRIGONE Kalisher 1 has plainly shown that the trigone, i. e., the triangular portion of the bladder floor lying between the orifices of the urethra and of the ureters, belongs to the urethra and not to the bladder. The trigone develops with the urethra and the ureters, while the bladder is developed from the allantois. The muscle of the trigone is the in- ternal sphincter. The mucous membrane contains papillae and a few scattered glands (which the bladder proper does not). The circulation of the lower ends of the ureters, the trigone, and the prostatic urethra is derived from the inferior vesical artery. The lymphatics of the tri- gone are more numerous than they are elsewhere in the bladder, and are in di- rect communication with those of the posterior ure- thra. Length.—The length of the urethra, varying as it does in different individuals and in the same individual ■with erection of the penis and hypertrophy of the prostate, may be set down as averaging 20.5 cm. (85 inches),2 and varying in different normal individuals from 18 to 23 cm. to 8f inches). The posterior urethra is usually 5.5 cm. inches) long—2.5 cm. (1 inch) to the membranous portion, 3 cm. inches) to the prostatic—and the anterior urethra 15 cm. (6 inches) long, subdivided as follows: 2.5 cm. (1 inch) to the navicular region, 6.25 cm. inches) to the penile, 3 cm. inches) to the scrotal, and 3 cm. inches) to the bulboperineal. Diameter.—The diameter of the normal urethra (Fig. 18) varies even more than the length—it has been estimated at from 2 to 6 lines. A fair average is not larger than 0.75 cm. (0.3 inch) ; about ISTo. 27, French scale. But, whatever its size, the urethra is not a tube of uni- form caliber from end to end. It has naturally four points of physio- logical narrowing: the first at the meatus, the second at the peno- navicular junction, the third beginning about half an inch hack of this, and becoming most pronounced at about the penoscrotal junction. The fourth and fifth constrictions are the voluntary sphincter (the entire membranous urethra) and the internal involuntary sphincter (the neck Fig. 18.—Longitudinal Section of Urethra, a, b, and c represent the prostatic, membranous, and spongy portions of the urethra. (Thompson.) •'“Die Musculatur des Dammes,” p. 151. 2 Keyes, Am. JMed. Set., 1898, cxvi, 125. 38 THE PASSAGE OF URETHRAL INSTRUMENTS of the bladder). Of these five narrow points, three, it will be ob- served, are organic and situated in the anterior urethra, while the other two are muscular and situated in the posterior urethra. The muscular constrictions are widely dilatable, and the caliber of the canal is deter- mined by the meatus, normally the narrowest point. Hence the caliber of the urethra is the caliber of its normal meatus. The penonavicular and penoscrotal constrictions are usually mere irregularities in the canal, besides which there are often lesser contractions at various points, making the urethra, when distended, not a smooth, evenly calibrated tube, but a very irregular one. The three chief dilatations of the normal canal are the fossa navicularis, which is situated just inside the meatus; the bulbous urethra, occupying a position immediately in front of the triangular ligament, and the prostatic urethra (Fig. 18). Of these the second is the largest. Curve.—In relation to these variations of caliber Guyon’s observa- tions upon the relative qualities of the urethral roof and floor are of in- terest far more from a practical than from a theoretical point of view.1 ITis observations may be classified as follows: 1. The roof of the urethra (when the penis is erect) forms an unin- terrupted curve from the fossa navicularis to the bladder. 2. All the variations of caliber, except the fossa navicularis, are produced at the expense of the floor, which is, in consequence, very ir- regular.2 3. The mucous membrane of the roof is more closely adherent to the subjacent structures than that of the floor. 4. The mucous membrane of the floor of the urethra is much more elastic than that of the roof. Therefore, not only is the floor of the urethra more irregular than the roof, but its irregularities may be increased with much greater facil- ity by any object introduced into the canal, as well as by disease. In other words, instruments, especially if small and rigid, may, with their points, furrow the floor of the urethra until, finally, they become pock- eted (usually in the bulb), and so are brought to a full stop, while an instrument whose point impinges always on the roof avoids these ob- structions and glides easily into the bladder. Therefore this eminent French surgeon has termed the roof the surgical wall of the urethra— the wall, namely, which is the guide to instruments entering the bladder. That fistulae and false passages almost always occur in the floor and lateral walls, and that the orifice of a stricture is usually nearer the roof than the floor—these two facts make the roof the surgical wall in dis- ease even more than in health. 1 *1 Lemons, ’ ’ ii, 309 et seq. 2 Though not absolutely accurate, both of these observations are clinically cor- rect. THE CURVE OF URETHRAL INSTRUMENTS 39 THE CURVE OF URETHRAL INSTRUMENTS From these considerations it follows that the curve of the urethra is the curve of its roof. Flow the entire anterior urethra is freely mov- able with the penis, and can be made to assume any curve. Not so the posterior canal. The membranous urethra, bound tightly at its ex- tremities by the two layers of the triangular ligament, is the real fixed point of the urethra, and runs at a distance of from 1 to 2 cm. (f to § inch) below the symphysis pubis. In front of this the bulbous urethra tends slightly upward because of the tension of the suspensory ligament and of the skin and fascia, while a similar elevation is given to the pros- tatic urethra behind by' the puboprostatic ligaments and the anterior fibers of the levator ani muscles. Thus is formed the so-called fixed curve of the urethra—not a true fixed curve, for by depression of the bulbous and the prostatic urethrae to the level of the membranous por- tion it can be, and often is, transformed into a straight line—as when a sound is pushed home until its shaft is in line with the patient’s body, or when straight metal instruments are introduced. The curve varies 1 slightly in different persons, and in the same person at different periods of life, being shorter and sharper in the child, longer in the old man. An enlarged prostate lengthens the curve. PHYSIOLOGY OF THE URETHRA Sensibility—Under normal conditions the sensibility of the an- terior urethra is slight, although it is exquisitely sensitive when in- flamed. The prostatic urethra may he excessively sensitive, while the 1 The proper average curve, as recognized by Sir Charles Bell and insisted on by Sir Henry Thompson and Dr. Yan Buren—the one which will mathematically accord with the greatest number of urethrae—is that of a circle 8.125 cm. in diameter; and the proper length of arc of such a circle, to represent the subpubic curve, is that subtended by a chord of 6.875 cm. long. An instrument made with a short curve of this sort will readily find its way through the normal urethra into the bladder without the employment of any force. It is very desirable that instruments intended for habitual use should be so constructed, inasmuch as many of the difficulties of eatheterism are due to a defective curve in the instrument employed. The defect most frequently encountered is too great straightness of the last half inch—a deviation of the curve at its most important point. In an instrument properly made it will be found that a tangent to the axis of the curve at its extremity will intersect the pro- jected axis of the shaft at a little less than a right angle. If the curve comprised only a quarter of the circle, the tangent would meet the projected shaft at a right angle; but instruments made a little longer, as they are usually found, invariably have the last part of the curve tilted off into a faulty direction, making the angle between a tangent to the axis of the curve at this point and the projected axis of the shaft obtuse, and falling within the right angle. 40 THE PASSAGE OF URETHRAL INSTRUMENTS membranous portion of the canal is always somewhat sensitive. Indeed, the first passage of an instrument through this part of the urethra of a nervous individual is attended not only by pain, but also by a decided shock. lie becomes pale and nauseated, may even faint, if not already in a recumbent position; while the recorded deaths ensuing upon this simple maneuver, though few, attest its severity.1 This acute sensi- bility becomes rapidly deadened, unless the canal is inflamed, so that after a few repetitions the operation is attended by no .shock and but little, if any, pain. This urethral shock is an element in some cases of so-called urinary fever. It is rarely the sole cause of death, but often contributory by its reflex action upon diseased kidneys, and tingeing the frankly septic cases with a neurotic element not otherwise to be explained. Moreover, it contributes to the elucidation of the mystery of urethral neuralgia and urethral spasm, and is doubtless concerned in the explanation of the fact that the form of septicemia known as urinary fever, so common after injury to the deeper portions of the canal, becomes less and less to be feared the farther forward the injury, and is unheard of when the trauma affects only the balanitic portion of the canal. Mobility.—The muscles of the penis and urethra are thrown into action only during urination or erection and emission, and their func- tions are therefore more fitly described under these titles. A few words concerning the cut-off muscle may not be amiss in this place. Besides its most important function of preventing the urine from escaping from the bladder by an effort of the will and of cutting off the stream, it pre- sents several interesting physiological characteristics. The urethra in front of the cut-off muscle swarms with bacteria, while all beyond is germ-free. This is so, not because the muscle presents an impassable barrier, for it does not. When violently contracted it doubtless does form an insurmountable barrier to bacterial invasion, but its periods of contraction, like those of the external sphincter ani—to which it bears a close resemblance—are comparatively infrequent and of short dura- tion. Its normal tone, however, is sufficient to make the channel a narrow and difficult one, readily cleansed of any chance invader by the periodical outflow of urine. It is suggestive, moreover, that the cut- off muscle surrounds the most sensitive part of the urethra. Hence the cause of spasm in this muscle, whether acute from some local or general shock, or chronic as a specific evidence of a neurotic habit, is not far to seek. 1They are doubtless due to status lymphaticus. TECHNIC OF PASSAGE OF SOFT URETHRAL INSTRUMENTS 41 TECHNIC OF THE PASSAGE OF SOFT URETHRAL INSTRUMENTS Antiseptic Preparations.—The instruments are sterilized, the opera- tor’s hands washed and the meatus and glans cleansed, as described in Chapter III. Lubrication.—The object of lubricating a urethral instrument is not to make the instrument slippery, hut to let it slip through the meatus. A small dab on each lip of the meatus is all that is needed, and this is best applied, not by greasing the whole shaft of the instrument, but by transferring a bit of lubricant to its tip, and with it smearing the lips of the meatus. Position of the Patient.—The patient should lie flat upon his back for the first instrumentation, since this sometimes causes marked nerv- ous shock. But for subsequent operations he may assume any con- venient position. Introduction of the Instrument.—The catheter is readily intro- duced as far as the bulbous urethra. Up to this point the urethra offers no obstruction, unless the meatus is unusually small (p. 213). But unless the penis is held at right angles to the patient’s body, the bend of the urethra at the point of attachment of the suspensory liga- ment (just back of the penoscrotal angle) offers a slight resistance. At the junction of the bulbous and the membranous portions of the urethra the catheter encounters the compressor urethrae muscle. This muscle may present a scarcely perceptible obstacle or it may be excited to reflex spasm of such intensity as to prevent the entrance of the catheter. Method of Overcomixg Spasm of tiie Compressor.—When the advance of the catheter is obstructed by the compressor urethrae, the tip of the instrument may lie just within the grasp of the outer fibers of this muscle or it may pass down into the pocket of the bulb. The first maneuver to overcome this obstacle is to crowd the catheter gently but firmly into the urethra and hold it there for half a minute. On releasing the catheter it either springs back or remains in place. If it springs back it may be taken for granted that the tip of the instru- ment is pocketed in the bulb, and does not present at the opening of the muscle; it must then be removed and another instrument selected. But if the catheter does not spring back it may again be crowded against the muscle in the hope that a slight advance has been made and that fur- ther pushing will finally overcome the spasm. The second maneuver is to select an instrument that will present its point accurately at the orifice of the muscle and have sufficient rigidity to overcome the spasm. The best instrument for this purpose is the 42 THE PASSAGE OF URETHRAL INSTRUMENTS “natural curve” woven catheter. It usually slips readily into the pos- terior urethra. The third maneuver is to aid the passage of the woven catheter by gentle pressure upon the lloor of the bulbous urethra with a finger against the perineum, while with the other hand the catheter is gently pushed forward. The fourth maneuver is to replace the woven instrument by a metal one, and to pass this according to the rules laid down below. If prop- erly performed, this maneuver always succeeds. Method of Passing the Heck of the Bladder.—When a flexible catheter has passed the compressor muscle of a normal urethra it enters the bladder without further difficulty. But if the catheter stops we know that its point has caught in the floor of the prostatic urethra in front of the internal sphincter. It may be lifted out by pressure with a finger introduced into the rectum. TECHNIC OF THE PASSAGE OF METAL INSTRUMENTS The penis, properly cleansed (p. 27) and with foreskin drawn, is held at right angles to the patient’s body while the lips of the meatus are lubricated by a touch with the tip of the instrument. The shaft of the instrument is held over the fold of the groin, its handle nearly in contact with the skin, from which latter (the integu- Fig. 19.—Introduction of Sound. TECHNIC OF THE PASSAGE OF METAL INSTRUMENTS 43 ment, first of the groin and then of the abdomen) it is not to be removed until the point of the instrument is about to enter the membranous por- tion of the urethra. The instrument, at first held along the groin, with point high and handle low (Fig. 19), is introduced at the meatus, and the penis molded up over it. It is not pushed into the urethra, but the urethra is made to swallow the instrument, as it were. When the curve, and perhaps an inch of the shaft, have disappeared within the meatus, the handle of the instrument is swept around over the surface of the belly, so as to lie exactly over the linea alba, parallel Fig. 20.—Introduction of Sound. with it, and still close to the integument. The whole shaft of the in- strument is now to be gently pressed toward the patient’s feet, being still kept close to and parallel with the surface of the belly (the penis, meanwhile, being lightly grasped behind the corona glandis and held steady). The point of the instrument may be followed with the little finger of the hand which manages the penis, and, when it gets fairly past the penoscrotal angle, the whole scrotum, with the testicles and penis, should be -largely seized with the hand and pressed against the pubis, with slight upward traction (Fig. 20). The point may now be felt to settle down and adapt itself to the subpubic curve, after which the weight of the instrument, properly directed, should carry it into the bladder. As soon as the curve lies well against the symphysis, the scrotum, testicles, and penis should be dropped; the hand which held them takes 44 THE PASSAGE OF URETHRAL INSTRUMENTS the instrument, steadies it in the median line, and gradually carries the shaft away from the abdomen (Fig. 21), making the handle describe the arc of a circle, and depressing the shaft between the thighs until it lies nearly in the same plane with them. Ho pushing movement should be imparted to the instrument during this time. The handle is made to describe the arc of a circle, and in a healthy urethra the point cannot go astray. While the instrument is being depressed between the thighs, the free hand is employed in pressing down upon the mons veneris and the root of the penis (Fig. 21), to stretch the suspensory ligament—a point of importance to the easy introduction of an instrument. Fig. 21.—Introduction of Sound. The instrument should be withdrawn with the same deliberation and care with which it is introduced. Ho traction is needed. The motions used in introduction are simply reversed. The handle of the instrument is lightly caught, and without traction made to describe the arc of a circle until it touches the abdomen over the linea alba. It is then car- ried around to the groin, and, by a tilting motion, unhooked from the urethra, ending exactly where it commenced along the groin, the handle low, the point high. The first principle of instrumentation in the urethra is to avoid the use of force. Even in a healthy subject the beak of the instrument may become pocketed in the floor of the urethra. It is to avoid this that up- ward traction on the scrotum and penis is made, whereby the beak of the instrument is held in contact with the roof of the urethra, the surgical TECHNIC OF THE PASSAGE OF METAL INSTRUMENTS 45 wall, until it gently slides of its own weight into the bulb and impinges against the triangular ligament. Here the beak of the instrument naturally sinks into the sinus of the bulb, and ceases to advance. How it is that the operator, by pressing downward the mons veneris, tilts the instrument so that its beak touches the roof of the canal, and slides gently into the membranous urethra, the cut-off muscle relaxing before it. But often the beak is not so readily liberated. That it is still caught in the bulb may be known by the bulging out of its curve in the perineum as the shaft is being depressed between the thighs, and by the rebound of the handle when liberated. The obstacle is overcome by gently maneuvering the point of the instrument, by partial withdrawal and reintroduction, or by slight depression of the beak, then lifting it over the obstacle with a finger in the perineum, at the same time press- ing dowrn upon the shaft of the instrument to make its point sweep the roof of the canal. The dangerous tour de maitre 1 should never be tried, nor any force used in the manipulations at this point, as a false passage is easily made here and under these very circumstances. The depression of the handle of the instrument alone is capable of exerting enormous power. The sound represents a lever of the first order, and the surgeon has the long arm. With a little patience a suitable instrument will always pass into the bladder unless there is a stricture. When the point has traversed the membranous urethra it must continue on freely if the prostate is normal. The so-called spasm of the neck of the bladder does not exist as an ob- struction to the passage of instruments. The sound need only be introduced far enough to bring its greatest diameter into the membranous urethra. This is accomplished when the shaft has been depressed almost, but not quite, to the plane of the body. To pass it farther, so as to straighten out the prostatic urethra, is un- necessary, painful, and, in certain cases, dangerous. Instruments small enough to engage in the sinuses of Morgagni are not used in the healthy canal. Instrumentation in morbid conditions will be detailed in connection with the different diseases requiring it. The cystoscope and the stone searcher are introduced in the manner above described; but the depression of the handle is carried far enough to permit the angle of the instrument to slip over the bladder neck, an occurrence signalized by a distinct jerk on the part of the instrument. The sensation experienced by a healthy urethra is that of hot points pricking the canal along the part being traversed by the instrument. As this enters the membranous urethra, a desire to urinate begins to be 1 The tour de maxtre consists in introducing a sound with the shaft between the patient’s legs until the point is arrested at the bulb; then the handle is rapidly made to describe a semicircle until it reaches a vertical position, when it is at once depressed between the thighs. This is brilliant but dangerous. 46 THE PASSAGE OF URETHRAL INSTRUMENTS felt, which increases as the prostate and the neck of the bladder become distended by the instrument, so that the patient sometimes believes the urine is flowing away, in spite of the surgeon’s assertions and his own observation to the contrary, Hausea, and even syncope, may occur as the instrument distends the prostate, especially on the first introduc- tion in sensitive young people. Occasionally distention of the prostatic sinus produces a partial erection. If the patient faints, the instrument should be withdrawn at once and the legs elevated, while the head is hung over the edge of the lounge upon which he lies. The facility with which this may be done, if neces- sary, is one of the reasons for placing the patient on his back for his first catheterization. The more serious complications of catheterization, such as false pas- sages, urethral fever, etc., will be considered in the succeeding chapters. Ordinarily speaking, none of these complications need be expected to follow the gentle passage of a clean instrument into a urethra which is neither inflamed nor lacerated; but in order to avert the possibility of cystitis or chill it is safe to terminate every catheterization or sounding by an instillation along the whole urethra of a few drops of silver- nitrate solution (1: 1,000), unless some other solution is used as a part of the treatment, or the temper of the urethra is well known. CHAPTER V CYSTOSCOPY Cystoscopy is inspection of the interior of the bladder. The instrument employed, the cystoscope, consists essentially of a tube or telescope, through which the operator looks, and a source of illumina- tion. Modern cystoscopes are of two types, viz.: 1. The closed tube cystoscope, employed with water or water in the bladder (Leiter, Xitze, Albarran, Brunner, Boisseau du Rocher, etc.). 2. The open tube cystoscope, employed with air in the bladder (Kelly, Buys). The Closed Tube.—This instrument, originally devised by Leiter and Xitze, modified and improved by many urologists and instrument makers, is almost universally employed at the present time. It is fully described below. The Open Tube.—For use in women Howard Kelly devised a straight open tube cystoscope, to he introduced with the patient in the knee-chest position and illumined by light reflected from a head mirror. Buys has adapted this instrument for use in the male, by intro- ducing it on a flexible obturator, and adding a suction tube to keep the bladder dry, so that the knee-chest position is not required. The direct vision posterior urethroscope is used for the treatment of certain bladder lesions. But the restricted range of vision disquali- fies all direct vision instruments for general diagnosis of bladder lesions. THE CYSTOSCOPE In its present form it consists of two parts, the sheath and the tele- scope. The Sheath.—The cystoscope sheath (Fig. 22) is a metal tube that serves three purposes: 1. It conveys an electric light into the bladder. 2. It permits irrigation of the bladder before, during and after the cystoscopy. 3. It admits a telescope through which the interior of the blad- der is observed. The Telescope.—The cystoscopic telescope permits the observer to 47 Fig. 22.—The Brown-Btjerger Cystoscope. 1, sheath; 2, obturator; 3, teleseooe. 48 THE CYSTOSCOPE 49 inspect the interior of the bladder, to insert catheters or bougies into the ureters, and to manipulate wires, snares, pincers, etc., for the purpose of performing certain operations within the bladder. The lenses of the telescope may be arranged in three ways, viz.: 1. The prismatic, or indi- rect-vision telescope (Fig. 23) looks out at right angles to the shaft of the sheath. The win- dow through which it looks may be on the concavity (Fitze type) or the convexity of the sheath. The Nitze type enjoys a more general popu- larity, hut admirable instru- ments are made in both types. Each has its advantages. The prism naturally inverts the image (Fig. 24) hut a system of lenses has been devised to correct this inversion without sacrificing light. 2. The direct-vision telescope (Fig. 24) looks directly out through the end of the sheath. It has the same restricted field of vision as the open tube instruments. This type of telescope, though never generally employed abroad, still enjoys considerable popularity in this country. But recent improvements in the prismatic telescope make it the better implement from every standpoint. 3. The retrograde telescope looks hack toward the observer. Such an instrument is calculated to give an exceptionally good view of the bladder neck and adjacent bladder wall. But though Schlagint- weit appears to have solved the problem of retrograde vision in his cys- toscope, here again the prismatic instrument leaves little to he desired. For through it, by the employment of different degrees of distention, all parts of the bladder may be viewed. The cystoscope is spoken of as catheterizing, operating, or examin- ing, to accord with the presence or absence of tunnels, attached to the telescope for the admission of ureter catheters or other instruments. The lever devised by Albarran for the manipulation of these implements Fig. 23.—Lenses of Prismatic Cystoscope. (After Young.) Fig. 24.—Lenses of Direct Vision Cystoscope. (After Young.) 50 CYSTOSCOPY forms an essential part of the telescope to a catheterizing or operating cystoscope. Special telescopes are made for cystoscopic photography. The Choice of an Instrument.—The following considerations may help in the choice of an instrument: 1. Its maker should be accessible. The importation of cystoscopes from distant countries involves harassing delay, expense and mis- understanding, when repairs are required. 2. The instrument should he simple, its sheath round, its lamp “cold,” and preferably with tungsten filament, its lenses corrected for inversion of image, its caliber not more than 24 F. It should admit two 7 F. ureter catheters. A similar instrument for use in children, of 18 F. caliber, admits one 5 F. catheter. Beyond this it is impossible to specify. Each year brings forth some new improvement or some change in fashion. Substitutes for the Cystoscope—While the cystoscope was ap- proaching its present state of perfection several instruments, entitled “urine separators” were devised by Harris, Cathelin and Buys, as sub- stitutes for the ureter catheterism. But perfection of the cystoscope has eliminated them from the field. PREPARATION FOR CYSTOSCOPY Cystoscopes.—As already described. Ureter Catheters.—The best sizes are 5, G and 7 F. The catheter should have at least two eyes. The Albarran flute-tip catheter (Fig. 25) catches the urine better than any other, but it is well to have a few olivary-tip catheters for entering rebellious ureters. In order to estimate how far the catheter enters the ureter, as well as for the purpose of distinguishing right from the left, it is wise to use an unmarked catheter for one ureter and for the other an instrument marked off in centimeters (Fig. 25). Cystoscopic Accessories.—Always have every- thing in duplicate: cystoscope, lamps, connecting cords, etc. Source of Light.—If no electric current is acces- sible one must use dry cells or a storage battery. Ordinarily it is more convenient to depend upon a rheostat attached to an electric light flxture. Hut when this is in use one must never forget the danger of ‘‘grounding55 by wet floors and pipes. INSTRUMENTS REQUIRED Fig. 25. — Flute- tipfed Catheter. Eyes at A, B, C. PREPARATION FOR CYSTOSCOPY 51 When employing the high frequency current for intravesical opera- tions it is safer to derive the cystoscopic current from a storage battery. Source of Irrigation.—At home one uses a wall tank full of cold sterile water (neither heat nor chemicals being required) ; elsewhere a Janet piston syringe. Anesthesia.—Morphin or morphin and scopalamin form an essen- tial preliminary anesthesia of timorous, unaccustomed or sensitive patients. For office work I employ morphin alone; for hospital work the “twilight sleep.” Contrary to what one might expect, the morphin does not inhibit the renal function sufficiently to invalidate clinical conclusions. In addition, the posterior urethra should be anesthetized by the installation into it of 1 c.c. of 10 per cent procain solution, another c.c. of which is deposited in the bulbous urethra. This instil- lation should be given 15 minutes before the cystoscopy is begun. Should the combination of “twilight sleep” and procain prove inadequate (e.g., in the presence of severe tuberculous cystitis) para- sacral anesthesia should be employed. Cocain should never be used in the urethra for fear of the intoxica- tion (and death) which (rarely, it is true) may result. Urethral Instruments.—One may require a blunt-end bistoury to cut the meatus, bougies or sounds to dilate a stricture, “natural curve” woven catheters, 10 F. (to place in the bladder with the ureter cathe- ter), or 16 F. (to empty the bladder after the cystoscopy). Other Accessories.—“Visible” ureter catheters for radiography, so- lutions and syringes for the injection of plienolsulphonephthalein, collar- gol, morphin, etc., sterile test tubes or bottles, appropriately labeled, for the collection of specimens of urine, basins, rubber apron, urine glasses, etc., should be provided, according to the requirements of the individual. STERILIZATION Instruments.—Most of tlie instruments and accessories used in cystoscopy may be sterilized by boiling or in the autoclave. Barney has even made the very ingenious suggestion that the ureter catheters be boiled in lengths of rubber tubing and be attached to the cystoscope encased in these, and so fed into the cystoscope, protected from contact even with the operator’s hand, not to mention his head. But the cystoscope itself may not he boiled. It must be sterilized (after due cleansing with soap and then alcohol) in a solution of car- bolic acid, alcohol or cyanate of mercury or in formalin vapor. Such being the case, and inasmuch as the patient’s urethra cannot be rendered fully aseptic, I prefer to deal in antiseptics. Accordingly my cystoscopes with their accessory cords, rheostats, etc., are kept sterile 52 CYSTOSCOPY in a cabinet in which a formalin lamp is lighted for at least half an hour before each cystoscopy. Ureter catheters are cleansed inside and out in running water immediately after use. Then they lie several hours in 1: 5,000 biclilorid solution. Then they are sterilized inside and out in a small formalin sterilizer. Then they are kept in the formalin cabinet with the cysto- scopes. This may seem an excessive sterilization; and, indeed, it pro- hibits cultivation of bacteria, unless the urine is directly implanted from the catheter into the culture medium.1 But contemplate the dangers of tuberculosis inoculation from unclean catheters! The Patient and the Operator.—The penis or vulva should be cleansed with soap and water and biclilorid solution and surrounded by a perforated sterile sheet, as though for a surgical operation. The urethra should be well irrigated with boric acid solution unless the antiseptic anesthetic lubricant is employed. The operator should be sterilized as for a surgical operation. PREPARATION OF THE PATIENT Preparation before Examination.—A preliminary course of bladder irrigation, urotropin medication, or toughening the urethra by the pas- sage of sounds, is appropriate in many instances. The operation may usually be performed in the physician’s office or at the clinic. But enfeebled or nervous patients, especially nervous women, will appreciate being examined at home or in a hospital. And for them a preliminary hypodermic injection of morphin is peculiarly appropriate. Anesthesia.—The technic I employ is described on the preceding page. That of others varies from the employment of no anesthesia whatever, as in many gyneocological clinics, to the spinal or general anesthesia sometimes given in the hope of performing a satisfactory cystoseope upon an intractable bladder, whether the patient be merely nervous or the bladder itself the seat of elusive, tuberculous, calculous or carcinomatous ulceration. General anesthesia is unsuitable because it interferes with renal function and actually endangers the patient’s life, if there is any con- siderable degree of impairment of the renal function. Position.—Since the bladder may not empty itself spontaneously through the sheath of the cystoseope if the patient lies flat, the head of the table should be raised. The buttocks are brought to the end of the table, the feet or knees supported on rests (the ordinary lithotomy stirrup is most uncomfortable). The nervous woman much prefers being cystoscoped in the Sims’ 1 But it does not interfere with guinea-pig inoculations for the diagnosis of tuberculosis. THE CYSTOSCOPY 53 position. If the bladder is fairly normal this does not entail very grave inconvenience to the operator. Antisepsis—See above. THE CYSTOSCOPY Testing the Instrument.—When all is ready, the operator glances through the telescope to be sure the lenses are not fogged, then attaches the sheath of the cystoscope to the source of electricity to test the lamp. The rheostat is set at the correct point, the wires again disconnected. Introduction of the Instrument.—The cystoscopic sheath with its obturator in place is lubricated and introduced. The female urethra presents no obstruction other than a little tight- ness sometimes encountered. The cystoscope is introduced into the male urethra like a sound. Its entry into the posterior urethra is facilitated by firm downward pressure over the pubes to relax the suspensory ligament. It may slip quite readily over the bladder neck or it may have to be still further de- pressed, aided by the pubic counterpressure until the long axis of the shaft swings beyond that of the patient’s body. The tip may even have to be lifted by a finger introduced into the rectum. But one must always remember that, as in the -case of the sound, entrance into the bladder is effected by swinging the shaft into correct position, not by 'pushing. Any doubt as to whether the instrument has actually entered the bladder is settled by removing the obturator, and injecting a little water. This returns freely if the cystoscope is properly placed (with its aperture turned toward the vault of the bladder). Irrigation.—Enough water is then injected to clear the bladder of blood, pus and lubricant. This is most quickly accomplished by in- jecting about 50 c.c. at a time. When using a modem irrigating instru- ment one need not irrigate the bladder beforehand, or take any special precaution to have the fluid absolutely clean before introducing the telescope. Eor repeated in-and-out irrigation during the operation is the best method of cleaning the field of much pus or blood. Examination—The telescope is then introduced, a stop-cock opened to admit the irrigating fluid, and the examination begun as the bladder is filling with water. The patient’s complaint, if the bladder is much inflamed, or the obliteration of folds, if it is not, is the signal for shutting off the inflow of water. The order in which the various parts of the bladder are examined will depend upon the habit of the operator, and will vary somewhat with the emergency of the case. But it is well to follow a definite sys- 54 CYSTOSCOPY tern lest one overlook some unsuspected lesion. The common practice of plunging the cystoscope into the bladder and two catheters into the ureters, and then retreating without so much as a glance about the rest of the organ cannot be too strongly condemned. We employ the following order in examining the bladder: the bladder neck, the trigone, the ureter orifices, the fundus, especially that part adjacent to the ureters, and finally the vault. With certain cysto- scopes one may also examine the posterior urethra as one withdraws the instrument from the bladder. Ureter Catheterism.—If indicated, the ureters are then catheterized (p. G7), or— Intravesical Operations—Any operative work performed. Close of the Cystoscopy—At the close of the cystoscopy the bladder is emptied, through the sheath, after withdrawal of the telescope. Then there should be injected about 50 c.c. of 1: 5,000 silver nitrate solution, to be urinated out by the patient (if he can empty his bladder) or withdrawn through the cystoscopic sheath (if he cannot). Treatment after Cystoscopy.—To most patients a cystoscopy means no more than a considerable discomfort for a few minutes, followed by a soreness at the neck of the bladder lasting a day or so. But the opera- tion may be followed by a chill, cystitis, pyelonephritis or renal colic. The infectious complications only occur in cases already infected and draining badly. Hence they may be foreseen and properly guarded against by antisepsis, gentleness, and keeping the patient quiet. Benal colic following ureter catheterism may not be foreseen. Its usual cause is probably ureteral occlusion by blood clot. Yet it seems much rarer in those who are able to rest after the operation than in those who have to go about. Consequently it is wise to set the cystos- copy for a time when the patient shall have nothing to do for the rest of the day. Inflammatory complications following the operation are to be treated in accordance with the usual rules. APPEARANCE OF THE NORMAL BLADDER The Normal Bladder Neck.—As soon as the bladder begins to fill with fluid one may examine the bladder neck. With the prism directed upward, the cystoscope is gently withdrawn until there suddenly appears in the field, close to the instrument, a dark red body. This is the bladder neck. If normal it has a crescentic fold with the concavity away from the cystoscope. This fold may be smooth and regular, and upon it one may see the red outlines of the vessels within the mucosa, or it may be lumpy and edematous looking, showing no visible vessels. Though such a picture suggests inflammation it may well be entirely within the normal, and one should not infer that the bladder THE CYSTOSCOPY 55 neck is inflamed unless tlie cystoscope shows evidence of inflamma- tion elsewhere. Keeping this crescentic fold in the field the cystoscope is now re- volved in the direction of the hands of a watch. The normal bladder neck retains its concave, sharply outlined appearance until the cysto- scope has made about one-tliird of a revolution. At “four o’clock,” however, the sharply outlined ring flows insensibly into the trigone. The ring is lost in this red surface until the cystoscope has completed another third of its circle. Then at “eight o’clock” it is picked up again and carried around to the starting point. At the junction of bladder neck and trigone one can follow the lateral edge of the trigone as a rather well-defined ridge, by pushing the instrument inward. The Normal Trigone.—Having completed the inspection of the bladder neck, the cystoscope is once again revolved a half turn to “six o’clock.” With the prism looking downward it is now pushed into the bladder about one centimeter and as it goes one observes the sur- face of the trigone; a surface covered with a sheaf of vessels spread fanwise from the bladder neck toward the posterior edge of the trigone (interureteric bar). That these vessels are not plainly visible may simply mean that the prism is too close to the trigone. Depress the instrument a trifle and they spring into view. After the cystoscope has thus been pushed in about one centimeter from the bladder neck the edge of the trigone, the interureteric bar, springs into view. Up to this point the mucosa of the trigone has been smooth, a rather dark red, and streaked with its radiating vessels. Beyond this transverse bar is seen the fundus, rather wrinkled than smooth, distinctly paler than the trigone, and etched with smaller vessels running hither and thither quite irregularly. The prominence of the interureteric bar varies greatly in different individuals, and with different degrees of bladder distention. If the bladder is only partly filled, and the patient a man, the bar usually stands out quite distinctly with a definite pocket immediately behind. But if the bladder is distended, and the patient a woman, especially a multiparous woman, the trigonal markings may be quite obliterated; so that one cannot tell precisely where the trigone ends and the fundus begins. Here again the novice is likely to make the mistake of keeping the cystoscopic prism too close to the bladder wall. If he becomes confused let his first thought be to depress the ocular end of the prism in order to get a more distinct view of the interureteric fold. Indeed, if the lens is kept a little way from the trigone the whole of it will be inspected by the motion of pushing the cystoscope in until the inter- ureteric fold comes into view, and then turning it to find the ureters. The Normal Ureter Mouth.—After the interureteric bar has been identified the ureter mouth is brought into view by simply rotating the 56 CYSTOSCOPY instrument to right or left until the angle of the trigone is seen (Fig. 26). As the cystoscope turns the eye follows the bar until a marked angle or rather peninsula of smooth trigonal surface is seen. This is marked by a few remaining radiating trigonal vessels, is more or less elevated from the surrounding fundus, and extends laterally and upward to be lost in the lateral bladder wall. As soon as this angle of the trigone is brought into view by rotation of the cystoscope, the rotary motion is exchanged for an angular de- pression, whereby the ocular end of the instrument is turned away from, and the prism is brought toward, the angle of the trigone. Near the base of the little peninsula, and usually fairly in its middle line, the ureter orifice will be seen. The description of the ureter orifice is an entirely hopeless task, for no two normal orifices look exactly alike. The color depends largely upon the illumination and distention of the bladder. One may lay down the rule that neither ureter orifice nor bladder neck should be considered inflamed unless there is evidence of inflammation on the adjacent bladder wail. In shape the normal ureter orifice may appear a wee round hole, a slit, or a “U” fold of mucosa. Contraction of the ureter shows itself by a slight motion in the mucosa followed by a sudden opening of the little hole or slit from which comes a swirl of urine. No very profound conclusions can be drawn from watching the contractions of the ureter. It may he important to note that a bloody or purulent flood issues from it, and one may note that it does contract. But that it does not contract proves nothing. This may be due to reflex inhibition of peristalsis. Another Way of Finding the Ureter.—Inasmuch as the ureter mouth lies at the junction of the base and lateral edge of the trigone, it may be found by following either of these lines. The method just described is the most generally satisfactory; but in some instances oblit- eration of the trigonal markings may make the lateral edge of the tri- gone a better guide. This extends from the bladder neck (at about “four” or “eight o’clock”) almost directly inward to the angle of the trigone, and usually can be quite readily followed, if the prism of the cystoscope is depressed fairly close to the trigone, and rotated toward the side so as to throw the lateral edge into sharp relief against the bladder wall behind it. The Normal Fundus.—The fundus is that part of the bladder lying immediately about and beyond the trigone. Its surface is somewhat irregular, even when the bladder is full, and when the organ is not fully distended the fundus may be thrown wrinkled in folds of con- siderable depth. For a proper examination of this surface it should be fairly well upon the stretch. Then it appears as a relatively pale mucous membrane, covered with interlacing small red blood vessels. Fig. 26.—Maneuvers in Catheterizing Right Ureter (Prismatic Cystoscope). 1, Cystoscope turned to “six o’clock” to fine interureteral ridge. 2\ Cystoscope rotated, following ridge. 3, Beak of cystoscope moved toward ureter. 57 CYSTOSCOPY 58 Tlie region about the angles of the trigone should be most carefully examined as this is the point of origin of most primary papillary tumors and saccules; while here also may he seen the most intense evi- dence of tubercular and other inflammations. To examine the fundus fully the ocular end of the cystoscope should be depressed, and the instrument pushed until it will go no further, or until the light becomes obscured by a fold of bladder wall. The instru- ment is then withdrawn again toward the trigone and, both going and coming, it is rotated gently from side to side, so that the eye sweeps across the whole base of the bladder. The Normal Vault—The cystoscope is then turned over until its prism points directly upward. In the rather dim distance one sees the pearly bubble of air that floats at the top of the water in the bladder, and forms the center from which our observations radiate. From this center one withdraws the instrument, moving it a little from side to side, and inspecting the bladder wall until the bladder neck comes into view; then back to the bubble, and a lateral wall is inspected, as the instrument is slowly swept downward until the trigone comes into view. The opposite wall is then covered in the same way, and finally the ocular end of the instrument is elevated and the instrument pushed inward until one has seen all that remains of the bladder wall beyond the bubble. The appearance of the wall of the normal bladder is the same at the vault as at the fundus. CHAPTEE VI CYSTOSCOPY OF THE DISEASED BLADDER Indications for Cystoscopy.—Cystoscopy is required for the precise diagnosis of every disease of the bladder and ureters, and every surgical disease of the kidneys. To enumerate these would be to waste space. Even the expert may profitably hold strictly to the letter of this rule. The very case in which it seems most reasonable to omit cystoscopy may conceal some important and unsuspected element that could have been revealed only by this method of examination. Contra-indications of Cystoscopy.—The most absolute contra-indi- cation to cystoscopy is ignorance or incompetence on the part of the operator. Interpretations of pathological conditions nmst be founded upon a long and careful study of normal conditions. In the patient, himself, urethral obstruction by stricture, prostate or calculus may pro- hibit cystoscopy. Gonorrhea is a contra-indication unless the need of information is imperative and the importance of the information to be gained outweighs the danger from urethral trauma. Other contra- indications, such as the irritable bladder itself or the patient’s debility, may usually he met by careful preparation and intelligent selection of anesthesia. THE INFLAMED BLADDER That the bladder is not inflamed is judged from the appearance in its mucous membrane of fine branching blood vessels. When these blood vessels cannot be seen (through a clear medium) the bladder is inflamed. The neophyte will mistake variations in color of the mucous membrane for inflammation, though such variations may be due to dif- ferences in bladder distention and degree of illumination. This tend- ency to see inflammation where it does not exist he will evince espe- cially in relation to the urethral and ureteral orifices. Mild, general cystitis shows itself only by the disappearance of branching vessels that should be seen in fundus and vault. The trigone is almost invariably the seat of the most marked inflammation. Here it is difficult to dis- tinguish slight inflammation since this may not absolutely obscure the vessels. A more intense inflammation shows itself characteristically by throwing the naturally smooth surface of the mucosa into little 59 60 CYSTOSCOPY OF THE DISEASED BLADDER irregularities resembling a granulating surface. But the suggestion of inflammation upon the trigone should always be certified by the absence of vessels in the adjoining portions of the fundus. Observation of this will prevent many mistaken diagnoses of inflammation about the blad- der neck, or about the ureter mouth. The more chronic the inflamma- tion of the bladder the more likely it is to be localized. The appearance of irregularly distributed areas of redness and obliteration of the bladder vessels is often spoken of as characteristic of tuberculosis. Yet this condition is seen in many non-tuberculous conditions; especially in cases of bladder sacculation, ureteral stone and non-tuberculous pyonephrosis. Bladder ulcers, occurring in the course of acute cystitis, appear as small whitish erosions, quite comparable to aphthous spots in the mouth. The ulcers of chronic cystitis rather resemble thickened red granulating areas set in an areole of inflamed mucosa. They may show markedly exuberant granulations and be covered by patches of slough or incrusted with phosphates. Such ulcers are readily mistaken for infiltrating carcinoma. On the other hand, ulcers of the so-called “Ilunner” or “elusive” type are red spots so small as to be readily overlooked altogether. They are readily diagnosed, however, by the fact that they crack and bleed freely when the bladder is overdistended and are exquisitely sensitive to touch by ureter catheter. Leukoplakia I have seen but twice. It showed a pearly whiteness in the midst of a red areola of cystitis. TUBERCULOUS CYSTITIS The changes described above (with the exception of leukoplakia) may, any or all of them, be seen in the tuberculous bladder. The more intense, ulcerative and localized the inflammation, and the more it cen- ters about one or the other of the ureter orifices, the more likely is it to be tuberculous. It is perilous to describe any type of cystitis as peculiar to tuberculosis. Even the little tubercules in the mucosa may be simulated in cystitis cystica. THE INFLAMED URETER MOUTH The acutely inflamed ureter mouth shows a distinct edematous swelling of its lips. The redness spreads over and obliterates the vessels on the adjacent portion of the fundus. As a result of the pouting of the ureteral orifice it looks as though the opening were enlarged, though doubtless the swelling actually diminishes the lumen of the canal. Chronic inflammation of the ureter mouth includes five changes. THE INFLAMED URETER MOUTH 61 viz.: surface inflammatory changes, change in shape, change in function retraction, and change in the ejected stream (See PI. I). Surface Inflammatory Changes.—These are similar to the changes of chronic cystitis already described. The ureter orifice may be lost in the inflamed mucosa or it may appear as an intensely inflamed or ulcerated region in the midst of which the ureter mouth is very hard to find unless dilated. Change in Shape.—Inflammatory infiltration and cicatricial con- traction about the chronically inflamed ureter mouth may cause various changes in its shape. As a rule the orifice is dilated while the inflamma- tion is still active. This dilatation may make it appear as a long slit, or as a relatively open round hole. The earlier cystoscopists used to describe a “golf-hole” ureter, a rigid, round, wide orifice. Such an ori- fice is typical of prolonged chronic ureteritis. But it is not often seen, nor is its absence any evidence of the fact that the ureter is not chron- ically inflamed. The “golf-hole” is changed to a “tunnel entrance” by retraction of the ureter mouth, as described below. Change in Function.—Just as the ureter may be chronically and severely inflamed without any notable change in the shape of its orifice, so its function is unimpaired by chronic inflammation unless that in- flammation has invaded the muscular coat and impaired its peristaltic action. If this has occurred the ureter remains still and open, while the purulent or bloody urine dribbles from it in a more or less constant stream. Retraction.—Retraction, like interference with function, means in- filtration of all the coats of the ureter of sufficient intensity and dura- tion to impair the elasticity of the duct and so to pull the ureter mouth upward and outward. Such retraction is often associated with con- siderable inflammation and ulceration about .the ureter mouth. But if this has in large measure subsided, the ureter mouth may he left open, “golf-hole,” and this “golf-holed” orifice retracted toward the side of the bladder appears like the entrance to a tunnel, with the smooth, pale, scarred, tense trigone appearing as the floor of the tunnel. Change in the Ejected Stream.—Inasmuch as the inflammation about the ureter mouth usually, though not inevitably, implies infection of the kidney pelvis, one may look for pus in the urine ejected. But even though the kidney he gravely diseased, the amount of pus in the ejected ureteral stream may be so little as to be distinguishable only under the best of circumstances as to light, freedom from pain and freedom from pus within the bladder, which can often not he com- manded. Therefore, while meatoscopy, as it is called (i. e., inspection of the ureter mouth) may reveal pus issuing from the ureter, this in- formation is obtained more accurately by ureter catheterism. Any con- siderable delay for inspection of the stream as it issues from the uretev 62 CYSTOSCOPY OF THE DISEASED BLADDER is worth while only when some previous effort has shown that it is impossible to introduce the ureter catheter. PROSTATIC LOBES The projecting lobes of an enlarged prostate show much more plainly within the bladder than they do by rectal touch. If there is enlarge- ment of the middle lobe this is distinctly seen as a tumor arising from the floor of the urethra; so that when the cystoscope is swept around the ring of the bladder neck, at about the place where this should dis- appear into the trigone, one sees a fold and then a marked projection, a convex instead of a concave object. This convexity crosses the middle line to where the ring of bladder neck is met beyond. If there is a single lateral lobe that side of the bladder neck is in the same way transformed from a concavity to a convexity with a sharp angle, or fold of the mucous membrane at each extremity. Two lateral lobes project on each side with a fissure between them above, and below. Two lateral lobes and a middle lobe show a set of three convexities with three deep folds between them (PI. II). The size of the lobe may be measured by the distance the cystoscope must be introduced to keep the edge of the projecting lobe within the field. Such measurements are not wholly accurate. BAR OR CONTRACTURE A bar or contracture may be utterly invisible. Sometimes, however, one sees a raised bladder neck with the trigone singularly depressed beyond it, somewhat similar to the normal picture of the interureteric fold. CARCINOMA OF THE PROSTATE A small carcinoma may, like a bar, produce no change in the cysto- scopic picture, while a large carcinoma may so distort the deep urethra as to prevent the introduction of a cystoscope. Sometimes the cysto- scope reveals irregular changes in the shape of the bladder neck—usu- ally a series of irregular small nodules. These may be mistaken for inflammation or for an irregular type of prostatism unless they extend into the trigone or vault. Actual infiltration of the mucous membrane, in the form of carcinomatous ulceration or papillary growths, is not so often seen (PI. I, Fig. G). Since the carcinoma is usually primary in the posterior lobe, one usually learns more by rectal touch than by cystoscopy. PLATE Ii 1 2 3 Cystoscopic Interpretation of the Appearance of the Bladder Neck in Prostatism. Fig. 1.—General prostatic hypertrophy, middle and lateral lobes forming one mass—as seen by the cystoscope. Fig. 2.—Schematic interpretation of Fig. 1. Fig. 3.—The actual condition. TUMOR OF THE BLADDER 63 TUMOR OF THE BLADDER Papillary Tumors.—Cystoscopic inspection does not disclose the malignancy of a papillary growth in the bladder. Inflammatory ulcera- tions whether encrusted or not may well be papillary. But such papillae are relatively short and are distributed over a relatively large bladder surface. They are obviously not neoplastic. The papillary neoplasm, if small, is seen as a tuft of villi growing from a tenuous pedicle. The large papillary neoplasm is likely to have a cauliflower-like appearance, the villi being packed so close together as to appear fused in bunches. Such a large neoplasm may more than fill the cystoscopic field, and bleed so freely as to obscure the diagnosis. The villi also choke the sheath of the cystoscope and interfere with irrigation. Such tumors are often multiple. The Ulcerated Papillary Tumor—Spontaneous ulceration of a pap- illary tumor usually means that it is malignant. The ulceration covers more or less of the surface of the growth with a white slough, to which phosphatic grit is likely to be found adherent. The Non-papillary Ulcerated Neoplasm.—Carcinomatous ulceration of the bladder wall cannot be readily distinguished by inspection from inflammatory ulceration. Inflammatory ulcers usually appear about the trigone and bladder neck while malignant ulcers affect the vault and fundus. Secondary Carcinoma of the Bladder.—Carcinoma invading the bladder from the prostate, the uterus, or other adjacent organs is dis- covered by other means than cystoscopy but the cystoscope measures the involvement of the bladder wall. The earliest change (excepting growths coming from the prostate) is fixation of the bladder wall at the point of invasion. The fixation may sometimes, though not always, be recognized when the bladder is fully distended by wrinkling or dimpling of the surface drawn to one side. This fixation in cases of tumors extending from the uterus is likely to show itself in the fundus just back of the ureteral orifices. As the carcinoma extends further into the bladder wall the surface of the mucous membrane is thrown into red, edematous folds. The picture shows a circumscribed region not unlike chronic cystitis in appearance. Ulceration does not occur until infiltration has existed for a considerable time. Bullous edema, or vesicles, may appear early (PI. I, Fig. 5). Non-infiltrating Neoplasms.—Under this term we include the non- malignant myofibroma of the bladder wall itself, and such tumors of the adjacent tissue (whether malignant or not) as depress the bladder wall without invading it. Such tumors are recognized, after full dis- tention of the bladder, by the fact that they project more or less mark- 64 CYSTOSCOPY OF THE DISEASED BLADDER edly into the bladder cavity, and difference in distention does not ma- terially alter the position of the point of projection. The mucosa over such projections may or may not be inflamed (Ph T, Fig. 4). Cystitis Cystica.—This condition is recognized as a scattered or grouped collection of pearly or pink vesicles distributed over a more or less reddened surface of the bladder. CHANGES IN THE SHAPE OF THE BLADDER Apart from the normal variations and inflammatory changes in the shape of the ureteral orifice, and the changes in the shape of the urethral orifice due to prostatism or neoplasm, the following changes are note- worthy : 1. Cystocele. 2. Ureterovesical cysts. 3. Trabeculation and sacculation. Cystocele.—The importance of cystocele is measured chiefly by the vaginal protrusion, the amount of residual urine and the secondary cystitis. A cystoscopic measure of its extent is the angle at which the cystoscope must be tilted in order to examine the ureter orifice; for in proportion as the anterior vaginal wall gives way, the trigone drops from the long axis of the patient’s body to the transverse axis. So that to approach the ureter orifice of the well-filled bladder in a case of cystocele, the ocular end • of the cystoscope must be carried well for- ward under the pubes. Even when this is done the trigonal markings are so much obliterated in these cases that identification of the ureter mouth is often extremely difficult (PI. I, Fig. 1). Ureterovesical Cyst.—Small dilatations of the submucous portion of the lower end of the ureter are seen as little pouches that balloon up with each wave of ureter peristalsis. If large they are seen as more or less fully distended cysts. If enormous they may so fill the bladder and distort its landmarks as to be very difficult of diagnosis without collargol injection (PI. I, Fig. 14). Trabeculation.—The beginner mistakes the folds in the fundus of the normal bladder for trabeculation; practice in cystoscopy will rem- edy this error. Slight trabeculation can only be recognized when the bladder is completely filled; it then appears as a crisscrossing of little short elevated ridges in the mucosa (PI. I, Fig. 3). It is usually most marked in the fundus. Marked trabeculation is unmistakable, and is often associated with sacculation. Sacculation—The orifice of a saccule is simply a hole in the bladder wall. The mucous membrane about this may or may not appear in- flamed. It may be possible to turn the cystoscope so as to be able to DIFFICULTIES IN CYSTOSCOPY 65 see the bottom of the saccule. But as a rule its size can only be meas- ured roughly by the introduction of a graduated ureter catheter, and more accurately for the larger saccules, by collargol injection and radiography. An enormous saccule may so distend the bladder as to confuse the cystoscopic picture. In such cases collargol injection is the only resource available. STONE Bladder stones so often contain no lime salts that they are over- looked by the x-ray. The cystoscopist readily identifies small stones as wrhite, yellowish or brown, rounded, movable bodies. They are usually seen beside or above the cystoscope, rather than below it. Large stones will be struck by the cystoscope as it is introduced and may simply show an irregular sloughy looking surface which is not always readily distinguished from that of a sloughy neoplasm. The hardness and mobility of the stone generally settles the diagnosis. It is to be remem- bered that neoplasms may be incrusted with phosphates, and thus give a gritty contact. Stone in a saccule is almost always phosphatic, and therefore discoverable by the x-ray. It may be visible within the orifice of the saccule. DIFFICULTIES IN CYSTOSCOPY The dangers of cystoscopy have already been mentioned on page 54. The difficulties of cystoscopy are derived from sources of urethral obstruction, bladder irritability, the presence of pus or blood, and the presence of lesions so extensive as to disfigure the cystoscopic picture. Urethral Obstructions—These are to be dealt with as for a passage of a sound or catheter: the meatus cut; stricture dilated or cut; the prostate surmounted by forcible depression of the ocular end of the cystoscope. The Irritable Bladder.—The bladder may be irritable on account of nervousness of the patient, severe inflammation or actual contraction. Sympathetic management of the individual and thorough anesthesia will overcome these difficulties in large measure. The modern cysto- scope permits a fairly complete examination with no more than 50 c.c. of fluid in the bladder, though under such circumstances one may fail to catheterize the ureter. Pus or Blood.—The presence of much pus or blood in the bladder req cures a relatively thorough repeated preliminary irrigation with small quantities of fluid. If the bladder is sensitive and there are no clots in it, this irrigation should be carried out chiefly by means of the CYSTOSCOPY OF THE DISEASED BLADDER 66 irrigation vents; these admit and expel the fluid much more gently and slowly than when the opening at the end of the sheath is employed. If hlood clots are present, however, a few injections through the open sheath with the syringe (alternated with suction if the injected fluid does not return) must precede the more gentle manipulation. Even if the bleeding is free at the time of the examination, a fairly satisfactory exploration may still be made by patiently going over the bladder wall bit by hit while alternating the inflow and outflow through the vents, so that the examination is made practically through clear fluid that is being injected into the bladder before contamination with blood has time to occur. This method of examination is conducted with the bladder almost empty all the time. The use of water at room tem- perature probably diminishes the bladder and ureteral contraction and this somewhat facilitates the examination. Pus in the urine itself is not nearly so grave an interference with cystoscopy as blood; for the pus even though it is pure and flows quite freely from the ureter never contaminates the bladder fluid so quickly as free bleeding does. Yet the bladder that contains much pus is likely to be a gravely inflamed bladder and the object of the examination is likely to be catheterization of the ureters whose mouths are lost amid this inflammation. Under such circumstances pyuria may prove an insurmountable difficulty. CHAPTER VII URETER CATHETERISM The object of ureter catheterism is, first, to obtain separate speci- mens of urine from the two kidneys; secondly, by means of wax bulbs to detect the presence of stone or stricture in the ureter; thirdly, to permit pyelography and ureterography; fourthly, for treatment. The complete study of a urological case should include all of these. It requires a stay in hospital for the patient from 4 to 24 hours (and perhaps several weeks if acute pyelonephritis results). It implies co- operation between radiologist and urologist. It may invoke the wisdom of the internist or the assistance of pneumoperitoneum. It is both perilous and injudicious to attempt such a study in the office of a physician or in the out-patient clinic. Certain large clinics, it is true, attempt such study upon ambulatory patients, and the mere catheterism of the ureter is of course entirely feasible as an office procedure. Yet even this is often followed by distressing renal colic. I have known death to result from mere cystoscopy. Pyelography adds to the incon- venience and the dangers of the procedure. Urological studies had, therefore, best be made in hospital, though there will still be left plenty of diagnostic or therapeutic cystoscopies for office or out-patient clinic. THE CATHETER Size.—European urologists use larger ureter catheters than we do. They employ rather larger cystoscopes with little or no provision for irrigation during the operation, and qualified to take two catheters or 8 or 9F (or as they would say, of 16 or 18) size. In the United States we employ cystoscopes of the Wappler type almost exclusively and these will take two catheters of 6F or 7F size or one of 10F or 12F size. In the attempt to make ureter catheterism an operation of precision it is not unnatural to attempt to introduce into the ureter a catheter large enough to plug it water-tight. It is the practice of some clinics to use but one big Garceau catheter and collect the urine from the other kidney as it flows into the bladder. The objection to such a practice is two-fold. In the first place, no catheter, however big, is guaranteed to plug a ureter (witness the eccentricities of the in-dwelling catheter) ; furthermore, and what is far worse, dependence upon the reliability of 67 68 URETER CATHETERISM such catheterism engenders an unwarrantable faith in the precision of the quantitative deductions derived therefrom. We must found our diagnosis upon qualitative rather than quantitative analysis of the specimens of urine obtained, i.e., analysis that is sound irrespective of whether or not a little urine has escaped outside of the ureter catheter into the bladder. Hence, the precise size of the ureter catheter is of no great impor- tance. Where circumstances permit, we use two of them rather than one. We have made many accurate observations using 5F catheters. We prefer 6F, for that size permits the routine use of at least a film of a “wax-bulb.” We make no protest against the use of larger catheters. But we do maintain that precision in diagnosis will result only from vigilant observation of the rhythmic drip from the catheter, controlled by examination of the fluid in the bladder at the close of operation. Markings.—The Americans alone use the plain ureter catheter. All others use the catheter marked in centimeters, yet a single gradu- ated catheter may serve as yard stick to all the others. One must form the habit of attributing distinguishing marks to the “right” and “left” catheters. One may nse a “plain” and a “graduated” catheter as a pair. Aly custom is to have the outer end of the catheter for the right ureter cut off square, that for the left cut obliquely. The Tips.—The flute-tipped catheter (Fig 25) is the best for routine use. The olivary tipped instrument will sometimes enter the ureter after the flute-tip has failed. CATHETERISM OF THE NORMAL URETER We assume that the instruments have been properly sterilized; the patient’s urethra anesthetized and washed clean; the cystoscope intro- duced and the bladder tilled and examined. Finding the Ureter Mouth.—-The two methods of finding the ureter mouth, i.e., by the interureteric ridge and by the lateral edge of the trigone, have already been described. The ureter orifice lies usually in the middle of the angle of the trigone at the base of its little penin- sula. It is a slit, a round hole or U-shaped. It is flat or slightly elevated; the same color as the surrounding mucosa or a little redder. In order to see it clearly the beak of the cystoscope must be moved to one side until its prism is almost over the orifice and about one centi- meter from it. If it is not discovered at first one must wait patiently for half a minute or so, when a little movement will he seen in the angle of the trigone as the ureter mouth opens to eject the urinary CATHETERISM OF THE NORMAL URETER 69 stream. If the cystoscope is rightly placed we look for one moment right up into the lumen of the ureter. If after a half minute or so no sign of the ureteral contraction is seen, the ureter catheter should be gently pushed out for about two centimeters and well depressed by turning the lever to a right angle. Following this one proceeds to make pressure upon different points of the angle of the trigone, using the tip of the catheter to probe any suspected region, or laying the whole catheter end against the mucosa, and so depressing it, in the hope of bringing the adjacent ureter mouth into view. The beginner will carry out these manipulations most successfully if he keeps the catheter fixed and moves catheter and cystoscope as a single instrument. If this also fails, the ureter mouth will have to be discovered by meatos- copy, as described below. Introduction of the Catheter—Having found the ureter mouth, the beak of the cystoscope is moved and turned toward it until the lens is less than a centimeter away from it, and a little to its inner side (so that we are looking at approximately “4 o’clock” for the left ureter). The corresponding ureter catheter is then pushed in until its tip appears, crosses the cystoscopic field and passes just beyond it. Then the lever is elevated enough to bring the tip back into the center of the field. After this, levers and catheters are kept rigid while, with cysto- scope and catheter acting as a solid body, the tip of the instrument is depressed until the tip of the catheter touches the mucosa just proximate to the ureter orifice. Then, using catheter and cystoscope as a single solid instrument, it is pushed inward until the tip of the catheter distinctly engages in the orifice of the ureter. With the cystoscope held very steady the catheter is now gently pushed into the ureter orifice. If it has caught in the mucosa it is gently withdrawn, turned a trifle and re-introduced. It is quite likely to be caught at about 1 cm. within the ureter orifice, and again at a depth of 5 cm. it passes the tight point where the ureter issues from the bladder wall. These are not points of true strictures but of normal irregularities in the ureter. If the flute-tipped catheter will not pass in, it must be exchanged for an olivary-tipped instrument. Beyond 5 cm. the catheter slips readily enough up the normal ureter and reaches the kidney pelvis at about 25 cm. It will be halted by contact with a papilla of the upper calyx at about 30 cm., if the kidney is normal. Such contact often excites free bleeding which interferes with subsequent proceedings and the blood is likely to clot in the renal pelvis, obstructing the eye of the catheter and inducing a severe renal colic as it passes down the ureter within a few hours 70 UKETER CATHETERISM after the catheterism. Worst still, a catheter coiled up in the kidney pelvis has been known to tie itself into a knot requiring pyelotomy for its release. Therefore the catheter should usually not be introduced beyond 25 cm., never beyond 30. If the catheter is stopped in this region, or if the urine has already begun to become tinged with blood it should immediately be withdrawn several cm. The manifold difficulties encountered in passing a catheter up a normal ureter are due to precisely the same causes that make the normal urethra so full of pit-falls. Too much haste; too much pushing. The ureter catheter will not, it is true, enter “by its own weight,” but it will frequently fail to enter at all beyond the intravesical portion of the ureter unless guided ever so slowly. The operator should imagine the ureteral mucosa as being furrowed by the tip of the catheter and allow plenty of time, especially in the first 10 cm. for the ridges to flatten out. Evidence of the trauma inevitable to ureter catheterism is borne by the thousands of desquamated epithelial cells, often enough to cloud the urine, and the blood in specimens of normal urine obtained by ureter catheter. In short, the mere fact that the ureter catheter fails to pass a given point is no indication that there is something wrong with the ureter at that point. Indeed the presumption is rather to the contrary. In- dependent evidence, notably the ureterogram, must be had to interpret the cause of ureteral blockage. Drawing Urine.—If no impediment has been encountered the catheter is inserted between 25 and '30 cm. Its tip is then in the renal pelvis and it should promptly begin to emit a constant succession of drops. The first ten or fifteen should be discarded, as these represent bladder content that has been carried up the ureter within the lumen of the catheter. After they have flowed away, a sterile test tube is applied to the outer end of the catheter and, while this is collecting urine from the kidney, the ureter catheter is pushed in 1 or 2 cm. to give sufficient slack, and the cystoscope is turned to follow the inter- ureteric bar until it reaches the opposite ureter. The second catheter is pushed in and the second ureter catheterized. With the two catheters thus placed in the kidney pelvis, before removing the cystoscope, the rate of flow is contemplated and if either catheter appears to be de- livering urine with abnormal velocity, this is noted; and no further move is made until the flow shall have become more normal. Thus any retained urine in the renal pelvis is emptied out and one estimates the amount of retention. But the mere fact of a rapid flow of urine does not of itself prove retention. It may be due to reflex polyuria in a normal kidney. CATHETERISM OF THE NORMAL URETER 71 If either one of the ureter catheters has not reached the renal pelvis the cystoscope will be kept in place until one is satisfied that this catheter is functioning regularly. The catheter in the ureter should emit from three to six or eight drops of urine in rapid succession with intervals of from two to ten seconds. Removal of the Cystoscope.—The cystoscope should not be removed, for fear of accidentally dislodging the catheters, until enough urine has been obtained (about 2 c.c.) to permit microscopical examination and urea estimation. Then— 1. Turn the cystoscope beak upward. Push the catheters in until little more than the ends protrude beyond the ocular end of the cystoscope. 2. Note that the lever is down. Unlock and withdraw the telescope about 3 cm. Push the protruding ends of the ureter catheters home and, as they spring outward from the shaft of the telescope, disengage their tips. Slowly withdraw telescope, resisting the egress of the catheters as well as may be. 3. Permit the bladder to empty. 4. Withdraw the eystoscopic sheath slowly and gently. If the catheters are being drawn out by being jammed in the eye of the sheath, endeavor to counteract this as soon as the tip of the instrument has vacated the bulbous urethra, by counterpressure in the perineum. With the sheath out, the catheters may well have been withdrawn somewhat. The marking on the catheter at the meatus (of the male) indicates the depth at which it still lies in the ureter (unless there is still some slack coiled in the bladder). Further Collection of Urine.—First relieve the patient from his uncomfortable position. Then resume the collection of urine for phenolsulphonephthalein estimation and culture or guinea pig inocula- tion. Whatever the final arrangements, the separate urines are collected in two properly labeled sterile tubes. As soon as the rhythmic flow of urine from each side has been assured an intravenous injection of one c.c. of standard six per cent phenolsuhphonephthalein solution is administered. The time of injection is noted and a square of gauze moistened at several points with a few' drops of alkaline (sodium hydrate) solution. After two minutes have elapsed, a drop of urine from each catheter is let fall on the alkali and this is repeated every half minute until the cerise color of alkaline phenolsulphonephthalein appears (page 79) ; then the catheter tips are transferred to two test tubes and the regular drip from them carefully noted during the ten minutes allotted for collection of phenolsulphonephthalein. 72 URETER CATHETERISM Then a few drops of urine for culture are dropped directly into culture tubes or a few c.c. set aside for guinea pig inoculation. PyelogTaphy and Ureterography.—Meanwhile, if a complete ex- amination is proposed, the radiographic connections have been estab- lished and we proceed to pyelography (page 91), after which the ureter catheters are withdrawn and the wax bulbs examined for scratches; the operation is completed. Failure.—An unsuccessful ureter catheterism is one that fails to obtain enough urine from each kidney for microscopic examination and urea estimation. Other considerations are so secondary to these cardinal ones that should the catheters balk thereafter we may at most call it a partial failure. The causes of failure are two: 1. Failure to introduce the catheter, 2. Failure of the urine to flow. Failure to introduce the catheter up the normal ureter may be due to the following causes: 1. Failure to introduce the cystoscope. 2. Failure to find the ureter mouth. The remedy is meatoscopy (page 83). 3. Failure to get the catheter beyond the normal irregularities of the intravesical portion of the ureter. The remedy is to try different catheters, preferably 5 F, flexible, olivary tipped; to pass them most gently, rotating them slowly as the obstacle is approached. If those fail on both sides, try again a few days later after injection of indigo carmine (page 83) ; if on one side, collect urine from the opposite kidney by ureter catheter and at the close of the operation collect the urine that has flowed into the bladder for comparison. The bladder urine may be diluted by water inadvertently left in the bladder, or by extra-catheter flow; i.e., urine that has escaped down the catheterized ureter outside of the ureter catheter. Failure of the urine to flow in regular jets from the catheters may be due to the following causes: 1. Catheter obstructed by pus or blood left from previous use. The remedy is obvious: clean after using, test before using. 2. Catheter obstructed by a fold of mucosa or by blood or pus in the urine. It is not easy to distinguish the cause of such failure. The catheter simply works inefficiently or not at all. To remedy this, first aspirate through the catheter, gently for fear of exciting bleeding. If this fails, withdraw the catheter about 5 cm. and gently aspirate again. Repeat this maneuver, if necessary, until the tip of the catheter is about 10 cm. up the ureter. If it still fails to deliver urine, inject quite sharply about 2 c.c. of sterile water. Let 30 drops issue from the catheter before beginning to collect urine for examina- URETER CATHETERISM OF THE DISEASED URETER 73 tion. The injection of water should always he reserved as a last resort for it invalidates estimation of the concentration of urea. Should even this fail, it is well to proceed to pyelography at once, recognizing, however, that the kidney may be quite normal or there may be— 3. Atrophy or absence of kidney (page 495). Reflux.—Reflux of fluid from the bladder up the ureter may occur whether the duct is normal or diseased and whether it is occupied by a catheter or not. It is much less likely to happen if the patient’s body is not horizontal but inclined obliquely, as in the usual position for cystoscopy; and if the bladder is emptied as soon as the catheters are in position reflux is negligible. Examination of the Urine.—The first urine drawn is centrifuged and examined, both wet and stained, for pus, bacteria, casts, crystals and urea content. Some experience is required to qualify the examiner to distinguish pus and epithelial cells. A drop of acetic acid is to he added to the wet specimen to bring out clearly the polymorphonuclear pus cells. Red blood cells should be disregarded and attributed to trauma. Renal bleeding can usually not be diagnosed by catheter but only by watching for a gush of bloody urine from the ureter mouth. The hypobromite test for urea is adequate since its findings are comparable for the two kidneys. Complications Following Ureter Catheterism.—The first cystoscopy is often followed by a good deal of bladder irritation for a day or so. Women suffer physically less than men, though mentally they often suffer much worse, so that one should be reluctant to cystoscope them at home or in the office. But the oftener the cystoscopy is repeated the less it hurts, unless the bladder is gravely inflamed. The passage of the ureter catheter adds but little to the discomfort during the operation, but even if conducted with the greatest gentleness, may result in renal colic or acute pyelonephritis. The after treatment of the operation, beyond a few hours’ rest, is the treatment of these conditions. URETER CATHETERISM OF THE DISEASED URETER Stone, stricture and dilatation are the three ureteral diseases dis- tinguishable by the catheter. Stone may or may not prevent or obstruct the passage of the ureter catheter. It may or may not scratch the wax bulb. Small rough oxalate ureter stones habitually cause colic and scratch the wax. Round urate stones cause less colic and little or no scratch. The importance of ureter stricture is not yet determined. That a catheter will not pass a certain point is no more evidence of stricture 74 URETER CATIIETERISM in the ureter than in the urethra. For either canal the sign of stricture is grasping of an instrument (wax bulb) as it is withdrawn. Dilatation of the ureter is shown bj a continuous flow of urine through a catheter, the tip of which is below the level of the kidney pelvis. Continuous rapid flow from both ureters is, however, usually due to nervous polyuria rather than to retention. CHAPTER VIII THE RENAL FUNCTION Estimation of the renal function forms an important element in the diagnosis of almost every disease of the urinary organs. Yet no method of estimating this function can claim to be wholly accurate or all embracing. Hence, perhaps, the accumulated confusion resulting on the one hand from over-enthusiastic praise of some one method, and on the other from undue pessimism in regard to all. Any attempt at exhaustive evaluation of all the methods advocated at home and abroad would but add to this confusion. We shall rest satisfied with a description of the methods employed by the majority of American urologists today. To this end we make two postulates: 1. In the first place, the following description refers exclusively to surgical diseases of the kidney. Eon-bacterial chronic nephritis does, it is true, frequently complicate the clinical picture of surgical renal disease (infection, retention, tumor) ; but the tests that most accu- rately measure the renal function in the latter class of cases are singularly inaccurate in “medical” cases. Furthermore, the test of renal function in Bright’s disease is at once so complicated in its technic and so indefinite in its conclusions that we feel doubly justified in neglecting it.1 2. In the second place, in the interests of brevity and lucidity we must take for granted a comprehension of renal physiology and also omit a description of many of the methods of estimating renal func- tion. Among these methods many have so definite a value that a brief excuse for this omission is called for. Thus “Ambard’s constant,” so much lauded by the French, is not used in the United States. It lacks supreme accuracy; it requires h relatively complex series of observations. Estimation of the freezing point, whether of blood or urine, has similar defects. (The freezing point of any solution, be it noted, measures the number of its molecules, while the specific gravity measures their weight.) Experimental polyuria and oliguria are but practical applications i Cf. Christian, Frothingham, O’Hare and Woods, Am. Jour. Med. Sci., Nov., 1915. 75 76 THE RENAL FUNCTION of the lack of adaptability so characteristic of the diseased kidney, and upon which we shall have occasion to insist. Indeed a study of this phenomenon forms a part of many of our observations. But nothing is to be gained by formal observance of the details either of experimental polyuria or of experimental oliguria. Phlorizin, methylene blue, and many other substances employed for “artificial elimination” tests have all been eclipsed by phenolsulphone- phthalein. Intravenous injection of indigocarmin for meatoscopy has a definite value. THE IMPAIRED RENAL FUNCTION With these postulates granted let us survey the two striking char- acteristics of the impaired renal function. These are: Diminished excretion of solids. Lack of flexibility. DIMINISHED EXCRETION OF SOLIDS Excretion of excrementitious solids in watery solution is the car- dinal function of the kidney. The gravity of any disease of this organ is measured best in terms of lack of efficiency in this, its excre- tory function. But this function is a very complex one. No test or combination of tests measures it with precision. Yet, as already noted, impairment of excretory function by infection is measured with a fair degree of accuracy by the excretion of urea (a little less accurately by specific gravity, a little more so by urine and blood nitrogen and freezing point), and by the phenolsulplioneplithalein test. Urea Estimation.—The total quantity of urine, if between 1,000 and 2,000 c.c., does not tell us much; but it exceeds these limits only because of an unusual excess or diminution of the intake of fluids, excessive perspiration or an impairment of kidney function. Pathological oliguria may mean obstruction to the outflow of urine, acute congestion of the kidney (as in acute Bright’s), or grave chronic impairment of kidney function. These conditions may be readily distinguished by collateral investigation. Polyuria is characteristic of certain types of chronic renal con- gestion, as in tuberculosis, stone, prostatism, retention (q. v.). The polyuria of nervousness, of arteriosclerosis, and other nonsurgical con- ditions do not concern us. The total quantity of urea passed for 24 hours should exceed 45 gm. (50 gm. is regarded as normal). Physiological variations in the total urine do not materially affect the total urea. But disease of the kidney THE IMPAIRED RENAL FUNCTION 77 reduces it. Tlie diminution of total urea is not, however, a good index of renal disease. Neurasthenia, for instance, may reduce it to 110 gm., or even less. The concentration of urea (gm. per liter) is in one sense an indi- cation of health. For the diseased kidney shows its reduction of func- tion very largely by its inability to excrete solids. Hence the concen- tration of urea by a diseased kidney is always relatively low. There are many physiological agencies that interfere with urea concentra- tion. Thus a very dilute urine may be passed as the result of nervous- ness, or of drinking large quantities of fluid, or of arteriosclerosis, quite independently of the condition of the kidney itself. Hence lach of urea concentration is no evidence in itself of disease of the kidney. On the other hand, the presence of urea concentration is an evidence of health of the kidney. A urea concentration of more than 18 or 20 gm. to the liter is evidence of a sound kidney.1 But urea estimation of the specimens obtained separately from the two kidneys by the ureter catheter is of the greatest value. The urine passed simultaneously by two normal kidneys should show a urea concentration which is either absolutely equal or varying not more than 5 per cent (i.e., 1 gm. in 20). In view of the inaccuracy of quantitative ureter catheter findings it is prudent to consider urea percentage 2 much more accurate than urea volume or phenolsulphonephthalein percentage. If they all agree, or if the urea volume or the phenolsulphonephthalein percentage vary in the same sense, but to a different degree from urea percentage, the accuracy of the observation is confirmed. But if they fail to agree, we may have grave doubts as to whether some technical error has not vitiated our conclusions. Retained Nitrogen.—When the kidney function is so impaired that it falls permanently behind the demands of the organism for urea excretion, several phenomena result; loss of flexibility in renal func- tion, loss of the renal capacity to excrete concentrated urine, nocturnal polyuria and the accumulation of excrementitious substances in the blood. 1. Note that the normal urea concentration in the urine varies' from hour to hour under the influence of diverse combinations of exercise, perspiration, eating and drinking and is, in general, dis- tinctly less by day than by night. Thus, for example, a man with normal kidneys passes at 9 p.m. (after dinner) a urine distinctly 1 Yet a patient of mine died of acute renal congestion 53 hours after nephrec- tomy, having passed about 600 c.c. of urine, one portion of which showed a concen- tration of urea amounting to 33 gm. to the liter. 2 Which is the only observation not vitiated by the leakage of urine alongside the ureter catheter. 78 THE RENAL FUNCTION more dilute than he passes at 7 a.m. (before breakfast), and if twelve hour specimens are collected, the total urine passed by day will be found greater in quantity and less in concentration than that passed at night. Loss of kidney function changes all this. The night urine increases in quantity (from about 300 c.c. up to 1,000 or even 2,000 c.c.) and becomes less dense than the urine passed by day. The day urine also, but to less degree, is diluted and the hour to hour fluctuations diminish or disappear. The kidneys are falling behind, as it were, and straining by means of an increased output of water to keep up with their task of excreting solids. The resultant lack of flexibility will be discussed below. For the moment we are concerned with the blood changes that result. 2. The excrementitious substances accumulate in the blood. This accumulation can be measured. It has been found that the nitrogenous compounds are the most profitably studied. The normal blood content of the more important of these is the following: Non-protein nitrogen; 30 to 45 mgm. per 100 c.c. Urea nitrogen; 10 to 15 mgm. per 100 c.c. Creatinin; 0.5 to 1.0 mgm. per 100 c.c. As a result of renal insufficiency the increase in non-protein and in urea nitrogen run quite parallel. For example, when the one reaches CO to 90 mgm. the other is likely to be 30 to 50 mgm. Hence the esti- mate of either suffices. The creatinin retention is rather slower to rise, but a rise in creatinin is distinctly more ominous in prognosis. While it is unsafe to lay down absolute rules, the following may serve as general indications of the significance of blood chemistry in the prognosis of renal insufficiency due to surgical disease of the kidneys. 1. Nitrogen retention indicates what lias happened. Urea concen- tration in the urine (and phenolsulphonephthalein excretion) indicates what is happening. Thus the two should be studied together. Adequate urea excretion may promise the relief of even a considerable nitrogen retention. 2. Nitrogen retention has, therefore, its least significance when it is the result of an acute relievable renal retention. For example, cal- culous anuria lasting several days may accumulate a urea retention of 200 mgm. and a creatinin retention of 5 mgm. Yet the surgeon per- forms bilateral pyelotomy with every expectation of cure through the subsequent adequate function of a relatively normal renal parenchyma. 3. Chronic retention, however, reaching only half the above figures may be most ominous, if the renal parenchyma has been in large part destroyed. 4. The administration of water by mouth, by rectum or subcu- THE IMPAIRED RENAL FUNCTION 79 taneously, is our mainstay in assisting the kidneys to get rid of the accumulated waste products. Bo accumulation of non-protein nitrogen or urea nitrogen in the blood need, in itself, he looked upon as justifying a fatal prognosis. But very few patients survive an accumulation of more than 5 mgm. of creatinin. I have witnessed but two such survivals. Phenolsulphonephthalein.—The “phthalein” test, as it is commonly called, stands supreme among the tests of renal function merely for practical reasons. The dye is almost entirely excreted by the kidneys, and its concentration in the urine is easily and accurately measured. It is an accurate check on the inferences to he drawn from the study of urea excretion and of the loss of Hexibility in the renal function. Idle test was introduced by Drs. Bowntree and Geraghty.1 The apparatus required is a 6 per cent solution of phenolsulphonephthalein; this is sold in 1 c.c. ampules. One also requires a colorimeter. The Dubose colorimeter is much the most accurate; but its readings‘are unnecessarily accurate, i.e., the reading is more precise than is war- ranted by the test. The Dunning colorimeter, though it permits errors of two or three per cent in the reading, is cheaper than, and fully as accurate as, any other for practical purposes. The Hellige colorimeter, though practically no more accurate, is more expensive. The kidney function of a person, known to empty his bladder, is estimated as follows: 1 c.c. of the solution is injected into the muscle of the lumbar or gluteal region. The time of injection is noted precisely. Ten minutes later the patient is made to urinate. If the renal function is normal the phenolsulphonephthalein output will have just begun, and the urine (if acid) will be of an abnormally bright yellow color. The addition of a few drops of sodium hydrate solu- tion, or other alkali, to this urine changes its color to a bright cerise. One hour later the patient urinates again. This urine is diluted to 1 liter and a few drops of 5 per cent sodium hydrate solution added to it render the urine alkaline and bring out the cerise color. The urine is then poured into the ampule provided, and measured in the colorimeter. At the end of a second hour the patient urinates again, and the urine thus obtained is alkalinized and measured in the same way. It will’be found that the normal kidney begins to excrete phenol- sulphonephthalein within ten minutes, eliminates at least 40 per cent of the amount injected within one hour (usually 50 per cent or more), and in the second hour 10 or 20 per cent more. The normal total for two hours is at least 50 per cent; it is usually 60 to 70 per cent, and i Jour, of Pharmacol, and Exp. Tlierap., July, 1910. Cf. also Keyes and Stevens, Am. Jour, of Urol., Oct., 1911, vii, 367, and N. Y. Med. Jour., June 1, 1912. 80 THE RENAL FUNCTION may rise as high as 80 per cent. Rowntree and Geraghty insist that the patient shall drink several glasses of water during the test. This has the advantage of filling the bladder with enough water to insure the patient’s ability to urinate at the end of each hour. The following precautions are to he noted in reference to patho- logical cases: 1. If the urine contains much pus it will become very ropy on addition of the alkali. Therefore the alkali should not be added until after the urine has been diluted. The dye is diluted with the urine and the resulting ropiness does not interfere with the correct estimation. 2. Blood in the urine is a rather serious impediment to exact estimation. Nevertheless, if the urine is permitted to stand for a while before being diluted, the blood corpuscles will settle to the bottom of the glass, and the supernatant fluid may then be used with a fair degree of accuracy. 3. If the patient does not empty his bladder, it is of course neces- sary to catheterize. 4. If the output of phenolsulphonephthalein is much delayed, it may be found that it does not appear in the urine at all for half an hour or even an hour after injection (even longer delay sometimes occurs, but in that case the total output in any one hour is never more than a trace). In such cases the output for the first hour is usually approximately the same as that of the succeeding hours. Most excep- tionally the kidneys delay the output of phenolsulphonephthalein as long as an hour or so and then excrete a relatively high percentage (as much as 35 per cent even) in the first hour, and very little in the succeeding hours. In such cases the delay in output of phenol suphone- phthalein is not nearly so significant of bad function as the ability to concentrate the drug, when it is excreted, is evidence of good function. Consequently in such instances it is well to repeat the test, injecting the plithalein intravenously and measuring the excretion by half hour periods. Phenolsulphonephthalein estimations are, of course, comparable not to percentages of urea, but to total urea, i.e., to the amount of urea excreted in grams during a certain period. Thus we must always bear in mind that quantitative inaccuracies in the amount of urine passed (such as result for instance from retention of some urine in the bladder or, when the ureter catheter is employed, from extra- catheter flow) introduce no inaccuracy in the estimation of urea per- centage but do introduce an unknown element of inaccuracy in the estimation of total urea and of phenolsulphonephthalein percentage. Thus the urea percentage is that estimation which is the freest of all from the element of technical error. But, apart from technical errors, tire phenolsulphonephthalein output is more sensitive than the urea THE IMPAIRED RENAL FUNCTION 81 percentage. On the other hand, phenolsulphonephthalein does rather magnify the loss of kidney function, and exceptionally the phenol- solphonephthalein output is very low although the kidney function is seemingly little impaired. I have, for instance, reported 1 a case of urethral stricture who entered Bellevue Hospital in acute retention. I promptly performed perineal section without a guide under ether. The next day, and several times during the next few weeks, he excreted only a trace of red in twenty-four hours. Yet he had no untoward symptoms. He remained in the hospital for a number of months. Dur- ing that time he was twice given a spinal anesthetic, once for a Cabot resection of the urethra, once for a Chetwood operation on the neck of his bladder, and finally the resulting fistula was closed under a local anesthetic. Yet during all this time he never showed more than 5 per cent of phenolsulphonephthalein in one hour, and during the greater part of the time he passed but a trace of the drug in the first twelve hours after its injection.2 Such a low phenolsulphonephthalein output is usually prohibitive of surgical interference. But the case is cited as showing that in some instances one may disregard a low phenol- sulphonephthalein output if all other signs point to a favorable general condition (and especially if the blood urea is low). Braasch has shown that intravenous injections sometimes give much more accurate readings than injections into the muscles, and attributes this to variations in the rapidity of absorption not directly attributable to renal disease. Perhaps the case cited is thus accounted for. Indeed the current practice seems to be to make all plithalein injections into a vein. Yet I cling to the intramuscular injections (except for ureter catheter estimations) because the rapidity of excretion after intravenous injection is so great that the personal equation of error is multiplied beyond the limit of safety, at least for routine hospital practice. When injected intravenously the concentration of phthalein in the urine reaches its maximum within 10 minutes after the appearance of the dye in the urine. The normal kidneys excrete at least 50 per cent in the first half hour. Estimates should therefore be made by two periods of half an hour each instead of an hour, as customary after intramuscular injections. Phenolsulphonephthalein Excretion in Disease.—Impairment of the total renal function is accurately reflected by diminution of the phthalein output. The immediate output is less, the curve of excretion lower, and the later output correspondingly high. This may be interpreted in terms of lack of flexibility by the statement that the impaired renal parenchyma can not keep up with the immediate demand for excretion. It does what little it can to begin with and excretes the balance later. 1 Am. Jour, of IJrol., 1912, viii, No. 11. 2 He was alive and at work two years later. 82 THE RENAL FUNCTION It is to be noted, however, that disease of one kidney may result in hypertrophy of its fellow to snch a degree that neither the total nrea nor the total phthalein excretion are perceptibly impaired. Hence the following propositions: 1. Impairment of total renal function lowers the peak of phthalein excretion and thus brings the periodic excretions closer together. 2. If the excretion is reduced to between 20 and 30 per cent for the first period (an hour for intramuscular, a half hour for intravenous injection), it rises to between 10 and 20 per cent for the second. 3. If it falls below 15 per cent in the first period an almost equal amount will be excreted in the second and even in the third period. 4. The first appearance of the dye in the urine is correspondingly delayed, usually by not more than 10 to 20 minutes. 5. Exceptionally, after intramuscular injection the appearance of the dye is delayed for an hour, yet the concentration of the dye in the urine may be as high as 30 per cent in the. first hour thereafter. Such a reading should be controlled by intravenous injection which will usually show the renal function but moderately impaired. 6. Even total destruction of one kidney is compatible with a normal phthalein output, due to compensatory hypertrophy of its fellow. 1. A phthalein output of less than 30 per cent in the first period signifies impairment of the function of both kidneys. Phenolsulphonephthalein with the Ureter Catheter.—The more im- mediate, intense and reliable excretion of phthalein following intra- venous injection is as essential for the study of specimens of urine obtained by ureter catheter as it is negligible for general use. Hence intravenous injection should always be employed. Mohan and 11 have found that the output of phthalein reaches its greatest intensity almost immediately after its appearance in the urine, the maximum being in the second or third c.c. unless the urine is very dilute, usually within the first five minutes, and always within the first ten. This concentration may reach as high as 6 per cent per c.c. But the reflex polyuria so common in nervous individuals may keep the maximum concentration down to 1 per cent per c.c., even though the kidneys be quite normal. The general rules governing the excretion of phthalein from normal kidneys, as studied by ureter catheter, are the following: 1. The dye appears in from two to six minutes after intravenous injection. 2. The maximum intensity of excretion occurs in the first five minutes. i Jour. A. M. A., 1921. THE IMPAIRED RENAL FUNCTION 83 3. Each normal kidney excretes at least 1 per cent of phtlialein per minute for the first 15 minutes. 4. A diseased kidney can not concentrate 2 per cent of phtlialein in a c.c. of urine. 5. Yet a normal kidney exhibiting polyuria may not concentrate even 1 per cent per c.c. It is my custom to collect urine for phthalein concentration for no longer than 10 minutes. When the output is free and intense 5 minutes suffices. An output of 1 per cent phthalein per minute proves the kidney normal and large enough to support life. A concentration of 2 per cent per c.c. proves the kidney normal, but does not ensure the presence of enough parenchyma to support life. Geraghty has provided a formula for the ureter catheter diagnosis of the small or atrophied kidney with normal parenchyma (page 496). When the kidney is diseased the changes noted in the output of phthalein as studied by ureter catheter are the same as those already described, viz., delay in appearance and flattening of the excretory curve. As compared with urea concentration the phthalein appears somewhat more sensitive, especially when there is hydronephrosis. Essentially, however, the two agree. Should they contradict each other markedly in a given case the examination should he repeated, greater reliance being placed upon the concentration of urea (or phthalein) per c.c. than upon the total phthalein excretion. Indig'ocarmine.—Indigocarmine is the best substitute for phthalein and has the advantage of being much better adopted to meatoscopy. The expert prefers phthalein. But in clinics, where cystoscopy is done by the internes, many failures to obtain satisfactory ureter catheter specimens of urine have given indigocarmine the preference for rou- tine use. Five to 10 c.c. (the smaller amount usually suffices) of saturated (0.6 per cent) solution is injected into a vein. The cystoscope is then introduced and the ureter mouth watched until a gush of dark bluish- green urine appears. Then the opposite ureter is watched and the intensity of the colors matched. The ureters are then catheterized, if possible. Inasmuch as the visible indigocarmine disappears within 20 to 30 minutes if the kidneys are normal, it is possible, by timing the operation with care, to employ phthalein after the green hue has faded from the urine. The great disadvantage of indigocarmine, as compared with phtha- lein, is that it is much more delayed in appearance and diluted in con- centration by minor degrees of renal insufficiency, so that it often rather distorts the picture. It is also in large measure decolorized by alkalinity of the urine and percentage readings of indigocarmine are not easy to make. 84 THE RENAL FUNCTfON LACK OF FLEXIBILITY Barringer has justly observed that the tests for renal function are actually tests of the reserve force of the kidney; a reserve upon which 1he surgeon usually intends to draw to withstand the shock of operation. Power to take on extra work (flexibility in other words) is, therefore, one of the striking characteristics of the normal kidney function. This flexibility is manifested in changes from hour to hour, indeed from minute to minute, in the quantity and quality of the urine. The dis- eased kidney shows a marked diminution in this flexibility. Such ordinary influences as eating and drinking, perspiring, etc., excite a change in the quality and quantity of its output much less than that of its normal fellow. This lack of flexibility has been made the founda- tion of various tests of renal function, notably the experimental polyuria test of Albarran.1 He collected the urine for four half-hour periods, administering three tumblers of water at the end of the first period. The result of his test may be plotted in very pretty curves, but its accuracy by no means compensates for the length of time consumed. Such formal and time-consuming operations are of use to the student of renal physiology. But the practitioner may, as has been already indicated, found his opinion of renal flexibility on obser- vation of the relative quantity and density of day and night urines and variations in density before and after meals (no need for the precision of a Mosenthal meal). He will also insist that phthalein tests be done in two periods, and will have constantly in mind the fact that efficient function means reserve force, the details of which have already been sufficiently dwelt upon. BLOOD PRESSURE The fact that an increase in blood pressure is frequently associated with (though certainly not the result of) chronic nephritis, is generally recognized. Hence the so called “cardio-nephritis.” But typical cardio- nephritics are not common among our surgical cases of renal insuffi- ciency. Indeed very considerable destruction of renal parenchyma by suppuration and, hence, great restriction of the reserve of renal power, marked renal insufficiency, are quite compatible with low or even sub- normal systolic blood pressure. High blood pressure is associated rather with retention which may only hold the renal function in abeyance, than with the suppuration which destroys it. Thus the relief of pro- static retention may be expected to reduce an abnormally high blood or pulse pressure. i ‘‘ Exploration des Fonctions Renales, ” 1905. CHAPTER IX RADIOGRAPHY It is not my province to instruct the radiologist how to obtain good pictures of the urinary tract. This can be learned only by long experience. Some radiologists obtain good pictures but interpret them rashly and inaccurately. Others get faint pictures, but interpret them with extraordinary skill. The radiologist who can be depended upon to obtain good pictures, and to interpret them with discretion, is as rare a treasure as the good diagnostician in any other branch of medicine. Obedience to the following rules is essential to success: 1. The best pictures are obtained in the morning after the patient has taken an ounce of castor oil the night before, and a low saline or soapsuds enema immediately before the picture is taken. 2. The whole urinary tract should be covered no matter what the preliminary diagnosis. Better results are obtained by using three to five small plates, rather than one large one. The urinary tract extends from the tenth rib above to the pubes below. 3. A good picture of the abdominal portion of the urinary tract should plainly show the tips of the ribs and of the transverse processes, and the border of the psoas muscle. If the diameter of the patient is no more than twelve inches, or if he is not so lean as to be bereft of perirenal fat, such a picture should at least suggest the outlines of the kidney. 4. A good picture of the bony pelvis should plainly show the tip of the coccyx, and of the iliac spines. The tube should be placed so high as to bring the prostate within the field of vision above the pubic bone. 5. All plates should be taken in duplicate, and stereoscopically. PROSTATIC CALCULI Prostatic calculi always contain a large percentage of lime, and apparently always show in the x-ray plate (PI. III). They appear as a group of dots occupying the regions of the lateral lobes of the pros- tate. The larger prostatic stones may reach such an extraordinary size 85 86 RADIOGRAPHY as to be mistaken for vesical calculi. I have several times known pros- tatic and vesical calculi to co-exist. In some instances the vesical cal- culus is shown by the x-ray (Fig. 27), in others not. The differential diagnosis is made by cystoscopy. VESICAL CALCULI In the diagnosis of bladder stone the cystoscope stands first, the searcher second, the x-ray third, in point of accuracy. Stones originat- Fig. 27.—Radiogram Showing Bladder and Prostatic Calculi. ing in the bladder are so often bereft of lime salts as to show very badly in tlie x-ray. It is to be noted that small stones often lie to one side of tlie median line, and sometimes even give the impression of being in the ureter (Figs. 29 and 30). Stones in the bladder, otherwise invisible, may be shown in the PLATE III Fig. 2.—Large Group of Prostatic Calculi. Rectal examination had led to a diagnosis of prostatic carcinoma. No symptoms be- yond a slight frequency and discomfort with urination. Fig. 1.—Small Prostatic Calculus Just Above Pubes. Bilateral ureteral calculus had been suggested by the shadows of the calcified iliac arteries. Fig. 28.—Vesical Calculus; Phlebolith in Region of Pelvic Ureter Fig. 29.—Vesical Calculi. 87 88 RADIOGRAPHY x-ray after injecting air into the viscus, or sometimes after coating them with collargol. These devices, however, are scarcely worth resorting to since cystoscopy shows the stone, and many other things besides. URETER CALCULI The characteristics of ureteral stone as revealed by radiography are the following: They are never spherical; they are usually oblong; in consistency they are not irregular and motheaten; they may be found in any por- tion of the ureter, but are most common near its two extremities. The presence of stone in the ureter may not be disclosed by the x-ray, either because the shadow of the stone is overlaid by that of bone, feces, or other solid matter or—we know not why. Cabot has called attention to the frequency with which stones are overlooked in the region of the sacro-iliac synchondrosis and has shown that by arch- ing the patient’s back over a pillow and taking the picture at the extreme of obliquity with the tube over the patient’s chest, and the plate under the buttocks, the ureters may be drawn clear of the shadow of the pelvis, and stones, otherwise invisible, may be seen. An unusually good x-ray will, however, show a stone even through the pelvic bones. The second reason for invisibility is no reason. I have known the same radiographer overlook a stone in the lower ureter in several plates, and a few weeks later to show it very plainly. The stone was composed almost exclusively of oxalate of lime. Differential Diagnosis of Stone in the Ureter.—The stereoscope is of great assistance in differentiating ureteral stone from other objects likely to be mistaken for this. The course of the ureters is shown in Fig. 30. In their abdominal portions they begin one or two centi- meters to the outer side of the second lumbar transverse process or thereabouts, and if normal, fall almost vertically to the brim of the pelvis where they appear to curve outward slightly, and then sweep inward well to the inner side of the spine of ischium. An oblong shadow in the course of the ureter is likely to be a ure- teral stone. But such a shadow is no more sufficient evidence of the presence of stone than the absence of such a shadow is evidence of its absence. The diagnosis of stone must he confirmed hy other physical evidence, notably hy the wax-tipped catheter, pyelography, or evidence of renal infection and deficient function (PI. IV). Ureteral stone must be differentiated from the following: Phlebolitli, or calculus in the seminal vesicle. Tuberculous glands. i Enteroliths and foreign substances in the intestines. PLATE IV Fig. 1 Fig. 2 Fig. 1.—Shows an oxalate stone in the lower ureter. Fig. 2.—Shows the same stone surrounded by collargol (in the dilated ureter about and above it) injected through the ureter catheter. Fig. 30.—The Stone-bearing Area. Over the pubes is the small oval area of prostatic calculi. From this the usual area for phleboliths runs along the edge of the pelvis (round dots). Bladder stones lie in the large black oval, high in the pelvis. The usual course of the ureters is shown in black. 89 90 RADIOGRAPHY Phleboliths (Figs. 28, 31) may be readily distinguished by being round .and not oblong, and lying near the spine of the ischium, or below it, rather than above and to the inner side of it. In doubtful cases the diagnosis may be thus made by repeating the x-ray with the Fig. 31.—Phleboliths. The. ureters are identified by visible catheters. visible catheter in place, or by pyelography or the wax-tipped catheter. -Not so very infrequently a sclerotic artery may be seen in the region of the pelvic ureter, either as a ring (PI. Ill) or a narrow ribbon suggesting a slightly dilated ureter. Tuberculous glands may well be oblong, though they are likely to bo rather rounded or irregular in shape and often very moth eaten in consistency (PI. V). In doubtful cases the diagnosis is made as in the case of phleboliths. RENAL CALCULI Figs. 33, 34 and 35 illustrate tlie situation, and various types of renal stone. It will he noted that in order to include all stones the photograph must at least cover the eleventh rib, and preferably the PLATE V Pyelography in the Diagnosis of Ureteral Calculus. The patient had an ancient urethral stricture and suffered from vague lumbar pain, while the urine showed mild pyelonephritis (pus, bacteria, albumin, and casts). Radiography showed what appeared to be a stone in the upper part of the left ureter and the functional tests revealed deficient function of the left kidney. Both pelves were accordingly in- jected with argyrol and a radiograph obtained, which showed both pelves undilated, the right ureter (left in plate) dropping normally in a straight line, while the left (right in plate) curved outward, evidently adherent to the lower pole of the kidney, leaving the shadow of the supposed stone between it and the spine. The pyelonephritis and the slight functional inac- tivity of the left kidne 7 (due to ureteral adhesions) were thus shown to be due to infection from the urethral retention and not to stone. THE VISIBLE CATHETER AND PYELOGRAPHY 91 tenth interspace. If stone is suspected, but not shown by x-ray, it may be disclosed by pyelography. Fig. 32.—Calculus in Seminal Vesicle. It is identified by the finger in the rectum. Gall-stones can usually be distinguished as round bodies, lighter in center than circumference, and situated nearer the anterior than the posterior abdominal wall (PI. VII). THE VISIBLE CATHETER AND PYELOGRAPHY The visible catheter is employed to identify the position of stone or suspected shadows in the ureter and kidney pelvis. At present two implements are employed, the one a catheter, the other a bougie, each heavily coated with bismuth paint. This metallic paint renders the catheter or bougie visible to the x-ray. Therefore its introduction into the ureter identifies its position in relation to any suspected stone (Fig. 31). ' Bugbee has shown that if the visible bougie is heated it becomes RADIOGRAPHY 92 extremely flexible, and can be employed, not only to identify the posi- tion of the ureter, but also to curl up in the kidney pelvis, and show its shape and position. But we may go further than this, and inject into the ureter and kidney pelvis a solution or suspension of some metallic salt visible to the x-ray, thus to exhibit misplacement and deformities of this portion of the urinary channel. This is pyelography (PI. IV, also Figs. 36 and 37). Pyelography or more properly pyelography and ureterography, is the injection into the kidney pelvis and ureter of a fluid of sufficiently Fig. 33.—Urate Stone at End of Lower Ureter, Invisible Until Visualized “ Negatively ” by Ureterography. (Stevens.) high atomic weight to throw a shadow upon an x-ray plate, followed by radiography to show their contour. Pyelography is employed in the diagnosis of almost every type of surgical disease of the kidney and ureter. It is especially valuable in the diagnosis of renal retention, tumor, tuberculosis or stone; ureteral retention, stricture or stone. Stones otherwise invisible are disclosed by pyelography by the distention they produce in the pelvis or ureter or even by appearing as a light or “negative” area in the injected fluid (Fig. 33). The capacity of the normal kidney pelvis is less than 10 c.c., usually about 7 or 8 c.c., rarely as little as 3 or 4 c.c. Solutions Employed.—Collargol, argyrol, argentide, thorium, have had their day. The ideal solution for pyelography is sodium iodid or PLATE VI Silent Bilateral Renal Calculi. This patient passed a stone when 14 years of age. When radiographed he was 63 and suffered from prolonged hematuria due to a small, scarcely visible stone (subsequently passed, with relief of all symptoms), just below the angular stone in right kidney pelvis. The stones filling the left kidney had doubtless begun to form 50 years ago. Fig. 35.—Silent Calculus Filling the Renal Pelvis. Fig. 34.—Renal Calculi. They extend from the tenth interspace to the upper border of the third lumbar vertebra. 93 94 RADIOGRAPHY bromid (the potassium salts are too irritating) in strength of about 12 per cent. But, inasmuch as the solution is likely to be considerably diluted with urine in the kidney pelvis, a 15 per cent solution is gen- erally employed. Higher concentrations are objectionable as irritating and not productive of any better pictures. Technic.—The operation requires only a rubber tube about 50 cm. long fitted at one end to the tip of the barrel of a 10 c.c. Luer syringe, Fig. 36.—Normal Kidney Pelvis, at the other to a cystoscopic rubber tip whereby it is attached to the ureter catheter. Pyelograms may be obtained with the catheter tip low down the ureter but better pictures will be had if the catheter is high; the pelvis drained of urine. The receptacle is filled with 15 per cent sodium bromid solution. The tube is filled by gravity and attached to the ureter catheter. The receptacle is now held as high as the short rubber tube will permit (not more than 3 feet above the kidney pelvis). If there is no bubble of air PLATE VII Gall-Stones (Courtesy of Dr. Cole). THE VISIBLE CATHETER AND PYELOGRAPHY 95 in the liquid column this immediately but slowly falls as the fluid flows into the kidney pelvis. Watch closely and the fluid will be seen to stop for an instant as the pelvis fills. Then the first radiogram should be taken. Add two more c.c.; take a second picture; withdraw the catheter until it is no more than 10 cm. up the ureter. Then inject again until the fluid stops a moment and take two more radiograms (injecting two Fig. 37.—Normal Kidney Pelvis. Note visible catheter extending to upper calyx, c.c. more before the second), leave the catheter in place until the fluid ceases dripping rapidly from it; then withdraw the catheter. The operation is completed. If performed in this manner and only upon one kidney, not hydro- nephrotic, the complications of pyelography will be few. But if one waits, as is usually done, until the patient complains of pain in the loin (as he will the moment the pelvis becomes overdistended) severe renal colic and acute pyelonephritis may ensue. Dangers of Pyelography.—Pyelography is a dangerous procedure. A number of deaths due to acute renal infection or to suppression have Fig. 39.—Damage Done by Pyelography. Collargol infil- tration of parenchyma of hydronephrotic kidney removed two days after injection. Fig. 38.—Damage Done by Pyelography. Microphotograph (from Fig. 39) showing collargol in glomeruli, tubules and stroma. 96 PLATE VIII Fig. 1 Fig. 2 Fig. 1.—Patient complained of pain in the hip. X-ray showed a suspicious shadow on tip of transverse process of fourth lumbar vertebra. Ureter catheter always stopped at 15 cm. Wax not scratched. Renal function perfect. Diagnosis: no stone. Visible Catheter Points Directly Toward the Shadow. Fig. 2.—Confirmed by injection of collargol, which showed a kinked ureter, remote from the suspected shadow. CYSTOGRAPHY been reported from it, and many more are unreported.1 The kidney is damaged in one of two ways: 1. The kidney pelvis is overdistended by the injection. The injected fluid is driven into the kidney tubules and lymphatics. Thence it radiates throughout the kidney producing cone-shaped areas of necrosis or infection (if the kidney is infected). (Figs. 38, 39.) 2. Secondary infiltration occurs in hydronephrotic kidneys, due to retention of the injected fluid by closure of the ureter from the trauma of catheterism. Figure '39 illustrates such an infiltration, occurring in spite of the fact that the patient felt no pain either at the time of injection or thereafter. The patient’s life was saved by nephrectomy three days later. A mild pyelitis, characterized by infiltration and edema of the mucosa and even of the whole pelvic and ureteral wall and by sub- mucous hemorrhages is frequently noted in kidneys removed shortly after pyelography. Hence the following rales: Rules for Pyelography.—1. Never pyelograph both kidneys simul- taneously. 2. Never pyelograph a palpably hydronephrotic kidney unless pre- pared to operate promptly. The diagnosis of hydronephrosis of any size can be readily made by noting the amount of fluid that flows imme- diately from the catheter when it reaches the kidney pelvis. 3. Never inject by syringe, always by gravity. 4. Watch the inflow of fluid closely to observe the moment that the pelvis is filled, before the patient feels the pain of over-distension. 5. Keep the patient in bed for at least four hours after pyelography. 97 CYSTOGRAPHY Radiography of the distended bladder is undertaken for the diag- nosis of the following conditions: 1. Diverticulum of the bladder. 2. Ureteral distension. 3. Tumor or stone in the bladder. For the first two, a five per cent solution of sodium bromid or iodid is employed. Stronger solutions irritate the bladder (which is much more sensitive than the kidney pelvis) and give no better pictures. The bladder should not be fully distended. As a routine, one em- ploys about 150 c.c. Radiograms of diverticula should never he taken in the midline as the bladder then overlies and hides the diverticulum. They may be taken at the usual stereoscopic angle. (Figs. 114, 115, pi. XVITI.) i Keyes, and Mohan, Amer. Jour, of Med. Set., 1915, cxiix, 30. 98 RADIOGRAPHY Radiograms of the ureter, especially the dilated ureter, may some- times be obtained by the same technic. One cannot prophesy with any certainty what ureter, normal or dilated, will permit reflux of bladder contents. Tumors of the bladder show very well by radiogram if the bladder is filled with air. This method of diagnosis is most useful in distin- guishing severe ulcerative cystitis from carcinoma. Bladder stones are visualized by air cystography. PNEUMOPERITONEUM Pneumoperitoneum consists in radiography of the abdominal cavity after it has been distended with gas. Air should not be employed as it is absorbed very slowly and causes grave abdominal cramps and dis- turbances of respiration and circulation that may result in syncope and death. Carbonic acid gas, on the contrary, is absorbed so readily that it occasions no inconvenience to the patient. The injection should he made by the technic employed for paracentesis and with the patient on the radiographic table. Radiograms may be taken at various angles. The method is chiefly used in the diagnosis of obscure tumors within the loin. It may be combined with pyelography. INJECTION OF OXYGEN INTO THE PERIRENAL SPACE Oxygen introduced through a needle into the perirenal fat so infil- trates this that subsequent radiograms give a remarkably clear outline of the kidney, even showing the suprarenal capsule. Carelli introduced the method. Quin by1 has obtained some inter- esting pictures with it. Several deaths have resulted from it. I have employed it a number of times with grave misgivings and have once caused acute renal suppuration by puncturing a tuberculous kidney, and do not feel moved to try it again. i Trans. Am. Urol. Ass’n, 1922. CHAPTER X GONORRHEA: ITS SOCIAL ASPECTS AND PREVENTION The importance of gonorrhea to the community rests chiefly upon four factors: first, its transmissibility by sexual intercourse; second, its rebelliousness to treatment, its capacity to extend to the uttermost parts of the urinary and genital mucous membranes and its involve- ment, no less terrible for being rare, of the whole economy in gonococcus septicemia; third, its chronicity and latency, which deceive the patient and even his physician into the belief that the disease is cured until a new outbreak in the patient himself, or infection of a sexual partner, or, if the patient be a parturient woman, of the eyes of her child, reveals the inveteracy and virulence of the disease; fourth, the ease with which female children are indirectly contaminated, and the hospital and family epidemics resulting therefrom; fifth, its sterilization of both sexes by occlusion of fallopian tube and vas deferens. PREVALENCE OF GONORRHEA “It is also a hopeless task to gather the data of this widely spread disease. There are so many cases that are mild and so many among young people who would naturally conceal their disease, that it is out of the question to get anything like complete reporting of gonorrhea. Much of value might result from investigation into the prevalence of gonorrhea among specific groups . . . But there would be many diffi- culties to overcome, primarily because of the present indifference of the communities to the disease.” (Dublin and Clark.1) The prevalence of prostitution in our cities makes gonorrhea en- demic among their population; smaller towns suffer in proportion to the laxity of their morals and their proximity to urban centres, while the countryside is subjected to epidemics of the disease by the return of the Prodigal Son. Morrow 2 estimates that 60 per cent, Forscheimer 3 that 51 per cent of the adult population of the United States have had 1 Social Hygiene, VII, Oct., 1921. 2 “Social Diseases and Marriage.” Also Trans. Am. Soc. Sanitary and Moral Prophylaxis, 1906, I, 18. 3 Boston Med. and Surg. Jour., Aug. 6, 1908. The statistics of gonorrhea in Germany and Austria are given by Erb (Munsch, med. Wochenschr., 1906, LIII, p. 2329, and 1907, No. 31) and Blascko (Zeitschr. f. Belcdmpfung d. Geschlechtskr., 1907, VI, No. 1). 99 100 GONORRHEA: ITS SOCIAL ASPECTS AND PREVENTION gonorrhea. He adds: “Twenty per cent of these young men will become infected before they are twenty-one, over 60 per cent before their twenty-fifth year, and more than eighty per cent before they pass their thirtieth year.” Among women, gonorrhea, though more mutilating, is less common than among men. The proportion of infected men to infected women is estimated at about 16 to 1. Among children, the disease occurs chiefly in the form of gonorrheal ophthalmitis acquired at birth, and as hospital epidemics due to indirect infection. European statistics as to the prevalence of gonorrhea are far more pessimistic than our own. This difference should not be cynically attributed to “Anglo-Saxon prudery.” Climatically, racially and edu- cationally our people are more protected than are the inhabitants of Europe against sexual licence and the diseases attributable thereto. At present our religious protection seems on the wane. Yet its place is being taken by the campaign for social hygiene and efficiency, whether to an advantage or a disadvantage remains to be seen. Prevalence in the Military Service.—Venereal disease is the pest of the Army and Navy, and though gonorrhea is not so dangerous to life and function (with the exception of the generative function) as syphilis, it nevertheless stands far ahead as the cause of temporary disability. Before the War, gonorrhea stood first among Army diseases in point of prevalence. Thus, during 1907, 12 per cent of the troops had gonorrhea; as a cause of non-effectiveness it stood first (36.93 per cent), with syphilis second, chancroid third and tuberculosis fourth. But as a cause for discharge it stood fourth to tuberculosis, syphilis and insanity. Only five deaths due to gonorrhea were reported in the Army during the preceding decade. The War, while increasing the number of admissions for gonorrhea, slightly diminished its relative importance. Thus in 1919 it stood fourth in admission to tonsillitis, bronchitis and mumps, and second, in days lost, to tuberculosis. In 1919 the venereal diseases accounted for 13.4 per cent of absentees from duty, in 1920 for 16.5 per cent, in 1921 for 17.9 per cent.1 Perhaps the most striking illustration of the inaccuracy of statistics concerning the prevalence of venereal disease is furnished by a com- parison of the statistics reported by the medical departments for the armies of different countries. The wide range in the figures bears vivid testimony to the fact that each country bases its statistics on a different set of facts. Thus in the French army the prevalence of venereal disease has hovered for years between 2 and 4 per cent. One might almost suspect that they were “pegged,” though doubtless the reported figures merely show that the absence of routine physical exam- i Clark, The Military Surgeon, Dec., 1921. DURATION OF THE DISEASE 101 ination for venereal disease and a lack of interest in its minor manifes- tations and sociological significance deprives the published statistics of any real value. DURATION OF THE DISEASE “A gonorrhea begins and God alone knows when it will end/’ said Ricord more than a generation since; and the aphorism is as true to- day as the day it was uttered. Where there are no glands (e. g., in the conjunctiva) gonorrhea runs an acute course and then disappears; hut in the genital passages it shows a marked tendency to become chronic by causing chronic glandular catarrh and periglandular sclerosis. From the male urethra tbe gonococci usually disappear within six months. Persistence of gonococci for more than eighteen months in the male urethra is exceptional. The catarrh may continue longer than this, but it is kept alight by the associated microorganisms that persist after the gonococcus has disappeared. The exceptional case whose gonococci remain alive and at least po- tentially virulent for two or three years—I have known but one case to persist any longer—proves the possibility of an indefinite infectiousness. Indeed, the infectiousness of gonorrhea in the male is comparable to that of typhoid fever. Most cases last an indefinite number of weeks and are cured. A small number continue infectious. It may be a mat- ter of great delicacy to determine the persistent infectiousness of a given case. But this does not alter the fact that almost all are cured within a few months. But gonorrhea in the female is a very different matter. Conservative gynecologists are entirely unwilling to set any limit to its infectiousness and are confessedly incompetent in some instances to cure it, in others to 1 “ It has been shown by a number of observers that among the poorer classes of New York City, a certain proportion (commonly estimated at 10 per cent) of female infants and young children are infected with gonorrhea, in an active or latent form, or as germ carriers. The widespread prevalence of this disease consti- tutes one of the most difficult problems in hospital management. No institution or hospital for children, however efficiently managed, has escaped ward epidemics from time to time. . . . “As an example of typical conditions, the Scarlet Fever Service at Willard Parker Hospital for 1913 will be found instructive: . . . “Three hundred and thirty out of 791 female patients on admission had suf- ficient evidence of vaginal infection to demand their segregation, and of these, 21 subsequently developed clinical and bacteriological evidence of the disease and were transferred to the infected wards. It is not to be understood that all of these 321 cases had gonorrheal infection even in the latent form, but experience goes to show that a large number undoubtedly did. Without prolonged and repeated examina- tions, causing an unjustifiable annoyance to the patients, this point cannot be accurately determined. ’ ’—Bull. N. ¥. Health Dept., Mar. 7, 1914. 102 GONORRHEA: ITS SOCIAL ASPECTS AND PREVENTION say whether it is cured or not. I have known a woman to infect her partner seven years after her own infection. To be sure most women, like most men, recover from gonorrhea in a few months. But the exceptions in women are much more indefinite in duration, much more difficult of diagnosis, much more rebellious to treatment. The vulvovaginitis of young children is exceedingly intractable. It commonly lasts for years. GRAVITY OF THE COMPLICATIONS The local inflammation, which is all that most patients see in a gon- orrhea, is actually the least of its dangers. Apart from the danger of conjunctival infection, which is common to both sexes but rare in the adult, the complications due to direct ex- tension of the disease are different in the two sexes. In man the complications are almost entirely under the control of the skillful physician with a faithful patient. But both are rare, and patients in the poorer classes have neither the means nor the leisure to avail themselves of the resources of medicine. Among our dispensary patients the greater number suffer the pangs of an acute posterior ure- thritis, and some 10 per cent to 20 per cent suffer acute epididymitis, which in perhaps one-quarter of these is bilateral and results in sterility. Chronic urethritis or prostatitis results in fully 70 per cent or 80 per cent of these cases, and severe urethral stricture in a small percentage. Sexual neurasthenia follows gonorrhea in 5 per cent to 10 per cent of clinic cases. Among our wealthy patients, who are well treated from the onset of their disease, epididymitis complicates less than 5 per cent,, chronic urethritis and prostatitis less than 20 per cent, and stricture is alto- gether exceptional. But even the wealthiest patient may not be willing or able to command good treatment at the onset of his gonorrhea, so that more than half the patients treated in the office of the specialist suffer from chronic gonorrhea. Such complications as prostatic and periurethral abscess and pyelo- nephritis are rare in the clinic, extremely rare in private practice. In women, on the other hand, grave complications are common. In- vasion of the uterus, the uterine adnexa, and the peritoneum were noted in 40 per cent of the women reported to the Committee of Seven. Gonorrhea reaches the uterus in 20 per cent, the tubes in 5 per cent of cases, says Schmidt.1 This invasion of the female generative organs takes places either at 1Zeitschr. f. Geb. u. Gyn., vol. xxi. GRAVITY OF THE COMPLICATIONS 103 the time of infection or after the birth of the first child. For the gon- orrhea may subside and become latent in the glands of the uterine cervix until pregnancy excites a congestion that increases the virulence of the gonococci. By these the child’s eyes are .endangered at birth, its mother’s uterus and tubes immediately thereafter. Gonorrhea of the uterus and tubes usually, though not always,1 im- plies sterility. Hence this sterility is total if the wife’s tubes or uterus are promptly infected; it is the so-called one-child sterility if they are infected at the time of parturition. Heisser and Bumm agree that the gonococcus causes about 30 per cent of sterility in women, while Mor- row states 2 it is responsible for fully half of involuntary sterility. But, besides depriving a woman of her children, gonorrhea may ren- der her a permanent invalid, may even cost her her life. It is a curious fact that gonorrhea in women is either much milder or much more severe than the disease in man. Some women are so little inconvenienced by it that they do not feel the need of summoning a physician. Others are overwhelmed by acute salpingitis, pelvic abscess, peritonitis even; they must either undergo a capital operation or die. Still another class suffer relatively less from the tubal or uterine complications at first; they are not mortally ill, but they are up one day and down the next, semi-in- valids all the time, with scarce a hope of release, unless it be by oopho- rectomy, a capital operation, implying loss of the faint remaining hope of children and perhaps a continued invalidism thereafter. Compared with these major evils the danger of infection of the eyes by the fingers or to the rectum by drips of vaginal secretion is nothing. Children are doubly endangered by gonorrhea. In the first place, their eyes are in imminent danger of inoculation at the moment of par- turition. From such inoculation is said to result more than one-third of congenital blindness.3 In the second place, the infant or the young child remains peculiarly susceptible to gonorrheal infection. Its eyes or its genitals may be the portal. Gonorrheal conjunctivitis and urethritis (in the male) present no very peculiar characteristics in the infant. But gonorrheal vul- vovaginitis in little girls has a horror all its own. The quite inex- plicable readiness of infection, the rebelliousness to treatment, the grave and lifelong complications, make it seem one of the cruelest of known maladies. The last count in the indictment of gonorrhea is systemic gonorrhea, often spoken of as gonorrheal septicemia or gonorrheal rheumatism. Systemic gonorrhea is very grave, quite rare, and fairly controllable. It is grave in that it causes iritis, endocarditis, a very chronic type of 1 Moskowitz has reported a tubal pregnancy co-existing with pyosalpinx. 2 Am. Jour, of Surgery, 1906, xx, 236. 3 Cf. Tivnen, Jour. A. M. A., 1914, lxiii, 1756. 104 GONORRHEA: ITS SOCIAL ASPECTS AND PREVENTION chronic rheumatism, and many other lesions. It is, fortunately, rare; its frequency being estimated at about 1 per cent of cases (Kolle and Iletsch say 0.7 per cent; Ward says 1.2 per cent). Of its control there is no absolute certainty. The disease in most instances progresses slowly to spontaneous cure. The horrors of gonorrheal rheumatism are more talked about than they deserve. Only 20 of the 5,782 gonorrheics in the army were permanently incapacitated by it. SOCIAL IMPORTANCE OF GONORRHEA The social importance of gonorrhea depends upon its prevalence, its transmissibility, its grave results in women and children, and the steril- ity in which it so often results. Prevalence—A disease that attacks more than half our young men, a disease that affects thousands of children and hundreds of thousands of women, is important to society by its prevalence alone. Transmissibility.—A disease that enters the family almost ex- clusively through illicit sexual contact, a disease that may be transmitted long after the patient thinks himself or herself well, a disease that may be transmitted to the wife from the prostitute via the offending husband, a disease that may be passed from the wife thus innocently infected to the eyes of her infant at birth or to its genitals thereafter, is eminently important to society. Grave Results.—A disease that incommodes the man and may invalid the woman, a disease that is the cause for most of the major gynecology of today, a disease that unsexes thousands of women, that makes chronic invalids of many, that kills not a few, a disease that in this country causes from one-quarter to one-half of the congenital blind- ness, that is accountable for about one-third of the blind in our asylums, is a real peril to society. Sterility.—A disease that causes fully 50 per cent of the involun- tarily sterile, or one-child sterile marriages, that destroys the power of procreation in man as well as in woman, is indeed a peril to the race. SOCIAL REMEDIES Three types of remedy for gonorrhea are submitted to society: Individual prevention. Methods of dealing with prostitutes. The moral compaign. To discuss fully the relative merits of the three would require a vol- SOCIAL REMEDIES 105 ume.1 Suffice it to say here that an individual preventive, injection of the urethra after a suspicious intercourse (p. 192), though diminishing greatly the danger of infection, does not entirely eliminate it. Segre- gation and reglementation of prostitutes is neither acceptable nor suc- cessful, while the moral campaign, the attempt to bring venereal dis- ease and all sexual matters out into the light of day, seems the only way to get at the root of the evil. Reglementation is employed with notable failure in France, with mediocre success in Germany. In our country it is impracticable.2 It fails in theory by not quarantining the males, in practice by not quaran- tining “illicit” females, the lewd housemaid or shop girl, and the errant widow. The moral campaign of education to old and young still has its spurs to win. It is very full of promise. The notion that child and bride need education in matters sexual, and that the boy needs clean ideas on these subjects is a new one. But it is hard to see how such education can fail to save many innocents from venereal disease and from moral woes far worse. 1 The important publications on these subjects are discussed in the various societies of Sanitary and Moral Prophylaxis and of Social Hygiene. Reference may be made to: Social Hygiene, Trans. Am. Soc. Sanitary and Moral Prophylaxis, Bull, soc. frang. de prophylaxis sanitaire et morale, Mitteil. Deutsch. Gesellschaft Belcampf d. GeschlechtskranTch. 2 ‘1 The Social Evil, ’1 Putnam and Co. CHAPTER XI THE GONOCOCCUS That the gonococcus is the cause of gonorrhea is no longer a subject for discussion. Ricord’s “recette pour attraper la chaude-pisse” is an- swered by the aphorism of Marcel See: “La plus belle femme du monde ne peut donner que ce quelle aNo person can impart or acquire gonorrhea except by imparting or acquiring the gonococcus. The gonococcus is a nonmobile diplococcus, occurring within as well as outside of pus and epithelial cells. It stains readily with the familiar anilin dyes. It does not take the Gram. It will not grow on the usual culture media. It produces endogenous toxins. It cannot be inoculated upon animals. Microscopic Characteristics.—When a drop of gonorrheal pus is properly stained and examined through an immersion lens of one-twelfth aperture, the gonococci seen present the following characteristics: 1. They are diplococci. Each individual of a pair is D-shaped (cof- fee bean shaped), with the flat (or slightly concave) border opposed to its fellow, so that the couple form an ovoid made up of two separate hemispheres. The length of the pair averages about 1.6m, and the inter- space is about half as wide as either segment. 2. The diplococci are found grouped in pairs, fours, and other mul- tiples of two, showing a tendency to rectangular disposition, in marked contrast to the irregular massing of staphylococci and the linear ar- rangement of streptococci. 3. The gonococcus, when it occurs in pus, is found both within and outside of the pus and the epithelial cells.1 The most characteristic groups are met with inside the cells. The extracellular gonococci may be scattered or irregularly grouped, but the intracellular specimens present a greater regularity of arrangement. Without being mathe- matically distributed, there is still a certain symmetry in the grouping, an absence of jumbling, which the observer soon learns to appreci- ate at a glance and which our plates attempt to reproduce (Plate IX, Figs. 1, 2). 1 There is no close clinical relation between the intracellular or the extracellular position of the gonococci and the grade or the stage of the inflammation. Every specimen contains gonococci both inside and outside the cells, and in no definite proportion. 106 TECHNIC OF STAINING THE GONOCOCCUS 107 Such are the characteristics of the gonococcus. It is a double D diplococcus occurring intracellularly and in typical groups. But these characteristics are sometimes shared by other bacteria met with in ure- thral pus. We must look further for a distinguishing feature. This we find in the reaction of the gonococcus to the Gram stain. Gram Reaction—Gonococci do not take “the Gram.” They are “Gram negative.” This means that if these cocci are stained first with an anilin dye and then with Lugol reagent (see below) the resultant stain may be washed from them, from the cells, from many other bac- teria, but not from most staphylococci (the exceptions are discussed on page 162) and other cocci which, under the microscope, may otherwise resemble true gonococci. Hence, when the Gram stain is applied, a thorough washing with alcohol leaves the cells and gonococci colorless, while the pseudogonococci stand out in bold relief, stained darkly by the combined color of the anilin dye and the Gram stain. In order to make the effect of the Gram stain more apparent, it is customary to restain the cells and gonococci with a contrasting color, in order that the true gonococci may be visible for direct comparison with the false (Plate II, Fig. 2). Preparation of the Specimen.—From what has been said in the pre- ceding paragraphs, it is clear that recognition of the gonococcus depends upon the proper preparation of the specimen—the proper performance of the Gram test—and while the test is not complicated, it is delicate, and, like so many other laboratory methods that appear entirely simple when one is familiar with them, it does not succeed at the hands of the beginner. Hence every practitioner is by no means competent to per- form and interpret the Gram stain; hut anyone who can smear a slide and focus a microscope may become competent by practice. 1. The Smear.—A very small drop of the pus to be examined is placed upon a clean glass slide. Upon this another slide is dropped, the two pressed together and slid apart. This leaves each covered with a thin film of pus (the thinner the better). Each is then dried by evapora- tion at a gentle heat and fixed by rapidly passing it three or four times through the flame of a spirit lamp or a Bunsen burner. 2. The First Stain.—One of the films is now covered with Pal- tauf’s solution.1 This is left on for three minutes, the excess washed off with water (no water must be used if the Gram stain is to be employed), the glass dried in the flame, and examined with the oil-immersion lens. If no 1 Anilin oil, 3 c.c.; absolute alcohol, 7 c.c.; distilled water, 90 c.c. Shake for two minutes. Filter through moistened paper until filtrate is clear. Add two grams of Griibler’s powdered gentian violet. Set aside for twenty-four hours. Pipette supernatant fluid as required. This solution keeps well for six weeks. 108 THE GONOCOCCUS bacteria with the morphological characteristics of gonococci are seen after a careful examination, it is a waste of time to employ the Gram. But if what appear to be true gonococci are found, the Gram test is applied to the other slide. The stain is applied for three minutes, as above described, but this time the excess of solution must be shaken from the specimen. No water or alcohol may be applied at this junc- ture. The slide is immediately blotted and flooded with Lugol’s solu- tion. 3. The Lugol.—Lugol’s solution is made up as follows: Iodin—1 part. Potassium iodid—2 parts. Distilled water—300 parts. This is applied for precisely two minutes. 4. The Alcohol.—As soon as the slide is removed from the Lugol solution it should be washed with absolute alcohol for precisely thirty seconds. 5. The Contrast Stain.—After using various more or less satis- factory counter-stains I now employ only the following: Carbolic acid—2 parts. Saturated aqueous solution of Bismarck brown—98 parts. If the decolorized smear is covered with this solution for three to five minutes and then rinsed in water, it acquires a light-brown tint, and under the microscope the cells and gonococci appear yellowish and in marked contrast to the deep purple, almost black, pseudogon- ococci. A more prolonged staining with the brown gives the gonococci a deeper color, which is not so readily distinguished from that of the pseudogonococci. Such is the technic of staining the gonococcus, which may be em- ployed by anyone having an elementary familiarity with medical micros- copy, and which may be depended upon to furnish accurate results, if followed accurately. The essentials likely to be overlooked are the em- ployment of Griibler’s violet, precise staining, by the watch, employment of absolute alcohol, and exclusion of all water until after counter- staining. GONOCOCCUS CULTURE The gonococcus can be made to grow only on special media and under special conditions. The medium must contain human blood serum and be slightly alka- line. This serum may be obtained from an aseptic effusion into the peritoneum, the pleura, or the tunica vaginalis. (Experts can obtain slight growth of gonococci upon ordinary culture media.) PLATE IX 1 2 3 4 Microphotographs of Gonococci and Tubercle Bacilli. Fig. 1.—Gonorrheal pus. First stain: gentian-violet solution. Fig. 2.—Gonorrheal pus. Bismarck-brown. Cells and gonococci take the brown stain, while the pseudogonococci remain black. Fig. 3.—Tubercle bacilli in urine. Fig. 4.—Smegma bacilli in urine. DIAGNOSIS OF THE GONOCOCCUS 109 Ileiman 1 employs the following culture medium: Sterilized liquid chest serum, 1 part. Agar, 2 per cent -f- peptone, 2 per cent + salt, 0.5 per cent -f- glu- cose, 2 per cent, 2 parts. lie sterilizes the liquid by heating it to 65° C. for one hour for six days, then he leaves it three days at the room temperature, then resteril- izes for three days more. The incubator must be kept at a temperature between 30° and 39° C. The ideal temperature is 36° to 37° C. The growth of gonococci is relatively slow. They are aerobic and facultative anaerobic. The colonies remain rounded and usually do not run together. They are grayish in color and slightly translucent. Growth ceases in about forty-eight hours; sooner if the surface of the agar dries. Examination should therefore be made at the end of the second day. To continue the growth it must be shifted to a new medium every three or four days or oftener. The vitality of the gonococcus is slight whether in smears or in culture. Desiccation kills it in a few hours. But Heiman has culti- vated the gonococcus from a thick drop of pus twenty-nine days old. It is killed by a temperature of 45° C., and ceases to grow below 30° C. Any weak antiseptic rapidly destroys the gonococcus in vitro. Cultures from urine must therefore be made without delay and before the urine cools. DIAGNOSIS OF THE GONOCOCCUS The gonococcus is usually distinguished from staphylococci and other Gram-positive cocci by the Gram stain. Errors in diagnosis by the Gram stain (apart from those due to ignorance and carelessness) have three sources, viz.: 1. There are other Gram-negative cocci from which the gonococcus can only be distinguished by culture.2 Such are the micrococcus catarrhalis, the diplococcus intracellularis, and certain chromogenic cocci. Happily none of these organisms, except the micrococcus catarrhalis, have been identified in the genito-urinary tract. Hone of them, except the m. catarrhalis, is believed to cause urethritis. The urethritis caused by m. catarrhalis is probably insignificant, and not to be clinically mis- taken for acute gonorrhea. I have encountered it but once in several hundred cases. 1Med.. Record, 1895, XLVII, 746; Ibid., 1896, L, 887; Ibid., 1898, LIII, 80. 2 Cf. Zupink, Berl. Min. Wochenschr., 1906, No. 52; Wollstein, Jour, of Expcr. Med., 1907, September 21st; Elser and Huntoon, Jour, of Med. Research, 1909, XX, No. 4, p. 369. no THE GONOCOCCUS 2. Apart from m. catarrlialis, it must be emphasized that in a small percentage of cases the normal urethra (and in a somewhat larger percentage the normal vagina) contains Gram-negative cocci which can usually be differentiated from the gonococcus by their form, size, and extracellular position. These organisms fail to grow on the ordinary culture media. 3. The most frequent source of error is the fact that the common staphylococci may be Gram-negative as well as Gram-positive. As Crab- tree has suggested, this variability is doubtless due to the presence or absence of albumin. But these confusing factors, that render the diagnosis by Gram alone quite valueless, apply almost exclusively to chronic urethritis. For clinical laboratory diagnosis of acute genital gonorrhea it is only necessary to identify a Gram-negative, intracellular diplococcus. The gonococcus in the conjunctiva and in joint exudates is equally unmistakable. Rectal, buccal, and nasal gonorrhea require diagnosis by culture. The cultural characteristics of the gonococcus have been described. An important feature in the diagnosis is that the gonococcus ferments glucose (and perhaps maltose, but not other sugars). The micrococcus catarrlialis grows more readily than the gonococcus on the usual media. On serum-agar it makes two kinds of colonies, the one thick and crumbling like mortar does not resemble the gonococcus, the other is quite similar to the gonococcus, except that the colony is smaller. But the distinguishing feature of the micrococcus catarrlialis is its inability to ferment glucose. The other members of this group grow more readily on the familiar media. Thus the diplococcus intracellularis grows on nutrient or glycer- in-agar and on Loeffler’s blood serum agar. Concerning serum reactions Elser and Iluntoon state that: When properly controlled, agglutination tests serve to differentiate the vari- ous groups from each other, providing the strains tested are sufficiently agglu- tinable. Diagnostic difficulties may arise in connection with certain gonococcus strains. These are unusually sensitive to the action of normal and of group agglutinins and may yield higher values in the presence of a meningococcus immune serum than moderately agglutinable meningococcus strains. Absorption tests served to differentiate the various groups of Gram-negative cocci from each other and to establish the identity of the agglutinable and in ag- glutinable meningococcus strains. COMPLEMENT FIXATION TEST The gonococcus complement fixation test of Schwartz and McNeil1 is peculiar only in that the antigen employed is made from mixed 1 Am. Jour. Med. Sciences, May, 1911, December and September, 1912; see also COMPLEMENT FIXATION TEST Ill strains of gonococci. The original antigen was made from eleven different strains and as various ones of these died off, or were lost, they have been replaced by others. The reaction becomes positive rarely before the fourth week, but usually in the sixth to the eighth week. It never becomes positive in cases that are so successfully repressed, or aborted, as never to have any considerable infection. The reaction usually remains positive as long as there is any active gonorrheal infection in the patient’s body. Thus a persistent joint lesion or tubal infection (in the female) may keep up a positive reac- tion after the urethral infection has been cured. Two exceptions are to be noted in the time of disappearance of the positive reaction as fol- lows : 1. The urethral lesion may become so slight and superficial that the complement fixation test becomes negative before the last gono- coccus has disappeared. I have never known this to occur excepting in cases of mild chronic anterior urethritis that reacted brilliantly to the passage of a sound in the form of an acute obviously gonorrheal urethritis. This check can, therefore, apparently be relied upon and the combination of a negative gonococcus fixation test with absence of reaction to the passage of a sound is an almost certain guarantee of cure. 2. The fixation test usually remains positive two to six weeks after all clinical evidence of infection has disappeared from the urethra and its glands. But it may persist for months. Such a persistent posi- tive reaction is extremely unusual, but I have seen three men with a positive gonococcus reaction a year after the last trace of gonorrhea had disappeared from the urethra; each of them was repeatedly tested by culture for gonococcus with negative results. Two of them married and did not infect their wives, though the reaction of one of these was still weakly positive six months after matrimony. I do not know what focus of infection kept up the reaction in these cases. The reaction presents two interesting medico-legal features: 1. If within three weeks of the time when a fresh urethral dis- charge appeared the patient’s blood is found positive the discharge is probably a relapse from a previous infection. If negative it is doubt- less a new infection. The nearer the test is made to the beginning of the infection, the more accurate it is likely to be. 2. The reaction of a person who has not recently had a gonorrhea cannot be made positive by the injection of gonococcus vaccines; but if the complement fixation test has been positive within the preced- confirmatory articles by Swinburne, Keyes and Schmidt, Am. Jour. Med. Sciences, Arch, of Diag., July, 1911, Am. Jour. Med. Sciences, January, 1912; Trans. Am. Urol. Assn., 1911. 112 THE GONOCOCCUS ing six months and vaccines are given it is readily made positive again. Diagnostic Value.—The accuracy of the complement fixation test, like that of the gonococcus culture, varies in accordance with the skill and experience of the operator; but, exception made for infection con- fined to the anterior urethra, technical errors are much less likely to interfere with the validity of the complement fixation test than with gonococcus culture. Positive culture, on the other hand, is more certain evidence that an infectious lesion persists in the urethra than is a positive complement fixation test. Nevertheless the practitioner will be wise to rely less upon the complement fixation test than upon any- thing else for the diagnosis of the presence of gonorrhea. GONOCOCCUS VACCINES Christmas 1 and Wassermann 2 have shown that gonococci produce only an endotoxin derived from dead and disintegrated microorganisms. Thus the toxin may be measured in units of bacteria. Accordingly, one speaks of a solution containing 20,000,000 or 1,000,000,000 dead gonococci, meaning a solution containing the toxins of that number of dead bacteria. The vaccine is sold in phials containing 20,000,000 to 500,000,000 dead gonococci to the c.c. Autogenous and Stock Vaccines.—Teague and Torrey 3 have shown that the serum of an animal immunized to one strain of gonococcus does not cause fixation of complement when tested against an antigen obtained from another strain. Following up this line of investigation Torrey was able to differentiate eleven strains of gonococci in New York City, and most of the stock vaccines now sold are from a mixture of these eleven strains. It is difficult to compare the efficacy of autogenous and stock vac- cines on a scientific basis. Autogenous vaccines have the advantage of giving a definite product distinctly and certainly applicable to a given case, but they have the disadvantage of requiring from two to four days’ preparation. We cannot get them at the time when we most need them. Local pain from the injection is slight, local inflammatory reaction rare. General toxic or febrile reactions are not unusual if the vaccine treatment is begun at a high dose or pushed rapidly. But the discomfort 1 Am. Institut Pasteur, 1900, XLY, 331. 2 Berl. Tdin. JVochenschr., 1897, No. 32. 3 Jour, of Med. Research, December, 1907. GONOCOCCUS VACCINES 113 of a reaction accompanied by a temperature of 103° F. and lasting not more tlian twelve hours is the most that may be expected. Dosage—The vaccines have been employed at an average dofee of 10,000,000 to 20,000,000, increased to a maximum of 50,000,000. Such doses are too small. One should begin at 40,000,000 or, in acute cases, 60,000,000 and increase by 20,000,000 or more at each dose (unless the symptoms are controlled, or the reaction is marked) until a dose of 200,000,000 is reached. Only in exceptional cases is it necessary to go higher than this. The injections are given into the muscle. They should not be re- peated oftener than every other day. Results.1—Gonococcic vaccines have been employed in various classes of cases, viz.; In localized gonorrhea— Acute urethritis. Chronic urethritis. Vulvovaginitis. In complications of local gonorrhea— Epididymitis. In systemic gonorrhea— Acute arthritis or iritis. Chronic arthritis. Sepsis. Localized Gonorrhea.—So long as gonorrhea remains localized upon the genital and urinary mucous membranes it excites no systemic reaction, and is seemingly uninfluenced by the injection of vaccines. In- dividual instances of the cessation of an intractable gonorrhea under the administration of vaccines prove nothing. Chronic gonorrhea is, as a rule, quite uninfluenced by the vaccine treatment. I have not even noted an increase in the gonococci in the urethral discharge, though certain Continental authorities rely upon the vaccine to excite a dis- charge if gonococci are present (focal reaction). Genital Complications.—It is my practice, whenever a gonor- rheic develops fever or any symptoms suggestive of acute epididymal, prostatic, or peri-urethral complications, to administer 50,000,000 gonococci and to follow this two days later by the same dose if all is well, by double the dose if the symptoms continue. One may thus perhaps abort the threatened complications. When the metastatic (e. g., epididymal) focus is established, how- ever, I have seen no positive good result from vaccine. 1 Cole and Meakins, Bull. Johns HopMns University, 1901; Irons, Jour, of Infect. Bis., June-July, 1908; Ballenger, Jour. Am. Med. Assoc., May 30, 1908, p. 1784; Van Riempst, Polyclinic Med. Jour., 1909. 114 THE GONOCOCCUS Systemic Gonorrhea.—The vaccine treatment finds its most rational application in the treatment of systemic gonorrhea. Thus many authorities rely upon frequent injections of from 50,000,000 to 500,000,000 killed gonococci. I at one time believed in this treat- ment ; but a large experience at Bellevue Hospital has left me rather skeptical. 'In the second place, the painful lesion oi many so-called cases of chronic gonorrheal arthritis is an organic one, an exostosis oi a change in ligament or synovial membrane due to a gonococcal inflammation that has passed, and preeminently unsuited to any \accine treatment. Gonorrheal septicemia sometimes reacts brilliantly, sometimes not at all. Autogenous vaccines should be used if possible. ANTIGONOCOCCUS SERUM The antigonococcus serum employed in this country is that of Rogers and Torrey.1 The serum is polyvalent (like the vaccine). It is derived from rams, since their serum seems much less toxic than that of goats or rabbits. Technic.—Two c.c. of the serum are injected every day or every Second or third day. Complications.—With ram serum the only reaction that one may anticipate is a varying amount of local swelling, redness, heat and sore- ness around the point of injection. This does not occur by any means in every individual case, and is not caused by any antibody in the serum, hut is due to the local toxic action of the serum itself. As the same serum has been found to cause this reaction in one individual hut not in another, it is partly referable to the idiosyncrasy of the patient (Rogers). Results.2—The results reported from the use of the serum are quite similar to those reported from the vaccine. I have not experimented with the serum. Rogers claims good results in 85 per cent of early joint cases, and some a’ood in late cases if treatment is continued for a month or more. Herbst, using three times the usual dose, achieved very satisfactory re- sults in all chronic joint cases, but nothing in epididymitis and acute arthritis. Swinburne warmly advocates the serum at the onset of epididymitis, stating that in 27 cases so treated the pain was relieved in forty-eight hours. xJour. Am. Med. Assoc., January 27, 1906, and September 14, 1907. 2 Rogers and Torrey, loc. cit.; Herbst, Jour. Am. Med. Assoc., May 23, 1908. Swinburne, Jour. Am. Med. Assoc., January 26, 1907, and Med. Record, November 14, 1908. IMMUNITY 115 IMMUNITY The gonococcus confers a relative immunity to the person who harbors it. He can usually not be reinfected; e.g., by a woman upon whom he has conferred the disease. Moreover, relapses of a given gon- orrhea are almost invariably less severe than the initial outbreak. But the immunity that persists after a cured gonorrhea is of the slightest. Subsequent attacks are usually milder than the initial one; but they may be quite as prolonged, quite as complicated. Marital immunity is a curious phenomenon. It consists in this: that a man having gonorrhea and bestowing it upon a woman cannot, when cured, be re-infected by his still-infected partner. One may well doubt the universality of such a rule, the permanence of such immu- nity. Yet we see many examples of it in the infection of the inter- loper who assumes the health of his lady’s lawful husband. CHAPTEK XII GONORRHEA: THE EXTRAGENITAL TYPES OF INOCULATION; THE SYSTEMIC MANIFESTATIONS The gonococcus is specific to the human race. It is impossible to give gonorrhea to any animal. The gonococcus may be inoculated readily in the eye, in the urethra of either sex, and in the female genital passages. The rectum is less vulnerable than the genitals. The mouth and nose are all but immune. The unbroken skin cannot be inoculated, and all squamous epithelium offers a marked resistance. Thus the urinary bladder, the preputial cavity of the male and the vagina of the female suffer rarely and, as a rule, mildly from gonorrhea, except in so far as they are involved in the contiguous inflammation of the urethra, the cervix, or the vulva. That children are much more vulnerable to gonorrhea than adults is evidenced by the readiness with which little girls acquire vulvovagin- itis, the frequency of gonorrheal conjunctivitis in children, and the fact that nasal and buccal gonorrhea occur almost, if not quite, exclusively in children. EXTENSION OF THE DISEASE Gonorrhea of the eye and rectum remain localized. In the genitals the disease extends by continuity as far as the vesical trigone, and throughout the genitalia of both man and woman. The gonococcus penetrates the epithelium of the inflamed surface and excites exudation and subsequently sclerosis in the subjacent con- nective tissue; but it shows no great tendency to cause lesions to any depth except when shut in by inflammatory occlusion of the orifice of a gland. Under such circumstances it may cause abscess, invade the veins (thrombosis), and be carried to distant parts of the body, there to set up metastatic gonorrheal foci. Clinically this local suppuration and general intoxication occur al- most exclusively in the genitals; i.e., the urethra, prostate, vesicle, and epididymis of the male, the glands of the urethra, vagina and cervix, and the fallopian tubes in the female. By means of the blood stream gonococci may be carried to almost any organ. The favored locations for systemic gonorrhea are the joints and the iris. Less frequently it attacks the bursae, the tendon sheaths, the 116 ANORECTAL GONORRHEA 117 pleura, the meninges, the periosteum, the parotid gland, the veins, the endocardium, the pericardium, the muscles. Lymphatic absorption is uncommon and gonorrheal lymphangitis and lymphadenitis rare. Absorption of gonorrheal toxins may affect the nervous system or the skin. The peritoneum is not rarely involved in gonorrheal salpingitis, but gonorrheal peritonitis is extremely rare in the male. The kidneys are probably reached by gonococci from the blood stream, though direct in- vasion from an infected bladder is not impossible. ANORECTAL GONORRHEA The anus is relatively immune to the gonococcus. Every acute vul- var gonorrhea pours pus over it, and yet, even in infants, it is not often inflamed. Jullien 1 has collected from the statistics of Howard, Schultz, and Baer, 1,037 cases of genital gonorrhea in women with 157 inocula- tions of the anus. Eicliom 2 noted anal infection in 72 out of 235 cases. Etiology.—Sodomy is the accepted cause for anal gonorrhea in men; but in women the infection is more often due either to direct inoculation by pus from the vulva or by indirect inoculation from the douche tube or the finger. Pathology.—The lesions are both deep and chronic. The epithelium of the rectum is eroded, infiltrated, and in places ulcerated for several inches up from the anus. Fissure and condyloma are common; the anus itself is infiltrated. Ischiorectal abscess and phlebitis of the hemorrhoidal veins have been noted as rare complications. Whether or not rectal gonorrhea is often a cause of stricture is not determined. The stricture is usually observed so late that its cause is not clear. Symptoms.—The symptoms are so slight that the condition is often overlooked. At the onset there is at most itching and burning. Later there are to all intents and purposes no subjective symptoms. Physical Signs—The lesion is rather rectal than anal. The anal orifice may be swollen; it is almost always fissured—“at six o’clock,” as the French say. A single moist, pointed, soft condyloma usually overhangs the fissure. There is often no external discharge, but a drop of pus may readily be expressed by pressure from the rectum. Proctoscopy reveals tumefaction, erosion, and ulceration of the rectum. 1 Le Blennorrhagie (formes rares et peu connues), Paris, 1906. Also Brunswick- le Bilian, Bull, de l’Acad, de Med., Paris, 1907, LXXI, p. 497. 2 Dermatolog. Zeitschr., 1909, XYI, No. 7. 118 EXTRAGENITAL TYPES OF GONORRHEA Duration—Rectal gonorrhea is extremely chronic. Jullien treated four successive cases 116, 169, and 174 days before achieving a cure. Diagnosis.—The gonococcus may be identified in the pus. If the condition of the genitals leaves any doubt as to the nature of the inflam- mation, the diagnosis should be verified by culture. Treatment—The rectum may be irrigated daily with potassium per- manganate (1: 200 to 1: 25) or with protargol (2 per cent to 10 per cent). Erosions and ulcers may be touched every second or third day with a nitrate of silver pencil. BUCCAL AND NASAL GONORRHEA That gonorrheal inflammation of the mouth and nose may occur we cannot doubt. That it does occur in infants may be considered proven. But its existence in the adult is at best uncertain. The existence of buccal gonorrhea in infants was proven by Ahl- feld.1 Kimball 2 has reported 8 cases of systemic gonorrhea in in- fants, one or more of whom were doubtless infected from the mouth. De Stella 3 has apparently proven the existence of infantile nasal gonorrhea. In adults, however, we hear only of sporadic cases. The cases col- lected by Jullien fall under two heads, those in which urethral gonorrhea has been attributed to coitus ah ore (cases of Howard and Honnorat) and those in which stomatitis (cases of Cutler, Petit, Columbrine, Juergens, and four of Menard) or rhinitis (cases of Duncan (1781), Forcade, Edwards) are alleged to be gonorrheal. The evidence against nasal gonorrhea in the adult is summed up in the experiments of Diday and Bormiere, who strove in vain to inoculate the nasal mucosa with gonorrheal pus. The clinical cases in favor are rare, ancient, and unconvincing. Buccal gonorrhea is fortified by more modern instances. But the alleged gonococcus found may perfectly well have been the meningococ- cus or micrococccus catarrhalis, and the “intense” stomatitis is precisely what one would not expect. A typical report has recently been made by Juergens.4 The stoma- titis was intense, the gums ulcerated, the breath fetid. Bacteriologic examination revealed the “gonococcus” and the bacteria of Vincent’s angina. In this instance the stomatitis was doubtless a Vincent’s angina, the 1Berl. Iclin. Wochenschr., October 19, 1896. 2 Med. Record, 1903, LXIY, 761. 3 Deutsche med. Zeitschr., 1899, No. 1. 4 Berl. Min. Wochenschr., June 13, 1904. SYSTEMIC GONORRHEA 119 “gonococcus” a micrococcus catarrhalis. Until such cases are tested by culture we cannot form a final decision. Clinical Picture—In infants the inflammation appears to be a severe one and always confined, curiously enough, either to nose or mouth. In some instances nasal gonorrhea has accompanied ophthalmia neonatorum and has been attributed to infection through the lacrimal duct. The duration of the inflammation is a few weeks, as a rule. Treatment—Antiseptic mouth wash and nasal spray effect a speedy cure. Argyrol in 20 per cent solution is the best wash, but frightfully dirty. SYSTEMIC GONORRHEA The gonococcus invades the system through the blood stream. Its toxins may he absorbed by the same route. Though no one has disproven the participation of gonococcus toxins in the causation of the local lesions of systemic gonorrhea, the gonococcus has so frequently been found in the pus of joints and on the vegetations of heart valves and even in the blood 1 that such lesions are attributed to the bacterium itself, leaving certain rare and manifestly toxic phenomena attributed to the toxin. Toxic Lesions.—Skin lesions, neuroses. Bacterial Lesions—Arthritis, osteo-arthritis. Endocarditis, pericarditis. Bursitis, tenosynovitis. Periostitis, osteitis. Myositis, abscess. Iritis, systemic conjunctivitis. Phlebitis, thrombosis. Pleurisy, pneumonia, parotitis. Neuritis, meningitis (?). Erythema and Neurosis—Erythema, urticaria,2 pruritus,3 and vari- ous neuroses may occur during gonorrhea and may be relieved by cure of the gonorrhea. The feeling of disgust, even amounting to neurasthenia, excited by “venereal” disease is, of course, purely psychic. Sexual neurasthenia is not peculiar to gonorrhea. 1 Irons, Arch. Tnt. Med., Dee., 1909. 2 Orlipski, Munch, med. Wochensclir., October 7, 1902. 3 Domenici, Gas. degli osp., March 1, 1903. 120 EXTRAGENITAL TYPES OF GONORRHEA GONORRHEAL ARTHRITIS Gonorrheal arthritis or gonorrheal rheumatism, as it is commonly called, is the commonest type of metastatic gonorrhea. Occurrence.—Gonorrheal rheumatism is said to occur in about 1 per cent of persons afflicted with urethral gonorrhea. Children are par- ticularly prone to it and may develop it from slight local lesions. Thus Kimball1 found 10 cases of gonorrheal arthritis among 70 children. Women are much less often affected than men, perhaps because they lack seminal vesicles. Eorthrup 2 reports 230 cases in the male to 22 in the female. It has been noted by Fournier as early as the fifth day after the onset of gonorrhea, hut is commonest between the third and the fifth week. It may occur at any time while the patient harbors gonococci. Etiology.—The occurrence of gonorrheal arthritis and indeed of all systemic gonorrhea, is subject to a curious law. The man who has once had gonorrheal arthritis will have a recurrence of this each time he contracts a fresh gonorrhea, unless this is immediately controlled. The first arthritis usually accompanies the first gonorrhea, though I have known it to await the second attack and yet follow the rule here- after. Moreover, no new joints will suffer in subsequent attacks that did not suffer in the first, with the exception that this rule is only regionally applicable to hands and feet; e.g., metacarpus in one attack and carpus in the next. A fair minority give a history of previous injury to, or inflammation of, the afflicted joint. Vesiculectomy does not prevent occurrences, I have never recovered gonococci or any other organism from joint effusions, though others have done so. From these considerations one may infer that, in many cases, the infection is rather a toxemia than a septicemia; that seminal vesiculitis is perhaps not a cardinal cause; that indeed a predisposing lesion in the joint rather than in the urethra is the chief difference between those gonorrheics who have rheumatism and those who do not. Distribution.—The lesions are ojfien polyarticular. Among Xorth- rup’s cases 76 per cent showed involvement of three or more joints. Moreover, synovitis, bursitis, and the other lesions of systemic gonorrhea are often associated with joint lesions. The knee is the joint most frequently affected (two-thirds of Four- nier’s 120 cases, one-third of Finger’s 3 375, seven-eighths of Boze- man’s 278 cases). 1 Medical Becord, 1903, LXIY, 761. 2 Presbyterian Hospital Beport (New York), 1896, vol. i, p. 53, 3 Archiv f. Berm. u. Syph., 1894, XXVIII, 2, 296. GONORRHEAL ENDOCARDITIS 121 Yorthrup’s statistics show gonorrhea of the knee in 91 cases, of the ankle in 57, of the foot in 40, of the wrist in 27, of the head and toes in 21, of the elbow in 18, of the hip and shoulder 16 each, of the hand in 11. The association of gonorrhea with spondylitis has been proved by Bouchard1 and Chute.2 Pathology.—Gonorrheal arthritis like other types of septic arth- ritis, varies from mere synovitis with peri-arthritis to arthritis and osteo-arthritis. The last is uncommon, suppuration rare. A noteworthy effect of arthritis is that it may keep up a positive complement fixation reaction for months after the gonorrhea is well. Clinical Types—The onset may be acute or subacute. If acute, the inflammation begins like an attack of acute articular rheumatism, with pain, redness, swelling, tenderness, and disability. But there are no sweats; the brilliant redness and exquisite sensitiveness of acute artic- ular rheumatism are not seen, and fever is relatively slight. A subacute onset varies in intensity from a mere ache with local tenderness to a moderately severe pain with some swelling and consid- erable disability. The duration of the inflammation is characteristically prolonged, although exceptionally an intense attack is brief. The mildest lesion may hang on for weeks and months. The severity of the infection, while usually sufficient to keep the patient awake at night, is not that of a suppurative arthritis. Indeed, among several hundred cases sent to my wards with the diagnosis of gonorrhea, no case of suppurative arthritis has proved to be gonococcic. Almost all of them were found to be tuberculous. Complications.—The complications due to direct extension from the joint are bursitis, tenosynovitis, and infiltrations of the surrounding tissues. Abscess outside the joint, as in the case reported by Ware,3 is even rarer than suppurative arthritis. Implication of the bone is, as stated above, primary and not secondary. The results of gonorrheal arthritis depend upon the treatment and the nature of the lesion. Osteo-arthritis may even result in total de- struction of the joint with bony ankylosis. The worst that simple arthritis can do is to cause fibrous ankylosis. The most discouraging features of the prognosis are the marked tendency to chronicity, and the tendency to relapse after apparent cure. Diagnosis.—Gonococcic arthritis occurs during acute gonorrhea or during an acute recurrence of gonorrhea. Yet I have seen acute gout and tuberculous arthritis during an acute gonorrhea. The history of iZeitschr. f. Min. Med., 1907, LXII. 2 Boston Med. and Surg. Jour., 1904. 3 N. Y. Med. Jour., January 13, 1906. 122 EXTRAGENITAL TYPES OF GONORRHEA previous attacks may help in the diagnosis though the very fact of previous non-gonorrheal arthritis predisposes the joint to gonorrhea] arthritis. The complement fixation test should he positive whether the joint is gonorrheal or not. Gonorrheal joints show a relatively marked para-articular infiltration as compared to other infections of like se- verity. Thus the appearance of the limb often suggests injury rather than arthritis. A suppurating “gonorrheal” arthritis I should suspect of tuberculosis and prove by radiography. Fever and sweats distinguish acute articular rheumatism. Kimball has reported acute gonorrheal arthritis in children without u rethral gonorrhea. Non-gonococcic septic arthritis, usually of a mild and very chronic type, may arise from chronic vesiculitis or prostatitis. Prognosis.—Gonorrheal arthritis is spoken of as chronic but, though the infection is long drawn out, its actual chronicity is rather due to adhesions, infiltrations, exostoses and ankyloses than to actual chronic reabsorption of infection. Yet, so long as the gonococci are active, new joints may be, and not infrequently are, successively at- tacked. A badly infiltrated joint usually keeps a patient two months in bed and function is often not fully restored for three to six months thereafter; but a severe case caught early may be well in two months. Prophylaxis.—Efficient treatment of gonorrhea almost infallibly prevents arthritis unless the patient has had it before. Curative Treatment.—The patient must be put to bed to cure his arthritis and to prevent extension to other joints. The urethral source of infection should be intelligently attacked. The rage for vesiculectomy is apparently dying out. It is probable that this operation is commendable for the treatment of chronic arth- ritis, not due to the gonococcus, but attributable to the absorption of other bacteria or toxins from the vesicles. Such cases are characterized by chronicity and resistance to other forms of treatment. I have cured such cases by operation upon the vesicles quite as brilliantly as their fellows are cured by tonsillectomy. But vesiculectomy in my wards has failed to cure gonococcic rheumatism or even to disclose gonococci in the vesicles. Vaccine treatment helps only in the first few days of the arthritis. I have had little luck with it, though I have used everything I could lay my hands on from horse serum to typhoid vaccine. But the real treatment for gonococcic arthritis is immobilization. Gonorrhea in a joint is just as self-limited, if given a chance, as it is anywhere else. At the first sign of arthritis the joint should be im- mobilized by a heavy plaster encasement. Nothing short of the heaviest, most extensive splint (if necessary, from head to ankle) will do. This, if properly applied, stops pain immediately; until it is applied the patient requires narcotics. The cast is left on two weeks; GONORRHEAL ENDOCARDITIS 123 then removed for inspection, passive motion, massage, and baking. After two days it is replaced for another two weeks and so on, until the infection is controlled. Then orthopedic treatment is continued and the patient got about as rapidly as possible. Few escape with one application of the splint; most with two. Exostosis of the Os Calcis.1—Though first described as recently as 1906 (by Baer), this condition is so common and so painful as to merit special mention. It begins as a myositis or periostitis at the attach- ment of the flexor brevis digitorum to the tubercle of the os calcis. With the subsidence of the acute inflammation an exostosis forms, pressure upon which (in walking) is exquisitely painful. The diagnosis is made by radiography. The treatment is operation. The exostosis must be chiselled or scraped away after exposure through an incision along the inner side of the heel. GONORRHEAL ENDOCARDITIS Systemic gonorrhea produces heart lesions in from 10 per cent to 20 per cent of cases. Thus ISTolan recognized heart lesions of probable gon- orrheal origin in 1G out of 115 cases of gonorrheal arthritis and Sears 2 in 25 out of 167. Sears has analyzed G8 cases of gonorrheal endocarditis, of which 61 were in men, 7 in women. The heart lesion was associated with ar- thritis in 56 cases, in 48 of which the lesions involved three or more joints, while in 10 there were no joint lesions. The heart was involved during the first gonorrhea certainly in 31 cases, probably in 9 more. In one instance the heart is alleged to have been involved during the second day of a gonorrhea. As a rule the lesion was first noted during the fifth or sixth week. Pathology.—The lesions are usually confined to the heart valves. Exceptionally there is pericarditis or myocarditis. “In 38 cases the mitral valve alone was involved, in 12 the aortic, and in 2 the pulmonic. The mitral and aortic were both involved in 8, the mitral and tricuspid in 1, the aortic and pulmonic in 1” (Sears). The pathologic changes3 in the valves usually consist in small friable vegetations made up of plasma cells, leukocytes, and red blood- corpuscles in a loose framework. Sometimes the valve is exulcerated, even perforated. Gonococci may usually be cultivated postmortem from the lesions and sometimes antemortem from the blood. Clinical Types.—Two clinical types are recognized, viz., simple gon- 1Winthrop, Jour. A. M. A., 1909, LIII, 715. 2 Boston City IIosp. Reports, 1898, IX, 201. 3 Cf. Rosenthal, Berl. Tclin. JVochenschr., November 26, 1900; Thayer and Lazaer, Jour, of Exper. Med., 1899, IY; and Thayer, Am. Jour, of the Med. Sci., November, 1905. 124 EXTRAGENITAL TYPES OF GONORRHEA orrheal endocarditis and malignant gonorrheal endocarditis. Neither type shows any clinical peculiarity to stamp it as gonorrheal. The for- mer is mild and insidious in onset, perhaps entirely latent, so that the resultant murmur, perhaps recognized years after, may be the only symptom. The malignant type, on the other hand, usually begins abruptly with chill, and progresses with intense septic fever. Yet the types are neither fixed nor exclusive; a case may begin mildly and be- come malignant later, or, beginning in the most acute fashion, it may rapidly subside. Diagnosis—A patient who develops a heart murmur or malignant endocarditis while suffering from gonorrheal rheumatism may be put down as a case of gonorrheal endocarditis. This diagnosis is con- firmed by the complement fixation test or the cultivation of gonococci from the blood.1 Prognosis.—Sears believes that a mitral lesion offers a better prog- nosis than any other, since of the 43 cases in his series that recovered, 33 gave signs of lesions in that valve. Cardiac symptoms, if present, usually persist a month to six weeks, septic symptoms two to four weeks. The damage to the valve is usually permanent and the murmur persists. Fatal cases usually terminate in two or three weeks, but the patient may survive several months. Treatment.—The treatment is that of endocarditis plus the anti- gonococcus vaccine or serum. 1 Lofaro, II Policlinico, Feb., 1911, No. 2, p. 49. CHAPTER XIII GONORRHEAL URETHRITIS IN THE MALE Goxoerhea, or gonorrheal urethritis, is the most venereal of all venereal diseases, since it is the commonest malady acquired during the copulative act. A most respectable antiquity is given to gonorrhea by the fifteenth chapter of Leviticus, although it is contended that the discharge known to the Jewish lawgiver was a simple urethritis, and that gonorrhea did not appear until later (according to Astruc in the year 1545-46). ETIOLOGY Gonorrheal urethritis is caused by implantation of the gonococcus upon the urethral mucous membrane. This implantation occurs almost exclusively in sexual contact. It is quite possible for the male to ab- stract outlying gonococci from the vulva of a timorous partner without effecting intromission (I have seen two instances of infection thus acquired). It is even possible to transmit gonococci to the urethra on the fingers. Less direct methods of contagion may be looked upon with suspicion. The mythical bathtub and the legendary privy are calcu- lated to excite derision. However certain it be that vulvovaginitis in little girls commonly results from indirect contagion, and that infec- tion of an adult from a drop of pus on the edge of the closet seat is perfectly possible, it is, nevertheless, singular that such a mode of in- fection is alleged almost exclusively by persons who are interested in concealing a transgression. Frequently enough our patient relates that his partner was “per- fectly clean.” Such “perfect cleanliness” is reducible to three heads: 1. Usually the woman is supposed to be exclusively attached to someone else, who marches about in apparent health. In this case all three of the parties are undoubtedly gonorrheal, the suppliant acutely, the woman perhaps unconsciously, the accredited proprietor probably chronically. This explanation is founded upon the assumption that a woman may have gonorrhea and yet think herself clean (a matter of common knowledge), and that a man and woman, both infected, may cohabit habitually without exciting symptoms of gonorrhea in either. 125 126 GONORRHEAL URETHRITIS IN THE MALE I have, for example, had two persons under my care, a woman (F) and a man (M), whose history may be summarized as follows: Spring, 1908, F infected with gonorrhea. Prompt “cure.” No- vember, 1908, F leaves her paramour and attaches herself to M. M promptly acquires gonorrhea. December, 1908, M consults me. The woman is “perfectly clean.” She has acute gonorrheal arthritis. I find gonococci in M and in F. They continue to cohabit frequently. February, 1909, gonococci can no longer be found either in M or F. There have been no further symptoms of gonorrhea in either. Local treatment has been employed by both. 2. Sometimes exposure is denied on the score that the male has worn a condom. In such a case the gonococcus has been acquired during pre- liminary skirmishing. 3. The most difficult case to explain is that in which the woman has been examined and pronounced clean by a physician. If the male actu- ally harbors the gonococcus and has cohabited only with one woman, sufficiently careful examination of that woman by smear and comply ment fixation will reveal the gonococcus. That a woman may pass through an attack of acute gonorrhea and remain infectious, while never suspecting that she is diseased, is abun- dantly proven. That a male or female gonorrheic may cohabit with but one partner for many months before transmitting the infection is equally true. We scarcely need to add that of two men exposed to infection from one woman, one may acquire the disease, the other not. PATHOLOGY Urethral gonorrhea begins as an acute inflammation at the meatus, whence it travels inward along the urethral mucous membrane. Unless repressed by local treatment, this inflammation invariably travels as far as the bulbous urethra and usually invades the posterior urethra as well. Although gonorrheal inflammation is essentially the same in the anterior as in the posterior urethra, we shall describe these processes separately. The cytology of gonorrheal pus has been studied by Joseph,1 Wile,2 Posner,3 Neuberger,4 and Taylor.5 The results obtained are nil. The predominating cell is polymorphonuclear. The eosinophil is always encountered, hut does not harbor gonococci and is not pathognomonic. 1 Archiv f. Dermat. u. Syph., 1905, LXXVI, 65. 2 Am. Jour. Med. Sci., June, 1906. 8 Berl. Min. Wochenschr., November 7, 1906. 4 Virchow’s Archiv, 1907, CLXXXVII, No. 2. *Jour. Am. Med. Assoc., 1907, XLIX, 1830. PATHOLOGY 127 As Taylor says: “All of this detailed study of cellular elements of gonorrheal discharge, interesting as it may be, has contributed very little to our understanding of the nature, prognosis, or treatment of urethritis."’ PATHOLOGY OF ACUTE ANTERIOR URETHRITIS Onset.—Tlie most accurate data we possess in reference to the in- vasion of the urethral tissues by the gonococcus are those published by Finger, Gohn, and Schlagenhaufer.1 These authors inoculated the urethrae of criminals condemned to death, and were able, by means of immediate post mortem examination, to investigate the various stages of invasion of the tissues by the specific microbe. Thirty-eight hours after inoculation the gonococci had only just begun to effect an en- trance between the epithelial cells. The lacuna of Morgagni was crowded with the cocci, diapedesis had begun, and intracellular gono- cocci were found among the few leukocytes on the surface of the epi- thelium. At the end of three days the inflammatory process was well under way. The surface of the mucous membrane was covered with pus, its epithelium infiltrated by bacteria from one side and by leuko- cytes from the other. The inflammation showed four striking char- acteristics, viz.: 1. The pavement epithelium of the fossa navicularis, although swollen with leukocytes, resisted the invasion of the gonococci almost absolutely; 2. the cylindrical epithelium of the penile urethra was generally invaded; 3. this invasion was most marked about the crypts and glands, which were packed with pus and gonococci; and 4. the subepithelial connective tissue, though showing every evidence of inflammation, contained few gonococci, except in the neighborhood of the crypts and glands. Height.—When the inflammation reaches its height the mucous membrane, from the tumefied meatus to the bulbous urethra, is intensely inflamed. Its surface is red and swollen, covered with pus and, in places, eroded or ulcerated. The epitlielia and the subepithelial con- nective tissue are infiltrated by the warring gonococci and leukocytes. The glands and crypts form the most important centers of inflam- mation. They are implicated in the general process; inflamed and distended with gonorrheal pus. The gland orifices become ob- structed by the tumefaction of the mucous membrane and the glands thus form centers whence infiltration (and even suppuration) extend into the surrounding tissues. Since the glands are numer- ous and extend to and, in some instances, even into the corpus spongio- sum, the submucous infiltration (or suppuration) arising from them is often widespread and intense a£ the height of an acute gonorrhea, 'Arch. /. Dermat. u. Syph., 1894, XXVIII, 277. 128 GONORRHEAL URETHRITIS IN THE MALE and leaves infiltrations that are the chief cause of chronic urethritis. Were the urethra as glandless as the conjunctiva, urethral gonorrhea would show as little tendency to chronicity, complications, and systemic absorption as does conjunctival gonorrhea. PATHOLOGY OF CHRONIC ANTERIOR URETHRITIS As tliis acute inflammation subsides the tissues involved may return to a normal, or at least a clinically normal, condition, or the urethritis becomes chronic. The transformation of an acute gonorrheal anterior urethritis into a chronic condition implies certain pathologic and bac- teriologic changes, as follows: 1. The inflammatory periglandular exudate becomes organized into cicatricial tissue of greater or lesser density and extent, according to the greater or lesser intensity and distribution of the acute inflam- mation. 2. The inflammation within the glands and crypts persists as a chronic catarrh (glandular urethritis of Oberlaender), or the orifice of the gland is occluded and the inflamed gland becomes a purulent or col- loidal cyst (dry urethritis of Oberlaender), or the glandular inflamma- tion ceases either by cicatricial obliteration or by return to normal of the gland. These changes may all occur in the same urethra. Chronic anterior urethritis is therefore denominated by the urethroscopic method in accordance with its predominant feature. The submucous glandular abscesses are minute and usually terminate by rupture within the urethra, exceptionally by invasion of the surrounding tissues and ex- ternal rupture. 3. The surface of the mucous membrane is chronically inflamed. The inflammation may be localized over one or more small areas or may be general. The quality of the surface inflammation depends upon the degree of submucous sclerosis. If the sclerosis is slight the surface is swollen, red, and eroded in spots, while here and there appear the inflamed orifices of glands and crypts. The urethroscope shows increased redness, diminution of the number of urethral striae and folds, and red, suppurating duct orifices. This is the urethritis mucosae, the soft infiltration of Ober- laender. More marked sclerosis causes a relative anemia of the overlying mucous membrane (after the redness of acute inflammation has disap- peared), which is therefore salmon colored or grayish, lighter in color than the adjacent healthy mucosa. There may be spots of opalescent whiteness, where the chronically inflamed epithelium has been trans- formed from a columnar to a squamous type with tendency to leuko- plakia; i. e., heaping up of this squamous epithelium into thick “cal- PATHOLOGY 129 lous” masses. Elsewhere there may be erosions, ulcerations, papillary outgrowths. The urethroscope shows a pale rigid mucosa with striae and folds almost or quite obliterated. Here and there one sees a white patch of squamous epithelium, red gland orifices, bleeding erosions, ulcers, or papillomata. This is the hard infiltration of Oberlaender. Still more marked sclerosis causes urethral stricture. The processes mentioned in the preceding paragraph are intensified. The rigid ure- thral walls do not yield to admit urethral instruments. The caliber of the urethra is more or less diminished, perhaps almost completely oc- cluded. Hard infiltrations of greater or less degree are classified by Ober- laender as hard infiltrations of the first, second, or third degree. Hard infiltrations of the first degree do not encroach upon the urethral caliber. Those of the second degree diminish the caliber of the urethra to such an extent that large instruments 1 can still be introduced, but only at the expense of more or less laceration of the epithelium.2 Those of the third degree do not admit large instruments until after they have been dilated. These more or less arbitrary subdivisions correspond to clinical types of urethritis. Yet it must not be forgotten that they are but degrees of the same process. Therefore, while the mildest form of chronic urethritis may exist alone, the more intense “hard” infiltrations are at first always accompanied by a more diffuse “soft” infiltration which may for a time conceal them. The soft infiltration may heal spontaneously; the hard infiltration requires treatment by dilatation, and leaves a permanent scar in the walls of the canal. 4. The flora of the gonorrheal urethra undergoes a marked change as the inflammation becomes chronic (p. 134). PATHOLOGY OF POSTERIOR URETHRITIS The pathologic changes produced by gonorrhea in the posterior urethra are essentially the same as those produced in the anterior ure- thra. But certain anatomical differences vary the actual conditions. These are: In the membranous urethra— The relative rarity of glands. In the prostatic urethra— The complexity of the glands immediately beneath the mucous membrane. The verumontanum. 1 Oberlaender makes a urethroscopic tube of No. 23 F. size the criterion, 2 This is the ‘ ‘ stricture of large caliber ’ ’ of the elder Otis. 130 GONORRHEAL URETHRITIS IN THE MALE The great complexity of the internal sexual glands (prostate, vesicles) emptying into the posterior urethra. In the trigone—- The rarity and simplicity of glands. We must, therefore, describe gonorrhea of: 1. The membranous urethra. 2. The prostatic urethra and verumontanum. 3. The prostate. 4. The seminal vesicles. 5. The trigone. 6. The vas and epididymis. The Membranous Urethra.—The glands of the membranous urethra are relatively few and simple. Hence, chronic gonorrhea of the mem- branous urethra is clinically mild and is overshadowed by the in- flammation of other portions of the canals. Submucous infiltrates are usually slight. Stricture is rare, chronic glandular catarrh usually mild. The Prostatic Urethra.—The relatively large and complex glands in the mucous membrane of the posterior urethra (p. 243) and the sinus pocularis of the verumontanum form nests for possible abscess formation during acute gonorrhea of the posterior urethra, and even after the acute general inflammation has passed. These abscesses are larger than those commonly formed in the glands of the anterior urethra. They excite fever and burst into the canal with a recognizable outpouring of pus. Chronic Posterior Urethritis.—The urethral mucosa undergoes much the same change as those of chronic anterior urethritis. But as the inflammation grows less it may become localized in certain special forms as follows: Yillosities (improperly termed papillomata 1) may persist in vari- ous parts of the posterior urethra. They are exuberant granulations arising from a small ulcer. Follicular Abscesses and Cysts are rare. They usually occur beyond the verumontanum. Vebumontanitis.—The verumontanum may be regarded pathologi- cally as a hood covering the prostatic utricle. Hence a chronically in- flamed verumontanum is always associated with utriculitis, usually with vesiculitis. The urethroscope shows a swollen, red verumontanum, perhaps much hypertrophied and covered with granulations. Irriga- tion of the utricle usually discloses pus in its cavity; amputation of the verumontanum (Eytina 2) shows submucous and periacinous round cell infiltration. 1 Surg., Gynec. and Obstet., 1913, XVII, 548. 2 Jour. A. M. A., 1915, LXLV, 45. PATHOLOGY 131 Stricture, at the bladder neck, or throughout the prostatic urethra, is rare. It is attributable to chronic sclerotic prostatitis (p. 217). The Prostate.—The prostate is implicated in almost every inflam- mation of the posterior urethra. Protatitis is by far the most im- portant complication of genital gonorrhea in the male. It is frequent, it is intractable, it is the source of many grave lesions within the pros- tate itself, and is a port of entry for systemic gonorrhea. Whereas the glandular lesions of the anterior urethra are almost ex- clusively due to gonorrhea, the prostate may be, and often is, inflamed by other bacteria. Three types of prostatitis are recognized: the catarrhal, the follicu- lar, and the parenchymatous. The distinction is a clinical rather than a pathological one. In the prostate, as in the less complex glands of the anterior urethra, the inflammation is a suppuration within the gland associated with more or less surrounding infiltration, which infiltration may terminate in sclerosis or in suppuration. Catarrhal Prostatitis.—The inflammation extends into the pros- tatic ducts, but spares or does not markedly involve the acini. The in- flamed ducts are dilated, filled with pus and debris. The surrounding stroma is but little infiltrated. The examining finger detects no change in the gland, but can squeeze pus from it. The diagnosis is not made until the acute posterior urethritis has subsided, leaving the chronic catarrhal prostatic lesion. Follicular Prostatitis.—The inflammation reaches the acini, which are distended with pus, while the surrounding stroma is infil- trated. In the acute stage the prostate is congested, tense, sensitive. As the inflammation becomes chronic the general congestion disappears, leaving the gland lumpy to the touch. The lumps are constituted by areas of diseased acini, suppurating, cystic, necrotic, or atrophic, in an indurated stroma. Parenchymatous Prostatitis.—The follicular involvement is more intense, the interstitial inflammation more widespread and intense. Abscess of the prostate results. The suppuration occurs in small multi- ple foci, few or many, which may resolve without rupture, or coalesce to form a large prostatic abscess and rupture into the urethra or into the ischiorectal fossa, or rectum. Chronic Prostatitis.—Mdcroscopic Changes.—To the examining finger the chronically inflamed prostate may show no change. More commonly it is enlarged. This enlargement consists of a general bulg- ing of one or both lateral lobes or the presence of masses of induration in or about the gland. The general enlargement of a lobe may be tense and irreducible by pressure, or it may soon yield to massage, leaving in its place a sunken pit surrounded by a more or less clearly marked rim of induration. 132 GONORRHEAL URETHRITIS IN THE MALE With this subsidence of a swollen lobe under massage there is an out- pouring of purulent prostatic secretion from the meatus. The indurations may be prostatic or periprostatic. They are irre- ducible by massage, but usually diminish in size or disappear after re- peated massaging or even, in time, without massaging. Microscopic Changes.—“Periacinous infiltration is so invariably present that we may speak of it as the essential lesion of chronic prostatitis. Sometimes it is combined with more extensive interstitial and endoglandular processes, but not infrequently in extensive areas the periacinous lesions may be present alone. “The changes in the acini are manifold. In some instances the culdesacs are dilated; this dilatation . . . may be due to stricture or obstruction in the excretory ducts, but is probably more often the result of an accumulation of inflammatory products in the glandular sacs, the muscular tone of whose walls has been injured by the inflammatory process. Acini, however, the caliber of whose lumina is diminished, are almost as frequently seen as are dilated ones, and this is especially true where the prostatitis is of long standing and an extensive periacinous sclerosis has formed. At times the acini are mere vestiges or may even he entirely replaced by fibrous tissue in areas of considerable extent. The acini are often partially or entirely filled with proliferating and desquamated epithelium” (Young, Geraghty, and Stevens). These lesions are unevenly distributed about the gland. Areas, large or small, of normal gland are usually present, and in some instances the diseased area is confined to that part of the gland adjacent to the urethra. The dilatation of the acini may be very considerable. This dilata- tion is the foundation for Ciechanowski’s theory of the inflammatory origin of prostatism. Changes in the Secretion.—The normal prostatic fluid is an opales- cent fluid, alkaline to litmus (and acid to phenolphthalein, whence the arguments as to its reaction). As obtained by massage, it usually con- tains gelatinous, transparent masses of vesicular secretion. The pure normal prostatic secretion is filled with minute lecithin bodies. It contains a moderate number of columnar and round epithelia (the nuclei of the latter almost fill the cell body), a very few leukocytes, a few corpora amylacea, and perhaps red blood cells from the trauma of massage. The abnormal prostatic secretion is purulent. It is not so opalescent as the normal secretion. When mingled with urine (passed after mas- sage) it often looks granular and flaky to the experienced eye. There often settles at the bottom of the glass a deposit of crumblike purulent masses (shreds). The normal elements are in inverse proportion to the amount of pus. The reaction, like that of the normal secretion, is acid or alkaline according to the reagent employed. Bacteria are some- times present in great numbers. In rare instances pus is only obtained BACTERIA OF CHRONIC URETHRITIS 133 after the second or third massage, the secretion expressed by the first manipulation being exclusively from the normal portions of the gland. The diagnosis of pus in the prostatic secretion should always be con- firmed by the microscope. Seminal Vesicles.1—Seminal Vesiculitis.—The acute changes caused by gonorrhea of the seminal vesicle are similar to those in the prostate, with this exception—that the vesicle is a gland of so much larger caliber and with so much larger a duct that recognized abscess in it is uncommon, and its parenchymatous changes, if unaccompanied by dilatation, are often clinically overlooked. Chronic Vesiculitis.—The normal vesicle is impalpable unless greatly distended with semen. Yet the vesicle, like the prostate, may be inflamed, though apparently normal to rectal touch. The walls of the vesicle are infiltrated and matted together in what is pathologically a perivesiculitis. This may or may not result in a palpable enlargement of the gland. The mucosa is infiltrated and eroded. The lumen is in places contracted or occluded by stricture, in others dilated. This general dilatation can always be demonstrated by injection of argyrol into the vas. In long-standing cases the vesicle may be changed from its normal state—a branching ramifying canal— to an irregular cavity containing several c.c. of pus. Chronically in- flamed vesicles have been appropriately termed by Belfield 2 “pus tubes in the male.” Vesiculitis is always bilateral, often impalpable. Secretion.—The secretion of the normal vesicle varies in consistency from thick gelatinous to sticky and ropy. The microscope shows mu- coidal masses entangling spermatozoa, sympexia, and epithelial cells. The color is usually opalescent, hut may be rusty, especially in older persons, from pigmentation of the contained epitlielia. When sper- matozoa are absent Boettcher’s crystals are usually found. The vesicu- lar secretion floats (in part) in water, whereas the prostatic secretion sinks. The secretion of an inflamed vesicle contains pus and bacteria. Live spermatozoa are sometimes, though not often, found in purulent vesicu- lar secretion. BACTERIA OF CHRONIC URETHRITIS The occurrence of mixed infection in chronic urethritis is due usu- ally to the bacteria harbored by the normal urethra, rarely to contamina- tion by instruments. Moreover, the bacterial findings are not quite the 1Cf. Palozzoli, T&ev. chir. d. urol., 1914, Jan., Feb., Mar. 2 Jour. A. M. A., 1909, liii, 2143. Also Thomas, Ann. Surg., Sept., 1914. 134 GONORRHEAL URETHRITIS IN THE MALE same in chronic anterior urethritis and in chronic prostatitis. Hence we must consider: The bacteria of the healthy anterior urethra; The bacteria of chronic anterior urethritis, and The bacteria of chronic prostatitis. Bacteria Found in the Healthy Anterior Urethra.1—Pfeitfer exam- ined 24 urethrae, and found diphtheroid bacilli in 21, streptohaciilus in 10, staphylococcus pyogenes aureus in 5, miscrococcus candicans in 4, sarcina alba in 14. Petit and Wassermann found 5 kinds of cocci, G kinds of bacilli. Franz, in 5G urethrae, found the sarcina once, the bacillus coli once, pyogenic staphylococci G times, streptococci twice, and 7 other varieties of cocci and 4 varieties of diplococci. .These bacteria are usually found at or near the meatus. The deeper portion of the anterior urethra is often sterile. Bacteria of Chronic Anterior Urethritis.—Of 154 cases 2 examined 20 were sterile, 10 showed gonococci alone, 10 gonococci mixed with other bacteria, 114 other bacteria without gonococci. Of von Hoffmann’s cases, the gonococcus apart, 18 showed pseudo- diphtheria bacillus, 12 streptohaciilus urethrae, 2 bacillus subtilis, 3 sarcina alba, 1 proteus vulgaris, 1 bacillus coli, 1 Friedlander’s bacillus. He also found 27 kinds of staphylococci, 3 other cocci, and G kinds of bacilli. Bacteria of Chronic Prostatitis—Young, Geraghty, and Stevens,3 examined 19 cases (2 nongonorrheal) and obtained a growth on agar in only 8. The staphylococcus albus was identified thrice, the strepto- coccus pyogenes twice. The anterior urethra was copiously irrigated and the prostatic secretion obtained through a sterile uretliroscopic tube. Control cultures were made from the bulbous urethra. Notthaft, using less careful methods, examined 120 cases. He found the gonococcus alone in 5 cases, all within eighteen months of the time of infection; the gonococcus alone or with other bacteria in GO per cent cases of less than eighteen months’ duration, in 18 per cent cases of from eighteen to twenty-four months’ duration, in 6 per cent cases of from twenty-four to thirty-six months’ duration. The gonococcus was not found after the third year. The gonococcus was found 47 times, other micrococci 119 times, bacilli were found 15 times, other bacteria 14 times. Cohn, in 12 cases, found staphylococcus albus 11 times, streptococcus 3 times, bacillus coli once, other bacteria thrice; no gonococcus. Bacteria of Chronic Vesiculitis—Gonococci are very rarely found in the chronically inflamed vesicle. Cultures are often sterile. The 1 Yon Hoffmann, CentraTbl. f. Ham u. Sex. Org., 1904, xv, 569. 2 Reported by Tano, Cohn, Owens and von Hoffmann. . * Johns Hopkins Hospital Reports, 1906, xiii, 276. BACTERIA OF CHRONIC URETHRITIS 135 flora includes staphylococcus, streptococcus, bac. lactis aerogenes, and bac. coli. Summary.—Thus the gonococci that swarm in the discharges of acute gonorrhea are by no means always present in chronic gonorrheal urethritis and prostatitis. Notthaft1 quotes in favor of his thesis that they disappear from the prostate always within three years, often within eighteen months, the names of Eeisser, Finger, Frank, AVassidlo, Jadas- sohn, Goldberger, and others. The thesis may, I believe, be extended to include all the urethral glands. I have seen but one apparently au- thentic case in which gonococci persisted for three years in the urethral secretion; not more than three or four in which, in spite of vigorous treatment, they persisted for over two years. Earnest investigation dur- ing the past three years, with the aid of the complement deviation test, has served only to confirm this belief. The rule is almost without ex- ception that a chronic gonococcic urethritis ceases to show gonococci in its secretion within three to six months of the beginning of intelligent local treatment. 1 Archiv f. Derm. u. Sypli., 1904. CHAPTER XIV SYMPTOMS, COURSE, AND COMPLICATIONS OF ACUTE URETHRAL GONORRHEA IN THE MALE Since acute gonorrhea of the male urethra always begins with in- flammation of the balanitic urethra,1 continues by direct extension of the inflammation along the urethral mucous membrane, and may terminate before the inflammation reaches the posterior urethra, to be accurate we should speak of anterior urethritis alone as essential gonor- rheal urethritis and class all other gonorrheal inflammations, including posterior urethritis, as complications. But inasmuch as the average uncontrolled urethral gonorrhea invades the posterior urethra, the trigone, and the prostate, it is clinically convenient to group anterior urethritis, posterior urethritis, and prostatitis in the type description of the disease and to follow with a description of other inflammations as complications. Accordingly, we shall describe: The incubation. Typical acute gonorrheal urethritis. Atypical acute gonorrheal urethritis. Prolonged or complicated cases. Mild cases. Severe cases. Cases modified by treatment. Complications of acute anterior urethritis. Abscess of the urethral glands. Periurethritis and periurethral abscess. Inflammation of the erectile tissues. Balanoposthitis, lymphangitis, lymphadenitis. Complications of acute posterior urethritis. Prostatitis. Prostatic abscess. Seminal vesiculitis and deferentitis. Epididymitis. Cystitis. Pyelonephritis. Peritonitis. 1 Excepting eases of reinfection of the urethra from gonococci that have lain quiescent in the urethral glands, which cases are properly classed as relapses. 136 TYPICAL ACUTE GONORRHEAL URETHRITIS 137 INCUBATION OF GONORRHEAL URETHRITIS The incubation period of gonorrhea varies from two to seven days. The earlier authors recognized longer incubation periods. Yet I con- fess to some suspicion of inaccuracy in reference to those cases on the subjoined list that give a story of more than a week’s incubation. Per- haps some of them had very long foreskins. Experimental inoculation produces a discharge on the second, third, fourth, or fifth day; but it has been my experience that the shorter in- cubations are clinically due to the association of sexual strain or of simple urethritis with the gonococcus. Such a condition may he ex- pected to occur most often in the damaged urethra of the roue; hence the relatively large number of short incubations among recurrences as compared with first attacks. Length of Incubation1 Day. First Attack. Recurrence. 1 0 2 cases. 6 6 2 . 2 cases. 12 3 2 i ( 15 (C 4 3 a 13 i( 5 11 i t 10 it 6 6 a 4 it 7 4 (( 10 it 8 1 case. 2 it 9 1 c i 1 case. 10 1 (( 4 cases. case. 11 1 n 1 12 1 a 0 13 1 (c 0 14 0 2 cases. Total 34 76 Average incubation of 34 primary attacks, 6 days. Average incubation of 76 secondary attacks, 4.88 days. Of the primary attacks, 20 per cent appeared before the fifth day; 61 per cent on the fifth, sixth, and seventh. Of the secondary attacks, 55 per cent appeared before the fifth day; 31 per cent on the fifth, sixth, and seventh. TYPICAL ACUTE GONORRHEAL URETHRITIS Onset—A tickling, teasing, itchy irritation is felt at the orifice of the urethra. The lips of the meatus are found adherent, or a bluish, 11 have included in this list only those cases in which the incubation period was unmistakable and the disease absolutely characteristic—microscopically, clinically, or both. 138 ACUTE URETHRAL GONORRHEA IN THE MALE sticky discharge is seen between them. A slight stinging is felt on urina- tion. The lips of the meatus now swell slightly and redden. The quan- tity of discharge increases and it becomes frankly purulent. The meatus feels hot and sore. The pain on urination increases. Height.—In a period varying from a few hours to two or three days the inflammation reaches its height at the meatus and has invaded the greater part of the anterior urethra. The symptoms of anterior urethritis are swelling of the meatus, purulent discharge, painful urina- tion, and painful erections. The Swollen Meatus.—The lips of the meatus are red, swollen, everted, sometimes eroded. Their tumefaction is almost pathognomonic of gonorrhea. It begins with the disease and usually subsides during the second or third week, long before the subsidence of the inflamma- tion of the deeper portion of the urethra. It is less constant and less marked with secondary than with primary attacks. The Discharge.—The drop of thick greenish-yellow pus constantly exuding from the swollen meatus completes the outward picture of acute gonorrhea. Blood may appear in the discharge from time to time. The pus ceases to be thick and creamy some time after the swelling of the meatus has subsided. It becomes less in quantity and more watery and opalescent in quality as the acute inflammation of the anterior urethra declines. The Pain on Urination.—The urethral mucous membrane is swollen, sensitive, and eroded. Hence, the passage of urine is painful, the stream slow and obstructed. The pain due to anterior urethritis reaches its height within ten to fourteen days and begins to subside between the fourteenth and the twenty-fifth day. The Painful Erections.—The urethral inflammation encourages nocturnal erections. The inflamed membrane is relatively inelastic, hence these erections are exceedingly painful. The inflamed surface may be so cracked and fissured that it bleeds copiously. Since the corpora cavernosa retain their normal distensibility, the inelastic, inflamed urethra is pulled taut beneath them when the penis is erect, so that in severe cases the organ is bent downward, while the pain is excruciating. This phenomenon is called chordee. Painful erections may continue for days after the surface of the an- terior urethra has ceased to be sensitive to the passage of urine. Invasion of the Posterior Urethra and Prostate—It is clinically impossible to distinguish acute posterior urethritis from acute pros- tatitis, and although in some instances the posterior urethra is involved and the prostate apparently spared, this cannot be determined until after the disease has become chronic. The frequency of posterior urethritis in acute gonorrhea is esti- TYPICAL ACUTE GONORRHEAL URETHRITIS 139 mated variously. Van der Poel estimates it at CO per cent, Wassidlo quotes various authors at from 80 per cent to 92 per cent. Prostatitis is estimated to complicate about 70 per cent to 80 per cent of acute posterior urethritis, though Columbini places it as low as 36 per cent. The confusion in these figures is due to the various means of exam- ination employed. Subjective symptoms of posterior urethritis are excited by the majority of initial gonorrheas, are less common in subsequent attacks, and are rare in office patients treated by repressive measures. On the other hand, if pus in the second flow of urine is taken as a criterion, the percentages run much higher. Let us be satis- fied to say that acute posterior urethritis is extremely common and usually associated with prostatitis. Posterior urethritis usually appears between the fifth and the fif- teenth day of acute gonorrhea. Symptomless Cases.—The figures given in the preceding para- graph illustrate the frequency with which gonorrhea invades the pos- terior urethra without causing subjective symptoms. The evidence of this invasion is pus in the second flow of urine or palpable enlargement of the prostate. It is probable that in these symptomless cases the prostatic urethra is only mildly inflamed, the trigone spared altogether. Symptoms of Acute Posterior Urethritis axd Trigonitis (Cystitis).—The symptoms of acute gonorrheal posterior urethritis, trigonitis, or cystitis are all referable to the irritation at the bladder neck. This causes frequent and urgent urination, painful urination, and terminal hematuria. Frequent and Urgent Urination.—So long as the pain of urination is due solely to anterior urethritis the patient urinates as rarely as possible. When it is due to posterior urethritis he must urinate fre- quently. As soon as a relatively small amount of urine has collected in the bladder an urgent call to urinate is felt; a call that will not be denied. If the victim does not quickly acquiesce he irrigates his trouser leg. The frequency of this urgent call may be so great that the patient dribbles away a few drops of purulent urine every ten or fifteen minutes night and day. A frequency of less than once in two hours may be accounted mild. Painful Urinatio7i.—The pain of posterior urethritis is more con- stant than that of anterior urethritis, and is often referred to some point on the surface of the body, usually the perineum, the anterior urethra just back of the glans, or the epigastrium. The pain at urination in posterior urethritis has several striking characteristics. It appears before urination, as we have just seen, in the form of urgency. During urination the posterior urethra can be more exquisitely sensitive than the anterior urethra. But it is at the 140 ACUTE URETHRAL GONORRHEA IN THE MALE end of urination that the full force of this pain is felt. As the muscles of bladder and urethra contract to expel the last drops of urine the in- flamed surface is violently wrenched. The resultant pain, like that of anal fissure, is a spasm or series of spasms that may last for many sec- onds after the bladder has emptied itself. In severe cases the patient may be said to pass from one terminal urinary spasm to another. Terminal Hematuria.—The intensity of the inflammation, together with the incessant trauma of the frequent urination, often excite bleed- ing from the posterior urethra. This bleeding may he constant or inter- mittent. In either case the amount of blood lost is not great, and the three-glass test reveals terminal hematuria; i.e., whether the body of the urine be bloody or not, the last jet is almost pure blood. Terminal hematuria is caused by terminal spasm. The Decline—The inflammation subsides first where it first began, i. e., at the meatus. The meatal inflammation often disappears in the second or third week, while the inflammation is elsewhere at its height. In the rest of the anterior urethra the inflammation usually begins to decline in the third or fourth week; the discharge becomes thinner and more watery, the erections less painful. The pain, frequency, and bleeding that mark posterior urethritis may begin to diminish at almost the same time. In the fourth or fifth week the patient’s symptoms are reduced to a semipurulent discharge, which grows less and less in quantity. From the sixth to the eighth week this discharge usually continues almost or quite exclusively as “a morning drop,” a drop of pus appearing at the meatus only before the first morning urination; during the rest of the day the urethra is apparently clean. Now the patient fancies himself well. But examination of the urine still reveals pus; examination of this pus still reveals gonococci. It is rare for the gonococci and pus to disappear within six weeks. It is common for them to persist eight to twelve weeks. By common consent the gonorrheal urethritis of less than two months’ duration is called acute, of more than three months’ duration chronic. The division is purely arbitrary, but it voices the fact that acute gonorrhea is often cured in from eight to twelve weeks. ATYPICAL ACUTE GONORRHEAL URETHRITIS The good or evil fortune of the patient in his choice of a physician as well as in his reaction to the disease so influences the course of each individual case of gonorrhea that the attempt to separate “typical” from “atypical” cases, though justified by expediency, has no founda- tion in clinical fact. The above description of a “typical acute gon- ATYPICAL ACUTE GONORRHEAL URETHRITIS 141 orrheal urethritis” describes many cases in general but none in par- ticular. Every case is actually “atypical” to a greater or less degree. Prolonged or Complicated Cases—What proportion of gonorrlieics become chronic I do not know. In the clinic most cases approach the three-months’ limit and perhaps half surpass it. In private practice, by the aid of repressive measures, we get better results. But practically every unrepressed case of gonorrhea is a “compli- cated” case. Some one of the complications mentioned below almost invariably arises unless repressive measures are employed. Mild Cases.—The initial gonorrhea is quite invariably severe. Sub- sequent infections, especially if often repeated, may run a much milder course; so mild, indeed, that it might be quite impossible to determine when a given patient was last infected. The bearing of this fact upon the alleged persistence of gonococci in urethral pus for many years in exceptional instances is most important. Reinfections may excite merely a slight mucopurulent discharge with the least possible subjective irritation. The acute attack may last but a week or so. Yet from such an infection gonococci may persist in the urethra quite as long as though the attack had been most severe. Moreover, the urethra thus inflamed may resent instrumental or other traumata, though the reaction to these is not so fierce as when the ure- thral inflammation is more intense. Acute Reinfections.—Sharp, short reinfections of the anterior ure- thra, with copious creamy discharge, yet lasting but a few hours or a few days, are more often due to reinfection from the patient’s own secretions (occasioned by instrumentation, sexual or alcoholic excess, spontaneous rupture of follicular abscess, etc.) than to fresh infection acquired from without. The striking feature of such reinfections is their brevity: the contrast between the profuse, creamy, gonococcus- laden discharge of today and the entire absence of all symptoms tomorrow. Severe Cases—Urethral gonorrhea may be severe in its onset (prompt involvement of posterior urethra or epididymis, early appear- ance of complications, intensity of subjective symptoms), in its com- plications, or in the severity or duration of its acute symptoms. Thus chordee, or the pain and frequency of posterior urethritis, may be almost or quite the first symptoms complained of; epididymitis, even, may apparently begin the attack. Yet, unless they be autore- infections, it is not correct to classify such outbreaks as beginning in the posterior urethra or in the epididymis. The prolongation of intense chordee or posterior urethritis through many weeks occurs just often enough to remind us of the total lawless- ness of gonorrheal inflammations. Cases Modified by Treatment.—The local treatment now almost 142 ACUTE URETHRAL GONORRHEA IN TIIE MALE universally employed throughout acute gonorrhea always materially modifies the course of the disease. If successful it ameliorates all the symptoms and minimizes the danger of complications; if unsuccessful, it intensifies the urethral inflammation, excites complications, or en- courages chronicity. COMPLICATIONS OF ACUTE ANTERIOR URETHRITIS Abscess of the Urethral Glands.—Minute abscesses due to obstruc- tion of the ducts of suppurating glands doubtless occur and pass un- noticed amidst the intense symptoms of every acute urethral gonorrhea. Such abscesses occurring during the declining stage cause a character- istic brief explosion of acute symptoms. After a day or more of vague localized uneasiness or itching a sharp reinfection of the urethra occurs. The discharge becomes profuse and creamy; the meatus may even swell, but there is usually no pain. But no sooner has the patient decided that he must look forward to weeks more of suffering than the discharge abates almost as suddenly as it appeared. This sudden abatement of discharge is doubtless due to local im- munity persisting from the preceding acute urethritis. It is exceptional for this immunity to be so slight as to permit prolonged relapse. Periurethritis and Periurethral Abscess—Extension of suppura- tion from an infected urethral gland to the periurethral connective tissue is to be expected only as a result of overtreatment or of scars left by antecedent gonorrheas. The suppuration arises from the balanitic, the pendulous, or the bulboperineal portions of the anterior urethra. Abscesses arising from the balanitic portion of the canal appear at one or both sides of the preputial frenum. They grow rapidly and, hav- ing opened or been incised, often leave permanent fistulae requiring a special procedure for their cure. Abscess of the pendulous urethra usually projects from the floor of the canal as a hard nodule. It may grow quite slowly and may resolve or break into the urethra. But it is far more likely to invade the skin and point directly opposite to its point of origin, or to travel beneath the fascia for a considerable distance before discharging externally, unless its course is cut short by incision. The fistula heals spontaneously. Abscess of the perineal urethra is usually spoken of as abscess of Cowpers gland, though it is impossible to say in what proportion of cases this gland is actually the oue involved. The inflammatory mass often appears to one side of the median line and usually travels to a distance beneath the deep fascia before breaking through this, thus causing extensive perineal infiltration, if not promptly incised. COMPLICATIONS OF ACUTE POSTERIOR URETHRITIS 143 All of these processes travel forward, so that, while abscess origi- nating in the pendulous urethra never points in the perineum, perineal abscess may show itself prominently only about the pendulous urethra. The attachment of the deep fascia to the anterior layer of the triangular ligament prevents extension of perineal suppuration backward. Inflammation of the Erectile Tissues.—Spongeitis and cavernitis are extremely rare complications of gonorrhea, if we except that type of the former that manifests itself in cliordee. Thrombophlebitis of the erectile tissues or inflammation of the fibrous envelopes manifest themselves as sensitive indurations of the erectile bodies. Under appropriate treatment they usually resolve, but they may suppurate and require incision. Balanoposthitis.—The gonorrheic with a long or tight foreskin usually develops balanoposthitis in spite of all his care. Yet the com- plication is rarely severe. It has no peculiar characteristics, is appar- ently due to mixed infection, and readily yields to the usual treatment. Lymphangitis and Lymphadenitis.—These complications are rare, inasmuch as they are due to extension of the gonorrhea beyond the urethra proper. They result usually from balanitis, less often from periurethritis, and, like the balanitis of gonorrhea, are not specific and are rarely severe. I have seen but one gonorrheal bubo that required incision. COMPLICATIONS OF ACUTE POSTERIOR URETHRITIS Prostatitis—Any inflammation of the prostate sliort of abscess adds scarcely any symptoms to those of tlie urethritis. Mild pros- tatitis, like mild posterior urethritis, may give no sign of its presence, while a more intense prostatitis, accompanying posterior urethritis, does not alter the clinical picture already described. The involvement of the prostate may or may not be distinguishable by rectal touch. Prostatic Abscess.—In drawing an arbitrary division between acute prostatitis and prostatic abscess, it is wiser to include with the latter all cases of acute prostatitis of sufficient severity to cause symptoms. This for two reasons: all such cases do represent retention of pus within the prostate ducts, and any one of them may progress to unmistakable abscess formation. To attempt to draw the line between the prostate in which mac- roscopic suppuration (abscess) has already occurred, and that in which it only threatens, is impracticable. Symptoms.—The symptoms of prostatic abscess follow one of three types, as follows: The local symptoms are accentuated. To the pain and frequency of 144 ACUTE URETHRAL GONORRHEA IN THE MALE urination due to posterior uretliritis is added a constant dull or throb- bing ache inside the pelvis, which may or may not radiate to the ure- thra, the testicles, the thighs, the hypogastrium, or the loin. If the pros- tate is much enlarged defecation is apt to be both painful and diffi- cult. Fever, often severe, and ushered in by a chill, is added to the afebrile urethral inflammation. But fever is no criterion of the extent or prog- ress of the prostatic involvement. Absence of fever is often noted in extensive prostatic suppuration.1 Retention of urine is a marked feature in many cases. Partial re- tention escapes observation; but acute, complete retention, requiring relief by the catheter, may occur. I have relieved by operation gonor- rheal abscess in both lobes of the prostate, the only symptom of which was acute retention of urine, preceded by no dysuria and accompanied by no fever. Yet in some instances dysuria, fever, and retention occur simul- taneously. Physical Signs.—The suppurating prostate is always enlarged, usu- ally sensitive. The whole of one or both lobes is involved. The diag- nosis should be made long before either boggy softening or fluctuation shows that the whole of a lobe has been transformed into an abscess cavity. Course.—The process may terminate by resolution; by rupture into the periprostatic tissue, causing ischiorectal abscess, or into the urethra, or the adherent rectum, or by passing on to chronic prostatitis. Alexander 2 studied 68 cases of gonorrheal prostatic abscess. Of these 31 appeared during the first gonorrhea, 37 during relapses; 35 caused retention of urine; 22 had hurst—into the perineum (16), the ischiorectal fossa (5), the rectum (1). The abscess was complicated by urethral stricture 9 times. If the pus burrows forward into the perineum it may occasion con- siderable mischief, burrowing along toward the corpus cavernosum, or even laying it bare. It has been known to go through the obturator foramen (Tillaux), and even to follow the connective-tissue plane about the spermatic cord and to point in the inguinal canal, or to get into the space of Betzius, to appear at the umbilicus, to pass by the sciatic notch (Guyon)—all very rare, but still possible culminations of neg- lected periprostatic suppuration. Seminal Vesiculitis.—Acute seminal vesiculitis, like acute pros- tatitis, usually gives no sign of its presence. If suppuration occurs in ihe vesicle the symptoms are those of prostatic suppuration, but a finger in the rectum discloses a tense, sausagelike tumor in the region of the 8 Keyes, New York Polyclinic Journal, 1908, xii, Nos. 9 and 10. * Ann. of Surg., 1903, xlix, 533, 563. COMPLICATIONS OF ACUTE POSTERIOR URETHRITIS 145 inflamed vesicle. It usually terminates in resolution, but may rupture into the ischiorectal fossa, the rectum, or the peritoneum. Vesiculitis does not occur without prostatitis. It is impossible to differentiate inflammation of the ampulla of the vas from vesiculitis. Epididymitis.—See Chapter LVI. Cystitis.—The familiar gonorrheal trigonitis already described im- plies some inflammation of the rest of the bladder, but this is not a clinical feature of gonorrhea. Pyelonephritis.—This is an extremely rare complication of gonor- rhea. It is best described in connection with other types of pyelo- nephritis. Peritonitis.—Pelvic peritonitis is as rare a complication of gonor- rhea in the male as it is common in the female. Battey 1 has collected 30 cases. Thomas 2 reports 2 more. The inflammation is due to vesicu- litis or deferentitis. Its symptoms are the classic ones of pelvic peri- tonitis. 1 These de Lyon, 1901; Brit. Med. Jour., April 5, 1902. * North Western Medicine, February, 1907. CHAPTEK XV COURSE AND COMPLICATIONS OF CHRONIC URETHRAL GONORRHEA Chronic gonorrhea is gonorrhea lasting more than three months. The term is arbitrary and by no means strictly accurate, for chronic gonorrhea may be interrupted by acute relapses of the disease without thereby ceasing to be chronic, and chronic gonorrhea may begin and end, from the clinical as well as from the pathological standpoint, within the two months usually allotted to acute gonorrhea. Course.—Gonorrhea becomes chronic because the urethral lesions caused by the gonococcus persist. These lesions may harbor the gonococ- cus alone, or in connection with other bacteria, or simply other bacteria without the gonococcus. They may involve the anterior or the posterior urethra or both. Chronic gonorrhea is therefore to be subdivided either as gonococcic and postgonococcic or as chronic anterior urethritis and chronic posterior urethritis. The clinical causes of chronic gonorrhea are not worth enumerating in detail. Any interference with the proper treatment of acute gon- orrhea may permit it to become chronic; in some instances it becomes chronic in spite of the best treatment. Varieties—Study of the flora of chronic gonorrhea (p. 134) shows the rapidly decreasing importance of the gonococcus and the rapidly increasing importance of mixed infection after the third month of the disease. USTo further subdivision is possible; apart from the gonococcus no bacterium has shown itself peculiarly virulent in the male urethra. Nongonococcic urethritis is usually postgonorrheal. Gonococcic chronic urethritis is distinguished clinically by a tendency to be more severe, to relapse more viciously, to resent the trauma of instrumentation and alcohol more sharply than does non- gonococcic urethritis. Yet these clinical distinctions are both vague and relative. They have meaning only to the expert. A specific urethritis may be latent for months, a nonspecific one may be peculiarly virulent. To distinguish the symptoms of chronic anterior urethritis from those of chronic posterior urethritis is a necessity, but clinically the two usually exist together, the one or the other predominating. 146 CHRONIC POSTERIOR URETHRITIS AND PROSTATITIS 147 SYMPTOMS AND COURSE OF CHRONIC ANTERIOR URETHRITIS The one subjective symptom of chronic anterior urethritis is a ure- thral discharge, greater or less in quantity, purulent, semipurulent, or sticky and mucoidal. Sensations of itching or pain almost invariably arise from posterior urethritis and its complications, even when the sensation appears to be situated in the anterior urethra. But, since this urethral discharge is hut the evidence of an overflow of pus, the flow may be intermittent and months, even years, may elapse while an anterior urethritis continues but gives no outward sign; hut produces only a little pus or a few shreds in the urine. The course of a chronic anterior urethritis may he interrupted by outbreaks of acute infection, either a relapse or a new gonorrheal in- fection. Such outbreaks are usually much less severe than the initial attack. The only complication of chronic anterior urethritis other than those mentioned in the last chapter is urethral stricture. Abscess of the urethral glands may remain as little suppurating pouches. These may (1) simply maintain the infection, or (2) be palpable as sliotty indurations, which (3) may at any time become acutely inflamed and tender and even (4) set up periurethral abscess. The urinary signs of chronic anterior urethritis are a major element in diagnosis (p. 163). SYMPTOMS OF CHRONIC POSTERIOR URETHRITIS AND PROSTATITIS Chronic posterior urethritis and chronic prostatitis can rarely he distinguished from each other. Indeed, chronic posterior urethritis is clinically synonymous with chronic follicular prostatitis. On the other hand, chronic prostatitis may not be complicated by chronic urethritis 1 (30 per cent of 280 cases studied by Young). Hence it is preferable to consider chronic posterior urethritis under the title of chronic prostatitis. The symptoms of chronic prostatitis are much the same whether caused by the gonococcus or not. If gonococcic, the inflammation is more likely, either spontaneously or as the result of massage or urethral instrumentation, to light up an acute urethritis, while nongonococcic (or postgonococcic) cases sometimes flare up in the shape of vesical bacteriuria. 11. e., the prostate may contain pus but the urine be free from pus and shreds. 148 CHRONIC URETHRAL GONORRHEA Hence it is clinically preferable to group all cases of clironic pros- tatitis, whether gonorrheal or not, under one head. “In our series of 358 cases, no etiology was obtained in 53 cases (14.8 per cent) ; there was a history of gonorrheal urethritis in 262 (73.2 per cent) ; of masturbation in 27 (7.5 per cent) ; of prolonged sexual excitement (without coitus) in 4 cases and withdrawal in 3 cases (2 per cent) ; of descending infection in 3 (0.8 per cent) ; of trau- matism (bicycling twice) in 3 (0.8 per cent) ; of instrumentation in 2 (0.6 per cent) ; of infectious diseases (grippe) in 1 case (0.3 per cent). When gonorrhea had existed, that was accepted as the cause of the prostatitis, although in some of these cases abnormal sexual practices may have played an important role” (Young, Geraghty, and Stevens). The symptoms of chronic prostatitis are classed by Young as urinary, referred, and sexual.1 The urinary symptoms are: Urethral discharge. Disturbance of urination. Mechanical obstruction to urination. The referred symptoms are: Reflex pains and abnormal sensations. The sexual symptoms are: Disturbance of the sexual function. Spermatorrhea and prostatorrhea. Urethral Discharge—Urethral discharge is a symptom of anterior urethritis. Yet persistent urethral discharge is the symptom that usu- ally brings the victim of chronic prostatitis to the physician. More- over, such urethral discharge can be cured only by treatment of the prostate. In the average case, therefore, chronic prostatitis is accom- panied not only by posterior urethritis, but by anterior urethritis as well. Disturbance of Urination.—Urination may be normal, frequent, painful (before or during the act), urgent, or difficult. The stream may be slow to start or slow to terminate. Hone of these symptoms is absolutely characteristic of prostatitis, nor can one infer the pathological process present from a consideration of them. Obstruction to Urination.—Obstruction to urination, though a rare result of chronic prostatitis, may, nevertheless, be the most important feature of a given case. The obstruction is due either to an enlarge- 1In their study of chronic prostatitis, Young, Geraghty, and Stevens have at- tributed to this malady certain symptoms (e. g., renal colic and pain in the rectum) characteristic of vesiculitis. For this reason the detail of symptoms given by them has not been precisely followed. CHRONIC POSTERIOR URETHRITIS AND PROSTATITIS 149 ment of the median isthmus in the form of a bar or to cicatricial con- traction of the vesico-urethral orifice, i.e., stricture (contracture) of the neck of the bladder. The symptoms are those of prostatism, occur- ring in a young person. The prostate is usually not enlarged, as felt from the rectum (p. 251). Reflex Pains and Abnormal Sensations—The abnormal sensation excited by chronic prostatitis may be a pain, an itching or burning sensation, or a sense of fullness. It may be constant or intermittent; it is rarely very severe. It may or may not be excited by a full bladder or by the passage of urine. The majority of patients with chronic prostatitis suffer little or no discomfort. The abnormal sensation is always referred to some point on the sur- face of the body. The sensation may be felt at any point below the navel, even as far away as the foot. But the characteristic pains of prostatitis are pain in the back, in the perineum, above the pubes, along the urethra, in the groin or testis. Certain of these pains merit a word of description. Pain in the Back.—The pain is usually in the upper sacral region, constant and aching in character, uninfluenced by urination. Pain over the kidneys is rare. Pain in the Perineum.—The perineal pain is usually so mild as to be little more than a sensation. It may or may not be influenced by urination. It is often associated with a peculiar sense of fullness in the perineal body, or with a peculiar irritability in that region, excited by continued pressure against the perineum. The patient who suffers from this symptom cannot sit still for any length of time, though, as a rule, he prefers a hard seat to a soft one. lie is debarred from the theater and the church, and on the railroad he either sits obliquely on one hip or paces the aisle. Pain Along the Urethra.—Two spots along the penile urethra are especially subject to referred prostatic sensations. These are (1) a point just behind the glans penis and (2) the penoscrotal angle. Many patients are obsessed with the belief that all their trouble lies in one or other of these spots, whereas the sensation there is a characteristic sign of trouble in the deep urethra and prostate. Disturbance of the Sexual Function—Premature and painful ejac- ulations, incomplete or painful erections, nocturnal emissions, and every other symptom of sexual neurasthenia occur in persons whose prostatic fluid contains more or less pus. They are sensory disturbances, due to pathological changes in the verumontanum, the utricle or the ejacu- latory ducts. These symptoms are rare in patients with severe pros- tatitis. They are fully as common in patients who have not had gon- orrhea as in those who have. Prostatorrhea and Spermatorrhea—Like the functional disturb- 150 CHRONIC URETHRAL GONORRHEA ance noted in the preceding paragraphs, prostatorrhea and urethror- rhea are usually functional sexual disturbances only accidentally post- gonorrheal (cf. p. 156). Symptomless Cases—It is not to be forgotten that many cases of chronic prostatitis produce no symptoms. SYMPTOMS OF CHRONIC VESICULITIS Chronic inflammation of the seminal vesicle is always associated with chronic prostatitis. In the clinical picture either inflammation may predominate. Neuralgia of the Testis and Cord—Neuralgia of the testis and sper- matic cord, whether dependent upon ungratified sexual excitement or not, is very commonly due to spermatocystitis, rarely to prostatitis. Chronic vesiculitis exhibits the following clinical types: Renal Colic.—Ilenal colic may be caused by vesiculitis hut not by prostatitis. I have seen several instances of this condition typical in every respect of a renal colic due to stone and requiring morphin for their relief. Yet in each instance the vesicle was manifestly diseased, pressure upon it elicited the pain, and massage relieved it. Rectal Pain.—A much more common and equally characteristic symptom of vesiculitis is pain in the rectum. It is felt in the region of the vesicle, high up in the rectum. It is usually intermittent, excited by defecation, erection, or ejaculation, or it occurs spontaneously. The spontaneous pain usually occurs at night quite independently of any sexual irritation. It is griping in character, lasts only a few minutes, recurs at irregular intervals, and has been appropriately termed vesicu- lar colic. Frequent Urination.—Adhesion of the chronically inflamed vesicle to the bladder wall may exceptionally cause frequent and painful urination. Painful Testicle.—This is usually a reflex pain from the corre- sponding vesicle (p. 534). Relapsing Epididymitis—This is doubtless due, as Belfield has suggested, to occlusion of the ejaculatory duct, with chronic suppura- tion both in the vesicle and in the epididymis (p. 554). Sexual Symptoms—Those symptoms, enumerated in the preceding section, are due to inflammation in the region of the verumontanum. They are allied much more closely to inflammation of the vesicle than to that of the prostate. Gonorrheal Rheumatism.—The importance of seminal vesiculitis in the etiology of gonorrheal rheumatism has already been alluded to. Fuller first suggested that gonorrheal rheumatism is due to chronic CLINICAL VARIETIES OF CHRONIC URETHRITIS 151 seminal vesiculitis. Ample confirmation is afforded by the observations of Squier, Young and others. But the mathematical relation has not been established. The great majority of inflamed vesicles result in no septic arthritis or other symptoms of absorption. Moreover a large minority of gonorrheal joints are not cured even by vesiculectomy (Cabot). Yet in many instances vesiculotomy unquestionably results in relief of the joint pains. Symptomless Cases.—So long as the vesicle is not distended, and the ejaculatory duct not obstructed, the mere presence of chronic in- flammation in the organ usually excites no symptoms. CLINICAL VARIETIES OF CHRONIC URETHRITIS The preceding array of symptoms fails to give a picture of chronic gonorrhea. To obtain this we must sum up the clinical types of the disease in a few brief paragraphs. All cases of chronic urethritis may be classed as follows: 1. Mild cases. 2. Intractable cases. 3. Relapsing cases. 4. Irritable cases. 5. Neurotic cases. 1. Mild Cases. } . _ . . . . . _ 2. Intractable Cases./ AlthouSh most ehronlc inflammations of the urethra are mild in their symptoms, few of them are mild in responding promptly to treatment. A slight discharge is all that marks the usual case. Yet this dis- charge may be utterly intractable. Rapidly curable cases are usually those in which the prostate is neither markedly inflamed nor hyper- trophied, the inflammation postgonococcic, the patient tractable and in good surroundings and health. Conversely, any complication, especially severe prostatitis, the presence of gonococci, or bad general conditions are inimical to a cure. 3. Relapsing Cases.—Every case of chronic urethritis has some tendency to relapse after a cure has apparently been effected. But cer- tain urethrae show a tendency in this respect little less than maddening. Perhaps the patient has been carried successfully through an acute gon- orrhea by repressive treatment when an unexpected outbreak of the dis- ease disappoints surgeon and patient alike. Or a chronic case may have gradually yielded to methodical treatment only to burst out afresh at the slightest provocation. It is absolutely essential to know, before pronouncing a patient cured, that his urethra and* prostate no longer 152 CHRONIC URETHRAL GONORRHEA harbor gonococci. This fact ascertained, we may at least assure him against severe or infectious relapses. The cause of relapse is a collection of pus in some gland or follicle. Its occasion may be alcohol, sexual excess, a cold in the head, or over- zealous local treatment. 4. Irritable Cases.—The irritability of some urethrae is such as to prohibit local treatment, whether because of the pain and spasm evoked, or because an outburst of acute inflammation in the urethra, the pros- tate, the vesicle, or the epididymis follows every instrumentation. This local irritability, while in a sense peculiar to the individual, is usually the result of habitual disregard of the rules of prudence. The patient is either a hard drinker, or addicted to sexual excess, or overworked and overworried, or—and this alternative is, unfortunately, not a rare one—he has been irritated by local treatment. An appreciation of this fact will help to direct the treatment of such cases. 5. Neurotic Cases.—The neuroses are not always due to antecedent gonorrhea, and it is only exceptionally that one encounters evidence of neurosis while the inflammation still continues. The neurotic taint adds many and various symptoms to those of the inflammation, and protracts the patient’s miseries even after his prostate has apparently returned to its normal state. But most of the so-called neuroses are due to the inflammation about the verumontanum. CHAPTER XVI NONGONORRHEAL URETHRITIS Noxgonorriieal urethritis as distinguished from postgonorrheal urethritis may be classified as follows: Nonspecific or “simple” urethritis. Tuberculous urethritis (p. 397). Traumatic urethritis. Neoplastic urethritis. Syphilitic urethritis. Ilerpetic and eczematous urethritis. Urethrorrhea. Prostator rhea. Spermatorrhea. NONSPECIFIC URETHRITIS Nonspecific urethritis may be defined as an acute urethritis due neither to the gonococcus nor to the tubercle bacillus, and usually ex- cited by no known cause other than sexual excitement or contact. Under this caption we may also include the so-called urethritis ab ingestis, and diathetic urethritis, neither of which seems to occur in virgin urethrae. Urethritis ab Ingestis—Certain substances taken into the stomach may occasionally produce a mild urethritis. Among these alcohol holds a high rank. Excessive potations, notably of beer or champagne, or prolonged excesses of alcohol in any form, will occasionally, without other cause, produce urethral discharge. As an adjuvant to sexual excess the influence of alcohol is paramount, more particularly if1 there be already a preexisting patch of chronic inflammation anywhere along the urethra. Cantharides, arsenic, purgative mineral waters, iodid of potassium, turpentine, asparagus, have all been accused of lighting up mild urethral inflammation, hut the rarity of such attacks makes their consideration trivial. Diathetic Urethritis.—A gouty urethritis is accepted in England and a strumous urethritis has been mentioned; but as essential mala- dies both are a refinement of diagnosis. The gouty old gentleman 153 154 NONGONORRHEAL URETHRITIS with densely acid urine is more liable to discharge because of his gout, and treatment of the latter may be essential to his recovery. There are also well-observed instances of the appearance of a dis- charge from the urethra upon the subsidence of an arthritic eruption upon the skin, and Desnos alludes to the sudden appearance of a spon- taneous urethral discharge during the course of the grip, believing it due to small prostatic abscesses bursting into the urethra. These diathetic agencies are then surely concomitant factors, if not essen- tial causes, of primary urethral inflammation, yet they are extremely rare. Etiology of Simple Urethritis.—That the normal male urethra is immune to infection by any bacterium except the gonococcus is almost, but not quite, universally true. Most, if not all, cases of so-called simple or nongonorrheal urethritis occur in urethrae damaged by gon- orrhea or by sexual excesses. Indeed, when the simple urethritis occurs in a canal that has not previously harbored the gonococcus, its origin will usually he found, not at the meatus, but in the prostate and seminal vesicles—evidence of its sexual cause. The bacteria found in the normal urethra are those usually found in simple urethritis. But such important questions as “Is the bacterium an etiological factor ?” and “Is simple urethritis transmissible ?” have not been adequately answered. It seems probable that nongonorrheal urethritis is sometimes transmissible. I have obtained a streptococcus from the urethra of a man with simple urethritis similar to that ob- tained from a vulvar abscess in his wife. A few similar cases have been reported, but they are most exceptional. In the opinion of the laity nonspecific urethritis may be acquired from a nongonorrheal woman at or near the period of menstruation. This opinion has as little foundation as that which attributes infectious- ness to nongonococcic leukorrhea. The male who acquires urethritis from a menstruating or leukorrheic woman with whom he has previously cohabited with impunity acquires gonorrhea. Pathology.—The lesion is a mild glandular catarrh. It may be most marked in the anterior urethra or in the prostate and vesicles. Symptoms.—Simple urethritis is usually a very mild inflammation. There is little or no swelling of the meatus; the discharge is mild and often only mucopurulent; urination and erection are not painful. The incubation may be but a few hours or many days. The inflammation may last but a day or two or it may last many months. These facts suggest that the condition of the patient’s urethra and general health are of more importance than the bacteria. The duration of the attack may be out of all proportion to its severity. I have known one to last several years. Diagnosis.—Simple urethritis is distinguished from gonorrhea by NEOPLASTIC URETHRITIS 155 the absence of gonococci from the discharge. The mildness of the attack may be suggestive, but is not absolute proof. The lesion does not require diagnosis until the first outbreak of dis- charge has been controlled by local treatment. But then a complete diagnosis should be made by rectal examination and urethroscopy. Treatment.—At the outset the condition should be treated ex- pectantly; i.e., by sandalwood oil, astringent injections and sexual hy- giene. Many cases are thus cured in a few days. But whether cured or not at the end of a week or so the urethra should be carefully explored by sound and urethroscope; the prostate and vesicles by massage, and treatment instituted as for the cure of chronic gonorrheal urethritis. TRAUMATIC URETHRITIS The causes are, wounds of the urethra by instruments, more espe- cially crushing or bruising injuries. Bending the penis when erect, as in tempestuous and badly directed coitus, may he followed by mild urethritis (sometimes ushered in by hemorrhage and followed by trau- matic stricture). A foreign body in the urethra, such as retained stone, may give rise to a mild discharge. ‘Rough catheterism, a fortiori if the instrument be dirty, may pro- duce urethritis, and the suppuration habitually attending instruments left indwelling in the urethra is too well known to require more than a statement of the fact. Caustic injections of any kind may excite urethritis. Some ure- thras are very sensitive to the irritation of solutions of corrosive sub- limate and carbolic acid, and much more so to the minutest dilutions of formalin, all of which substances, used as sterilizers of instruments, sometimes provoke the very mischief they would avoid. NEOPLASTIC URETHRITIS Papillomatous Urethritis—The papillomata are exactly like sub- preputial warts, varying greatly in size. Oberlaender 1 considers that papillomatous urethritis is only a more pronounced stage of the hyper- trophic urethritis that sometimes follows gonorrhea. The diagnosis and treatment are urethroscopic (p. 171). Other Neoplasms.—Other neoplasms of the urethra are less inti- mately connected with urethritis. They are described in Chapter XL] X. 1<(Sajous’s Annual,” 1888, ii, 212. 156 NONGONORRHEAL URETHRITIS SYPHILITIC URETHRITIS Syphilitic chancre not infrequently involves one lip of the urinary meatus, more often perhaps the entire circumference, stiffening it, thick- ening the lips, and being more or less eroded and ulcerated down into the canal of the urethra. The discharge in these cases is very slight, but the sore lasts many weeks. Concomitant symptoms—inguinal adenopathy, spirochetes, etc.—clinch the diagnosis. The urethritis is only an epithenomenon. But the chancre may he overlooked if it is situated at some distance within the urethra. The discharge is then slight, the incubation period long (unless, unhappily, there be double infection). There may be only the symptoms of stricture. But care will detect the enemy. A hard lump about the size of a pea, may usually he plainly felt from the outside, and the endoscope clears up the diagnosis by disclosing a gray or livid, bleeding ulcer. I have also noted urethritis accompanying the development of a patch of tubercular syphilid upon the outside of the penis and disap- pearing under the use of mixed antisyphilitic medication by the mouth. Bassereau and Bumstead speak of a mucopurulent urethral flow coming on with the first appearance or with a relapse of secondary syphilitic eruptions, the cause of which was the development of syphilitic mucous patches upon the urethral mucous membrane. I have several times seen a patch of tubercular syphilid involve the urinary meatus and occasion a slight discharge. Gummatous ulceration of the balanitic urethra is not uncommon. HERPETIC AND ECZEMATOUS URETHRITIS That an attack of ordinary vesicular herpes may occur within the urethra is well known, although not common. I have seen a group or two of vesicles outside and a mild urethral discharge, with smarting on urination, coinciding with the attack and disappearing spontaneously with it. Alternating attacks, one outside, the next inside, have also been observed. Eczematous subjects sometimes suffer from a mild discharge coincident with a new outcrop of cutaneous eruption upon or near the genitals, or with the sudden disappearance of the outside eruption. URETHRORRHEA Urethrorrhea is a nonpurulent urethral discharge due to excessive secretion from the urethral glands. This discharge is mucilaginous PROSTATORRHEA AND SPERMATORRHEA 157 in consistence, bluish-white in color. It sticks the lips of the meat- us together. When caught upon the finger it strings out in a gummy way. When abundant it stiffens, but does not stain the linen. The micro- scope shows it to be composed of epithelial cells, leukocytes, films of striated mucus, granular debris, no pus threads (unless there be also chronic urethritis), no prostatic bodies, no spermatozoa, no lecithin bodies, no Boettcher’s crystals.1 The causes of this affection are prolonged, ungratified sexual desire, constant impurity of thought, a sort of mental masturbation through the imagination, often indulged in by weak-minded youths, as well as by old men who are regretfully conscious that they are getting beyond the potential stage of sexuality. Another cause is delayed orgasm during intercourse or withdrawal before emission. Masturbation if excessive, or too much natural sexual exercise under the stimulus of mental provo- cation—all these and the like, being a violence to the various urethral mucous glands and to the circulation of the urethra by prolonged, sustained, excessive nervous tension, lead to passive congestion of the urethra and its glands and follicles, and thus occasion an excessive mucous secretion, together with more or less desquamation of pavement epithelium—and this is the whole malady. The beading of the meatus during erection is physiological. It is equivalent to the watering of the mouth when one is hungry and smells appetizing food. Treatment.—Urethrorrhea may sometimes he cured by local treat- ment, i.e., astringent injections, overdilatation or prostatic massage. But overzealous local treatment is calculated to irritate, and any in- jection may do as much harm as good, notably in those self-centered cases where morbid introspection is the salient feature of the malady. Here anything that keeps the patient’s mind upon his genitals harms him, and any local treatment may be mischievous. Indeed true urethrorrhea, be it due to whatever cause, gets slowly better with the elimination of that cause—be it lust, masturbation, excess, or what not—and by virtue of sexual and general hygiene. PROSTATORRHEA AND SPERMATORRHEA Prostatorrhea is the nonsexual discharge of prostatic fluid from the meatus. Spermatorrhea is the discharge of semen. The fluid is dis- charged by the act of the pelvic muscles, usually during defecation, rarely during urination. It is impossible to distinguish prostatorrhea 1 The fluid must be examined in substance. It cannot be recovered by the pipette from urine since this dissolves it. 158 NONGONORRHEAL URETHRITIS from spermatorrhea except by the aid of the microscope. The prostatic or seminal fluid discharged may be normal or purulent. Etiology.—These conditions occur almost exclusively in young adults. They signify a relaxation of the prostatic or ejaculatory ducts due to sexual excesses or irregularities. They are not themselves in- flammatory, though they may accompany inflammation. Symptoms.—The sensible man pays no attention to these discharges; the neurotic attributes to them any symptoms of sexual debility from which he may suffer. There is no such disease as spermatorrhea. The alleged malady is a fetich created by Lallemand; a fetich to which its morbid wor- shipers, young and old, bow down throughout the community morn- ing, noon, and night, offering to it the incense of their distorted erotic fancies. I have known men who had sexual intercourse nearly every night for years, who had no single symptom of any sexual malady, and surely, if an excessive expenditure of seminal fluid were in itself capable of producing symptoms, these individuals should have shown some of them.1 I have known every symptom attributed to spermatorrhea to occur in individuals who had no seminal loss whatsoever, voluntary or invol- untary. Finally, one often finds spermatozoa in the urine of vigorous men, ignorant of the fact, perfectly healthy in a sexual sense, and absolutely devoid of any of the alleged symptoms of the bugbear. Therefore, spermatorrhea does not cause symptoms, does not inter- fere with bodily or sexual health, does not threaten life or entail any consequences, and it may be and should be wholly disregarded. The self-respecting urologist must give the lie to quackery and disabuse the public of false ideas on this subject. That the prostate and vesicles may be kept empty by massage is, of course, true. But such treatment, by concentrating the patient’s atten- tion upon his genitals, is only calculated to bring him new misery when, with the cessation of massage, the discharge returns. The only cure is common sense, the only relief matrimony. 1 Let this not seem to imply approval of such gross abuse of the sexual function. CHAPTER XVII DIAGNOSIS OF GONORRHEAL URETHRITIS Tiieee are two essential features in the diagnosis of urethral gon- orrhea. We must distinguish both the presence or absence of the gono- coccus and the distribution of the urethral lesions. Diagnosis of the gonococcus: Differentiation between simple urethritis and gonorrhea. Discovery of the gonococcus in chronic urethritis. Diagnosis of the seat of the lesion: In acute urethritis. In chronic urethritis. Urethroscopic diagnosis. DIAGNOSIS OF THE GONOCOCCUS Acute Simple Urethritis and Gonorrhea—When a patient presents himself complaining of having contracted a gonorrhea, an inspection of his penis will often confirm or refute this opinion. If the lips of the meatus are red and swollen, exuding a creamy discharge, there can scarcely be a doubt of the specific nature of the infection. But unless the urethral orifice is greatly swollen—unless there is ardor and chordee —an examination of the discharge is necessary to differentiate true gonorrhea from simple urethritis. It may he that the gonorrheal in- flammation is not yet well under way, or that there is chronic gonorrhea, of which this is an exacerbation, or, on the other hand, the whole matter may be a mere simple urethritis. In either case the discharge may be slight or profuse, watery or creamy. The microscope and “the Gram” are required for an immediate decision, to save the surgeon from the possibility of an erroneous diagnosis and to afford the patient the advantages of immediate local treatment. I fear not everyone will accept the statement that nongonorrheal urethritis can simulate the true specific inflammation; but I have seen cases that went through a very fierce attack and proved exceptionally unmanageable, although the patients denied any sexual act for many weeks before the beginning of their attacks, while repeated microscopical examinations revealed no gonococcus in the discharge. In many other 159 160 DIAGNOSIS OF GONORRHEAL URETHRITIS cases the acuteness of the onset gave every promise of a true gonorrhea, but the negative microscopic evidence was confirmed by the rapid sub- sidence of the inflammation under a course of treatment that never could have conquered the gonococcus. Discovery of the Gonococcus in Chronic Urethritis.—“May I get married ?” The frequency with which the sufferer from gonorrhea presents himself with this question on his lips is a sad commentary upon the levity of youth. Yet it is a question which the practitioner is fre- quently—nay, commonly—called upon to answer. And upon the cor- rectness of that answer the happiness of a household often depends. An error on the side of overcaution—forbidding a man to marry when he has a perfect right to do so—is only less heinous from the patient’s point of view than the permission to marry before the danger of in- fection has passed. On the one hand there is the prospect of moral despair for both parties, on the other the certainty of infection of the innocent with all its train of physical woes and the possible discovery of the guilty partner, with results that need not be dwelt upon. And unhappily the question is not an easy one to answer. So diffi- cult is it, indeed, that scarcely any two authorities agree as to the criteria upon which the answer shall be based. Against the genial vagueness of the light-hearted practitioner, himself a roue, who pro- claims that one is free from danger as soon as he is down to his custom- ary morning drop, we may oppose the Spartan severity of those few authorities who assert that once a gonorrheic always a gonorrheic, once infected always infectious. The broad-minded adviser will avoid either extreme. He knows full well that the majority of men who have had gonorrhea become and remain absolutely sound and clean. lie recognizes also, that while most of those who exhibit the traditional morning drop are undoubtedly infectious, there remains an important minority even of these that can- not impart its disease, under whatever stress of sexual excitement. These are practical commonplace facts. We need not concern ourselves with those rare cases of alleged marital infection ten or twenty years after a cured gonorrhea. By their very nature such cases are open to a suspicion of that symptom common to all venereal disease, viz.: lying; and against them I can advance the experience of thirty-five years, during which countless patients have been advised to marry by my father and his associates with but a single error so far as I know. (And all will recognize the probability that such an error would rebound forcibly enough upon its perpetrator.) Such being the case, I am willing to assert the possibility of determining the presence of gono- cocci in any given urethra.1 1 While the diagnosis may thus always be definite, the prognosis must remain indefinite. I can tell a man that he is or is not now infectious, but if he is now DIAGNOSIS OF THE GONOCOCCUS 161 When does the gonorrheic patient cease to be in danger of infecting the woman with whom he cohabits? Not until the gonococci have been entirely eliminated from him. The gonococcus is the sole infectious agent. If it is present, there is danger; if not, there is none. But to find the gonococcus is no easy matter. Its presence may be suspected on ac- count of the symptoms the patient presents—and this clinical evidence was all we had to go by until within a few years—or it may be proved by the evidence which bacteriology has at last provided. Clinical Evidence.—The clinical evidence of the presence or the absence of gonococci, which has been for so many centuries the physi- cian’s only criterion, is overshadowed nowadays by recent advances in bacteriology. Yet the bacteriologist is by no means infallible, and it is absolutely essential that the clinical evidence should accord before the laboratory is permitted to conclude that a patient is clean. The notable clinical evidence of the presence of gonococci is pus, and in view of the prevalence of gonorrhea it is a general rule that whenever there is pus anywhere in the genital or the urinary tract the presence of gonococci may he suspected, and conversely when the whole tract is proved free from pus the presence of gonococci may he denied} Clinically speaking, a great many classes of cases may be ruled out at once. Thus, gonorrhea of the kidney is very rare and never occurs except in conjunction with gonorrhea of the lower urinary passages. Similarly the history of suppuration due to prostatism, stone, tubercle, or tumor is usually such as to rule out gonorrhea. The cases that come for diagnosis may be divided into three classes: First, those who, having had gonorrhea, continue to have pus in the urine or are subject to relapses of pyuria or urethral discharge. Second, those who, having had gonorrhea, whether they allege a continuance of the discharge or not, are not subject to acute relapses, no matter how much sexual and alcoholic dissipation they indulge in. Third, those who, after a gonorrhea, have no longer a discharge or any other symptom, show perfectly sparkling urine and from whose prostates and vesicles no pus can be expressed. Of the first class the majority are still infectious ; of the second class the majority are no longer infectious, while all who continue in the third class for a month are certainly free from gonococci and from all danger. For these last, then, the clinical diagnosis suffices; for the others there is only a probability from .which the experienced physician may often infectious I cannot tell, with any certainty, when he will become clean. That is a matter of relative immunity, severity of lesion, faithfulness to treatment,—details differing for every case. 1 With the single exception that the patient may have just been infected and may still be in the incubation period. 162 DIAGNOSIS OF GONORRHEAL URETHRITIS reach an assured conclusion one way or another, but a probability which always deserved to be conlirmed by scientific tests. Most important of all, the only dependable laboratory test for the presence of gonococci is culture. But laboratory culture is beset with difficulties and by no means universally accessible. However, the patient’s own urethra presents a culture medium, not quite ideal it is true, for it has acquired at least a partial immunity; but it will serve. If there are gonococci in the urethral glands, let them be traumatized. With blood serum as culture medium; with the traumatized tissue as their forcing bed, these gonococci will set up a fresh infection, an acute urethritis, in which the microscope will find cells crowded with Gram- negative intracellular diplococci. Urethral culture of gonococci is the most unmistakable test of their 'presence. How to apply the trauma is the practical question. In Chapter XXIV will be found a description of the way this axiom of the re- action of gonococci to trauma is made use of to hasten the decline of a controlled gonorrhea by the use of sounds. If there is any prostatic or vesicular suppuration, massage of the prostate and vesicles should be employed, to excite mild acute infection if gonococci are pres- ent. If the diagnosis of the urethral lesion calls for the urethroscope, this may be employed as the traumatizing instrument instead of a sound. Laboratory Evidence.—The laboratory evidence of the presence of gonococci is threefold: (1) Smear; (2)Culture; (3) Fixation test. 1. The Gram-stained pus smear of a profuse urethral discharge gives the expert technician reliable evidence of the presence of gono- cocci, though their absence from a given smear does not prove them absent from the urethra. In acute urethritis, therefore, a positive smear is reliable. But in chronic urethritis even a smear pronounced positive bv an expert is not in itself in the least reliable (p. 111). The test of trauma described above gives far sounder clinical assurance. The mere pi'esence of Gram-negative intracellular diplococci in pus obtained from a mildly or chronically inflamed urethra does not war- rant the diagnosis of gonorrhea. 2. Culture, if positive, is infallible. Negative laboratory culture tells us nothing of clinical significance. And, unfortunately, the dif- ficulty of getting a good specimen to the laboratory, added to the labo- ratory difficulties of culture itself, put this means of diagnosis out of the reach of many practitioners, and make it for all of secondary and merely confirmatory value as compared to the urethral-trauma culture test. 3. The complement fixation test for gonorrhea is subject to so many DIAGNOSIS OF THE SEAT OF THE LESION 163 variations, even at the hands of the best technicians that it is, generally speaking, unreliable. Strongly positive reactions are occasionally obtained with the blood of persons who have no longer a trace of gon- orrhea. The observations on page 112 are true, but the findings are not generally reliable. The gonococcus fixation test of to-day has about the same accuracy as the Wassermann test of 15 years ago. In short, 1 now depend for the diagnosis of cure of infectiousness upon the clinical evidence and the trauma test, confirming these always by smears studied in my own laboratory and seen by myself. Laboratory culture and complement fixation test I employ only exceptionally. Yet I look forward to the time when the complement fixation test shall be wholly reliable. DIAGNOSIS OF THE SEAT OF THE LESION DIAGNOSIS OF THE DISTRIBUTION OF ACUTE URETHRITIS Acute nongonorrheal urethritis may originate either in the anterior or the posterior urethra. The diagnosis of its origin and extent is con- ducted precisely as is that of chronic urethritis. Acute gonorrheal urethritis always begins in the anterior urethra. The pouting meatus and creamy discharge amply attest the presence of anterior urethritis. But to diagnose the presence of posterior urethritis is not always possible. If both the first and second flows of urine are cloudy there is pos- terior urethritis. If only the first flow is cloudy, there may be posterior urethritis. This is negligible for the time, but may cause trouble later by delaying the cure. In other words, the mere fact that throughout a carefully ob- served gonorrhea the second urine has always been clear by no means eliminates posterior urethritis, and in the event of such a urethritis becoming chronic the posterior urethra must not be neglected. Examination and massage of the prostate reveal lesions in that organ as in chronic urethritis; but in view of the freshness of the infection this examination should be conducted with the utmost gentleness. DIAGNOSIS OF THE DISTRIBUTION OF CHRONIC URETHRITIS Since it is not my custom to use tlie urethroscope in the diagnosis of gonorrhea except in rebellious and protracted cases, I prefer to describe the routine method of examination followed at the patient’s first visit, leaving the matter of urethroscopic diagnosis for subsequent discus- sion. Upon accurate diagnosis depends the patient’s prospect of cure, and 164 DIAGNOSIS OF GONORRHEAL URETHRITIS sucli diagnosis, even without urethroscopy, may require several exam- inations. The patient presents himself with a history of chronic or relapsing urethral discharge, with shreds or pus in the urine, or with various sexual or painful symptoms. The First Examination—The examination for gonococci already described takes first place. The routine examination of the lesion is as follows: 1. The meatus is examined for discharge (and a smear taken for microscopic examination) and inflammation, the urethra for nodules of periurethral infiltration, the testicles for evidence of epididymitis. 2. The patient then urinates in two glasses, as described in Chap- ter II. 3. A 16 F. catheter is introduced, the site of pain, bleeding or obstruction noted, residual urine estimated (to be confirmed by subse- quent examination), and about 100 c.c. of saturated boracic acid solu- tion injected into the bladder. 4. Prostate and vesicles are then massaged; any expressed secre- tion is caught upon a slide for examination. 5. The patient then empties the bladder into two glasses, if no secretion has been expressed by massage; otherwise into one. If residual urine is suspected, this is verified by measuring the amount passed. From this examination we glean the following diagnostic points: Anterior Urethritis.—Usually pus at meatus. Second flow of urine clear. Ho abnormality felt in prostate or vesicles. Ho pus in the secretion expressed from these organs or in boracic acid solution. Posterior Urethritis.—Ho pus at meatus, unless there is anterior urethritis as well. (Clinically there is almost always enough anterior urethritis to produce a morning drop.) Second flow of urine may be clear or cloudy. Prostate and vesicles feel normal, but in the secre- tion, expressed or centrifuged from silver solution, there are a few pus cells. Prostatitis.—Same as posterior urethritis except that indurations or abnormalities of contour are usually discerned in the prostate, and the expressed secretion is frankly purulent. There may be residual urine. Vesiculitis.—Same as prostatitis, except that vesicles are distended or indurated. Just as there is always prostatitis with vesiculitis, so there is often impalpable vesiculitis with prostatitis. The attempt to distinguish the expressed secretion of the two is likely to prove mis- leading, for though a large part of the vesicular secretion floats in urine, pus from the vesicle, like pus from the prostate, sinks. Stricture.—Marked stricture obstructs or prevents the passage of the catheter. Slight stricture is not diagnosed until a subsequent exam- DIAGNOSIS OF THE SEAT OF THE LESION 165 ination. Cicatricial or prostatic obstruction at the neck of the bladder gives residual urine. Cystitis.—It is probable that some inflammation of tlie bladder, or at least of the trigone, exists whenever the second flow of urine is puru- lent. But this cystitis is a negligible quantity that disappears long before the posterior urethritis is cured. Retention cystitis is, of course, important. Pyelonephritis.—The diagnosis of gonorrheal pyelonephritis offers no peculiar difficulties excepting in so far as urethritis prohibits cystos- copy. The renal colic due to vesiculitis and the lumbar pain due to epididymitis are distinguished by physical examination. Object oe This Method of Examination.—The object of this examination is to obtain the maximum of information about the patient while doing him the least possible harm. By it the precise lesion in the anterior urethra is not as accurately determined as though the urethroscope were used. But the risk of stirring up a urethra whose temper is not known warrants deferring this more precise examination to a subsequent date (the following day, if the patient cannot be kept under observation), but preferably after a few days of treatment, unless the case is very chronic and the temper of the urethra has already been well tested by others. Secondary Examination—In order to obtain precise information as to the condition of the anterior urethra one must use an exploring instrument. I usually employ a 26 F. sound. (The meatus may have to be cut.) If this is grasped there is stricture. If it is not grasped but brings blood (not from the meatus) there is anterior urethritis. The precise surface conditions of both anterior and posterior urethra are determined by— Urethroscopy.—See Chapter XVIII. The Bulbous Bougie.1—The largest bougie that will pass the meatus is lubricated and passed gently into the anterior urethra. As it advances the physician notes the position of every obstruction and even of every sensitive spot encountered. When it is just entering the bulbous portion of the canal it is withdrawn and the obstructions en- countered verified as the instrument passes over them again on its way out. The bulb is then carefully examined and wiped off to discover traces of blood or pus upon it. It is then reintroduced rapidly to the bulbous urethra and, aided by firm counter-pressure on the perineum, insinuated into the membranous urethra. By this examination we distinguish any stricture or erosion in the anterior urethra and locate it with considerable accuracy. For an efficient examination the bulb must be 26 F. in size. Any meatus too small to admit this must be cut (p. 741). 166 DIAGNOSIS OF GONORRHEAL URETHRITIS A 2G F. bulb detects infiltrations that do not perceptibly encroach upon the caliber of the urethra. If the bulb detects nothing and anterior urethritis is nevertheless suspected, its presence is shown by urethroscopy. Contra-indications to the Method.—Acute relapses or compli- cations (e. g., in prostate or testis) prohibit instrumental examination until they shall have passed. Inferences Drawn.—The diagnostic horizon is not limited by physical signs. We find by our examination that the patient has this, that, or the other lesion; indeed, we usually find that he has several lesions. But before the diagnosis is really complete we must know which is the predominant lesion and what part the patient’s general condition plays. Our examination reveals, let us say, prostatitis, anterior and pos- terior urethritis. Under these conditions we may feel confident that one of these lesions is more important than the others; is indeed the underlying lesion that keeps the others going. It may be that prostatic massage alone will cure the case promptly and permanently. Or maybe posterior irrigation is required. Or perhaps any attack of the posterior urethra does harm and the patient will recover on an interior injection. Or dilatation may help. Or any local treatment may irritate. These are not theoretic possibilities but practical facts. Diagnosis of the lesion is necessary, but an absolute therapeutic conclusion can rarely be drawn from that diagnosis. We must feel our way and try first one treatment and then another. Concerning Shreds.—The purulent urine of acute urethritis does not contain shreds, but as the inflammation subsides and tends to be- come localized little scabs form upon the more inflamed areas and are washed away in the urine. These are called shreds (Tripperfaeden). They consist of a mass of mucous or fibrous matter entangling pus and epithelial cells. To the general practitioner shreds simply mean that the general inflammation is subsiding or has subsided. When, day by day, the urine shows less pus and more shreds, conditions are improving. The following general observations concerning shreds seem warranted: 1. Shreds are no index of gonorrhea. They are currently found in the urine passed by men who have never had gonorrhea. 2. The shape and size of shreds do not indicate what part of the urethra they come from. 3. Shreds mean chronic localized inflammation of the urethra. 4. Shreds heavy with pus sink rapidly in the urine. They indi- cate relatively active inflammation or ulcer or stricture. 5. Lighter shreds often testify to an inflammation so mild that it presents no dangers and is entirely uninfluenced by treatment. 6. Shreds call for treatment by dilatation or urethroscope (unless this irritates). CHAPTER XVIII URETHROSCOPY URETHROSCOPES The urethroscopes commonly employed in the United States to-day are the following: 1. The original straight open tube of Desormeaux with external illumination. This instrument goes under many names, but is usually sold as a Young urethroscope. 2. The straight tube closed at the outer end, with internal illumi- nation and fitted for water or air distention such as the instruments of Buerger, Stern, Geiringer and Greenberg. 3. The indirect vision urethroscope or cysto-urethroscope of McCarthy. I prefer the Stern lo any other urethroscope, though I possess and use each of the above three types. In my own clinics, no two men seem to agree as to which is the best instrument. Doubtless, neither the urethroscope nor the human mind is, as yet, wholly perfected. DIAGNOSTIC URETHROSCOPY Anterior Urethra.—The straight open tube is used. The patient is on a cystoscopic table. ISTo anesthesia is required unless for meat- otomy. The tube is lubricated, the glans penis cleaned, the tube intro- duced, directed downward until it will go no further, then it is grad- ually inclined to an angle of 60° or more. The operator then steadies the tube with his left hand; the forearm steadying itself against the patient’s body. The obturator is then removed with a gentle rotary movement to disturb the lube as little as possible. The source of illu- mination is then affixed and one looks for the orifice of the membra- nous urethra. Usually the tube has not been bent over far enough; one sees only the floor of the bulb. By rotating the tube still further downward the puckered lumen comes into view; then the tube is slowly withdrawn, at such an angle as to keep the lumen of the canal in the center of the field of vision. The tube is slowly withdrawn, all parts of the canal being inspected as they pass under the eye; blood, pus or lubricant is mopped away with a cotton swab on a wooden applicator. 167 168 URETHROSCOPY ISTormal Anterior Urethra.—The walls of the urethra fall to- gether over the end of the tube to make a hollow cone. The mucous membrane varies in color from pale to salmon pink. The absence of inflammation is evinced by the suppleness of the walls of the canal which fall together in longitudinal folds from four to twelve in num- ber, radiating from the center to the circumference of the field; between these folds the pink mucosa is lined by longitudinal deep red striae. Upon the roof of the urethra (and less frequently upon its floor) the crypts of the Morgagni appear as deep red indentations (the normal ducts of Littre’s glands are invisible). In the bulb the lumen of the urethra forms a lateral slit; openings of Cowper’s ducts upon the floor of the bulb are usually concealed by a fold of mucous membrane. The navicular urethra is pale and rigid; the lumen is a vertical slit; there are no folds or striae; the opening of the lacuna magna is seen upon the roof. The Inflamed Anterior Urethra.—Alien subacutely inflamed the surface is red and velvety. The gloss and the brilliant red striae are lost. The swelling of the mucous membrane reduces the number of longitudinal folds. Patulous crypt orifices are seen exuding pus. ATild chronic anterior urethritis (soft infiltration) shows much the same picture. The redness is not so marked, the luster of the surface may be increased, but the striae are lost, the folds reduced, the crypts red, patulous, purulent, or cystic. Severe chronic anterior urethritis (hard infiltration) in which the inflammatory exudate has been largely converted into scar tissue shows a gray, eroded, lusterless surface with no striae, few or no folds. The ducts of Littre’s glands may project as minute vivid red points in the midst of a mass of congestion (glandular type) or these red spots may be absent (dry type). Sclerotic white patches or stellate white scars may appear here and there. When anterior and posterior urethroscopy are done simultaneously, as is often convenient, the anterior urethra is viewed in distention through the straight closed tube. Its walls do not fall together. One sees infiltrations much more plainly than with the open tube, as pale or granulating, rigid areas encroaching upon the lumen of the canal. They may be cracked and bleeding. They must be distinguished from the normal irregularities of the canal which appear as crescentic folds, especially on the roof and chiefly in the scrotal portion of the urethra. The normal mucosa does not show the red striae described above, but is all of one pale pink color. In the floor of the bulb, a fold of mucosa overlying the orifices of Cowper’s ducts may be seen. Granulomata appear more plainly in the distended than in the collapsed urethra. TECHNIC OF URETHROSCOPY FOR DIAGNOSIS 169 Posterior Urethra.—I employ cystoscopic position and anes- thesia, water distention, straight tnbe. As the tube is introduced one may note the presence of obstruction at the bulbomembranous junction, suggestive of infiltration, and the angle to which the urethroscope must be deflected in order to enter the bladder, suggesting rigidity at the bladder neck. The obturator is then removed and the bladder emptied, the optical piece affixed with the water running so as to fill the tube and exclude air. Before withdrawing the tube from the bladder one glances at the fundus for cystitis or stone or ulcer, then at the postureteral regions for tumor or diverticulum, then at the' ureter mouths themselves and the trigone. What is seen looks much as it does through the indirect vision cystoscope with the following exceptions. The ureters, though harder to find are more highly magnified. Trigonitis may be much better studied. It appears as a rough granular mucosa often with little elevations suggestive of tubercles or of cystitis granulosa (which they doubtless are). These may he cystic (cystitis cystica). The area of infection surrounding them may be followed over the bladder neck into the posterior urethra. The urethroscope is now withdrawn through the bladder neck in which are noted the relaxation of paralysis or the rigidity of sclerosis, while one observes the granular irregular edematous looking folds char- acteristic of infection, the waving fronds of granulations, the intrusion of enlarged lateral lobes of the prostate, the bullous edema or infiltra- tion of carcinoma. On retreating into the posterior urethra, one looks sharply for minute surface changes and, if any such catch the eye, one interrupts the constant inflow of water as repeatedly as necessary to bring the suspected lesion into various degrees of focus or to make granulomata flop to and fro, thus identifying them more precisely. The floor of the urethra is readily inspected. One must not fail to glance at the posterior wall of the verumontanum, as it begins to ap- pear; and at the lateral walls of the urethra with their overhanging masses of lateral prostatic lobes; and at the roof, to see which the ocular end of the tube must he pulled firmly downward; and at the lateral sulci at the base of the verumontanum. One notes the tone of the bladder neck at different water pressures (flaccidity is a sign of paralysis), the increased length of the descent from bladder neck to veru (significant of prostatic sclerosis or adenoma), the irregular scars in this region left by operation or abscess, the enlargement of the veru from sexual un-hygiene or inflammation, its atrophy from severe inflammation and also the following patho- logical conditions: Chronic urethritis when generalized and active gives the mucosa a 170 URETHROSCOPY red, rough, swollen appearance. As it subsides it may leave a scle- rotic bladder neck, the mucosa over this inflamed and dotted with Pelouse bodies, or it may leave granulomata in various portions of the posterior urethra. The Pelouse bodies 1 begin as minute granules similar to those seen on the trigone. They often develop into thin-walled cysts. They cluster about the bladder neck. Granulomata may develop of such size as to fill the lumen of the urethroscopic tube. They occur everywhere in the prostatic urethra. They are indistinguishable from true papillomata, which occur in the urethra secondary to papilloma or carcinoma of the bladder, except at biopsy. Polyps are distinguished by their smooth surface and long pedicle. They do not bleed from contact with the urethroscope as do granulo- mata. They are very rare. The membranous urethra shows nothing to the urethroscope beyond the redness of urethritis, inflamed orifices of glands or the eroded rigid surface of an infiltrate or stricture. URETHROSCOPIC TREATMENT Anterior Urethra.—llrethroscopic treatment of the anterior urethra is calculated to benefit only those cases that show distinctly localized granulomata or suppuration. The unskilled uretliroscopist always sees a few reddened or infiltrated spots along the urethra; wastes his time in cauterizing or incising these and accomplishes nothing, for in most cases the underlying lesion is a widespread sclerosis, to be influenced only by general dilatation. Yet there are exceptional cases: ulcers and granulomata to he cured by cauterization with 20 per cent silver nitrate solution, or by the high frequency current; single suppurating glands to be drained by incision and healed by applications of silver nitrate solution once a week or so; long para-urethral ducts exudating pus and requiring that they be slit to the bottom and then cauterized. Yet the neophyte will not profit by attempting this form of local treatment. Posterior Urethra.—The lesions that are treated by urethroscope are granulomata, papillomata, polyps, cysts and Pelouse bodies, veru- montanitis, inflamed glands, sinusitis, vesiculitis, sclerosis of the blad- der neck. Granulomata are destroyed by cauterization. The 10 per cent silver nitrate solution usually employed is efficient but slow. This re- quires too many treatments. Fulguration is very efficient, employed as for bladder tumors. With efficient apparatus it is not too painful, i Jour, of Urology, 1922, Mar., VII, 165. TECHNIC OF URETHROSCOPY FOR DIAGNOSIS 171 though the posterior urethra is much more sensitive than the bladder and nervous patients protest against the duration of each treatment. I habitually use pure liquor hydrargyri nitratis (N. E.), but this drug is much more intense in its action than silver nitrate. If Lallemaud used to cause posterior urethral strictures by his porte caustique, I can well imagine that a liberal swabbing with this drug would do so even more surely. I know it would cause agony. Therefore if liq. hy- drargyri nitratis is to be used it must be employed in the most homeo- pathic manner, as follows: The apparatus required is an indirect vision urethroscope, an aspi- rator (a metal tube about 10E in diameter, with a rubber bulb at one end) and some long wooden applicators with a cotton swab at one end as big as will pass through the urethroscope and at the other end the smallest swab that can be made—scarcely more than a veil of cotton. The urethroscope is introduced, the lesion identified, the tube steadied with the operator’s elbow resting firmly against the patient’s thigh. The telescope is then withdrawn very, very gently, so as not to alter the position of the tube. The bulk of the water is then re- moved by means of the aspirator. Meanwhile an assistant has dipped the small swab into the drug and absorbed any excess of the fluid on a bit of gauze. The operator then gently introduces the large pledget of cotton to absorb the last drop of water (this may have to be re- peated). On withdrawing this he looks for blood on it. If there is none he knows that the tube has moved and the lesion must be searched for all over again. If blood is seen he introduces the small pledget, gives it a rapid twist, withdraws the swab and then the tube. It will be noted that this operation requires much more dexterity than fulgura- tion does. The result is considerable pain, frequency, pus and blood for a day or two. The operation should not be repeated within two weeks. Two applications suffice to destroy any one granuloma. True Papillomata and Polypi are destroyed in the same way. The liquor hydrargyri nitratis is peculiarly efficacious in destroying masses of bladder papilloma about the bladder neck so large as to baffle intra- vesical fulguration. The drug may be employed here with relative generosity. Cysts and Pelouse bodies are not benefited by urethroscopic treat- ment and indeed require none. Verumontanitis is treated in the same way with due recognition for sexual hygiene. Littritis is treated as are inflamed glands in the anterior urethra. Sinusitis is treated by irrigation of the sinus pocularis with 1 c.c. of 1 per cent silver nitrate introduced fhrough a ureter catheter. Vesiculitis has been attacked by catheterization of the ejaculatory URETHROSCOPY 172 ducts by Luys and Young. Such treatment has not been shown to have any clinical value and may excite epididymitis. The sclerotic bladder neck has been divided urethroscopically by Goldschmidt and Luys. The operation has not found favor elsewhere. TREATMENT OF THE BLADDER The Kelly school has shown what a variety of operative work can be done in the bladder of women through the straight open tube cysto- scope. The closed straight tube with water or air distention may serve as well in men. I have had very satisfactory results with figu- ration or the chemical treatment of papillomata and ulcers, provided the lesions were localized previously by cystoscopy. URETHROSCOPY IN THE FEMALE To one familiar with urethroscopy of the male urethra, urethro- scopy in the female requires no interpretation. Inflammation, granu- lation, papilloma, caruncle, stricture, rigid bladder-neck, Skene’s glands (which suggest Littre’s) ; the variations of any of these from the male prototype is not noteworthy. CHAPTER XIX METHODS AND DRUGS EMPLOYED FOR THE LOCAL TREATMENT OF URETHRITIS Local treatment of the urethra is administered in the following ways: Injection with small piston syringe. Forced irrigation with piston syringe. Forced irrigation with wall tank. Catheter irrigation. Instillation of fluids. Instillation of ointments. Urethroscopic applications. Rectal massage. Rectal irrigation. METHODS EMPLOYED Preliminary.—The patient should empty his bladder, if he can, immediately before any treatment is applied to the urethra. INJECTION The instrument employed is a two dram glass or hard rubber syringe. The tip may he of soft rubber and should be blunt, so as not to injure the urethral mucous membrane. The syringe is filled and its nozzle applied within the lips of the meatus. To accomplish this these lips must he gently drawn apart, the nozzle inserted snugly between them, and the lips then carefully pressed against the syringe, while the injection is made by slowly depressing the piston. The pressure upon the meatus should be lateral, not from above downward. If the fluid is to be retained more than a moment the syringe is withdrawn while the lateral pressure is continued. Excepting in the prophylaxis of gonorrhea, there is never any reason to prevent the solution from entering the bulbous urethra; no pressure should therefore be put upon the urethra at the penoscrotal angle. If 173 174 LOCAL TREATMENT OF URETHRITIS gently and intelligently performed, tlie injection will never irritate the posterior urethra or the epididymis. In the first days of a gonorrhea injections may be repeated as often as every three hours, thereafter not oftener than three or four times a day, and in chronic gonorrhea not oftener than once or twice a day. Some patients can voluntarily relax the external sphincter and per- mit the injection to flow into the posterior urethra. This may be en- couraged by massaging the urethra with one hand while holding the meatus with the other. But this practice is not without danger and should be employed only in chronic cases. FORCED IRRIGATION The motive force is obtained either from a large (150 c.c.) piston syringe or from a wall tank so arranged that it can be lowered or raised at will. The nozzle I employ on the syringe is a soft rubber tip removed from a glass urethral syringe. For the wall tank, the nozzle usually employed is some modification of the Janet’s nozzle, shield, and cut-off. One may use the Chetwood scissors and two-way glass nozzle for irrigating the an- terior urethra, the Swinburne cut- off and shield and the Janet (the so-called Valentine) nozzle for the irrigation of the posterior urethra. The tank is more convenient than the syringe for anterior irri- gation. The level of the fluid in the tank should stand one to two feet above the urethra. For posterior irrigation either tank or syringe may be employed. In order to force the sphincter the tank must he raised three to five feet above the urethra. The sphincter may be forced more gently with the hand syringe 1 than with the tank. With it one appreciates and yields to the varying pres- sure of the sphincter, forcing the fluid vigorously only when this re- sistance is overcome. To irrigate the anterior urethra 1,000 c.c. is generally used. This is run in and out of the urethra by alternately approaching the nozzle and opening the Swinburne cut-off and removing the nozzle while closing the cut-off. The force of the inflow is gauged by the patient's sensations, which should not he painful, and the sense of urethral dis- Fig. 40.—Chetwood Irrigation. Filling the nozzle. xThe Janet, Janet-Frank, and Janet-Hayden are the best. METHODS EMPLOYED 175 tention imparted to the fingers holding the meatus. The shield catches the splashing outflow. Instead of this slopping way of irri- gation I prefer to employ the Chetwood scissors shut-off and two-way nozzle. The nozzle and scissors are attached and the instrument filled in the manner shown in Fig. 40. The nozzle is then applied to the meatus (Fig. 41) and the scissors alternately opened and shut, permitting intermittent irrigation of the canal. Fig. 41.—Chetwood Irrigation. Inserting the nozzle. CATHETER IRRIGATION The catheter is introduced as described in Chapter IV. If the an- terior urethra is to be irrigated the catheter should be not larger than 15 F. and should be introduced (about 12 cm.) into the bulbous urethra. If the posterior urethra is to be irrigated the catheter (16 to 18 F.) should be introduced until its eye enters the bladder and a few drops of water flow away. As soon as the bladder has thus been drained the catheter is withdrawn 1 to 2 cm. into the posterior urethra. The fluid is then introduced by tank or syringe. If the patient can empty his bladder the catheter is then withdrawn and the fluid urinated out. If there is retention the fluid must be withdrawn by pushing the catheter back into the bladder. If the retention is slight either method may be followed. INSTILLATION The Keyes or the Guyon instillator may he employed for fluids; only the former can be used with ointments. The object of instillation is to place upon a given portion of the urethra a few drops of a solution so concentrated that it could not be used over an extended area or in large quantity. The instillator is introduced like a sound or a woven catheter. Inas- much as the instillation is usually intended for the prostatic or the membranous urethra, one should have a clear idea of the precise position of the instrument as its tip enters the posterior urethra. The Fig. 43.—Tip of Instillator in Posterior Urethra. Fig. 42.—Tip of Instillator in Bulbous Urethra. 176 177 METHODS EMPLOYED jump as it passes the external sphincter is often quite palpable; but in case of doubt one may always feel confident that when the instrument has reached a point in the urethra where its shaft rests without pres- sure at any angle between the perpendicular and the patient’s feet, its point is in the membranous urethra (Figs. 42, 43). Beyond this the instrument should not be introduced. The fluid injected will bathe the whole deep urethra. In order to instill an ointment I employ a screw-piston syringe screwed to the Keyes instillator. The syringe must be taken apart for filling. I see no peculiar virtue in any of the numerous ointment ap- plicators that are devised from time to time. URETHROSCOPIC APPLICATIONS For urethroscopic applications see p. 203. RECTAL MEDICATION On account of its proximity to the posterior urethra, the rectum has always been a favored receptacle for drugs intended to benefit the uri- nary canal, especially when that channel was too acutely inflamed to permit local applications directly to it. Opium and antipyrin to relieve pain, and ichthyol and iodoform to reduce inflammation, are the drugs in vogue. I have had no luck with any of them. Opium is more efficient when given by mouth or by hypodermic, and rectal irrigations of hot and cold water have proven much more efficacious than any chemical medication by this route, while massage, if permissible, is more efficacious still. Massage.—The way to examine the prostate and seminal vesicles by rectal touch has been described in Chapter I. Massage of these organs, to be intelligent, requires familiarity with their normal contour. The technic of massage is described on p. 242. Antisepsis.—Inasmuch as the prostate and vesicles may contain gonococci, the extension of which into the urethra is quite likely to set up acute urethritis, or other bacteria that may cause a milder infection, as a general rule the urethra should he flushed with some antiseptic after massage. The easiest way to accomplish this is by filling the bladder with potassium permanganate (1:3,000) or silver nitrate (1: 5,000) before the massage, and instructing the patient to emit this afterwards. Instillation of silver salts may also he employed. If the temper of the urethra is well known the antisepsis may be omitted in certain cases. It is then better to have the patient retain some urine with which to flush the canal after massage. Irrigation.—Rectal irrigation may be given either by a closed tube, LOCAL TREATMENT OF URETHRITIS 178 the psychrophore, through which the water flows in and out, or by a double-current tube. The former is a much neater instrument to use, but it does not impart so much heat (or cold) to the patient as does the double-current tube. If no double-current tube is to be had, Tuttle’s apparatus may be employed. It consists of two large soft-rubber catheters, bound or sewed together, side by side. The water flows in through one, out through the other. When the outlet is plugged with feces, the current is reversed. Of the special tubes, I find Chet- wood’s model (Fig. 44) more convenient than those of Kemp or Tuttle. The patient fills a two-quart douche bag, at- taches it to the tube, hangs the bag so that its elevation above the outflow' shall be about two feet, and greases the tube with vaselin. lie then seats himself toward the back of a privy seat, leans back against the wall, opens the cut- off of the douche bag until the water flows warm through the tube, and then inserts the tube into the rectum for about half its length. He then turns the water on, and it flows into the rectum. If it does not return through the outflow, he stops the inflow as soon as the rectum feels full, pokes about with the tube until a gush of water announces that it is in the right position, then turns the water on again. It often takes from four to eight attempts before the patient learns to do the trick neatly. The douche is usually employed once a day. The fluid is water at a temperature of 120°-130° F. (as hot as the finger can bear). Ex- ceptionally, cold water (50° F.) works better than hot. Fig. 44.—Chetwood’s Tube for Rectal Irrigation. SOLUTIONS EMPLOYED All solutions to be employed in the urethra or bladder should be made freshly with boiled water in the manner described in Chapter III. The following list represents the solutions usually employed, the form in which they are most conveniently kept, and the strength in which they are usually dissolved. The list might be doubled or trebled without being exhaustive. The remedies are classified in a purely SOLUTIONS EMPLOYED 179 arbitrary way. Manufacturers’ claims as to silver content of the or- ganic compounds are disregarded as being of no clinical importance. Name. Form. Injection. Irrigation. Instillation. Argyrol Crystals 5-20% i 0.25-1% i 0.1-1% 1 3-10% 0.1-0.5% 0.05-0.2% 0.01-0.05% 0.01-0.02% 0.1-0.2% 0.01-0.05% 0.1-0.5% 10-50% 1-5% 1-5% Protargol 0.5 gm. powders. . . . Albargin Potass. perman 0.2 gm. tablets 1 gr. tablets Silver nitrate 10% sol 0.1-10% 0.2% Acriflavine 0.2 gm. powders ..... 0.2% Hg. oxycyanid 0.25 gm. powders. . . . Zinc sulphate 1% sol.. .* Zinc acetat see text 0.2-0.5% Zinc permang 1% sol 0.05-0.2% 0.5-4% Copper sulphate 10% sol 0.5-5% Vegetable astringents Ointments and bou- }■ see text gies J 1 Must be retained three to ten minutes in the urethra. First and foremost, let us condemn the use of any local anesthetic as a preliminary to urethral injection in acute gonorrhea. This masking of the natural irritative reaction is an unwarranted and dangerous procedure. THE ORGANIC SILVER SALTS War still rages as to the relative value of the organic salts of silver. Thus Marshall and INTeave,1 experimenting upon the staphylococcus pyogenes aureus, showed that whereas the majority of silver salts ex- perimented with were powerfully bactericidal, argyrol showed no such effect. Cragin, comparing the effects of silver nitrate, protargol, and argyrol on streptococcus, staphylococcus pyogenes aureus, and gono- coccus, showed both the latter to be markedly inefficient except against the gonococcus, which was killed in thirty seconds by 5 per cent pro- targol and 20 per cent argyrol, in three minutes by 2 per cent, and in twelve minutes by 1 per cent protargol, in twenty minutes by 10 per cent argyrol. Burnett,2 experimenting on dogs, found that neither argyrol nor silver nitrate showed any power to penetrate the urethral mucous membrane. The report of Puckner3 and its discussion ex- emplifies the impracticability of classifying these salts by any laboratory standard. The only standard is that of the clinic. The clinic decides that the organic silver salts are, by virtue of their power to destroy gonococci and 1 Brit. Med. Jour., August 1, 1906. 2 Am. Assoc, of G.-TJ. Surgeons, 1903. 3 Jour. Amer. Med. Assn., October 20, 1906. 180 LOCAL TREATMENT OF URETHRITIS their relative lack of irritation to the urethral mucous membrane, the best remedies against acute gonorrhea, and useful in chronic gonorrhea in proportion as the urethra is hypersensitive and irritable to other remedies. But in nongonorrlieal or postgonorrheal urethritis, acute or chronic, the organic silver salts are all but useless. Argyrol.—Argyrol is the least irritating of these remedies, and is accordingly the most useful in acute gonorrhea. Yet even argyrol may irritate. I have seen three patients who could not employ it, and two others with prostatic abscess due to its intemperate use. Yet argyrol is so filthy that one gladly employs one of the other salts in its stead as soon as the urethra will permit. The stains of argyrol may be removed by immediate washing or by prolonged soaking in 1: 500 corrosive sublimate solution. Protargol.—This is fully as efficient as argyrol, but, in efficient strength, more irritating. Albargin.—Albargin is efficient, but somewhat more irritating than protargol. ASTRINGENT ANTISEPTIC INORGANIC COMPOUNDS The above clumsy title best describes a group of drugs that vary widely in usefulness and antiseptic power, but possess the common prop- erty of healing the inflamed urethra—a property only inadequately ex- pressed by the word “astringent.” Astringent properties, in the chemical sense, are claimed for the organic silver compounds; hut these exhibit very faint healing power when applied to the urethra. Potassium Permanganate.—For the irrigation treatment of acute gonorrhea its virtues are exceeded only by those of the organic silver salts. It is our best remedy to hasten the cure of an active chronic urethritis. It equals nitrate of silver as a preventive of infection when sounds are passed or the prostate rubbed, as well as in the treat- ment of nonspecific and chronic urethritis. Yet it has its limitations. It achieves the best results when employed in weak (1:3,000 to 1:8,000) solutions and in large quantity, as an irrigation. As an injection for the anterior urethra it is distinctly inferior to many other drugs. In chronic urethritis that is almost healed it is inferior to silver nitrate instillation. The statement often made, that while gonococci are present in the urethra silver salts should be employed, and after they have disap- peared permanganate resorted to, is a misleading half truth. The or- ganic silver salts are, it is true, pre-eminent as slayers of the gonococcus, but the inorganic silver nitrate and potassium permanganate are useful for all sorts of urethritis, except the most acute, whether gonococci be present or not. SOLUTIONS EMPLOYED 181 Silver Nitrate.—On the general utility list silver nitrate stands equal to potassium permanganate. It has not served me well in the abortive treatment, and no one now uses it in advancing acute gonorrhea, excepting as an instillation for hyperacute posterior ure- thritis. It is useless for anterior urethral irrigation or injection. But for posterior irrigation it is as efficient as permanganate. Moreover, for instillation and urethroscopic application silver nitrate is used almost exclusively. The pain excited by instillations of silver nitrate varies within the widest limits. Many a patient after receiving one instillation of 1: 1,000 silver nitrate solution will never take another. Yet this is the strength at which we usually begin, and some patients grow so ac- customed to it that the strength may be increased to as high as 10 per cent. Silver Permanganate.—This salt is made by adding silver nitrate to potassium permanganate. To 500 c.c. of 1: 8,000 solution of the latter I usually add from six to ten drops (minims) of a 10 per cent solution of the former. I have found it useful only as a posterior irrigation in chronic cases, as an alternative for either of its components alone. Mercury Oxycyanid.—The cyanate or oxycyanid of mercury is highly spoken of by European writers for the treatment of nongonor- rheal urethritis. I have repeatedly tried it and found it relatively irritating and inefficient. The Zinc Salts.—The zinc salts have been little used except as in- jections for the control of chronic anterior urethral discharges. (Yet zinc sulphate, in 5 per cent solution, makes an adequate bladder irri- gation.) They rarely cure, but they control the discharge better than any other remedy and are thus of great assistance by the encourage- ment and sense of cleanliness they impart to the patient (but not, it is to be hoped, to his physician), while giving nature and the more efficacious local treatments time to effect a cure. Zinc Sulphate is the most popular of these salts. It is usually em- ployed in a 1 per cent solution or even stronger, though I fancy it is as efficacious in much greater dilution. Zinc Acetate is more efficacious. I employ the following formula almost without variation. The combination throws down an insoluble zinc sulphate which helps to retain the acetate in the urethra. B Zinci sulpli 00.2 gm. gr. iij; Liq. plumbi subacetat. dil. . .ad 100.0 c.c. § iij. M. Shake. S. Inject b.i.d. 182 LOCAL TREATMENT OF URETHRITIS Zinc Permanganate is a hygroscopic salt and is, therefore, best kept in solution. At a strength of 1: 2,000 it is extremely efficacious; sometimes more so than the acetate. It is possible, but apparently unnecessary, to use it in much stronger solution. Other Astringents.—The following composite preparations are recommended by various authors: Zinci sulphatis gr. xv; Plumbi acetatis gr. xx; Tr. opii. Tr. catechu aa 5 ij ; Aquae ad § vj. (Brou.) Zinci sulphatis. Pulv. alum aa gr. jv. ad gr. xij ; Acid carbolic gr. jv; Aquae o jv* (Ultzmann.) Zinci sulphatis gr. xij; Besorcin gr. xxjv; Aquae o jy* (Morton.) Cupri sulphatis 0.20 gr. iij ; Alum crud 1.00 gr. xv; Aquae 200.00 § vij. (Kreissl.) VEGETABLE ASTRINGENTS The vegetable astringents are legion. Almost every known fluid, from hot and cold water to tea and claret, has been employed in the course of a gonorrhea that terminated in a cure. These remedies are only employed as injections in chronic or nongonorrheal urethritis as substitutes for the zinc salts. I am not enthusiastic over any of them. The following are advised: Extr. liydrast. fl.1 Bismuth subcarb. Boroglycerid (25 per cent) aa 5 vj; Aquae destill ad 5 vj. (White and Martin.) 1 The ‘ ‘ colorless ’ ’ preparation has been shown to be but a dilution of the colored drug. Hydrastis leaves an indelible yellow stain on linen. SOLUTIONS EMPLOYED 183 Ichthyol gr. xxtoo jss; Aquae q.s. ad § jv. (Baumann.) ]y Berberine hydrochlorate gr. v; Aquae § viij. (Belfield.) OINTMENTS AND DRUGS The application of urethral medication in an oily or greasy form has seemed to many an ideal way of treating chronic urethritis. Re- sults have generally fallen below expectations. I have derived no ad- vantage either from ointments or soluble bougies. Young,1 who has reviewed the subject exhaustively, employs lanolin as excipient and uses the following formulae: For cases with marked epithelial changes, salicylate acid (0.5 to 1 per cent). For “less severe cases,” iodoform (10 per cent), silver nitrate (1 to 2 per cent), or boric acid (10 per cent). For cases with considerable glandular involvement, protargol (2 to 5 per cent), or bichlorid of mercury (1:10,000), or forinaldehyd (1: 5,000). Janet, Caspar, Finger, and Bazy are among the other advocates of the method. Formulae similar to the above are made up as suppositories, to be inserted into the anterior urethra. I have not found them as useful as injections. 1 Johns Hopkins Hosp. Reports, 1906, XIII, 115. CHAPTER XX SYSTEMIC TREATMENT OF URETHRAL GONORRHEA The efficacy of local treatment in repressing acute urethral gom orrhea leads many practitioners to forget the old “methodic” treatment, the sole reliance of our fathers. The methodic, or systemic, treatment of acute gonorrhea has indeed been relegated to second place; yet it is still important, not only when repressive local treatment is inapplicable, but also as an accessory to this local treatment. The hygienic and dietetic part of the treatment is of the utmost importance. If disre- garded, the best directed efforts may miscarry. CLEANLINESS The parts should be washed as often as required, soap and warm water being as good as an antiseptic solution and more readily at hand. The discharge should be kept from smearing the underclothing. If the foreskin is long, the glans penis may be thrust through a slit in the center of a small square of gauze until the slit lies snugly behind the corona glandis; thus held in place, the gauze is folded forward over the glans penis, covered by replacing the foreskin, and left puckered up and long enough to protrude in a hunch in front of the preputial orifice.1 If the prepuce is short, an apron of old cotton or linen doubled may he fastened to a string about the waist or pinned to a suspensory bandage, and the entire genitalia wrapped up in this; or one of the penis bags furnished by the shops may be employed. Inasmuch as suspension of the testicles is advisable as a preventive of epididymitis, a “jockstrap” should he worn. This will act, inci- dentally, as a bag to contain the gauze or cotton garnishing the meatus. Finally, the patient must be told the danger to his eyes from con- tamination with his urethral pus, and cautioned to touch the genitals as little as possible and to wash his hands thoroughly with soap and water every time he has touched his penis. The pledget of absorbent cotton, which is so efficient when the discharge is mild, retains the more profuse discharge in contact with the head of the penis, thus preventing proper drainage of the inflamed urethra. 184 SEXUAL HYGIENE 185 DIET The rigorous diet usually prescribed excludes all alcohol, spices, rich and indigestible sauces and foods, fruit, coffee, tea, and sparkling water. I have found it of no benefit to the patient’s urethra to he so strict, and a great encouragement to his mind to permit a greater lati- tude. Alcohol, spices, and condiments must, of course, be prohibited, and it is well to specify ale, beer, cider, and ginger ale, besides insisting that any substance which burns the palate as it enters the body will burn the urethra as it issues forth (we speak, of course, of chemical, not of physical heat). Indigestion, whether from overeating or from indis- creet eating, is harmful, and acid fruits, especially lemons and grape fruit, as well as asparagus, are apparently irritating. But there is no reason to prohibit these absolutely nor to prohibit tea or coffee at all. I do not prohibit sparkling waters. REST Physical rest is most important. Were it possible for the business of the world to be transacted with all the sufferers from acute gonorrhea in bed, and were rest in bed not the very worst thing for the state of mind of these same sufferers, it w7ould be wiser to place them all upon their backs. But, taking the world as it is, the best plan is to urge each patient to rest as much as may be; to ride rather than to walk, to sit rather than to stand. Railroad and automobile trips seem to be a peculiarly injurious form of locomotion. SEXUAL HYGIENE During the acute stage absolute continence is essential, and this should be extended at least two weeks after the cessation of all discharge, with the avoidance of anything liable to induce sexual excitement—asso- ciation with women, racy books and pictures, erotic thoughts et id genus omne. Such is the general rule; yet I have known patients accustomed to frequent sexual intercourse to be constantly distressed by painful erec- tions unless they relieved their sexual tension by cohabitation (with a condom). Such license should nevertheless he absolutely prohibited. Massage of the prostate and vesicles cannot wholly replace it. 186 SYSTEMIC TREATMENT OF URETHRAL GONORRHEA DILUENTS The patient should drink (between meals if he is dyspeptic) about eight glasses of water a day. Ordinary drinking water suffices, but, if he can afford it and it does not prove too diuretic, an alkaline diluent, such as Vichy Celestins, is preferable. But here again common sense must temper routine practice. In acute gonorrheal cystitis and in very acute posterior urethritis more harm may be done by the muscular straining attending the frequent repetition of the urinary act than is atoned for by any amount of dilu- tion of the urine. INTERNAL MEDICATION The drugs that may be effectively exploited to combat acute urethral inflammation belong to five orders: 1. Urinary antiseptics. 2. Alkalies. 3. Demulcents. 4. Anodynes. 5. Balsamics. 1. URINARY ANTISEPTICS Urinary antiseptics, such as hexamethylenamin, methylene blue, salol, benzoic acid and the benzoates, boric acid and the borates, have no recognizable influence upon urethral inflammation. Theoretically, they ought to be of paramount importance, hut practically these sub- stances, so valuable in suppurative conditions of the urinary tract above the bladder, are useless below that point, whether because their bac- tericidal efficiency is slight, or because their sojourn in contact with the inflamed urethral wall is limited, or because the bacteria are shielded from the antiseptic action of the medicated urine by the tissues in which they lie. The value of hexamethylenamin and of methylene blue in acute gonorrhea has been vaunted. In my opinion it is slight; so slight that it does not deserve consideration. Yet hexamethylenamin is very useful to protect the kidneys. It should be given whenever there is an unexplained rise of temperature in the course of a gonorrhea. 2. ALKALIES The virtue of alkalies in the treatment of urethral inflammations depends rather upon the condition of the urine than upon the grade of INTERNAL MEDICATION 187 the inflammation. The urine, normally acid and often dense, is, ipso facto, harmful except in so far as it washes the urethra, and the alkali is negatively a very good thing, but good only when required to counter- act acidity. In other words, there is no specific action whatsoever in the alkalies. They do not in the least control suppuration. If one had two burned hands, and placed one of them in vinegar and water and the other in a watery solution of bicarbonate of soda, he would doubtless prefer the sensations experienced in the hand immersed in the mild al- kali, and so it is with the urethra. Patients having normally bland, alkaline, dilute urine (and there are many such) stand in no need of alkalies, and, indeed, may occasion- ally be injured by them, through indigestion. When the urine is acid an alkali is indicated. If the urine be also dense a diuretic alkali is called for; if dilute (sp. gr. 1.015 or less), the diuretic quality is not needed. Alkalies produce the greatest effect relative to the size of the dose, if administered toward the end of the second hour after eating. Bicarbonate of Soda.—This is the mildest of the alkalies. Its chief virtue is that it aids digestion, while the other alkalies impede digestion more or less. Dose, 0.50 to 1 gram. It is prescribed in the form of tablets. Sweet Spirits of Niter (spts. etheris nitrosi).—Sweet spirits of niter is notable for its anodyne rather than its alkaline properties. It is chiefly employed for the slight irritation of the bladder so common in women. Dose: 2-6 gm., in water. Potassium Citrate, Potassium Acetate, Liquor Potassae..—These three salts are employed more than any others as urinary alkalinizers. The citrate is the most efficient as an alkali, but irritates some stomachs, the liquor the most anodyne, the acetate the most diuretic. Therefore the liquor is most useful in acute cases, and the citrate in chronic cases. The acetate is a stronger diuretic than the citrate, hut I have found it also more irritant to the stomach. The dose of each drug is about 0.5 gram in a considerable quantity of water. The disagreeable taste is well disguised by syrup of cinnamon. Bromid of Potassium.—This acts as an alkali and is sometimes effi- cient in controlling the smarting upon urination. 3. DEMULCENTS Demulcents are much less used now than formerly, but may be comforting when combined with an alkali. To this class belong flax- seed tea, gum water and elm-bark water, the various fluid extracts made from buchu, pareira brava, uva ursi, triticum repens, and corn- silk. 188 SYSTEMIC TREATMENT OF URETHRAL GONORRHEA 4. ANODYNES Anodynes are called for to moderate pain on urination, and for this bromid of potassium or the tincture or fluid extract of hyoscyamus gen- erally suffices. A favorite old-fashioned prescription is: I£ Liq. potassae 8.00-25.00 gr. 3 ij-vj; Tr. hyoscyami 15.00-35.00 gr. § ss-j; Syr. cinnamon q. s. ad 100.00 gr. § iij. M. Sig.—Teaspoonful in water two hours after each meal (or oftener). For Intense Chordee.—Lupulin in doses of 2 to 4 grams taken upon retiring is sometimes effective, or a similar dose of the bromid of potas- sium. The coal-tar products are useless, codein feeble, opium risky. Hot water is a good preventive, cold water a quick relief (as stated be- low). The patient should sleep lightly clad in a cool room. For Painful Urination.—The anodyne mixture given above is excel- lent. Codein or bromids may be added for a severe case of acute cys- titis. It is an advantage to instruct the patient suffering from this complication not to empty his bladder completely, but to let the last of the urine dribble away without the aid of the distressful piston stroke. The instruction is hard to follow, but it may afford great relief. The uses of water in this connection are mentioned below. The role of the prostate must not be forgotten, and if all else fails, local treatment (p. 200) or even operation may be resorted to. Hot Water is of value in various ways. When the pain on urina- tion is intense it may be somewhat moderated by immersing the p6nis in very hot water and urinating into it. Prolonged soaking of the penis, just before retiring, in water as hot as can be borne, will often prevent or moderate chordee during the night. A Hot Hip Bath is full of comfort for the patient with any form of acute prostatic, vesical, or seminal vesicular inflammation. Such a bath may be repeated every few hours. It should be short, not lasting more than five minutes. The temperature of the water at first should be near 104° F., and after the patient is in the bath more hot water should be added until the temperature is as high as he can tolerate. The Hot Rectal Douche (p. 177), once or twice a day is even more efficient. Iced Water is useful when the penis is erect and in chordee. The patient naturally urinates at once, if he can, and then by pouring iced water over his turgid and unruly member, or by placing it alongside a cold piece of metal, he strives to reduce it to subjection. To break a chordee is to invite stricture. INTERNAL MEDICATION 189 5. BALSAMICS Balsamies have fallen into almost complete disrepute in the treat- ment of acute gonorrhea in this country. This is, in part at least, because of the general misapprehension of the way in which they should be given. The benefit derived from balsamies depends upon their concentration in the urine. Hence they should be given to the point of saturation and with as little dilution of the urine as prac- ticable. Thus given, they distinctly alleviate the discomfort due to gonorrhea and even markedly control the inflammation. (They are equally efficacious for other infections of the urethra and prostate.) Thus the decision to administer balsamies during acute gonorrhea depends chiefly upon the failure of local treatment, diluents and alkalis to control the inflammation. The less active the inflammation, the less the virtue of any general medication. Sandalwood oil.—01. santal. flav. seems fully as efficient as any of the synthetic remedies that have been devised to supplant it. Gono- san or arrhovin need be employed only by the patient who can not digest the sandal wood oil. The drug is administered in 5 minim capsules. These should be given six times a day (at three-hour intervals), and the dose increased by doubling the size of two doses each day until twelve capsules are being given a day or the digestion rebels (colic, eructations, diarrhea) or pain the loin appears. If these symptoms of poisoning occur, the dose should be reduced to the limit of toleration. If six capsules a day cannot be given a therapeutic effect can scarcely be expected. Copaiba (overdose of which occasions erythema), Cubeb, Winter- green oil, and Kava-kava are among the more popular substitutes for sandalwood oil as ingredients in antigonorrheic capsules. INSTRUCTIONS TO PATIENTS Of late years the commendable practice has arisen of distributing to dispensary patients, suffering from venereal diseases, a card indicat- ing the chief dangers of the disease and the precautions they personally must take to encourage speedy cure and to protect their fellows. The following list has been approved by the Associated Clinics of New York City: INSTRUCTIONS TO THOSE HAVING GONORRHEA You have a serious contagious disease. It may continue for years after the discharge ceases and you seem well. Therefore you must not marry or have any sexual relations until a reputable physician has pronounced you cured. 190 SYSTEMIC TREATMENT OF URETHRAL GONORRHEA A woman with this disease may become sterile, or be an invalid for life, or have to undergo a very serious and mutilating operation. A child born to a woman with this disease is likely to become blind. For your own protection, and the protection of others, observe the following precautions: 1. Always wash the hands after handling the parts; the discharge, if car- ried to the eyes, will make you blind. 2. Sleep alone, and be sure that no one uses your toilet articles, particularly towels and wash cloths. 3. Never lend your syringe to anyone, and as soon as you are well, de- stroy it. 4. Avoid all sexual relations and excitement. 5. Be sure that the bowels move every day. If constipated, take a laxative. C. Do not use alcohol in any form, as it always prolongs the disease. 7. Drink from six to eight glasses of water a day. 8. Avoid all spicy food and drink, as ginger ale, mustard, pepper and horseradish. 9. So long as the discharge is free, walk as little as possible. GENERAL TREATMENT OF CHRONIC URETHRITIS General Hygiene—Many of the general hygienic rules for the treat- ment of acute gonorrheal urethritis do not apply to the treatment of chronic inflammations. Thus the diet, which should he light during the acute period of the disease, should be rather full and stimulating in the chronic stages. Exercise, which is always harmful in acute gon- orrhea, is often beneficial to a chronic case. Exercise should not only be permitted, but should be encouraged. There is no reason to prohibit even such violent pastimes as tennis and swimming, to a patient suffer- ing from chronic urethritis; but they should be begun gradually, and the patient should feel his way, taking more and more exercise as he assures himself that it does him no harm. The intelligent use of alcohol is one of the most thoroughly misun- derstood points about the treatment of chronic urethritis. Although we realize that many of the drugs and methods of local treatment employed for chronic urethritis are used chiefly because they are irritating, yet we forget that alcohol is one of the best known urethral irritants, and we are too much inclined to scoff at the story of the patient who, despair- ing of a cure after many months of treatment for his local urethritis, breaks training, enters a wild debauch, and comes out of it cured. Such a case is not the exception that proves the rule, but is only an illustration of the rule that what we seek for the cure of chronic urethritis is tlio proper irritant, and alcohol sometimes fits the case. Alcohol is almost universally harmful so long as gonococci can be found in the urethral pus (though there are rare exceptions even to this rule) ; but after the gonococci have disappeared, if the patient is an habitual drinker, it is GENERAL TREATMENT OF CHRONIC URETHRITIS 191 proper to urge him to return gradually to the use of alcohol, and such a course frequently has a most beneficial effect, both upon the patient’s mind and upon his catarrh. It is an exhibition of intelligence on the part of the physician to cure his patient by giving him whisky to drink, rather than to run the risk of permitting the patient to make this experiment for himself. Other hygienic measures, such as sending a patient away from the city to the country, or bidding him change his climatic conditions by a trip at sea or to the mountains, are very rarely called for. Yet, when local measures fail after a thorough trial, it is imperative that the pa- tient leave his work and his home to take a vacation. Under such con- ditions a brief trip may well effect cure, or at least put the patient in such a condition that local treatment, which previously was tive, will now prove curative. Sexual Hygiene.—While gonococci persist sexual intercourse is as likely to reinfect the gonorrheic as it is to infect his partner. But after their disappearance it is likely to do good by relieving the sexual con- gestion of one who is (presumably) accustomed to frequent sexual in- tercourse. The irritation of ungratified sexual desire, the effort to check the sexual habit, is to many gonorrheics the most distressing feature of the disease. Drugs.—Most cases of chronic urethritis may be treated successfully without any internal administration of drugs. Very exceptionally a patient is benefited by the internal administration of balsamics or alka- lies. More commonly, a brief, severe course of water drinking will cure a mild catarrh by flushing the canal. The alkaline mineral waters are, apparently, the best suited for this purpose. Urotropin is employed as an antiseptic preliminary to the use of sounds or dilators, and for the treatment of pyelonephritis or bacteriuria. Alcohol should be used intelligently, as stated above. Tonics may be required. CHAPTER XXI LOCAL TREATMENT OF ACUTE GONORRHEA The local treatment of acute gonorrhea comprises five entirely dis tinct subjects, viz. : The preventive treatment. The abortive treatment. The repressive treatment. The terminal (expectant) treatment. The treatment of complications. THE PREVENTIVE TREATMENT The man who practices promiscuous cohabitation sooner or later catches gonorrhea in spite of every precaution. The condom is still “a cuirass against pleasure, a cobweb against infection,” as Ricord used to say. The condom may tear and so admit infection; and once in a great while one is consulted by a victim w7ho alleges he was infected in spite of its protection. The infection in such cases doubtless results from preliminary skirmishing. Some measure of safety is afforded by urination and thorough wash- ing with soap and water immediately after cohabitation. To this any one of the following therapeutic measures adds a far greater assurance of safety: Instillation into the meatus of a few drops of 20 per cent argyrol or 5 per cent protargol. Irrigation of the anterior urethra with permanganate of potassium (1: 1,000). Injection and retention for five minutes of 20 per cent argyrol or 1 per cent protargol. The safety afforded by any of these is approximate but not absolute. The treatment should be employed within twelve hours of the contact and should not be repeated. A traumatic urethritis, lasting a day or two, may result. THE ABORTIVE TREATMENT In the production of chronic urethritis the abortive treatment has taken the place of the sound of our forefathers. 192 REPRESSIVE TREATMENT 193 In exceptional cases it is possible to abort gonorrhea. Indeed, in some cases gonorrhea almost aborts itself. But it is almost impossible to abort a first gonorrhea, and often impossible to abort subsequent attacks. After experimenting with every method of aborting gonorrhea I ever heard of, it is my present conviction that the surest way to abort gonorrhea is not to try to abort it. The treatment employed should be repressive. REPRESSIVE TREATMENT The repressive treatment of acute gonorrhea consists in the employ- ment of local treatment calculated to control the inflammation; but with the prime object of lessening the symptoms, the complications, and the prospects of chronicity, not of cutting short the acute attack. The systemic treatment described in Chapter XXI11 is always employed. Repressive treatment occasionally and quasi-accidentally results in abortion of gonorrhea. Indeed, I believe it so results quite as often as the abortive treatments detailed above, while it has the supreme advantage of leaving those cases that are not aborted soothed rather than irritated and in the best possible condition to weather the weeks to come. Cases Suitable to Repressive Treatment.—The physician unfamiliar with the local treatment of urethral disease can expect but little suc- cess with the repressive treatment of gonorrhea. The expectant treat- ment will give him better results. The physician moderately familiar with the subject should under- take this treatment with fear and trembling. He should apply it at first only to cases that he can absolutely control, who apply for treat- ment during the initial stage of the disease, before the meatus is much swollen, the discharge free, the “second” urine cloudy, or pain on urina- tion or erection present. This admits most cases from one to three days old. The expert will determine how far his personal success permits him to disregard the above rules. Hone of them are absolute to him, so long as he proceeds gently and is in no hurry to get the patient well. Choice of Repressive Treatment.—The ideal antiseptic for the gon- ococcus has not yet been discovered. We therefore describe the three types of treatment generally employed, acknowledging our preference for the first named, and insisting only on the early use of mechanical treatment in the declining stage of the disease. Acriflavine.—This drug was first employed as an antiseptic by the British during the World War. It proved of little value as a dress- ing for inflamed wounds, but singularly efficacious in preventing fresh 194 LOCAL TREATMENT OF ACUTE GONORRHEA wounds from becoming infected during transfer to Base Hospital. Young sent some of the drug to Johns Hopkins where it was studied and first used in the treatment of gonorrhea. Its use in a strength of 1 to 1000 was advised. Subsequent experience has proved this much too strong. Anyone employing acriflavine in the urethra must bear in mind its peculiar property to irritate without causing discom- fort. In using any other drug the patient may be depended upon to note irritation. Hot so with acriflavine. It will produce stricture quite painlessly. I have known a patient to produce with it a lesion that looked like a chancre of the meatus, blissfully unconscious that he was doing himself any harm. Hence the acriflavine treatment must he given only hy expert urologists and never entrusted to the patient. The rules to be followed with the utmost precision are: 1. Inject only the anterior urethra until anterior urethritis is controlled. 2. Use a syringe (bulb or piston) of the most delicate description which will register the lightest resistance of the patient’s urethra. Thus only may one surely avoid trauma. The string-wound piston is taboo. The piston must be of ground glass; the bulb, if bulb is used, old and soft. 3. The amount injected must not exceed 10 c.c. 4. The solution should be 1 to 4,000 and not more than a few days old, made from a stock 1 per cent solution which will keep a month. 5. The injection is given but once a day; held in the urethra for one minute. The question whether one brand of acriflavine is better than another L am unable to decide. Of neutral acriflavine I am not able as yet to judge the value. For a time we used permanganate of potassium in conjunction with acriflavine. Lately we have discontinued its use. Argyrol.—Argyrol should be employed with the same extreme of gentleness in 10 per cent solution, freshly made, and retained in the urethra for 10 minutes four times a day. The patient may use this injection himself, but should visit the physician daily. Protargol.—This should be employed like argyrol, but in strength of from 0.25 to 0.50 per cent. Kreissel injects 0.125 per cent for one minute every two hours during the day and twice during the night. On the fourth day he changes to 0.25 per cent every three hours by day and once during the night. Four days later 0.5 per cent every four hours by day and retained five minutes. Potassium Permanganate—Janet introduced the use of this drug. Though I do not employ his method of treating anterior urethritis, yet REPRESSIVE TREATMENT 195 potassium permanganate is universally recognized as the most generally useful mild antiseptic for the treatment of almost every variety of infection of the urinary organs. He irrigates the anterior urethra twice a day for three or four days, then increases the interval from twelve to eighteen hours. When the cloudiness of the first urine is pretty well gone, he makes the interval twenty-four hours. When the discharge is no longer purulent, he makes it forty-eight hours. When the second urine becomes cloudy, he irrigates the posterior urethra according to the same method, twice a day at first, later every day or every other day. For each irrigation, of anterior or posterior urethra, he employs 500 c.c. of fluid, at a temperature of 110° F. If the case is seen before the appearance of marked inflammatory symptoms, he employs a 1: 500 solution of permanganate, immediately followed by a like quantity of boric acid solution. If this does not prove too irritating, he continues at this strength until the inflamma- tion has subsided sufficiently to permit intervals of thirty-six to forty- eight hours, when he drops to 1: 4,000 to 1: 6,000 permanganate and omits the boric acid. If the posterior urethra becomes inflamed, he begins irrigating it with solutions of 1: 4,000 down to 1: 10,000. If these are well borne, he increases the strength to 1: 2,000 or 1 : 1,000, and follows it with a boric acid irrigation. If the patient is first seen after the appearance of acute inflam- matory symptoms, the irrigation is begun at 1:10,000 to 1:4,000 strength, and only for the anterior, even if the posterior urethra is inflamed. He begins treatment of the posterior urethra only when the anterior inflammation is under control. In the declining stage he gives a daily irrigation of 1: 6,000 to 1: 8,000. Other Methods.—Valentine and the other followers of the Janet method in this country follow his method with certain variations. They usually employ much weaker solutions (1:4,000 to 1:20,000) and larger quantities (1,000 c.c. or more), and often irrigate the pos- terior urethra every day or every alternate day as a routine measure. Results of Repressive Treatment.—The success of the repressive treatment of gonorrhea, by whatever method, is not universal. Suc- cess depends upon the skill and gentleness of the practitioner and upon the intensity of the infection. First infections are much less con- trollable than subsequent ones. Duration of the gonorrhea, intensity of anterior urethritis, are adverse phenomena which usually forbid the attempt at repression of a gonorrhea, and render its success dubious in any case. The test of the success of repressive treatment is diminution and 196 LOCAL TREATMENT OF ACUTE GONORRHEA disappearance of the patient’s subjective symptoms (pain or discom- fort). The patient must be impressed with the fact that the success or failure of the treatment is in his hands, and that the sign of danger is pain, the cause of pain trauma, lie must he gentle in injecting, gentle in compressing the meatus, and should not repeat an injection in case a first effort fails. Pain is never the same in any two cases. To say that an injection of protargol to be efficient should be painless, is obviously untrue. But each successive injection should he less painful than its predecessor, and the appearance of any new or increased pain at any time is the one signal that calls for immediate cessation of local treatment. Moreover it is expected that the discharge, the gonococci in the dis- charge, and the pus in the urine will daily grow less. Accordingly, examination of the meatus, smear of discharge (if any) for gonococcus examination, and passage of urine in two glasses are essential prelimi- naries to each treatment. If things go badly, it is vain to try frantically one treatment after another; all local interference must be discontinued immediately. If things go well, the discharge promptly lessens and gonococci disappear from it within a few days. All discharge may even disappear after the very first injection. Yet we are well aware that gonococci are still present in the mucosa. Their eradication is our next problem. This may be termed the Stage of Control or Decline. Treatment of the Stage of Control.—The outstanding feature of many a case of gonorrhea when it has reached this Stage of Control or Decline is that it declines to decline any further. Perhaps for a few days only, perhaps for weeks, pus and gonococci vary but little; more one day, less another; complete disappearance of all pus followed in a ifew days by recrudescence. We know that the cause of this is an uncontrolled focus of infection in some lacuna or gland, the occasion usually some variation in the patient’s sexual life. What shall we do about it? To change from one antiseptic to another does not avail. We must attack the focus in the mucosa, by the passage of sounds. In discussing the diagnosis of cure of gonorrhea we have shown that sounds must be passed and that this may be done with impunity even if gonococci are still present, if only the sounds are passed gently. The same is true here. Accordingly, after the acute infection is controlled, even though there is still some pus in the urine, even though there are still some gonococci in this pus, but on condition that improvement has come to a standstill, one proceeds as follows: After the patient has urinated the injection is made as usual; then a 22F sound is passed gently—but, oh, so gently! to the bulbous urethra and no further. REPRESSIVE TREATMENT The next day witnesses an increase in both discharge and gonococci. Injection is continued as before. Within a few days the infection is again controlled. Four days later the sound is passed as before; the same size if the reaction has been sharp, the next size larger if it has been mild—but no further than the bulb in any case until size 25F has been reached with no reaction. Then, after the usual four-day interval the injection is forced, slowly and with the utmost gentleness, into the posterior urethra. One feels the resistance of the sphincter, one calls upon the patient to relax his muscles and to go through the motion of passing water and then, as the resistance of the sphincter is felt to give way, about 5 c.c. of solution is passed into the posterior urethra. Then a 25F sound is once again, oh, so gently! introduced into the posterior urethra until its shaft lies at about 45° from the horizontal and its point is in the bladder, but no further for fear of bruising the posterior urethra too severely. Thereafter the whole urethra is injected daily in the same manner until once again a four-day interval of control has elapsed. Then the sound is passed as before, and so on, until a 28F sound can be passed without exciting any reaction whatever (the meatus may have to be cut). The patient is seen and injected thereafter thrice in the first week, twice in the second, the sound passed and the prostate massaged (on different visits) once a week, and if no reaction occurs and the urine and the prostatic secretion are free from pus for this two weeks he is discharged as cured. This is no abortive treatment. It takes at least six weeks, often eight. But it cures the average patient quicker than any other method and proves him cured with greater certainty. Only exceptionally, and in patients the temper of whose urethra is proved by previous infections, may it be abbreviated. Treatment of Posterior Urethritis. — Freedom from posterior urethritis, absence of pus from the second glass of urine, has been assumed in the preceding description. Indeed, posterior urethritis is, generally speaking, a contra-indication for repressive treatment. The physician who attempts to repress the posterior urethritis of a first gonorrhea is foolhardy. In subsequent attacks he does so at his peril. But the posterior urethra may become inflamed during treatment. Pus appears in the second glass of urine. One may then persist in the treatment, very gently insinuating a little of the injection into the pos- terior urethra in the manner above described, so long as this at least controls the situation. FTo change is thereby indicated in the routine of treatment by sounds. Complications.—That the repressive treatment may fail is obvious. But if once the acute infection has been repressed and sounds used, failure is inadmissible. If the infection then flares up uncontrollably, 197 198 LOCAL TREATMENT OF ACUTE GONORRHEA if periurethritis or epididymitis result, let the physician attribute this to his own lack of dexterity or care. Xo such complication has occurred in our practice. EXPECTANT TREATMENT Should the acute gonorrhea be so far advanced that repressive treat- ment is deemed impracticable or should it be tried and fail, the case is to be treated expectantly by the measures detailed in Chapter XX. In the course of three or four weeks the disease will reach its culmina- tion and begin to abate spontaneously, unless complications arise (see below). Then one begins repressive treatment as above described. But we are not now dealing with a normal urethra attacked by an acute infection. The acute infection has already produced various lesions in the urethra which must be taken into account. There may be prostatitis or other complications, and in the end the patient may be left with a post-gonococcic urethritis. These require their appropriate diagnosis and treatment. TREATMENT OF COMPLICATIONS Abscess of the Urethral Glands.—Acute relapse or chronic pro- longation of gonorrhea because of infection of the glands or of the para- urethral ducts is a matter for treatment in the chronic stages of the disease; nothing can be done while the whole urethra remains acutely inflamed. Periurethritis.—Stop repressive treatment. All pus formations about the urethra, whether diffuse or circum- scribed, are treated during the acute inflammatory stage on general surgical principles—by rest, protection from friction and injury, moist weak bichlorid or mild carbolized wet dressing under gutta-percha tis- sue. Incision is required as soon as the abscess is as large as a pea, if not sooner. When the abscess projects internally and not externally, an attempt should be made to open it from within through a urethroscope. When permanent fistula results it should be treated by Chetwood’s method, viz.: the injection into the urethral end of the fistula of a 25 per cent ethereal solution of peroxid of hydrogen, using a fine-drawn, rubber-capped, glass pipette (Fig. 45) with bent extremity. By means of this instrument, aided by a wire speculum, a few drops of the solution are thrown into the fistula. This is repeated every three days until the fistula closes. This treatment should be applied from within the urethra the internal orifice of the fistula being en- larged for that purpose, if necessary. Fistulae that do not yield to this treatment require a plastic.operation. Tf little shotlike bodies remain under the skin, refusing to sup- purate actively, these may be excised, but fistula may result. TREATMENT OF COMPLICATIONS 199 Spongeitis and Cavernitis.—Chordee, the commonest evidence of inflammation in the corpus spongiosum, is a contra-indication to re- pressive treatment. If the erections are rendered more painful by the injections these must be stopped. Chordee is self-limited. It usually ceases in ten days. To prevent chordee the patient should eat and drink little in the evening, avoid all sexual associations, sleep under light covers, and arise to urinate in the middle of the night. To palliate it he should bend the erect penis gently downward and check the erection by immediate urination, or by first plunging the penis into cold water and then urinating. Prostatic massage has been suggested as a means to reduce the sexual tension and so prevent erections. I have not found Fig. 45-—Injection of Urethral Fistula. it of any service, though one occasionally sees an amorous patient in the declining stage of acute gonorrhea benefit by sexual intercourse. The rare, true spongeitis or cavernitis is treated by rest and cold or heat, until resolution occurs or abscess requires incision. Balanoposthitis, Lymphangitis—These are treated in the usual way (pp. 609 and 611). Paraurethral Canals.—Inflamed paraurethral canals or pouches should be slit up as soon as they are recognized, unless the anterior ure- thra is acutely inflamed at the time. Acute Posterior Urethritis and Cystitis.—Under this title we con- sider the treatment of cases of posterior urethritis unaccompanied by palpable change in the prostate, and too severe to be controlled by routine treatment of the posterior urethra. In such cases all local treatment of the urethra must be abandoned. The patient is persuaded to rest as much as possible, in bed if the pain 200 LOCAL TREATMENT OF ACUTE GONORRHEA is very severe. Some sedative, such as the liquor potassae and tr. hyoscami mixture, is administered. The bromids are, next to opium, the best sedatives; they may be added to the above mixture. To alleviate pain I usually advise the constant application of a hot- water hag to the perineum, and a sitz bath of five minutes in water as hot as can be borne, to he taken tv,dee a day, or, if it gives great relief, before each micturition. Hot rectal douches should also be given each day and the prostate massaged with the utmost gentleness every other day to prevent or control, if possible, the progress of gross suppuration in it. Should this treatment fail to control the symptoms within a wTeek, prostatic abscess, acute vesiculitis or acute pyelonephritis may be sus- pected; or there is a stricture left by a previous infection, or tubercu- losis, or stone. Prostatic Abscess.—Outside of hospital practice one sees the non- gonorrheal prostatic abscess rather more frequently than the gonorrheal. In hospital cases, four out of five are gonorrheal. In Chapter XIV we have pointed out the impossibility of dis- tinguishing sharply between acute prostatitis and prostatic abscess. Any acutely swollen prostate may contain abscesses. The best rules of treatment are the following: 1. Prevent prostatic abscess by discretion and gentleness in local treatment. 2. 1 reat prostatic abscess for a week as an acute posterior urethritis unless there is (a) complete retention of urine, (b) continued high fever, (c) unbearable painful urination, (d) a distinctly soft or fluctuating point detected by rectal examination, or (e) a sense of great distention, pain and heat referred to the rectum and lasting several days. 3. Retention may be attacked by catheter for 24 hours. If it does not then yield, operation is required. 4. The other conditions enumerated above, unless relieved in a few days, call for operation. Seminal Vesiculitis and. Deferentitis.—The seminal vesicle very rarely requires treatment during acute urethral gonorrhea. Acute in- flammation in it is rare and is habitually but a minor accompaniment to a more important acute prostatitis. The treatment is the palliative treatment of acute prostatitis. When active suppuration occurs in or about the vesicle, this is asu- ally not discovered until adhesion with the bowel has taken place. In this event the abscess should be incised from the rectum. But if sup- puration tends to spread off into the ischiorectal fossa or threatens the peritoneum, vesiculotomy should be performed. Epididymitis—See p. 530. Pyelonephritis—See p. 317. CHAPTER XXII LOCAL TREATMENT OF CHRONIC URETHRITIS There is no occasion for the existence of chronic gonococcic urethritis. Proper treatment of acute gonorrhea will eradicate the gonococci within three months. And should the case be seen for the first time after it has existed for many months it may be localized, by the treatment described above,1 to one or more circumscribed spots; e.g., prostate or vesicles, where massage will bring it to the surface and cure it; infiltration that requires massage by sound or dilator; abscess or fistula, where surgical drainage and pyrozone or 10 per cent silver nitrate will do the business; lacuna or paraurethral duct, or posterior urethral granulomata, requiring urethroscopic treatment. But if the attack on the gonococcus is direct and definite, the attack on the lesions it may leave behind, the post-gonococcic urethritis, is not. Tn treating chronic urethritis the following fundamental considera- tions are to be borne constantly in mind: 1. Accurate Diagnosis—-This must begin with the individual, not with his urethra. If he has a grave systemic disease, advanced nephritis, diabetes, carcinoma, even anemia, his urethritis may be quite incurable; in any case it is unimportant. The most it requires is an astringent injection once or twice a day. If the patient is substantially sound the diagnosis of the urethral lesion should be made prudently, gently, with the greatest possible precision and yet with the utmost reserve. The lesions are commonly multiple. What appears to be the predominant lesion one day may be subordinate the next. The very diagnosis may stir up dormant foci of infection. If the treatment of a given lesion does not produce results, begin the diagnosis all over again, as described in Chapter XVII. 2. Economy of Treatment.—The less done for and to the urethra the better. After the departure of the gonococci only good sexual habits, good surgical drainage and the destruction of gra,nutations is required. Many cases will establish all this on a basis of good sexual habits, without even the assistance of an astringent injection. Indeed this consideration often overrules the requirement of thorough diagnosis, or rather the experienced urologist makes his diagnosis without running i Chronic gonococcic urethritis need not necessarily be attacked by the drugs mentioned in the last chapter. The infection is less vigorous and may be well handled by the astringent injections or irrigations. 201 202 LOCAL TREATMENT OF CHRONIC URETHRITIS the risk of damaging the urethra by too much poking. So many gonor- rheas will get well if only sufficiently let alone! 3. Sexual Hygiene.—What caused the gonorrhea is what keeps it going. Chronic post-gonococcic prostatitis is a lesion which the physi- cian may despair of curing, but he should instruct the patient how to control it. 4. Mechanical Treatment Is the Real Treatment If sexual hygiene and a little zinc sulphate or potassium permanganate do not cure the urethritis, it must be attacked by prostatic massage, dilatation, urethroscopy. Vague wandering from one wash to another will have the same influence that soap has on freckles, if they are real freckles. They may disappear during the course of treatment, but scarcely be- cause of it. 5. Rediagmosis.—If the treatment does not help the patient he must have an incurable lesion, a wrong diagnosis, or a wrong treatment. At least every three months he should have a new diagnosis, including urethroscopy. 6. Local Treatment, Even Diagnosis, May Do More Harm than Good.—When I was young it used to be after an instillation of silver nitrate that the patient’s history suddenly stopped in my case books. Now-a-days it is after urethroscopy. Yet many patients clamor for urethroscopic treatment, and a few for silver nitrate, but only if treated with discrimination and gentleness. INJECTIONS, IRRIGATIONS AND INSTILLATIONS Unless there is some indication to the contrary, the first local treat- ment to be employed upon any patient with chronic urethritis is urethral injection or irrigation. It is, perhaps, a matter of taste whether to be- gin, as a routine measure, by bidding the patient to use injections for the anterior urethra or to return to his physician for irrigations of the posterior urethra. Ho fixed rule can be given. If the discharge is profuse, it is usually, but not necessarily, wise to begin with injections. If it is slight, irrigations may usually be depended upon alone. The patient’s mental attitude, the frequency with which he is able to return for treatment, and the results of experimental treatment in each direc- tion, must be the guide in a given case. Injection—The astringent injections are the most generally useful. My preference is for the zinc acetate mixture (p. 181) employed twice a day and retained in the urethra only long enough to fill the canal. Iso effort should be made to prevent its reaching the deeper portions of the urethra, nor should it be forced into the posterior canal. Whatever injection is employed may do good at first and irritate later. Its use should, therefore, be intermitted every few week, The DILATATION 203 chief value of this injection is that it keeps the patient clean, by con- trolling the discharge until time and treatment shall cure the ure- thritis. Irrigation—Having completed the diagnosis in the manner de- scribed on p. 162, it is my custom to begin treatment by irrigating the bladder with permanganate of potassium (1: 4,000 every day or every other day), using at the same time sounds and massage as detailed below. Instillations—The object of instillations is to place a few drops of a relatively strong solution upon a definite lesion. I use them for the following purposes: 1. To follow instrumentation (if irrigation has not preceded this) by sounds or cystoscopes, for the purpose of minimizing the reaction of the torn mucosa, notably in the bulb and posterior urethra. 2. To destroy granulations in the posterior urethra when urethro- scopy is too painful. I used to employ silver nitrate much more frequently than I do at present. It is so excessively painful to certain patients. For antisepsis acriflavine or 1 per cent carbolic acid appear equally efficacious, but for destroying granulomata nothing equals silver. It must be as concen- trated as the patient can bear it, and to this end not more than one or two minims should be injected. Silver instillations should not be re- peated oftener than once or twice a week. DILATATION Dilatation, by massaging and causing the resorption of infiltrations of the mucosa, is the backbone of the treatment of chronic anterior urethritis. It may profitably replace urethroscopic treatment of the anterior urethra almost entirely. Heat1 and electricity (Newman, Le Fort) do not replace the sound. But the theory of dilatation must be understood. The prevalent notion that a sound should be chiefly employed for the purpose of tear- ing open the scar of stricture, for example, is wholly erroneous. It is no more possible to diminish the amount of scar in the urethra by tearing it open than it would be elsewhere in the body. The more a scar is torn the more scar is produced. The sound must merely massage. The beneficial effect of the passage of sounds or dilators is directly proportionate to the skill and gentleness with wrhich they are passed. Exceptionally the prostate is so readily inflamed by the least urethral interference that no urethral treatment of any sort may be employed. Such cases must, temporarily or permanently, do without sounds. The sound, thus gently passed, massages the infiltrated mucosa with a minimum of laceration to its surface, though it crushes exuberant i Porosz, Am. Jour, of Urol., Jan., 1911. 204 LOCAL TREATMENT OF CHRONIC URETHRITIS granulations. Hence, a mild hyperemia, a straightening out of the urethral canal, a squeezing out perhaps of some of the inflamed glands. This, if accomplished gently, is beneficial; if roughly, it is harmful. The immediate result of this hyperemia is at least an acute congestion of the mucosa. This must pass before a sound is introduced again. The ideal interval between sounds is 5 to 7 days. Dilators.—The sound suffices to dilate the anterior urethra (except the bulb) and the membranous urethra. The ideal size ultimately arrived at is 28F to 30F (unless there is true stricture of the penoscrotal urethra). Sounds are preferable to dilators since they may be manipu- lated more gently. But chronic urethritis of the bulb or of the posterior urethra may require greater dilatation, even up to 45F. (In doing perineal section, we note that the index finger may be introduced snugly into the normal bulb, loosely into the prostatic urethra, but tears the membranous urethra and can not be passed through the scrotal urethra at all.) For this the Kollman dilator must be employed. But the extra power that the dilator bestows must not be abused. It should excite no bleeding if that is possible, in any case no more than a drop of blood. MEATOTOMY Meatotomy is often required and should be undertaken without com- punction to the point of admitting a 30F sound. Many a urethritis fails to get well solely for lack of meatotomy. The normal urethra is a hose and a good hose has a small nozzle. But the inflamed urethra is a drain and a good drain has a wide orifice. MASSAGE Massage of the prostate and seminal vesicles has been the fashion since advocated by Fuller almost 30 years ago. Yet most massage does not the least good. Its nse must he based upon the following considera- tions, which apply to the vesicles as well as the prostate, though it is convenient to speak only of the latter. The prostate and vesicles are sexual organs and produce the hulk of the seminal fluid. While acutely inflamed their function must he held in abeyance, for an emission is a deleterious trauma. But as soon as the inflammation becomes chronic, resumption of their normal func- tion is the basis of cure. Social considerations commonly interfere with carrying this precept out in practice. So long as gonococci linger and unless the patient is married, cohabitation may not be advocated. But that should not blind us to the fact that sexual starvation or gluttony are as bad for the chronically inflamed sexual organs as constipation and gluttony are for the chronically inflamed digestive organs. MASSAGE 205 Now one of the things that massage does is to till this breach between sex hygiene and social hygiene. But it does this inefficiently. A con- stipated movement of the bowels will often squeeze out more semen from a boggy prostate than any finger can. A seminal emission is never so small as the few drops extruded by massage. Yet, for the period between the subsidence of acute gonorrhea and the return to cohabita- tion, massage is the best alleviation we have to offer for the treatment of chronic prostatitis and vesiculitis. As soon as the acute symptoms subside massage may be profitably begun. At this time the prostate is usually still tense and perhaps obscured by an enveloping inflammatory edema. Within a few weeks, however, unless irritated by unusual sexual stress, the tense prostate becomes normal to rectal touch or boggy, the edema is absorbed or changes into scattered areas of induration which commonly lie along the borders of the prostate and at the apices of the seminal vesicles. The gonococci usually disappear within a month or two. For purposes of treatment, bogginess should be considered as exist- ing within the prostate and vesicles, indurations as periprostatic, peri- vesicular. If really chronic, of more than three months’ duration, massage has little influence over either condition. Massage such a patient for a couple of years and he will usually end about as he started. But sexual hygiene will relieve the bogginess if anything will. This and the lapse of time will reduce induration to a minimum. The more chronic the lesion the less it will be benefited by massage. What then can be done for chronic lesions that do not get well under sexual hygiene? In the first place, investigate the sexual problem a bit further. As a very simple example let me cite the case of a handsome big youngster who came to my office with a boggy indurated prostate, pus, perineal pain. He stated that prostatic massage helped a lot. I found it did, for without it he complained of much pain. He confessed to cohabitation once a week. I massaged vainly for about a month before I waked up.—“How many times do you cohabit every Sunday ?” “Oh, about three times.” Chronic prostatitis is often not curable. The effort to free the prostatic secretion from all pus is vain. Sexual hygiene accomplishes more than massage and habitually reduces the pus to such an extent that it no longer is found in clumps under the microscope. No more need be required. Yet it is not to be forgotten that the cardinal symptoms attributed to chronic inflammation of these internal sexual organs (urethral dis- i The use of electricity (Newman), hot solutions or hot sounds (Porosz, Am. Jour, of Vrol., Jan., 1911), to excite hyperemia and replace dilatation, has not met with any general success. 206 LOCAL TREATMENT OF CHRONIC URETHRITIS charge, pyuria, pain) are, if not due to sexual irregularities, actually caused by lesions on the surface of the posterior urethra, such as granulations, verumontanitis, sinusitis, sclerosis of the bladder neck. The prostatic secretion may be full of pus and yet the urine free from it—and vice versa. In short, massage' hastens the subsidence of subacute prostatitis and vesiculitis, expels gonococci and is the best available substitute for sex relations. The treatment of posterior urethral surface lesions plus sexual hygiene is the treatment of chronic prostatitis and vesiculitis, with massage to control exacerbations. The symptoms, pyuria and pain, are due chiefly to urethral lesions and sexual strain. A little residual pus in the prostate is unimportant. The chronically boggy prostate needs a sexual diet. Periprostatic indurations take care of themselves. Surgical drainage of prostate and vesicles is very rarely indicated. Technic of Dilatation.—If examination with the bulbous bougie reveals an induration in the anterior urethra, which is not promptly ameliorated or cured by irrigations, it should be dilated. If the patient’s meatus is sufficiently large, the dilatation should he begun with sounds, and these should he carried to the limit of the meatus. The urethra should be dilated not more than three numbers at a given occa- sion, and the usual precautions as to hexamethylenamin and local anti- sepsis should be employed. When the first sound is passed, the urethra should be palpated upon it to discover any perceptible infiltrations or minute glandular indura- tions, and if these are found they should be gently massaged each time the sound is introduced thereafter until they disappear, or until it becomes evident that they are permanent scars. Sounding should be repeated twice a week, and when the limit of the meatus is reached, dilatation with the Kollmann dilator should be begun. In using the dilator it is often possible to advance much more rapidly than with the sound. The instrument is screwed up gently, one waits a moment, and then gently turns the wheel a trifle more. By thus turning intermittently, one gains two or three numbers with little pain to the patient and without exciting much bleeding. I see no advantage in leaving sounds or dilators in the urethra for more than a few moments after the desired dilatation has been achieved. It is a general rule that bleeding is a sign of too severe dilatation. Yet, if the surface of the urethra is much inflamed, the very introduc- tion of the instrument may cause bleeding. Contea-indications to Dilatation.—While gonococci persist in the urethra, dilatation is dangerous. It may do good; but only if most gentle (p. 196). While the urine contains free pus, even though that pus show no gonococci, dilatation is still somewhat dangerous, and should be undertaken only after every effort to clear the urine of free DILATATION AND MASSAGE 207 pus lias failed; but when only a very light, purulent cloud remains, and the urine shows many shreds, dilatation is likely to be most serviceable and almost free from danger. Yet it is always possible that the dilata- tion may excite acute prostatis or epididymitis. These may be avoided, to be sure, by restricting the dilatation to the anterior urethra. Yet the dilatation, to be efficient, must include the posterior urethra, since the bulb and the membranous portion are likely to be the regions most in need of stretching. The sensitiveness to dilatation may be overcome by the use of local anesthesia. Technic of Massage—One often speaks of massaging the prostate; but it is prudent, in view of the fact that the vesicles may be inflamed even when they feel normal, always to massage the vesicles first and then the prostate, no matter which organ feels the most diseased, though paying most attention to obviously diseased regions. The question whether these organs should be massaged severely or gently cannot be decided academically. A physician who rubs so hard as to make many of his patients faint loses many a case before it can be cured; and, on the other hand, the physician who massages too gently fails to cure certain cases that require severe rubbing. The intelligent practitioner will rub gently at first and increase the severity of the manipulation up to the point of the patient’s endurance, and with an eye to the results obtained. Severe massage may do physical harm by exciting acute prostatitis, vesiculitis, and epididymitis. Mild mas- sage very rarely does this. Yo two physicians massage with precisely the same method or with precisely the same severity, as patients are quick to note. A simple method is to begin upon one vesicle, and, reaching up as far toward its fundus as possible, to press upon it and then withdraw the finger in a zigzag way until one reaches the prostate. This maneu- ver is repeated half a dozen times and then the same treatment given to the opposite vesicle. If the vesicles are impalpable, this is enough. If distended or indurated, the maneuver should be repeated often enough to make a distinct reduction in their size, if the patient can bear so much manipulation. The finger is then brought down to the prostate. Hard, angular in- durations in and about this organ had best be avoided, and pressure made chiefly upon the more yielding portions of the gland. Beginning with one lobe, pressure is made upon it either with a to-and-fro lateral sweep of the finger or with a circular motion. This manipulation, if gentle, may be continued for one minute; if severe, half a dozen strokes may suffice. The same treatment is given the opposite lohe of the gland, and the manipulation concluded by a half dozen strokes over the pros- tatic sinus for the purpose of emptying the main ducts into the urethra. 208 LOCAL TREATMENT OF CHRONIC URETHRITIS The general tendency of all such massage should be to express the secretions in the direction of the apex of the prostate. Meanwhile, watch is kept for the expulsion of secretion from the meatus. This is caught upon a slide for examination. Massage should usually be repeated not oftener than two or three times a week. If severe, longer intervals are better. In exceptional cases, when the return from massage is very great, gentle rubbing may be employed once a day. THE RECTAL DOUCHE The rectal douche is essentially a treatment for acute inflammation. It may help alleviate the pains of chronic prostatitis or vesiculitis. OPERATIVE TREATMENT In the absence of complications specifically requiring operation, such as abscess or intractable stricture or sclerosis of the bladder neck, it is, generally speaking, unwise to operate upon cases of chronic pos- terior urethritis. Drainage of prostate and vesicles is, however, the only relief for grave intractable suppuration in these organs. Operations for the Relief of Vesiculitis.—The operative relief of in- fections of the seminal vesicles has been attempted in two ways: by drainage through the vas deferens, and by direct operative attack upon the vesicle itself. BelfieiWs Operation.—Belfield picks up the vas in the scrotum, incises it after local infiltration of the skin with cocain, injects the prox- imal end of the duct with 10 per cent argyrol or 4 per cent collargol, and fixes fhe duct in the wound so that any reflex of the fluid injected will issue from the wound itself and not flow info the subcutaneous tissue, there to cause an irritative phlegmon. He hopes thus to obtain both antisepsis and drainage of the vesicle. Edema around the little wound interferes with subsequent injections. Excellent results have been reported from this operation, and it is believed that if the vas is not completely divided or if it is brought together again by a single catgut suture so that the two ends are opposed to each other, occlusion of the vas does not occur. Caulk states that the vas is occluded in about half the cases operated upon. Thomas has suggested that the injection be made through a needle puncture of the exposed vas. This readily finds the lumen and supplies antisepsis without drainage. Whatever form of operation is employed, care must be taken not to infiltrate the tissues about the vas. The operation is simple enough. In my hands it has been quite without effect excepting in a few cases of recurrent epididymitis. I am TREATMENT OF URETHRAL NEUROSES 209 inclined to suspect that the benefit in these cases has been due to occlu- sion of the vas at the point of operation. Vesiculotomy and Vesiculectomy.—The direct attack upon the vesicles is more successful than Belfield’s operation. I favor vesi- culotomy over vesiculectomy as less likely to cause sterility and im- potence. URETHROSCOPIC TREATMENT Urethroscopic treatment, as previously described, is required for the cure of those cases of chronic urethritis that fail to heal under dilatation and massage. It is therefore only employed after the more active symp- toms have disappeared, chiefly for the cure of a mild morning drop and when the urine shows little or no free pus but only shreds. It often heals the last surface lesion and occasions the disappearance of the last shred—and it may fail. A few persistent shreds in the urine unaccom- panied by any appreciable urethral lesion must perforce be disregarded. TREATMENT OF URETHRAL NEUROSES The neuroses due to chronic prostatitis and seminal vesiculitis may or may not be postgonorrheal, as has already been suggested. Yet they are often attributed to gonorrhea by the patient, and are, therefore, mentioned here. They may be divided into three groups: Sexual neuroses. Painful neuroses. Sexual neurasthenia. To these may he added, for the sake of convenience: Prostatorrhea. Spermatorrhea. In order properly to treat these various conditions, an accurate diag- nosis is necessary as to the presence of complications. If gonococci are present, one must first get rid of these by appro- priate measures. If the prostate and vesicles are markedly inflamed, these must be massaged until the amount of pus expressed is reduced to a minimum. If there is stricture, this must be dilated; if there is residual urine, the bladder neck must be divided. Hyperesthesia of the uretha may be dulled by sounds, that of prostate and vesicles by the rectal douche or by cauterization of the verumontanum. But sevuul strain is the usual cause of chronic prostatic and vesicular pains, sex hygiene the essential treatment. So many of these difficulties 210 LOCAL TREATMENT OF CHRONIC URETHRITIS depend entirely upon sexual irregularities and derangements that the patient’s sexual habits, both previous and present, should be intimately investigated, and every effort made to lead him to as clean, as whole- some, and as normal a sexual condition as it is possible for him to attain. Although matrimony cannot be prescribed like a pill, and although these patients are often sorry subjects to place on any woman’s hands, truly happy married life is often the only real remedy for the patient’s condition, and, unfortunately, almost as often it is a remedy beyond the patient’s reach. CHAPTER XXIII SPASMODIC AND CONGENITAL STRICTURE A loss of dilatability of any portion of the urethra constitutes stricture. This loss must he unnatural, for the urethra has certain points of normal contraction—namely, the meatus, the middle of the pendulous, and the beginning of the membranous urethra, and these are not strictures. They become so, however, if unduly small. True stricture is of two kinds: (1) Muscular or spasmodic; (2) permanent or organic—the latter congenital or acquired. Any inflam- mation lessens the caliber of the canal in proportion to the turgescence of the mucous membrane; but no amount of inflammation constricts the canal enough to occasion serious symptoms, unless occurring in connection with abscess or stricture. Obstruction of the urethra by stone, slough, or foreign body does not constitute stricture. MUSCULAR OR SPASMODIC STRICTURE Spasmodic stricture is an involuntary contraction of the compressor urethrae muscle of sufficient force to impede or to prevent, temporarily or permanently, the passage of urine from the bladder. I have en- countered no case of spasm of the pendulous urethra, though De Bovis 1 records two cases. Spasmodic stricture is a symptom, not a disease. It always depends upon some separate and distinct condition. It varies with the varia- tions of this etiological factor and disappears with its cure. A common predisposing cause is a sensitive, high-strung nervous organization, particularly in one who is sexually .excessive. Such a one is unable to urinate in the presence of his fellows, and the more anxious he is to pass his water, and the more water there is to pass, the more difficult does he find it to satisfy his desire. Certain mental sug- gestions contribute to increase or to diminish the spasm. The sound of running water often breaks the spell, while derision or absolute silence has the opposite effect. I have known a commercial traveler who, dur- ing twenty years of life spent mostly on the road, could not urinate in 1 Gas. des hop., 1897, LXX, 583. 211 SPASMODIC AND CONGENITAL STRICTURE 212 a railroad car except by means of a catheter. Yet such a man may well go through life with no great inconvenience from his urethral idiosyn- crasy, his urethrismus, as Otis termed it. But let him acquire an organic stricture or a vesical calculus, let him be operated upon for hemorrhoids, or suffer any local or constitutional strain or shock, and his urination immediately becomes difficult or impossible to accomplish for a greater or less space of time. I have known an operation for hemorrhoids to occasion complete retention lasting ten days, long after the patient was up and about. Such a spasm, if unrelieved by catheteri- zation, may even cause rupture of the bladder. Thus there is this much in the theory of Otis that an abnormally small meatus may cause ure- tlirismus, that if the meatus is small enough to irritate the urethra by impeding urination, it may excite a spasmodic stricture, though I have never known it to do so. Symptoms and Diagnosis.—The cardinal symptom of spasmodic stricture is inability to urinate. Hence, it is sometimes confounded with organic stricture. Indeed, not a few patients with stricture deemed impassable, when put upon the operating table, have been found to admit a full-sized sound, being cases of spasm with little or no organic stricture. The following differentiating points are therefore mem- orable : 1. Spasmodic stricture occurs only in the membranous urethra. 2. Unless there is some organic lesion of the urinary tract the urine is bright and sparkling and free from shreds, which it very rarely is if there is organic stricture sufficiently marked to seriously arrest urination. 3. Although it may be impossible to introduce a filiform bougie or a small sound, a full-sized sound, if allowed to rest for a few moments against the face of the stricture, will usually tire the muscle, and finally slip into the bladder. If it slips in by its own weight its course will often be jerky and irregular, as the muscle gives way by succeeding spasms of lessening intensity. 4. When the instrument is once introduced the obstacle is wiped out, and the withdrawal of the instrument is not opposed by any such grasp- ing as is felt when there is tight organic stricture.1 5. Even though a spasmodic stricture be absolutely impassable, gen- eral anesthesia will entirely relax it. 6. Organic and spasmodic stricture often co-exist.2 Indeed, organic stricture is the most common cause of spasm, and spasm may be the notable symptom of an organic stricture of large caliber. 1 But if the instrument passed is a small one (less than 20 F.) it does not over- stretch the muscle and may therefore be grasped on withdrawal. 2 Indeed, continued spasm may doubtless cause ulceration, just as spasm of the bowel causes fissure in aho. (Cf. Keyes, Am. Jour, of Urology, 1905, i. 218.) CONGENITAL STRICTURE 213 Treatment.—The retention may be relieved by a hot sitz bath or by catheterization. The tendency to spasm is overcome by removing the cause and im- proving the general hygiene, special attention being paid to sexual irregularities, concentrated urine, and organic stricture. To prevent recurrence of the spasm I know nothing better than the passage of a full-sized steel sound to overstretch the muscle, and silver nitrate instillations to blunt the sensibility of the deep urethra. CONGENITAL STRICTURE Congenital strictures, or even total occlusions of the urethra, usually occur at three places, though they may occur anywhere in the canal: 1. At the meatus. 2. At the outer limit of the fossa navicularis (internal meatus) and 3. At the membranous urethra. The stricture takes the form of a valve or a stenosis. Englisch rec- ognizes two types, those that are present during fetal life, but disap- pear later; and those that persist. Such strictures at any point deeper than the internal meatus are rare and usually cause death by retention, in utero or in infancy. Bazy 1 has however operated upon several cases and I have cut two. On the other hand, congenital stricture at the meatus, or at the outer end of the fossa navicularis (aptly termed the second meatus), is very common. Indeed, the size of the meatus is no more fixed than the size of the mouth or the nose, though, in gen- eral, a small penis is more likely to have a con- tracted meatus than is a large one. How much contraction constitutes stricture of the meatus ? Strictly speaking, a meatus is stric tured if a probe, introduced into the fossa navicu- laris and rotated so as to sweep the point outward along the floor of the urethra, encounters a thin membrane which it must surmount in coming out through the meatus. This obstruction always occurs on the floor of the canal, and is never anything more than a fold of mucous membrane that may be pushed out by the probe (Fig. 46). The second meatus is strictured if it is not so large as the normal true meatus. Strictly speaking, the above rule holds good. Practically, how- ever, stricture of the meatus—to which so many reflex ills were once attributed—rarely produces any symptoms. If actually so small as to Fig. 46- — Congenital Stricture of the Meatus. A probe is inserted into the pock- et behind the stric- ture. 1 Cf. Neumann, Zeitschr. f. Urol., 1910, iv, No. 11. 214 SPASMODIC AND CONGENITAL STRICTURE interfere with urination it may, perhaps, like a tight prepuce, cause hernia or even epilepsy in a child, and spasmodic stricture in later life, and the urethra may become considerably dilated behind it. But such cases are exceptional. Most men can go through life in blissful ignorance of the size of their meati unless they acquire a urethritis, in which event the stricture should be cut lest the little pocket behind it perpetuate the inflammation. Treatment.—The only way to cure a stricture of the meatus is to cut it. As above remarked, this is, as a rule, quite unnecessary, except for the surgeon’s purposes. The operation of meatotomy has occasioned the invention of various more or less ingenious meatotomes, of which the best is a blunt-pointed straight bistoury. This is the only instrument required, and the opera- tion may be very neatly performed as follows: After cleansing the parts with soap, bichlorid, and alcohol, a cocain tablet is inserted within the meatus and pressed into the little pocket below it. This is dis- solved by dropping upon it twTo drops of 1: 1,000 adrenalin solution. In a few moments the tip of the meatus is seen to blanch. The bistoury is then inserted and the membrane deliberately divided upon a finger placed beneath the frenum, which appreciates the fibrous ring about the meatus and at the second meatus, and by feeling the blade of the bistoury beneath the skin recognizes when they have been effectually divided. The passage of a bulbous bougie proves that the obstructions have been sufficiently cut. If this technic is observed there will be no pain and little bleeding. The meatus is flushed clean and packed with cotton. The cotton is removed at the first act of urination, and the wound is kept open by inserting the curve of a clean hairpin into the urethra once a day. The hemorrhage may be profuse if no hemostatic applications are made, but there are no other complications, and lateral pressure will always check the flow of blood. Some surgeons prefer to suture the little wound in order to hasten healing and to prevent adhesion. CHAPTER XXIV ORGANIC STRICTURE OF THE URETHRA—ETIOLOGY, PATHOLOGY, SYMPTOMS, RESULTS, DIAGNOSIS Although two conditions commonly known as stricture have been described in the preceding chapter, the one, spasmodic stricture, is a mere symptom, and the other, congenital stricture, a condition which, except in extreme cases, is absolutely innocuous. Organic stricture, the stricture that is never innocuous and always active in its work of under- mining its possessor’s health, except when kept at bay by the surgeon’s efforts, has yet to be considered. True organic stricture of the urethra is a cicatrix of the urethral wall left there by some injury or inflammation, and manifesting a con- stant tendency to contract, and thus to diminish the lumen of the ure- thra. This tendency to contraction, which is always manifested in a greater or less degree, is doubtless caused by the irritation incident to micturition, the impact of the stream against the barrier; for the deep- est stricture, the one that most obstructs the flow of urine, is almost always the tightest, and if the stricture is kept dilated so as to afford little or no obstruction, the tendency to recontraction is slight. Stricture occurs in the female as well as in the male urethra. But this lesion in the female is much less common than in the male, and manifests no distinguishing peculiarities, either in pathology, symp- toms, diagnosis or treatment. Oberlaender very properly refused to recognize any pathological distinction between chronic anterior urethritis and stricture. The patho- logical difference is only one of degree; but the clinical distinction is clear. Infiltrations larger than 26 F. are readily cured by dilatation and show but a very slight tendency either to relapse or to contract. But infiltrations tighter than 26 F. show a marked tendency to con- tract progressively and require the treatment described in the ensuing pages to cure or even to control them. VARIETIES Strictures may be classified from several points of view: thus, for prognostic purposes, strictures are considered as anterior (at or in front 215 216 ORGANIC STRICTURE OF THE URETHRA of the penoscrotal angle) and posterior (behind this point) ; therapeuti- cally considered, strictures are of large caliber (admitting a 20 F. bul- bous bougie) or of small caliber; while from a pathological and etiolog- ical point of view strictures are classified as gonorrheal and traumatic. The old descriptive division into linear, annular, and tortuous or irregu- lar stricture is clinically convenient to describe the nature of the ob- struction to the exploring instrument, and the terms soft, fibrous, and modular (or indurated) are descriptive of important features. ETIOLOGY All true strictures are either inflammatory or traumatic, and almost all inflammatory strictures are gonorrheal. By far the greater number of strictures are gonorrheal. Thus out of 220 cases studied by Thompson, 164 (75 per cent) owed their origin to gonorrhea; while Martin found among 219 cases 187 gonorrheal strictures (85 per cent). My office case books record 583 gonorrheal to 43 traumatic strictures. The causes of gonorrheal stricture are, however, many. The inflam- mation itself usually causes the stricture; but it is difficult to estimate what proportion of strictures is due to breaking a chordee, to a false motion in coitus causing a tear in the inflamed mucous membrane, to the ill-advised use of caustic injections for the purpose of aborting the attack, or to the injudicious use of instruments in the urethra before the attack has subsided. Such strictures are properly traumatic, since trauma' of the same kind, but greater in degree, may cause stricture when the mucous membrane is not inflamed and the gonorrhea thus only plays the role of a predisposing cause. There is a small class of intermediate cases in which the stricture is neither absolutely inflammatory nor traumatic. To this class belong strictures caused by urethral chancres 1 and ulcerations, or loss of sub- stance from periurethritis, etc. The causes of traumatic stricture vary widely. The penile portion of the urethra may be divided by knife or bullet, or torn by bending the erect penis, by a false motion in coitus, or by breaking a chordee. The bulb is the portion usually affected by trauma from within, by ulceration from stone, foreign body, or retained catheter, or by the sharp point of a blundering instrument. The prostatic urethra is said to become stric- tured when torn by disruption of the pelvis. But of all traumatic strictures, recognizable as such, stricture of the membranous urethra is the most frequent. The stricture is caused by 1.Ten cases of diffuse urethral syphiloma have been reported. Guyon’s Annales, 1898, xvi, 892. ETIOLOGY 217 a crushing force applied to the perineum, which brings the urethra sharply into contact with the subpubic ligament, crushing it beneath the sharp edge of this structure or tearing away from it in front. The injuries which have caused traumatic stricture in the perineum, with or without a penetrating wound, are innumerable. They may be summarized in the term “straddle injuries.” They may be overlooked by the patient if they do not give rise to immediate hemorrhage or retention. Yet in after years symptoms of stricture come on, and the canal is found tightly contracted at its membranous portion. Pathogenesis.—The most notable modern theories upon the forma- tion of stricture are the theory of Finger and the Guy on school, and the theory of Guiard. The Finger-Guy on theory 1 makes stricture the result of chronic urethritis. According to these authors, chronic urethritis is essentially a sclerotic process, characterized by deposits of cicatricial tissue in the submucosa and even in the corpus spongiosum. This fact is illustrated by numerous pathological findings that would prove its truth were it not contradicted by the notorious clinical facts. For although, as we have seen, acute urethritis is an exudative proc- ess that does tend to pass into a chronic sclerotic stage, the essential cause of the exudation is the acuteness of the attack and the extent of exuda- tion, and subsequent cicatrization is proportional rather to the acuteness of the attack than to its duration. Hence, although stricture is always accompanied by chronic anterior urethritis, chronic anterior urethritis may exist for years without inducing stricture. We therefore accept Guiard’s theory,2 that stricture depends upon the virulence of the urethral inflammation. The more severe the initial attack, the more intense the chordee, the more frequent and violent the relapses, and the longer the gonococcus can be found in the discharge, the greater is the probability of stricture. He believes that in a mild chronic stage the urethral inflammation is neither deepseated nor pro- ductive of any permanent lesion; while the acute inflammation, with its involvement of the lacunae and glands, its circumscribed or diffused areas of periurethritis, is the inflammation calculated to leave behind permanent scars in and beneath the mucous membrane. In the etiology of traumatic stricture urinary infiltration must play some part. It is true, severe contusion and laceration of the urethral wall are ample causes for stricture; but it is incredible that the muscular disturbance of urination and the distention of the wound with a fluid containing urinary salts and urethral bacteria should cause no increase 1 ringer, Internat. Min. Rundschau, February 12, 1893. Wassermann and Halle, Guyon’s Annales, 1891, ix, 143 et passim. Wassermann and Halle, Ibid., 1894, xii; 244, 321. 2“Les urethrites chroniques chez l’homme.” Paris, 1898, p. 90 et seq. 218 ORGANIC STRICTURE OF THE URETHRA in the inflammatory reaction. The admirable results obtained by simple perineal section and diversion of the stream of urine from the wound confirm this belief. In this connection the time of occurrence of stricture after gonorrhea and injury is of interest. Of the 164 cases of stricture following gon- orrhea, tabulated by Thompson, in 10 symptoms appeared immediately after or during the attack; 71 within one year; 41 between three and four years; 22 between seven and eight years; 20 between eight and twenty-five years. Hill1 makes the length of the period between the cause and the first symptoms of stricture noticed: after gonorrhea, short- est period two years, longest thirteen years; after urethral chancre, shortest period ten months, longest three years; after injury, shortest period four months, longest eighteen months. I found among 212 cases of gonorrheal stricture 121 cases within the first year, 65 distributed between the second and tenth years, and 26 after the tenth year. On the other hand, I have seen an impassable stricture in the perineum six weeks after a severe injury, and Guyon 2 has met a stricture which only admitted a 16 F. sound two weeks after injury, and another which would not admit a 12 F. after six weeks. The deductions from the above statistics, confirmed by daily observa- tion, are that the symptoms of stricture appear earlier after traumatism than after gonorrhea (the date of their appearance being measurably proportionate to the extent of the injury) and that the greatest di- vergence is noticeable after gonorrhea. It is totally exceptional, how- ever, for symptoms of organic stricture to come on immediately after or during the attack of gonorrhea—as Thompson states occurred in ten of his cases—unless stricture existed previous to the attack, unnoticed by the patient. PATHOLOGY Number of Strictures.—While Thompson,3 in examining 270 patho- logical specimens, found only 4-4 cases of multiple stricture, Guyon 4 lays down the clinical rule that gonorrheal strictures are multiple, while traumatic strictures are single. These statements, properly interpreted, conform perfectly with each other and with the facts. Concerning trau- matic strictures, there is no doubt; they are almost always single. But gonorrheal strictures, while frequently single from the pathologist’s point of view, often present a number of ridges to the examining sound. 1“An Analysis of One Hundred and Forty Cases of Stricture of the Urethra.” London, 1871. 2 ‘ ‘ Leqons cliniques, ’ ’ 1894, vol. i, p. 239. 8‘‘Stricture of the Urethra.” Second edition, 1858, p. 76. 4 Op. cit., I, 139. PATHOLOGY 219 Clinically, therefore, gonorrheal strictures are often multiple, patho- logically they are usually single. Seat of Stricture.—Thompson divides the urethra into three regions: 1. The bulbomembranous, including 1 inch in front of and % inch behind the junction of the spongy with the membranous urethra. 2. From the anterior limit of region 1 to within inches of the meatus, embracing from 2 J to 3 inches of the spongy urethra. 3. The first 2-J inches of the canal from the meatus. Ills 270 preparations showed 320 strictures: 67 per cent in region 1; 16 per cent in region 2; 17 per cent in region 3. Otis placed a majority of all strictures within the first inches from the meatus—the next most common posi- tion being somewhere in the middle portion of the pendulous urethra. He believed deep urethral stricture to be far less common; hut these views depended upon his theory that the urethra is a tube evenly calibrated throughout. Therefore the points of physiological narrow- ing or of non-contracting infiltration left by urethritis (p. 129) he denominated stricture. It is convenient to associate the region in which the stricture occurs with' its cause. Thus, strictures at or near the meatus, if not congenital, are usually caused by chancrous or chancroidal ulceration, less frequently by caus- tic injections and by gonorrhea. Strictures of the pendulous urethra are commonly gonor- rheal. Strictures of the bulb and at the bulbomembranous urethra are also commonly gonorrheal. Strictures of the membranous urethra are rarely gonorrheal, almost always traumatic. Stricture in the prostatic urethra may be gonorrheal or traumatic. Form of Stricture.—In the first place, the stricture is usually chiefly built up from the floor of the canal. This is most notable in the bulb, and commonly results in an eccentric position of the orifice of the stricture, close to the upper wall of the canal. The cause is not far to seek. It is in the loose floor of the canal, especially in the pocket of the bulb, that the gonococci commit their greatest ravages. It is the floor of the canal that is most often torn or crushed. It is the floor of the canal that is damaged by overdistention, when urination is obstructed. In the second place, it is a matter of clinical experience that in the broad, irregular strictures that are clinically multiple, the constrictions become progressively narrower as they approach the bladder. Begin- ning, perhaps, at the penoscrotal angle, there is a constriction which admits a 20 F. sound. A short distance farther on this, too, is ob- Fig. 47 —Stricture of An- terior Urethra. (Voil- lemier.) 220 ORGANIC STRICTURE OF THE URETHRA structed, and only a 15 F. will pass, and finally the stricture in the bulb admits only a filiform instrument. In other words, the deeper extremity of the stricture, which receives the strongest impact of urine, is more irritated than the rest and contracts more rapidly. Gross Pathological Changes (Figs. 47, 48, 49).—When the strictured urethra is slit longitudinally, the mucous mem- brane may be found only slightly thick- ened and congested. Or it may be cicatri- cial in character or covered with granu- lations. A band or a mass of cicatrix may replace the mucous membrane through- out its thickness, and may even penetrate the corpus spongio- sum. This tissue may be slight in ex- tent, cicatricial in character, tightly contracted; or it may be exuberant, knobbed, and exces- sive in amount, so as to be readily felt from the outside of the canal. In this callous, fibrous mass there may be irregular areas of inflammation and suppuration. Behind the stricture the canal is distended and more or less extensively ulcerated, and immediately in front of the stricture there may be lesser dilatations and ulcerations. If the retention has been prolonged and grave the upper urinary organs show the results of retention and infection illustrated in Fig. 49 and described on page 290. Microscopic Changes.—These have been described (p. 128). Fig- 48.—Strictube of Membranous Urethra. (Voille- mier.) A, bladder; B, bladder neck (ecchymotic); C, di- lated prostatic urethra; D, verumontanum; E, one of the prostatic ducts; F, G, K, the stricture; F, dilatations in front of the tightest part of the stricture; H, orifice of small abscess cavity; K, mucous membrane in front of the stric- ture, thin and ulcerated; L, corpus spongiosum; M, an- terior urethra. Fig. 49.—Results of Stricture. A, A', Kid~ neys dilated, sclerosed, pyonephrotic; B, B', ureters irregularly dilated; C, bladder con- tracted and thickened (concentric hyper- trophy); D, dilated ureteral orifice; E, pros- tatic urethra dilated (prostatic abscess) ; F-H, the stricture; F, its tightest point; G, corpora cavernosa involved in the scar. 221 222 ORGANIC STRICTURE OF THE URETHRA SUBJECTIVE SYMPTOMS Organic stricture may exist for years, producing no symptoms and unsuspected. On the other hand, the usual symptoms of stricture, gleet, the irregular stream of urine, and the final dribble, are of daily occurrence among men who have not, and never had, stricture. The Onset.—Symptoms occur within one year in over half the cases, though one-quarter of them show no symptoms until after five years have elapsed, and the onset may be deferred for 15 years or even longer. But only one-third of my (private) cases submitted to treat- ment within a year of the beginning of their symptoms; another third within five years; and one-seventli delayed treatment until their symp- toms had existed for 10 or more years.1 Gleet.—The initial symptom is usually the presence of shreds (Trip- perfciden) and more or less free pus in the urine. If the stricture follows immediately after a gonorrhea the urethral discharge is per- petuated; but more often there is a lull while the shreds, and perhaps the general cloudiness of urine, persist, but, in the absence of a notable gleet, do not attract the patient’s attention. The shreds and pus are evidence of the local inflammation on the stricture, which is adding fuel to the flame, and encouraging extension and contraction of the fibrous tissue beneath. As the stricture contracts the urethritis grows worse and, sooner or later, produces a moderate chronic discharge, perhaps only visible in the morning when the urethra has not been scoured by the urinary stream for eight hours, perhaps persisting throughout the day. This is gleet. It is usually the first symptom noted by the patient. The gleet of stricture gets better or worse according to the general condition of the patient, the degree of acidity of the urine, and the amount of sexual indulgence or of venereal excitement. Exacerbations of gleet from slight causes, or repeated attacks of gonorrhea, as the patient usually considers them, often constitute the most marked feature of the case. In fact, it is the rule in mild cases for the patient to be wholly unconscious that his urethra is at all narrowed. Gleet was the initial symptom of 238 of my cases. Changes in the Stream.—As the stricture tightens, fresh symptoms are added. The gleet continues, the stream of urine is small and irregu- lar.2 The last few drops of urine are retained in the canal, both me- 1 Trans. Am. Assn. G.-TJ. Surg., 1915, x, 11. 2 It is to be noted that while an impediment anywhere in a water-pipe (such as the urethra) modifies the force of the stream, the shape of the stream depends chiefly upon the shape of the nozzle (the meatus). Thus the shape of the stream, upon which so much stress is commonly laid, has no bearing on the diagnosis of stricture. It is modified by the meatus itself more often than by any other cause. RESULTS OF STRICTURE 223 chanically by the obstruction of the stricture, and because the wave of blood, impelled by the contraction of the accelerator urinae upon the bulb in the final effort at clearing the canal, cannot pass along the corpus spongiosum, on account of the obliteration of its meshes at the point of stricture, and thus fails in its function of expelling the last few drops of urine from the canal. By this same obliteration of spongy tissue, erection is sometimes rendered imperfect and painful. Ob- structed urination was the first symptom in 77 of my cases. Frequent Micturition.—Next to gleety discharge frequency of mic- turition is the commonest symptom of stricture. It is due to one or all of the following factors, viz.: congestion from straining to overcome the urethral resistance, cystitis, polyuria due to renal congestion. With the frequency there is more or less pain. This was the initial symptom in 61 of my cases. Retention—The congestion of the stricture may be kindled by a heavy dinner, a little excess in drink, or a chilling of the legs; the mucous membrane swells, the stricture closes, and acute retention of urine results. If this retention is unrelieved, the bladder becomes over- stretched, and the case progresses like an acute prostatic retention (p. 256). Retention may be the only prominent symptom. The gleet may not have been noticed, the gradual decrease in the size of the stream may have been ignored, when, after exposure, excess, or a carouse of beer, retention suddenly comes on. Such was the procedure in 31 of my cases. Hematuria.—Exceptionally hematuria may be the most prominent symptom of stricture, indeed the only one noticed by the patient. (This happened 3 times in my series.) The bleeding comes from an ulcerated spot and may be quite profuse. The blood usually continues to drip after the close of micturition (uretlirorrhagia). Pain.—Pain on urination is due to prostatitis, cystitis, or retention. The pain is felt at the neck of the bladder, in the perineum, at the point of stricture, or near the glans penis. Sexual Symptoms.—Excepting the impotence which results from grave stricture, all the other sexual symptoms that have been tradition- ally accredited thereto are actually referable to prostatitis, vesiculitis, or verumontanitis. RESULTS OF STRICTURE Hemorrhoids and Hernia.—The constant straining in urination keeps the hemorrhoidal vessels congested. This not infrequently results in an attack of piles or of rectal prolapse; occasionally, hernia occurs from the same cause. 224 ORGANIC STRICTURE OF THE URETHRA Prostatitis, Vesiculitis, Epididymitis.—Prostatitis, vesiculitis, and epididymitis are common results of stricture. Cystitis.—The inflammation of the bladder caused by stricture is usually superficial, but it may become parenchymatous. In neglected cases the bladder usually becomes concentrically hypertrophied (p. 269). When this concentric hypertrophy is of long standing the contracted bladder does not dilate with relief of the stricture: the frequency of urine persists unabated. Stone.—Urinary calculus is a rare result of stricture. Pyelonephritis.—Infection and dilatation of the ureters and kid- neys occur as in prostatic retention. RESULTS OF THE MALTREATMENT OF STRICTURE The results of the maltreatment of stricture are hemorrhage, inflam- mation of the stricture itself, periurethritis, infection of the upper urinary tract, and false passage. Of these only the last requires detailed mention here. False Passage.— False passage results from the rough or unskillful use of small instruments in an obstructed ure- thra (Fig. 50). The surgeon making a .false pas- sage may he uncon- scious of the escape of the point of his instrument from the canal, hut he soon perceives that it is behaving unusually. It is obstructed, but yet not held as though in the grasp of a stricture. The point, moreover, seems often to be turned out of the median line, and, after the instru- ment has been introduced far enough to reach the bladder, a rotary motion, imparted to the shaft, will show that the point is fixed in the connective tissue, and not freely movable, as it would be in the cavity Fig. 50.—False Passage. (Dittel.) RESULTS OF NEGLECTED STRICTURE 225 of the bladder. In such a case a finger in the rectum will feel the point of the instrument just outside the wall of the gut, at the apex of the prostate, or perhaps lying between the prostate and the gut. On with- drawing the instrument, blood flows freely from the meatus. RESULTS OF NEGLECTED STRICTURE In view of recent researches, many of the fundamental notions con- cerning infiltration of urine have been completely changed, and this condition and its associated phenomena now appear as inflammatory and not as mechanical complications of stricture. Since the time of Voille- mier the accepted theory has been that all urethral dilatations and uri- nary pouches in the region of a stricture, as well as all urinary extrav- asation and infiltration, are due to the pressure of the urine forced against the weakened, inflamed urethra by the bladder filled to over- flowing. The urine was supposed to burst through the urethra, and thus to cause these complications. But a certain number of phenomena are unexplained by this hypothesis. These are: 1. Urethral dilatations, abscesses and urinary pouches in front of the stricture. Such cannot be caused by any urinary pressure. 2. Urinary extravasation or gangrene caused by strictures of large caliber, when the back pressure is by no means sufficiently violent to cause rupture of the urethra. Moreover, in direct contradiction to the theory of acute extrav- asation are the observed facts that: 1. The more the bladder is distended the less able is it to exert any great force or to produce more than a dribbling stream, even after the urethral right of way has been re-established. 2. When a urinary pocket is opened, and its urethral orifice found, the urine never gushes out, but flows drop by drop. Indeed, Escat1 and Cottet 2 go so far as to deny that the clinical picture of mechanical extravasation exists. The terrible straining and agony suddenly relieved with a feeling of something giving away in the perineum, and soon followed by extravasation, is, it would seem, a description devised to fit a theory. The inflammation assumes one of the following types: 1. Suppuration within the stricture causes 'periurethral abscess, which: a. Remains localized and quiescent. b. Is absorbed. lGuyon’s Annales, 1898, xvi, 897 and 1026. This article is a detailed and brilliant elucidation of the whole subject. 2 Iiid., 1899; xviii, 590. 226 ORGANIC STRICTURE OF THE URETHRA c. Extends into the perineum and scrotum. d. Opens into the urethra and— 1. Discharges and heals. 2. Remains as a fibrous sac filled continuously or intermit- tently with urine, and communicating with or shut off from the urethra. (Urinary pouch.) 3. Fills with urine and bacteria, whose ravages rapidly spread the infection, causing infiltration, extravasa- tion, phlegmon, abscess, or gangrene. 2. Suppuration on the surface of the sclerotic tissue, usually behind, sometimes at, and rarely in front of the stricture, may cause dilatation of the urethra, periurethritis, periurethral abscess (with the associated lesions just noted), or, if the physical and bacterial conditions are ap- propriate,1 gangrene of the urethra alone or of the surrounding tissues as well. 3. To fill out and complete the theory that these accidents depend solely upon the combination of individual predisposition and bacterial virulence, two other conditions may be explained by it: the one, malig- nant gangrene of the genitals, a spontaneous gangrene extending over the genitals, sparing the deeper tissues, terminating in recovery, occur- ring in young subjects with genito-urinary history or disease, and quite comparable to noma, though not fatal; the other, genital gangrene of old prostatics long habituated to catheter life, a similar condition, not dia- betic in origin, terminating in death (Guyon and Albarran, quoted by Escat). These rare conditions can arise from no source other than a fortuitous combination of soil and seed, comparable to that presented by gangrenous extravasation. Periurethritis.—In almost any long-strictured urethra there can be felt, by introducing a sound and palpating the canal against it, ir- regular masses of cicatricial tissue occupying more or less of the whole length of the canal. A sensitive nodule in this mass indicates an area of periurethral inflammation that may, at any time, develop into an abscess. Periurethral Abscess.—With the onset of suppuration in this tis- sue there is a sharp, septic febrile reaction. The lump grows rapidly larger, more painful, and tender, and it may encroach upon the urethra sufficiently to cause retention. Ultimately it opens into the urethra, or passes into a chronic stage, or more commonly extends into the peri- neum, burrowing thence throughout the subcutaneous tissue of the ex- ternal genitals, the thighs, the groins, and even to the lower belly, dis- 1 Cottet quotes Veillon and Zuber’s law: “No gangrene or putrefaction with- out anaerobic bacteria,” and finds in all the cases examined by him that when anaerobic bacteria were present there was gangrene, and wrhen they were absent, even with extensive infiltration, there was no gangrene. RESULTS OF NEGLECTED STRICTURE 227 charging at many points, and leaving the whole region a mass of fistulae, through which the nrine escapes, perhaps not one drop passing by the natural channel. In these cases the patient makes water sitting, the urine escaping as though through the sprinkler of a watering-pot. Civiale reported such a case with fifty-two external openings. Urinary Infiltration (Periurethral Phlegmon, or Gangrene).—Be- ginning as an acute or a chronic periurethral abscess, or as a gangrene of the urethral wall, the acute infective process rapidly spreads over the perineum and the genitals. The first sign is a tender edematous swelling in the median line of the perineum, which rapidly increases in size and spreads superficially in every direction. If there is gangrene this spreads with frightful rapidity. If there is not gangrene, the enormous edematous swelling, which may reach the size of a child’s head, breaks up into innumerable foci of suppuration, from which pus, and, later, pus and urine pour out. Accompanying all this are shock, severe septic symptoms, and usually retention of urine. It is usual in these cases for the tumor to be extensively infiltrated with urine, and to contain one or more irregular central cavities filled with urine, necrotic tissue, and pus; but there may be no appreciable infiltration nor any communication with the urethra, and urethrotomy without a guide may he required for the purpose of relieving the re- tention. The bladder never becomes gangrenous, though the urethra slough to its very neck. The suppuration and gangrene may leave a urethro- rectal fistula, but the cavity of the pelvis is never invaded. Inasmuch as urinary infiltration generally occurs in debilitated per- sons, and is itself a very virulent septic process, it often terminates fatally. Urinary Fistula.—The periurethral abscess may open and dis- charge in remote regions,1 but it usually opens in the perineum. The internal orifice is usually single, however many the outward openings. The fistula, if long and tortuous or branched, contains diver- ticula which repeatedly close, form abscesses, and discharge; or they may contain foreign bodies or calculi, or the entire tract may be in- crusted with calculus. Prognosis.—Blind internal fistulae tend to close unless there is stricture. If they persist, they may form the starting-point for abscess or infiltration. Blind external fistulae close spontaneously, or after cauterization or curettage. Complete fistulae usually require operation. 1 Desnos mentions a urinary fistula opening at the lower angle of the scapula. I have seen one that reached the loin. 228 ORGANIC STRICTURE OF THE URETHRA DIAGNOSIS Inasmuch as stricture is only an accentuation of the pathological process that constitutes chronic anterior urethritis, it may be diagnosed by the bulbous bougie. Any infiltration larger than 26 F. may oe termed “chronic urethritis/’ if smaller, “stricture.” But inasmuch as the tendency to contract is the essential feature of stricture, I prefer the sound to the bougie and term “stricture” only such infiltra- tions as grasp the sound (see below). There are certain points in the history and urinary signs that are peculiarly suggestive. History.—A history of prolonged mild intermittent gleet is pecul- iarly suggestive of stricture. Spontaneous urethrorrhagia is suggestive of stricture. Retention of urine is due either to stricture, prostatism, or paralysis of the bladder. The Urine.—Large shreds in the urine are an indication of local- ized hard infiltrations in the anterior urethra, actual or potential stric- tures. These shreds may be obscured by free pus; but unless the stricture is controlled by treatment the urine always contains more or less shreds. Diagnosis of Impassable Stricture.—When a filiform bougie cannot be passed to the bulbous urethra, there is impassable stricture. If the bougie reaches the bulb but will not enter the membranous urethra, the obstruction is either stricture or spasm. An attempt is then made to pass the largest sound that will enter the meatus. If this is passed gently into the bulbous urethra and held against the face of the obstruction, it overcomes the contraction of spasm but absolutely fails to pass the stricture. DIFFERENTIAL DIAGNOSIS So much for the method of examination. The presence of an ob- struction having been determined, the differential diagnosis lies between organic stricture, spasm, and chronic inflammation. The position of the obstruction and the various points dwelt upon in the preceding para- graphs, and in the chapter on Spasm, are elements in the diagnosis. But the most distinguishing characteristic of all is resiliency. Organic stricture is always elastic and resilient, the others are not. To test this resiliency a sound—the largest that will pass—is gently introduced through the supposed stricture. It is allowed to rest in place for a moment, and then an attempt is made to withdraw it. If there he or- ganic stricture the withdrawal of the instrument will he opposed hy a firm grasping as long as the instrument remains engaged in the stric- DIAGNOSIS 229 ture. If, however, there be no grasping there is no organic stric- ture. To tabulate these features briefly: Organic Stricture. Spasm. Urethritis. Shreds or pus.. Obstruction ... Grasping Always present, j Always present. Always present. Not present unless there is an inflammation. Only in membranous urethra. No. | Present. Sometimes. No. CHAPTER XXV STRICTURE OF THE URETHRA: PROGNOSIS AND TREATMENT PROGNOSIS The prognosis of stricture 1 depends upon the treatment more than upon any other one thing, but varies according to the nature and loca- tion of the scar. Traumatic strictures often contract rapidly, in spite of treatment. Gonorrheal strictures, on the other hand, contract far less energetically. Strictures of the perineal urethra are far more diffi- cult to cure than strictures of the pendulous urethra. The latter con- tract slowly and are commonly curable by urethrotomy; the former contract more rapidly and are incurable—that is, they may be relieved by sounding or urethrotomy, but they almost inevitably relapse after a time. Finally, the more extensive a stricture, the more irregular its surface, and the denser the cicatricial tissue composing it, the more diffi- cult will be its treatment and the more dubious its cure. In the matter of life or death, however, the prognosis of stricture is far less gloomy. Stricture is very rarely fatal, except in neglected cases. Death occurs in various ways. 1. Periurethral phlegmon, which, if extensive, kills at once by shock, or, later, by exhaustion, suppuration, abscess, gangrene, or pyemia. 2. Urinary septicemia, the retention resulting in pyelonephritis or pyonephrosis. The patient may die from such a cause even after the stricture has been dilated, or, as is more commonly the case, the treat- ment itself, whether by sound or knife, may induce urinary septicemia which closes the scene. 3. Sudden death following the passage of a sound. Such deaths are extremely rare, and are apparently due either to the use of cocain, to status lymphaticus, or to nervous shock upon an impaired heart. TREATMENT Enlarge the urethra by dilatation, aided, if necessary, by cutting. Then maintain its caliber by dilatation. Or perhaps the negative view 1Cf. Trans. Am. Assn., G.-TJ. Sura., 1915. 230 TREATMENT 231 is more forcible. Never cut if you can dilate; and recognize that the patient is not cured unless he stays cured. Cutting is at best a substitute for dilatation, while divulsion and electricity are no substitutes. PROPHYLAXIS Since most strictures are caused by gonorrhea, and the occurrence of gonorrheal stricture is favored by the intensity and the duration of the inflammation, every effort made to control this inflammation is so much toward the prevention of a possible stricture. Yet this is but an indirect prophylaxis, since it is impossible to prophesy which case of gonorrhea will terminate in stricture and which will not. But when the disease becomes chronic in the anterior urethra, although there be no stricture present, the inflammation is encouraged by and is in turn encouraging a periurethral sclerosis, which may develop into a veritable stricture. Therefore, intelligent treatment of anterior urethritis is the surest preventive of stricture. For traumatic stricture the proper prophylaxis is immediate peri- neal section at the time of injury (p. 492). Since the sound is the instrument best adapted to the cure of stric- ture, and since, unfortunately, it is easier to use a sound wrongly than rightly, a few words on the use and effects of sounds are required. The surgeon attacking a stricture of the urethra may fairly analyze the therapeutic problem thus: “Here is a scar with a congested surface; shall I cut or shall I massage it ?” If he cuts through it the symptoms are relieved, the obstruction is apparently removed, but the scar is still there. In fact, there is rather more scar than ever, and if the former scar contracted and gave trouble, so much the more will this one. To prevent this he will keep the lips of the wound separated by sounds, so that it may heal with so broad an insertion band that the contraction will be of no moment. Such a course will succeed in the pendulous urethra; but if the stricture is in the perineal urethra and of such density as to give the shadow of an excuse for cutting, it will certainly relapse after the operation unless subjected to systematic massage by sounds. The knife only relieves the congestion plus a temporary relief of the contraction, while the sound actually causes the resorption of the exudate. The effect is quite comparable to the effect of massage applied to the outside of the body. Moreover, the maximum of effect is produced by the minimum of effort, or, as Guy on puts it, “the effect is due, not to the pressure of the sound, but to its mere contact.” It is a matter of everyday experience that the brutal passage of a CURATIVE TREATMENT 232 STRICTURE OF THE URETHRA sound, bruising and tearing the congested urethra, is followed by a sharp inflammatory reaction, which increases rather than diminishes the exu- date. Such treatment is inexcusable. The stricture is already con- gested, the mucous membrane already inflamed. What more futile pro- cedure than to add irritation to irritation! Such is not the object of the sound. On the contrary, the sound, if a metal one, should slip in almost by its own weight; slowly indeed, but surely. Such a maneuver has the treble effect of lessening congestion at the point of contact, straightening out irregularities in the canal, and stimulating the deeper tissues to a favorable reaction, which will result in softening the cica- trix. But to do this the sound must press without bruising. If a given sound will not pass, try a smaller one. The effect is readily judged. If a sound is properly introduced, it may usually be followed by sounds of the next larger sizes with less pain than the first. Larger sounds may be introduced at each sitting; the rapid amelioration of the symptoms shows that the congestion is relieved, the obstruction is disappearing, and the canal is resuming its normal condition. Yet, however gently a sound is introduced, it will be followed within forty-eight hours by a congestive reaction of more or less intensity. Hence, in treating stric- ture by dilatation it is bad surgery to introduce instruments—unless filiforms—before the lapse of seventy-two hours, and even longer in- tervals will often produce better results. Lastly, and above all, gently, gently, gently! TREATMENT OF VARIOUS KINDS OF STRICTURE The treatment of stricture at the meatus aud of spasmodic stricture has been dealt with. Apart from these, the treatment of stricture may be considered under the following captions: 1. Stricture of large caliber. 2. Stricture of small caliber. 3. Stricture admitting only a filiform. 4. Stricture complicated by retention. 5. Impassable stricture. 6. Traumatic and resilient stricture. 7. Stricture complicated by prostatitis. (Irritable stricture.) 8. Stricture complicated by false passage. 9. Stricture complicated by periurethritis or prostatic abscess. 10. Stricture complicated by fistula. 11. Stricture complicated by acute pyelonephritis. 1. Treatment of Uncomplicated Stricture of Large Caliber After the diagnosis has been made by the passage of a bulbous bougie, no further instrumentation is advisable (if the patient can spare the time) until the effect of exploration has been observed. The chances of TREATMENT 233 urethral chill after the first examinations must be remembered. The patient’s general condition and habits must be studied, and his urine tested for acidity or possible kidney disease. He must be instructed in urethral hygiene, the nature of his malady must be explained, and, to forestall future disappointment, he should he informed at the outset that, after his symptoms have been relieved by treatment, the per- manence of his cure, if his stricture is deep in the urethra, may depend upon his use of an instrument upon himself at proper intervals, in order to prevent recontraction. Being instructed not to mind the smarting at his next urination, a few drops of silver nitrate are instilled, and the patient is instructed to take a tablet of hexametliylenamin after each meal and to return in two days for dilatation. Sounds.—The treatment best adapted to the majority of these cases is dilatation with a conical double taper steel sound. One of these in- stillments properly warmed and sterilized is introduced in the manner already detailed. Its size should correspond to that of the bougie that has passed the stricture, and the utmost delicacy, care, and gentleness should be used in its introduction. As soon as the instrument has en- tered the bladder it should be gently withdrawn at once. Nothing is gained by leaving it even for a moment. During withdrawal the stric- ture is usually felt to grasp the sound. After one sound has been with- drawn, a second and even a third may be introduced, if considered safe. It may be stated as a rule, subject to judicious exception, that if a coni- cal steel instrument of any size larger than No. 15 F., when held in proper position, will not enter a stricture almost by its own weight after a little delay, it should not be used. Every urethra, however, has its own temper; some are aroused by the slightest disturbance, while others bear considerable violence without protest. A surgeon should acquaint himself by gradual experiment with the temper of a given urethra before he takes liberties with it. The mischief to be feared from the employment of large sounds with force (besides false passage, which is not likely to be produced by large instruments) is threefold: 1. Epididymitis, a common result of violence to the urethra, and a complication which suspends treatment and confines the patient to bed for several days or weeks. 2. Inflammation in the stricture, which aggravates its condition and defeats the end of the treatment. 3. Chill and urethral fever. The third danger, the chill and fever, is very unusual after manipu- lation of the pendulous urethra—witness the impunity with which many surgeons cut far and wide through that part of the long-suffering canal —and increases as we approach the bulbomembranous junction. Some 234 STRICTURE OF THE URETHRA persons have a predisposition in this regard, and the presence of some renal lesion is essential as a predisposing cause of any real septic chill. Yet in no given case can the prognosis be definite, and the only safety lies in hedging the operation about with all possible precautions. The rule which I have found most efficacious is: Hexamethylenamin before, Gentleness during, Nitrate of silver or permanganate of potassium after sounding. At each subsequent visit of the patient, the surgeon commences with a sound from one to two sizes smaller than the last instrument intro- duced at the previous visit, and carries the dilatation as far as possible without the employment of force, till the full size is reached. The Interval.—The most important feature in the treatment of stricture by dilatation is a proper regulation of the intervals to be al- lowed between the visits. The intervals usually recommended are too short. We can only repeat that it is bad surgery, in treating stricture by dilatation, to reintroduce instruments—unless filiform—before the lapse of at least seventy-two hours, and even longer intervals will often produce better results. The Full Size.—As to the degree of dilatation which is to be aimed at, every urethra has its own gauge in the size of its meatus—provided that meatus be not congenitally small, or contracted by disease. If there is any cicatricial tissue in the circle of the meatus, or if a probe can make out any pouching below the lower commissure (Fig. 46), the meatus is too small. In the majority of cases this physiological gauge—the normal meatus—is adequate. A stricture once dilated to this size—which will vary from 27 to 32 F.—will stand the test of a cure—that is, the in- flammation about it (not necessarily the prostatitis) will rapidly dis- appear, and the stricture will not recontract during the lengthened intervals of sounding that constitute the after-treatment. But occa- sionally the meatus is too small a gauge. The outer fibers of the scar lie so deep and are so elastic that they are unaffected by the pressure and tend to recontract as soon as the lengthened intervals of sounding permit them to do so. Such strictures must be cut or stretched with the Koll- mann dilator until a point is reached where they do not recontract.1 1 Otis ’s Theory.—Such was the basis of Otis’s famous theory. Meeting many strictures incurable by the half-hearted methods of dilatation then in vogue, and finding that a generous incision cured stricture of the anterior urethra, he evolved the theory that the urethra is an evenly calibrated tube whose size bears a direct relation to that of the flaccid penis. This ratio he fixed at 10 mm. of urethral circumference to every inch of penile circumference. Thus, a 3-inch penis should take a 30 F.; a 3%-inch penis a 34 F. The objection to Otis’s theory is that it is incorrect. The urethra is no more an evenly calibrated tube than the ureter, the esophagus, or the bowel. Its size no more varies with that of the penis than does the TREATMENT 235 Dilators.—There is no question but that sounds of a size readily admitted by the meatus may be passed with less discomfort to the pa- tient than any dilator. But if the stricture when dilated to the size of the meatus recontracts with undue rapidity, further dilatation may be performed by the Kollmann dilator. This instrument is employed in the same manner as in the treatment of chronic urethritis. Urethrotomy.—If at any stage of dilatation the stricture rebels and can not be dilated any further, urethrotomy must be resorted to. Choice of Urethrotomy.—External section is best suited to strictures of the bulb, internal section to strictures of the pendulous urethra. There still remains a choice of instruments for internal urethrotomy, which choice is simply a matter of taste. Eor my part, I like the bistoury for strictures near the meatus, Otis’s dilating urethrotome for any stricture of the pendulous urethra large enough to admit that in- strument, and Maisonneuve’s urethrotome only for those strictures through which an Otis instrument will not pass. After-treatment.—The after-treatment depends upon the loca- tion of the stricture. If the stricture is in the pendulous urethra, the surgeon may feel confident that a cure persisting three months will prove permanent. When the stricture has been dilated fully, so that there are no longer any large shreds in the urine (unless from the posterior urethra), the patient may be dismissed to report in two weeks. If at that time there is no recontraction, he may be dismissed for a month, and again for two months, when his cure may be pronounced permanent. If, however, there is a relapse on any of these occasions, visits must be renewed, and the patient’s cure insured by higher dilatation or a further cutting. If the stricture is in the bulb the matter is different. In all such strictures, except those soft bands that yield to one or two passages of a sound, recontraction will almost inevitably take place, unless the cure be maintained by the passage of a full-sized sound. This is easily done by the patient. In a few lessons he acquires the art of gently passing a sound upon himself, and he should be seriously cautioned to perform this trifling but important operation once or twice a year. If the sound fails to pass on some such occasion he must report for examination. In this way, in some cases, the use of instruments may be gradually aban- doned; in the majority, it will have to be continued indefinitely, at intervals varying from a week to a year. Thus the cure becomes radical. The surgeon is responsible for the cure only on condition that the pa- size of the esophagus with that of the neck. The objection to Otis’s practice is that it involves an unnecessary and harmful amount of cutting, since, as a rule, the patient can get well without it, and the operation may leave a canal defective in expulsive power. Moreover, though this wide cutting cures strictures of the pendulous urethra, it does not cure deep strictures. 236 STRICTURE OF THE URETHRA tient carries out this plan; or, rather, the patient is responsible for the permanence of his own cure, and this he must be made distinctly to understand. 2. Stricture of Small Caliber—To this class belong strictures admitting any instrument less than No. 15 F. They are considered separately, not because they require different treatment, but in order to emphasize the fact that they are better treated with soft than with steel instruments. The danger of making a false passage in an obstructed urethra with a small metallic instrument cannot be overrated. No one can appreciate the ease with which a false passage is made until he has himself made one. Indeed, a surgeon, not well acquainted with the urethra, may make a false passage, and go on dilating it instead of the stricture, wondering meantime that the size of the stream is not in- creased or the symptoms alleviated. Only a surgeon who knows every line of the urethra may occasionally assume the risk of using a small metallic instrument in the canal without a guide. Dilatation is carried on as already directed, steel instruments being used as soon as the stricture will admit No. 15. Urethrotomy.—Cutting may be resorted to: a. If the stricture will not dilate. b. If the patient has not the time to go through a long course of dilatation. c. If urethral fever follows all attempts at dilatation. 3. Stricture Admitting Only a Filiform, but Not Complicated by Retention.—It may he impossible to enter the bladder with any instru- ment, either on account of the tightness of the stricture, or because the point of the instrument does not engage in the latter, or is arrested by some fold beyond. In these cases gentle perseverance and skill will rarely fail of success. Preliminary Measures.—The very failure of larger instruments to pass, which tells us that filiforms must be employed, so distorts the orifice of the stricture as to make the passage of filiforms most difficult. Consequently only one or two brief efforts should be made at this time. If these fail further efforts should be deferred for forty-eight hours. As a preliminary the urethra should be injected with anesthetic lubricant. This is preferable to oil or adrenalin. Introduction of Filiforms.—Filiforms (p. 22) are apt to catch in the urethral folds and crypts both in front of and behind the stricture. The following maneuvers are employed to overcome this diffi- culty : 1. When an instrument catches, partially withdraw and slightly rotate it, pushing it forward while making the rotatory movement. This device rarely fails in finally engaging the instrument in the orifice of the stricture, especially if the filiform point be bent or twisted so that TREATMENT 237 its extremity may lie outside of the axis of the shaft of the instru- ment. 2. An excellent method of finding the orifice of a stricture consists in cramming the urethra full of filiform bougies, engaging their points in all the lacunae and false passages, and then trying them, one after another, until that one is pushed forward which is presenting at the orifice of the stricture, when it will at once engage (Fig. 51). 3. If the point of the filiform passes the stricture but catches in the prostatic urethra, it may be lifted into the bladder by a finger introduced into the rectum. 4. Where filiforms fail a 10 F. ure- thral sound may pass by virtue of its curve. Only the expert surgeon may employ such an instrument with impunity. 5. If the stricture is a single band the face of which may be reached by the ure- throscope, this instrument is introduced, the stricture wiped with adrenalin until it ceases to bleed, and a filiform then intro- duced, guided by direct ocular observation. This maneuver rarely succeeds where other means fail. After-treatment.—After a filiform has been introduced the stric- ture is dilated to 10 or 12 F. When the patient is next seen, two days later, a 10 F. bougie will usually pass, or we may have to resort to filiforms again. If drainage of the upper urinary tract is deemed necessary, a fili- form may be tied in (p. 647). 4. Retention.—Acute retention requires immediate relief. The patient should be placed in a hot bath, more hot water being added after he has become accustomed to the first heat, and this carried as high as bearable. lie should remain in the bath from fifteen to twenty minutes, and should attempt to empty his bladder while in the water. If the heat is sufficient to induce nausea or faintness, it is more likely to produce the desired effect of relaxing the stricture. Following this relief an attempt at dilatation should be made as described in the pre- ceding section. If these expedients fail, the bladder may be aspirated every eight hours for one day or drained by suprapubic puncture (p. 687). Then the patient is put into a hot bath for twenty minutes and a final attempt made to introduce a filiform. This failing, the stricture may be fairly considered impassable. In drawing the urine from a distended bladder it is well not to re- move more than 500 c.c. (§ xvj) at a time. If there is more than this, Fig. 51.—Introduction of Fili- forms. (Bryant.) a, guide bent upward; b, guide in lac- una; c, numerous guides in urethra, one passing stricture. 238 STRICTURE OF THE URETHRA draw off the remainder after twenty minutes. Too quick emptying of an acutely distended bladder has been followed by hemorrhage, collapse, and even sudden death. 5. Impassable Stricture.—No stricture (congenital atresia ex- cepted) is impervious unless the urethra has been cut across and all the urine escapes behind the cut, or unless the urine escapes through large fistulae. If a drop of urine can pass, the stricture is pervious. Our inability to pass instruments is due to the crookedness, not to the tightness, of the stricture. IIow far the surgeon shall continue coaxing the urethra before re- sorting to external urethrotomy without a guide is a matter to be decided on the merits of each individual case. If the patient is difficult to manage, and there is fear that, once relieved from his present necessity, he may not submit to treatment, it is a kindness to take advantage of his misfortune by insisting upon perineal section at once. But external perineal urethrotomy without a guide is a difficult operation, and is not to be undertaken lightly. If it is the patient’s first retention, if he was previously passing a fair-sized stream, and if the bladder is not already too full, it is always well to try palliative measures. But, on the other hand, it is not wise to fritter away time to the permanent detriment of the patient’s bladder and kidneys when a stroke of the knife would solve the difficulty.1 6. Traumatic and Other Resilient Strictures.—Traumatic strictures close down with great rapidity and are very rebellious to treatment. They are resilient. When dilated ever so little they recontract and often are made worse, rather than better, by sounds. Under such conditions dilatation is a losing game. The knife must be used. When the scar is linear, simple perineal section will suffice to render it amenable to the sound. When, as is often the case, the scar is annular and fibrous, all the scar tissue, both on roof and floor, must be cut away. The urethral wound may need to be closed by suture or graft, but that does not signify: the scar must be removed at all costs, since it never loses its retractile quality, and simple section will be followed by a recontraction almost as rapid as after the original injury. Cabot’s resection (p. 703) is the ideal operation for such cases. Other resilient strictures must be dealt with similarly. 7. Stricture Complicated by Prostatitis (Irritable Stricture).— Strictures classed as irritable in reality present no peculiar irritability in themselves, but they are complicated by prostatitis. As soon as the point of the sound or the bougie passes well through the stricture it glides over the prostatic urethra, the really irritable point—though, be 1 Special instruments, such as Sinclair’s retrograde cystoscope, devised to obviate urethrotomy without a guide, are so rarely needed that their use will never become general. TREATMENT 239 it understood, only the minority of strictures complicated by prostatitis are irritable—and provokes an exacerbation of tlie prostatic inflamma- tion or a sharp chill. When such a complication presents itself the simplest solution is perineal section; hut this is not always essential. By bracing the patient’s general health, by employing rather large doses of hexamethylenamin, by using the utmost gentleness in sounding, by preferring bougies, which are less violent to the prostatic urethra than sounds, or else blunt sounds whose points need not enter the prostate at all, and by treating the stricture only sufficiently to permit local treatment of the prostatitis until the latter is materially improved —by such means operation may often be avoided. 8. Stricture Complicated by False Passage.—The treatment for a fresh false passage is to let it absolutely alone for two weeks, if the patient can urinate, and is in no pressing need of relief. Blood will flow for a day or two, then pus for a few days, and at the end of two weeks, in favorable cases, the passage opened by the instrument will often have closed. In avoiding an old false passage, the seat of chronic suppuration, its position must be accurately studied, by observing at what point in the urethra an instrument engages in it, and from which wall of the canal (upper or lower *) it starts. The orifice of a false passage once accurately located, may be sub- sequently avoided by making an effort to present the beak of the instru- ment at a different portion of the canal when passing the dangerous point. If repeated attempts fail, or if suppuration and periurethritis inter- vene, perineal section should he performed without delay. 9. Stricture Complicated by Periurethritis.—There is no sane pal- liative treatment of periurethritis and its complications. The simple inflammatory areas should be treated by methodical soundings, perhaps aided by hot sitz baths and leeches to the perineum. Under such a course they rapidly suppurate or disappear. Periurethral or Prostatic Abscess requires prompt evacuation and drainage by median perineal incision. The urethra should he opened and the stricture cut. In dealing with small abscesses this is a simple matter. Large ones should be cut and drained like infiltra- tions. Infiltration of Urine demands immediate and radical incision. The patient’s life is entirely in the surgeon’s hands. Timorous incision is the patient’s death-warrant. The infiltrated area must be slit open 1Guyon states that he never met a false passage on the roof, hence advises following that wall of the urethra to avoid it. I have, however, met two cases of false passage on the roof, as shown by external urethrotomy, and have seen one other with the urethroscope. 240 STRICTURE OF THE URETHRA from end to end. Necrotic tissue must be sacrificed with no thought of ultimate disfiguration. 10. Stricture Complicated by Fistula.—The chief aim in the treat- ment of fistula is to remove the impediment to urination—to dilate the stricture. This done, the fistula may close. If it fails to heal promptly, perineal urethrotomy should be performed. 11. Stricture Complicated by Acute Pyelonephritis.—The kidney must be drained either by a retained catheter or by perineal section. The tube should remain in place until the temperature touches normal. This failing, nephrotomy is required. SUMMARY OF TREATMENT OF STRICTURE 1. Ilexametliylenamin, sedatives, alkalies, and rest are serviceable in some cases of stricture; indispensable if there be any serious com- plication. 2. All uncomplicated strictures, not highly irritable or resilient, should be treated by dilatation with soft instruments up to No. 15 F., and with conical steel sounds afterwards—reintroductions being made every fourth day. 3. Until well acquainted with the temper of a given stricture, every sounding should be preceded by Ilexametliylenamin, followed by nitrate of silver. 4. Dilatation need rarely be carried beyond the caliber of the normal meatus. 5. Any stricture resisting dilatation must be cut. 6. For the pendulous urethra, internal urethrotomy. For the peri- neal urethra, external urethrotomy or the combined operation. 7. In general, anterior stricture of the urethra is curable, deep stricture of the urethra incurable. 8. Impassable stricture without retention may usually be overcome with filiform bougies by time, patience, and skill. If finally proved impassable, the treatment is external perineal urethrotomy. 9. Retention is treated by hot baths; these failing, by aspiration, or by external urethrotomy without a guide. 10. Traumatic stricture may be prevented by section at the time of injury. Once having shown itself, it usually requires resection. 11. Resilient and inodular strictures are best treated by resection. 12. Irritable strictures may often be cured without cutting. 13. Acute inflammatory complications usually call for operation. 14. Unless secondary retention has occurred in the ureter or renal pelvis, drainage of the bladder by division of the stricture will relieve an acutely infected kidney. CHAPTER XXVI THE PROSTATE: ANATOMY, PHYSIOLOGY—PROSTATISM ANATOMY The prostate is a sexual organ, partly glandular, partly muscular, lying in front of the bladder and surrounding the prostatic urethra (Figs. 52, 65). In shape the prostate is an irregular truncated cone. It has been aptly compared to a horse-chestnut. Its apex rests against the posterior layer of the triangular ligament. Its base, toward the bladder, is pierced above by the urethra, below by the ejaculatory ducts. Its up- per (anterior) and lateral surfaces are rounded, its lower (posterior) Pig. 52.—Sagittal Section of Prostate, Bladder Neck and Membranous Urethra. Division of gland by urethra and ejaculatory ducts well shown. 241 242 THE PROSTATE surface presents a boss on eacli side of the median line. It is to this lower surface particularly that the title heart-shaped or chestnut-shaped applies. The diameters of the prostate, as given by von Frisch 1 (and Thomp- son 2) are: length, 33 to 45 mm. (25 to 30 mm.) ; width at the base, 34 to 51 mm. (32 to 40 mm.) ; thickness, 13 to 24 mm. (20 to 25 mm.). Its weight is 16 to 24 grams. In position it is 8 to 12 mm. below the symphysis, and its apex is 30 to 40 mm. from the anus. Its long axis makes an angle of 20 to 25 degrees with the perpendicular. The prostate is supported by the puboprostatic ligaments and the levator prostatae (anterior fibers of the levator ani). It is fixed in its relations to the urinary organs by the urethra, which pierces it from base to apex, as well as by the decussation of its muscular fibers with those of the bladder and the urethra. It is sep- arated from the pubic arch above and in front and from the rectum behind by a loose fascia, the fascia of Denonvilliers, an offshoot from the pelvic fascia which passes down behind bladder, vesicles, and pros- tate, separating these from the rectum. Within this fascia and sur- rounding the prostate, especially in front, lies the prostatic plexus of veins. Gross Anatomy.-—The prostate may be considered as a gland divided into two parts by the ejaculatory ducts. These enter the gland at the posterolateral angles of its base, and run through it obliquely, opening finally into the urethra at or near the sinus pocularis. That part of the gland behind the ducts is called the posterior lobe. This part of the gland may become carcinomatous. It never becomes adenomatous. The glandular tissue in front of the ejaculatory ducts is divided more or less arbitrarily into an anterior, a median and two lateral lobes. Lowsley 3 has shown that in fetal life these lobes are usually quite distinct. But after birth the glands of the anterior lobe usually disappear and the separation between the other three, lying behind and to each side of the urethra, is quite arbitrary. The median lobe may be inseparable from one or both of its lateral fellows. The median lobe of the normal prostate makes no projection from its surface. The “middle” lobe of prostatism is quite a different matter. The prostate has a thin fibrous capsule. Microscopic Anatomy.—The muscular tissue is arranged in so irregular a manner that no two observers are agreed as to its exact distribution. Walker 4 believes that the prostatic muscle is so arranged as to compress the gland as a whole, and each individual lobule of it 1 Nothnagel’s Specielle Path. u. Tlierap., 1899, six, ii, iii, 4. 2 “The Diseases of the Prostate,” 1883, p. 5. a Am. Jour. Anat., 1912, xiii, 299. 4 Johns Hopkins Bull., 1900, xi, 242. DILATATION AND MASSAGE 243 as to make many of liis patients faint loses many a case before it can be cured; and, on the other hand, the physician who massages too gently fails to cure certain cases that require severe rubbing. The intelligent practitioner will rub gently at first and increase the severity of the manipulation up to the point of the patient’s endurance, and with an eye to the results obtained. Severe massage may do physical harm by exciting acute prostatitis, vesiculitis, and epididymitis. Mild mas- sage very rarely does this. No two physicians massage with pre- cisely the same method or with precisely the same severity, as patients are quick to note. A simple method is to begin upon one vesicle, and, reaching up as far toward its fundus as possible, to press upon it and then withdraw the finger in a zigzag way until one reaches the prostate. This maneu- ver is repeated half a dozen times and then the same treatment given to the opposite vesicle. If the vesicles are impalpable, this is enough. If distended or indurated, the maneuver should be repeated often enough to make a distinct reduction in their size, if the patient can bear so much manipulation. The finger is then brought down to the prostate. Hard, angular in- durations in and about this organ had best be avoided, and pressure made chiefly upon the more yielding portions of the gland. Beginning with one lobe, pressure is made upon it either with a to-and-fro lateral sweep of the finger or with a circular motion. This manipulation, if gentle, may be continued for one minute; if severe, half a dozen strokes may suffice. The same treatment is given the opposite lobe of the gland, and the manipulation concluded by a half dozen strokes over the pros- tatic sinus for the purpose of emptying the main ducts into the urethra. The general tendency of all such massage should be to express the secretions in the direction of the apex of the prostate. Meanwhile, watch is kept for the expulsion of secretion from the meatus. This is caught upon a slide for examination. Massage should usually be repeated not oftener than two or three times a week. If severe, longer intervals are better. In exceptional cases, when the return from massage is very great, gentle rubbing may be employed once a day. Massage should be continued until the sub- jective symptoms are relieved, and the return from the rubbing very slight and not densely purulent. If the return to normal is rapid, one may continue to rub until all pus disappears. The success of treatment must almost always be verified by three or four observations at intervals of one to three months. If pus has reaccumulated during these inter- vals, a few rubs will get rid of it. Contra-indication to Massage.—Massage is dangerous only in the presence of acute inflammation of the urethra, the prostate, the vesicle, or the epididymis; but massage is harmful in case it increases 244 THE PROSTATE throughout its mucous membrane, but more probably it is confined to the verumontanum. When erection has been stimulated by friction of the glans penis the verumontanum becomes congested and irritated, perhaps by a spinal reflex, perhaps by the gradual influx of semen into the prostatic urethra, and ejaculation results. The glandular function of the prostate is no less interesting. Be- sides acting as a simple diluent, it adds something to the semen that keeps the spermatozoa alive for several days, whereas other diluting fluids keep them alive only three or four hours. The secretion of the prostate is a thin, turbid fluid of watery con- sistence, of slightly acid reaction, and of seminal odor. Its qualities in health and disease have already been described (p. 132). There is probably an internal prostatic secretion that stimulates spermatogenesis. PROSTATISM Prostatism, miscalled prostatic hypertrophy, is an adenomatous or sclerotic condition of the prostate, causing obstruction to the out- flow of urine through the urethra. Although every adenomatous prostate shows areas of sclerosis and every sclerotic prostate adenoma, it is convenient to distinguish the common or adenomatous type of prostatism from the rare sclerotic type. ETIOLOGY Age.—Prostatism is a disease of later life. It rarely causes symp- toms before the fiftieth year. Although individual cases have been reported at the ages of nineteen (Stretton), twenty-five (Englisch), thirty-seven (Thompson), etc., these are altogether exceptional. The pathologic changes begin early in life,1 yet there is no clinical evidence of any such change until many years later. The patients begin to suffer, for the most part, between the ages of fifty and sixty-five. Frequency.—According to "Thompson’s figures, 34 per cent of men reaching the age of sixty have enlarged prostates, and less than half of these (15 to 1G per cent of the whole) suffer from prostatism. This estimate is substantially accurate. The size of the hypertrophy bears no relation to the age of the pa- tient, nor, as we shall see, to the symptoms. Pathogenesis—Though no satisfactory theory has yet been ad- 1 Gardner and Simpson (Trans. Am. Urol. Assn., 1913) found only one adenoma among 15 prostrates of men less than 40 years of age. They found five adenomata among 19 prostates of men between 40 and 50 and seven among 21 in the next decade. PROSTATISM 245 vanced to account for prostatism, many ingenious suppositions have had ardent defenders, and so require at least a brief notice. 1. Arteriosclerosis (Guyon,1 Launois2).—The lesion of the pros- tate is supposed to be only part of a series of senile changes affecting the whole urinary tract and associated with general arteriosclerosis. Casper 3 and Motz 4 overthrow this theory by sliowung that sclerosis could exist without prostatism, and prostatism without sclerosis. The association of the two appears to he purely fortuitous. 2. Fibromyoma (Velpeau5).—Velpeau suggested that there exists a biological analogy between the prostate and the uterus, and a histo- logical analogy between fibromyoma of the uterus and prostatism. Thompson 6 amplified and defended the theory, and it has received ad- ditional weight by the alleged effects of castration upon uterine myoma and prostatism. This theory has been exploded by the recognition of the fact that the prostate is analogous to the uterus neither in development, in structure, nor in function, and that prostatism is not fibromyomatous, but adenofibromatous. 3. Sexual Senility (White7).—“The function of the testis, like that of the ovary, is twofold—the reproduction of the species and the development and preservation of the secondary sexual characteristics of the individual. The need for the exercise of the latter function ceases when full adult life is reached, hut it is possible that the activity of the testis and that of the ovary in this respect do not disappear coincidently, and that hypertrophies in closely allied organs like the prostate and uterus are the result of this misdirected energy.” The facts adduced by White cannot he denied; but his theory, based upon the false pro- stato-uterine analogy and the implied power of the testicle to cause prostatism and devised to defend the cause of castration as a remedy for prostatism, is an assumption not borne out by the facts. 4. Congestion.—A chronic congestion of the gland has been consid- ered by many the chief predisposing cause of prostatism. Many varie- ties of congestion have been insisted upon. Some authors incriminate a pelvic congestion, such as is caused by gormandizing and a sedentary life, and expressed by hemorrhoids. Others insist upon chronic ure- thritis or sexual excess; and a few would even blame a too strict conti- nence. Young has noted that most of his patients were married men. 1 Guy on’s Annales, 1885, iii, 148. 2<ur. A. M. A., 1915, lxv, 1436. ENURESIS OF CHILDHOOD 431 Etiology—The cause of enuresis is sometimes obvious enough, hut usually obscure. 1. Enuresis due to congenital deformity such as epispadias is readily diagnosed. 2. Enuresis due to tuberculosis or stone is overlooked with singular frequency. The little patient cries out when he urinates and complains of various pains, but the physician often fails to consider the symptoms and neglects to examine the urine. Needless to say a careful urinary examination for pus and other elements should precede the treatment of any case. 3. Many cases are associated with phimosis, pin worms, adenoids, hypertrophied tonsils, and other of the minor diseases of childhood. The enuresis may often he relieved by their removal and is therefore usually spoken of as reflex. Without quarreling about the treatment, one may question the theory. These little lads are often thin and anemic and their enuresis is apparently due to this general condition rather than actually reflex. 4. In general it may he said that a child with enuresis who is below par should be a subject for hygiene in the hope that the improvement of his general condition may relieve the bed wetting. 5. Enuresis is rarely associated with such nervous disorders as chorea, tabes, etc. 6. There remains a large, perhaps the large, class of patients still unaccounted for. Their adenoids have been removed, they are not anemic, deformed or tuberculous, their urine contains no pus, and their nervous system is intact. The cause of enuresis in these cases is unknown. The three latest theories to account for it are: (1) Insufficient nervous impulse, (2) thyroid insufficiency, (3) mild tuberculosis. Prognosis.—Even though all treatments fail, the prognosis is ex- cellent. With the advent of puberty the child is almost certain to stop bed wetting. Treatment.—As has been stated above, the treatment of the enuresis should be preceded by a careful examination of the patient for enlarged adenoids or tonsils, for pin worms, for adhesions of foreskin or clitoris, the urine should be collected and examined for albumin and sugar, and for pus and bacteria. If pus is found, stone or tuberculosis may be suspected. The blood should be examined for anemia, and the child carefully gone over for evidences of tabes or chorea. In most instances, the examination will fail to reveal any of these conditions, and we are left with the so-called idiopathic enuresis. Many devices have been suggested and successfully employed for the treat- ment of these cases; such as the cutting down of the amount of water drunk, especially after three o’clock in the afternoon, getting the child 432 PHYSIOLOGY AND VARIOUS DISEASES OF BLADDER into good habits by wakening it at night to urinate, and actually inter- fering with urination by some form of urethral compressor placed on the penis at night. (If such machinery is to be used, the parents should be carefully instructed so that no harm shall be done to the child.) If these remedies fail, we may have recourse (with little hope of success, I confess) to drugs empirically employed. Extract of bella- donna, beginning with a dose of gr. 1 /10, and increasing until the pupils or the throat show the physiological effect, is well spoken of. Perlis states he cured 102 out of 156 cases by administering rlius aromatica; he employs the fluid extract in doses of from 10 to 80 minims. I have used both of these remedies without success. One may turn with more confidence to treatment founded upon a definite theory. Thus if we believe in the lack of nervous impulse, this may be stimulated by Cathelin’s suggested injection of 20 c.c. of normal salt solution into the sacral canal. This I have tried several times without success. Or we may try faradization of the membranous urethra by means of a urethral electrode or stimulation of the nerve endings by instillations of a few drops of strong silver nitrate solution into the posterior urethra. These treatments I have also employed in vain. Hertoghe and Williams 1 claim excellent results from the use of thyroid extract in small doses. To children between 2 and 6 years of age, -J gr. of dried thyroid extract may be given twice a day; for the older children the dose may be gradually increased to four or five times as much. Keersmacher claims excellent results from treating enuresis on the theory that it is a manifestation of slight general or pulmonary tuber- culosis. lie states that his patients usually show a slight evening rise of temperature, and positive von Pirquet test. lie administers tuber- culin in the usual manner, and states that his results are excellent. POSTPROSTATECTOMY ENURESIS Incontinence of urine may follow any operation upon tlie prostate or bladder neck. It is so much more often seen as a result of perineal prostatectomy than after any other operation that it seems not invidious so to label it. Its cause is most obscure, witness the following facts: 1. It does not follow perineal section for stricture, even though the membranous urethra is divided from end to end. 2. It does not follow suprapubic prostatectomy,2 even though the , 1 Lancet, May 1, 1909, p. 1245. * Though it must be admitted that partial incontinence may rarely follow supra- pubic prostatectomy. '■ PARALYSIS OF THE BLADDER 433 internal sphincter is freely divided and the whole prostatic urethra torn away. 3. It does follow Bottini’s operation, which divides only the internal sphincter. 4. It is seen after Chetwood’s operation and perineal prostatectomy. 5. It occurs almost as often after simple operations as after com- plex and destructive ones. Doubtless, therefore, the physical basis of incontinence is operative disturbance of any part of the sphincteric mechanism. Some are incon- tinent by day, others by night. Treatment.—Incontinence during the first weeks after operation is unimportant. The patient should be reassured and a complete cure hoped for. But if the incontinence persists much good may be done by filling the bladder with an unirritating solution and then training the patient by bidding him “start—stop-—start—stop” until the bladder is empty. Instillations of silver nitrate are distinctly useful until the urethro- scope shows the.posterior urethra to be entirely healed. If, at the end of six months, the patient is still incontinent the membranous urethra should be sutured. I have thrice performed this operation with two failures and one success. PARALYSIS OF THE BLADDER True paralysis of tlie bladder is one of the gravest complications of fracture of the spine and other injuries and diseases to the lower spinal cord. Under such circumstances, the cause of the condition is obvious enough, and its treatment futile unless the spinal lesion can be cured. Of singular interest, however, is that paralysis of the bladder which results from tabes. This is not infrequently one of the earliest lesions of tabes. It occurs usually at a period of life hut little antecedent to that when prostatism is common. Consequently it is often mistaken for prostatism by the most accurate observers. I have recently seen several cases with paralysis of the bladder due to tabes who gave no history of syphilis, and no evidence of the disease excepting the para- lyzed bladder, absence of deep muscular sensibility, and absence of ankle jerk. All of the other reflexes were entirely normal, the blood was negative to Wassermann reaction; but the spinal fluid showed the characteristic lymphocytosis and positive Wassermann reaction. The symptoms of this condition are comparable to those of prosta- tism; inasmuch as retention of urine is one of the striking features. In the clinical historyx however, it will often be noted that the lack of deep muscular sensation while permitting these patients to go around 434 PHYSIOLOGY AND VARIOUS DISEASES OF BLADDER with greatly distended bladders and little discomfort also permits them to urinate with great infrequency. Indeed, one occasionally learns that the patient cannot urinate at all until the bladder fills to almost over- flowing; then, by an effort, urination can he started, and the bladder entirely emptied. The condition may be suspected when rectal examina- tion and cystoscopy fail to show a prostatic enlargement adequate to explain the retention of urine. It may also be suspected when there is a striking variation in the amounts of retained urine, when the fre- quency of urination does not compare with the amount of retained urine, when there is a history of syphilis, and of lack of sexual power, when the trabeculation of the bladder is out of all proportion to the prostatic enlargement. It has been frequently stated that a certain type of trabeculation, most clearly marked about the ureter orifices, is characteristic of tabes. This is by no means the case. The diagnosis is made by an examination of the reflexes, notably the ankle jerk, and of the spinal fluid, and by cystoscopy. Prostatism and paralysis may, of course, co-exist. Infection occurs early and dilatation and infection of the kidneys follow just as they do in prostatism. But the management of these cases by the catheter is much more successful than it is when the pros- tate is enlarged. The prognosis of tabes itself is intimately bound up with the prog- nosis of these bladder and renal infections. Barney 1 states that 50 per cent of all tabetics die of renal infection and insufficiency. Treatment—The essential treatment is that of the tabes. If the bladder paralysis is not of long duration, one may hope that a vigorous antisyphilitic treatment will control the tabes, and relieve the paralysis of the bladder muscle at least to the extent of permitting the bladder to empty itself. While awaiting this cure, the patient should be regularly catheter- ized, often enough to keep the bladder from becoming overdistended, and should receive appropriate treatment by bladder irrigation and hexamethylenamin. By close attention to the detail of systematic catheterization, and the employment of such combinations of hexamethylenamin and irriga- tion of the bladder as best suited each individual case, I have, in a number of instances, succeeded in keeping the bladder practically clean and in protecting the kidney from any important dilatation or infection for as much as ten or twenty years. One can scarcely hope to cure retention of urine due to paralysis of the bladder by operation. Yet if there is a considerable prostatic en- largement it may be worth while to remove this, both in order to make 1 Boston Med. Surg. Jour., 1910, clxiii, 933, 995; and 1911, clxiv, 13. HERNIA OF TIIE BLADDER 435 catheterization safer, and in the hope that the retention may actually be relieved. In such instances, however, one must not forget the possi- bility of exchanging an unpleasant retention for an unbearable incon- tinence. “Better be a catheter man than a bag man,” as a wise old gentleman once said to me. The reported operative cures may be taken with a grain of salt. I have reported some myself. But if stricture or prostate call for opera- tion, an intelligent opening up of the bladder neck may really have excel- lent results in relieving some of the patient's symptoms, even to the point of emptying his bladder. HERNIA OF THE BLADDER (CYSTOCELE) Cystocele is scarcely recognizable except during herniotomy, and its whole clinical interest centers on the diagnosis of the condition before the bladder is injured by the knife, and on its remedies in case it is so injured. Abdominal, inguinal (scrotal, sometimes on both sides), crural, peri- neal, and ischiatic cystocele, and cystocele through the foramen ovale have been noted. In women vaginal cystocele and femoral cystocele are most common; in men, inguinal. Thus, among 22 femoral cystoceles collected by Gibson,1 1G occurred in women, while 10 among his 77 cases of inguinal cystocele occurred in men. Lotheissen 2 collected 113 cases of inguinal cystocele in men and only 11 in women. He believes that cystocele occurs in 3 per cent of all inguinal herniae, although the usual estimate is from 1 to 2 per cent. Inguinal cystocele is extra- peritoneal in 69.2 per cent of cases, paraperitoneal (“mixed”) in 24.2 per cent, and intraperitoneal in only 6.6 per cent. As extraperitoneal cystocele is met with only in direct inguinal herniae, it is in this class of cases that cystocele is to be looked for. Cystocele is especially common between the ages of thirty and sixty. Its pathogenesis, depending partly upon the hernial traction, partly upon dilatation of the bladder, has been studied by Lotheissen, Lam- bret,3 Cheesman,4 and Alessandri.5 Diagnosis.—The diagnosis is rarely made before operation. The suspected presence of cystocele is verified by the introduction of a sound into the bladder. Treatment.—The proper treatment of cystocele is herniotomy. If 1 Med. Record, 1897, li, 401. 1 Bruns Beitrdge, 1898, xx, 727. 2 Bull, med., 1899, xiii, i, 397. 4 Med. Record, 1901, lix, 985. 5 Guy on’s Annales, 1901, xix, 25, 153, and 325, 436 PHYSIOLOGY AND VARIOUS DISEASES OF BLADDER the cystocele is extraperitoneal, it may not be easy to close the abdominal wall firmly over it. Unintentional incision of the bladder during herni- otomy is rather a grave complication. Lotlieissen collected G5 such cases with 18 deaths. The bladder should be closed by two layers of Lem- bert sutures, the efficacy of the line of suture tested by the intravesical injection, and the radical cure completed. At the end of the operation a catheter should be tied into the urethra. If the patient’s condition does not warrant the delay necessary to accomplish a satisfactory suture of the bladder, the organ may be fixed in the external wound and per- mitted to heal after the manner of a suprapubic cystotomy wound. INTESTINAL FISTULA Yesico-intestinal fistula may be traumatic, ulcerative, cancerous, tuberculous, or congenital. Congenital fistula is extremely rare. Yinety- five reported cases of acquired vesico-intestinal fistula in man have been collected by Chavannaz.1 Of these, 13 were traumatic, 29 ulcerative (from stone, abscess, etc.), 19 cancerous, 7 tuberculous, and 27 unclassi- fied. The fistula usually opens into the rectum (43 cases) or into the sigmoid flexure (14 cases), but it may open into almost any part of the intestine, even the appendix-vermiformis (as a result of the bursting of an appendicular abscess). The fistula may be short and direct, hut in fully 25 per cent of the cases there is an intermediate suppurating cavity between the vesical and the intestinal orifice. Symptoms.—The most notable symptom of vesico-intestinal fistula is the passage of gas from the urethra (pneumaturia). This symptom is always present and is always noted by the patient. The urine may also be passed partly or wholly by the bowel, and, when the opening is large, feces may enter the bladder and issue with the urine. Cystitis is inevitable. Diagnosis.—As a rule, the diagnosis may be made from the presence of pneumaturia, although gas may be evolved by fermentation within the bladder itself. Thus the intravesical action of the yeast fungus upon saccharine urine has been known to cause pneumaturia, and I have seen two obscure cases in which the presence of gas could not be ac- counted for. If the evidences of bladder disease do not sufficiently con- firm the diagnosis of fistula, an injection of methylene-blue solution into the bladder will decide the question by transuding through the fistula and appearing in the dejecta. The position of the fistula may be esti- mated by cystoscopy, by rectal touch, or by the rectal speculum. 1 Cf. Parham and Hume (Ann. Surg., 1909, 1, 251), who have collected 385 cases; also Minakuchi (Beitr. z. Geburts. u. Gynec., 1913, xvii, No. 3), who enumerates 45 cases, 27 of them due to obstetrical and operative injury. INTESTINAL FISTULA 437 Prognosis.—The prognosis depends on the nature of the fistula. Traumatic fistulae often heal spontaneously if the bladder is kept clean and the urethra clear. Tuberculous and malignant fistulae will not heal. Treatment.—Palliative treatment consists of daily irrigation of bladder and bowel. Colostomy is the only appropriate treatment for incurable fisfula. Temporary colostomy is also employed as a pre- liminary to the attempt at radical cure. A radical cure may be attempted in several ways. Chavannaz re- ports three cures by dilating the fistula and scraping its rectal extremity. Separation of the viscera through a laparotomy, and excision of the fistula with suture of its orifice is the proper radical operation. CHAPTER XLVI DISEASES PECULIAR TO THE FEMALE BLADDER Many of the conditions peculiar to the female bladder require no special mention here, or are sufficiently dealt with elsewhere in this work. Thus, for example, the bladder very rarely becomes tuberculous as a result of invasion from the fallopian tube.. Acute infection of the uterine adnexa may involve and rupture into the bladder. Adhe- sions may cause irritation and even cystitis by pulling upon the bladder, and the fibroid uterus may cause similar results. The pregnant woman often suffers a temporary bladder irritation and cystitis. The so-called puerperal pyelitis is a usually descending infection. But certain features of the pathology of the female bladder require a rather more detailed mention. CYSTOSCOPIC PECULIARITIES OF THE FEMALE BLADDER Although cystocele may occur in the virgin, as a general rule the bladder of the woman who has not borne children presents a cystoscopic picture not very different from that of the young male. If anything, the trigonal landmarks are not so clearly and distinctly marked, so that the ureters are harder to find. But the multipara usually loses practically all the trigonal markings. The ureters are found only by a knowledge of where they should be looked for. There is no interureteric ridge or lateral edge of the trigone sufficiently marked to lead the eye to them. This absence of trigonal markings is most commonly seen in cases of cystocele. The amount of cystocele may be measured, not only by the bulging to be seen in the vagina, but also by the amount of residual urine, as well as by the angle to which the cystoscope must he brought in order to approximate its lens to the ureteral orifices. These will usually be found much nearer the urethra than the inexpert cystoscopist expects to find them. Marked cystocele causes retention of urine and symptoms in the female similar to mild prostatism in the male. Marked anteflexion of the uterus and tumors on the anterior uterine wall as well as other pelvic tumors and adhesions may depress and 438 CYSTOSCOPIC PECULIARITIES 439 distort certain portions of the bladder wall (PL I). Pregnancy lias a similar effect. Carcinoma of the Cervix.—When a carcinoma of the cervix uteri invades the anterior or lateral vaginal walls, the most accurate means of ascertaining the condition of the vesicovaginal septum is by means of the cystoscopic examination. The cystoscopic examination becomes progressively more important as the growth extends, and the nearer it approaches the borderland between operative and nonoperative. When the carcinoma approaches and invades the vesicovaginal sep- tum it interferes with the blood supply of the bladder, particularly in those portions supplied by the middle and inferior vesical vessels. And cystoscopically we have bladder pictures of all grades of venous stasis (PI. I). A number of these bladder alterations are similar to those occurring with vesical or perivesical inflammations, and care must be taken in distinguishing between the two. The differentiation can, however, prac- tically always be made. The cystoscopic examination includes: A. Estimation of the direction of the urethra and the position of the trigone, marked elevation of the trigone meaning inoperable car- cinoma. B. Conditions within the bladder: 1. Tumor masses encroaching upon or causing retraction of the bladder. 2. The alterations of the bladder which are similar to those occurring with vesical or paravesical inflammations. These are (a) folding and swelling of the bladder mu- cous membrane, (b) varicosities of the bladder vessels, (c) submucous hemorrhages, (d) congestion of the blad- der, (e) cystitis, (/) bullous edema. The most important among these conditions within the bladder which indicate involvement of the vesicovaginal septum are: Tumor masses encroaching upon or causing retraction of the bladder; folding and swelling of the bladder mucous membrane; marked varicosities. Bladder Neuroses.—Bladder neuroses can be divided into three classes: First, those due to a definite nerve lesion, e. g., tabes dorsalis. Second, those in which the nerve lesion is not definitely known—as when we have bladder disturbances in a neurasthenic or hysterical patient. Third, those in which the bladder disturbance is a reflex, as in a rectal fissure or disease of the pelvic organs. These conditions are seen alike in men and women. The general symptomatology of bladder neuroses is classified by von Frankl-Hoch- wart as follows: 440 DISEASES PECULIAR TO THE FEMALE BLADDER 1. The Sensory anomalies. A. Pain. B. Anomalies of urination. a. Increase. b. Decrease. 2. Dysuria. 3. Urinary Retention. 4. Incontinence. Pain.—The cause of painful and frequent urination is more often obscure in women than in men. Nevertheless, it always has a cause, and this cause should be disclosed by a careful examination. The physi- cal examination should include an investigation both of the kidneys and of the pelvic organs for palpable displacement, adhesions, tumors, enlargement, inflammation, etc., which may, either by infection or by mechanical means, cause irritation of the bladder. If no such causes of the disturbance are found, one has recourse to cystoscopy, urethros- copy, and urinalysis. Thus we may, in a good many cases, readily rule out the usual stone, tumor, inflammation, tuberculosis, etc., which are common to male and female and give gross and readily recognizable lesions in most cases. There still remain cases of bladder pain and frequent urination to be accounted for. Many of these will be found to have a very slight infection dependent upon a mild pyelonephritis and curable by lavage of the kidney pelvis with silver nitrate or by improving the patient’s general health. Others will be found to have mild degrees of cystocele and other slight displacements improvable by mechanical or operative means. Others still have obscure inflam- mations of the bladder which are of two types: 1. Ulcerative cystitis, which may be the simple ulcer of the vault described by Hunner or the diffused aphthous staphylococcus cystitis with little intervening general inflammation, or leukoplakia, or cystitis cystica. 2. Trigonitis, due to the extension of urethritis to the adjacent portion of the bladder base, is a diagnosis upon which the unskilled cystoscopist relies too often to explain a condition for which he can find no other cause. The diagnosis of trigonitis should only be made when the trigone is actually seen to be inflamed. The trigonitis may descend from the kidneys, or ascend from the urethra. If the kidneys are uninfected (as disclosed by culture of the urine) the trigonitis may be looked upon as of urethral origin, and a cure may be expected by treatment of the urethra, either by dilatation by sounds or by the application of 1 per cent silver nitrate solution, or 2 per cent carbolic acid, or 20 per cent argyrol. Retention and Incontinence of Urine.—Retention is only in- teresting because it is so rarely looked for and hence so frequently CYSTOSCOPIC PECULIARITIES 441 overlooked. Its results are quite tlie same in women as in men. It can usually be cured by dilating the urethra or by plastic operation for the relief of cystocele. Incontinence of urine is a much more difficult topic in women, be- ca use the normal woman has so slight a hold upon her bladder sphincter. Many women not obviously diseased lose control of their bladder sphinc- ter to a certain extent through such slight causes as catching cold or diarrhea. Incontinence is, of course, often a symptom of overflow in women as it is in men, and retention should always be carefully ex- cluded in these cases. Finally, there is a class of operative cases in which the spliincteric relaxation is due to pregnancy or to surgical operations. Kelly 1 has reviewed the treatment of this condition and advises for its operative relief a median vertical incision made in the anterior vaginal wall over a Pezzer catheter in the bladder to identify the position of the bladder neck. The vaginal wall is carefully dissected free until the finger can grasp at least one-half or two-tliirds of the neck of the bladder including the contiguous urethra. Two or three lateral mattress sutures of fine silk or linen are then used to approximate the tissues on each side of the vesical neck. The first one takes in about 1.5 cm. of tissue, the next takes in another fold over this one. The catheter is removed, the superfluous vaginal mucosa resected, and the incision sutured in several layers with fine catgut. A perineorrhaphy may be done at the same time. Postoperative catheterization is avoided as far as possible. Kelly reports 16 successful operations. 1 Surg., Gyn. & Obstet., April, 1914, xviii, 444. CHAPTER XLVII IDIOPATHIC RENAL HEMATURIA—VARICOSE VEINS OF THE BLADDER IDIOPATHIC OR ESSENTIAL RENAL HEMATURIA The hematuria that occurs with tumor of the kidney is at once the most important and the most profuse spontaneous hemorrhage from that organ. Bleeding is also a common symptom of renal stone and tuber- culosis ; and when the kidney bleeds, one of these three conditions— stone, tubercle, or tumor—is usually suspected. But there are a great many other diseases, a few of them surgical in their aspects and most of them medical, in which renal hemorrhage—even profuse renal hemor- rhage—may occur. To such profuse hemorrhage from an obscure cause has been given the name of essential or idiopathic renal hematuria. Etiology.—The causes to which this essential renal hematuria has been attributed may be classified as follows: 1. Hemophilia, scurvy, purpura. 2. Drug-poisoning (turpentine, cantliarides, etc.). 3. Parasites (e. g., distoma hematobium). 4. Acute or chronic febrile diseases (scarlet fever, malaria). 5. Surgical diseases (hydronephrosis, renal mobility). 6. The passage of crystals. 7. Angioneurosis. 8. Chronic nephritis. 9. Papillitis. It is not necessary to consider all these conditions in detail. Dis- toma, for instance, is practically never heard of in these latitudes. Renal hemorrhage caused by drugs or occurring in the course of one of the bleeding diseases has no surgical interest. There remain the hema- turia due to surgical causes, to angioneurosis, to chronic nephritis, and to papillary varicosities. It is possible that any of these causes may produce a profuse renal hemorrhage. Ureter catheterization, pyelog- raphy and examination of the loin should eliminate hydronephrosis and movable kidney, and there are left for our consideration only angioneu- rosis, chronic nephritis, and papillary varicosity. That hematuria may be due to chronic nephritis requires no proof. Examples are commonplace. But such examples, representing a hem- 442 IDIOPATHIC OR ESSENTIAL RENAL HEMATURIA 443 orrhage—even a profuse hemorrhage or a series of such—in the course of an acute or active nephritis have no peculiar surgical interest. What we need to know is whether a prolonged, profuse hemorrhage may result from chronic nephritis in the absence of any other sign of this inflammation. lTp to 1895, or thereabouts, the question was answered mainly in the negative. Otherwise inexplicable profuse or persistent hematuria was attributed to angioneurosis. But in the following decade many nephrec- tomies performed for this condition revealed, almost constantly, either parenchymatous or interstitial nephritis, which had given no symptoms or urinary signs other than the bleeding. In spite of the fact that the bleeding point was not found, the so-called idiopathic hematuria was therefore attributed to nephritis. But as early as 1898 the bleeding point was found in three cases to be due to oozing from varicose veins of a renal papilla. Fenwick 1 re- ported six such cases, Hugh Cabot 2 added another, and subsequent observers have added others, preferring to attribute the condition to inflammation under the title “Papillitis.” The affected papilla bleeds and looks purple and “spongy.” Section demonstrates the varicosities. Papillitis explains many but not all cases. A few still remain abso- lutely unexplained (cf. Schwyzer3). Symptoms.—There is but one symptom—viz., profuse hematuria. This may be constant or intermittent. It is rarely sufficiently severe to cause anemia. The bleeding may last a few hours or it may continue for days; hav- ing once occurred it may never appear again; or it may return time after time, and be so profuse as to threaten the patient’s life. In the pres- ence of a condition so various in its manifestations, so comparable in its only symptom to carcinoma of the kidney, so dangerous in its con- tinuance, a diagnosis is of the utmost importance, and a diagnosis is difficult to obtain. Full realization of the fact that the bleeding, which is so often the first symptom of malignant growth in the kidney, may occur two, three, or even five years before any other symptom, cannot fail to impress upon the surgeon the necessity for the utmost caution in deciding the nature of the malady. It is' not sufficient that the hemorrhage cease. This it does spontaneously. The patient should be warned that his bleeding may be the first symptom of serious renal disease and a careful examination insisted upon. The surgeon must recognize that the more spontaneous the bleeding and the more entirely free the patient from any other symptom, the greater is the probability of malignant disease. Cystoscopy,” London, 1904. 2 Trans. Am. Assn. Gen.-Urin. Surgeons, 1908, iii. 3 Ann. Surg., 1909, xlix, 628. 444 VARICOSE VEINS OF THE BLADDER Diagnosis.—Renal tumor and idiopathic hematuria may usually be readily distinguished by palpation of a loin tumor and ureter catheteri- zation, revealing a deficient function in the case of tumor. If these fail pyelography reveals deformity of the kidney by tumor. If the examina- tion fails to show chronic nephritis, stone, tuberculosis or tumor, the diagnosis of papillitis or essential hematuria is made by exclusion. Treatment—Idiopathic renal hemorrhage may often be checked by the administration of 0.5 gram of turpentine in capsules three times a day. By this treatment I have been able to cure some five or six cases. In one striking case the patient had been bleeding profusely for a month. Every drop of urine passed was stained dark red by the contained blood. One week on turpentine sufficed to check the bleeding absolutely and permanently. Yet in another case the bleeding was checked by turpentine, recurred several years later, and was then not amenable to that drug, nor would the patient accept operative exploration. ITagner 1 has checked several cases (notably one of constant bleeding for thirty-six years) by passing the ureter catheter. Others have achieved a like result by injection of adrenalin into the renal pelvis. In case such methods fail, nephrotomy should be performed and the bleeding papilla curetted. If the papilla is not found, nephrotomy (or even decapsulation) may still cure. Nephrectomy is the last resource. Braascli2 reports 77 cases. In 26 cases ureter catheterization checked the bleeding (4 relapses) ; in 18 pelvic lavage succeeded (3 relapses) ; 6 were checked by adrenalin injection (5 relapses). Ne- phrotomy was performed 12 times with 7 cures. Nephrectomy was performed 16 times with one death. VARICOSE VEINS OF THE BLADDER A few cases Lave been reported which showed only one symptom— i. e., a spontaneous, profuse, uncontrollable hemorrhage of the bladder, which hemorrhage was found to arise from a ruptured varicose vein lying immediately under the mucous membrane. The diagnosis was made either by cystoscopy as the hemorrhage was ceasing, or by' supra- pubic cystotomy undertaken for the relief of the hemorrhage. If the hemorrhage does not stop spontaneously the only treatment is cystotomy with ligature or cauterization of the bleeding point. I have several times seen varicose veins in the bladder (PL I), but have never known them to bleed. 1 Trans. Am. TJrolog. Assn., 1907, i. 2 Jour. A. M. A., June 1, 1913. CHAPTEP XLVIII CYSTS AND TUMORS OF THE KIDNEY CYSTS Sevex varieties of cysts occur in and about the kidney. These are: 1. Multiple small cysts. 2. Paranephritic cysts. 3. Large simple cysts. 4. Tuberculous cysts. 5. Cystic degeneration. 6. Echinococcus cysts. 7. Dermoid cysts. 1. Multiple Small Cysts.—Multiple small cysts are those dilata- tions of the renal tubules that are often seen in kidneys affected with chronic nephritis. They usually occur in the cortex and often project beneath the capsule. They may be single or multiple; they do not seem to attain a large size and are of purely pathological interest. 2. Paranephritic Cysts.—Paranephritic cysts also may be dismissed wTith a word. They are extremely rare; they may arise from the suprarenal capsule; they may be hydatid or the result of an encysted perinepliritic hematoma. They are not distinguishable from other cysts of the kidney except by exploratory incision. Morris 1 has col- lected their published records. 3. Simple Cysts of the Kidney.—Single, large serous cysts are oc- casionally found projecting from the surface of the kidney. Such cysts may be single or multiple. They may be associated with chronic in- terstitial nephritis; they are rarely bilateral. The contents of the cysts are serous or hemorrhagic, never urinous. Such cysts give rise to no symptoms unless they attain such a size as to produce a tumor or to cause pressure pain. Under these circumstances the tumor is habit- ually mistaken for hydronephrosis, renal echinococcus, ovarian cyst, or some other tumor. Exploratory incision reveals the nature of the disease. The proper treatment of such cysts is to excise them with the adjacent portions of the renal tissue, or, if this is impracticable, to cut away as much of the cyst as possible, to sear the surface of the remainder with carbolic acid, and to close the lumbar wound, leaving 1“Surgery of the Kidneys.” 445 446 CYSTS AND TUMORS OF THE KIDNEY a drainage-tube to the kidney. When the cysts are multiple Morris advises that the smaller ones be neglected. Englander 1 has reviewed the reported cases from the surgical point of view. 4. Tuberculous Cysts.—Large cysts are infrequently seen in renal tuberculosis. They have no clinical interest. 5. Cystic Degeneration of the Kidney (Large Polycystic Kidney). •—The kidney is converted into a congeries of cysts which leave scarcely any of its parenchyma in a normal condition (Fig. 99). The patho- genesis of this condi- tion is hotly debated. The three favorite the- ories are: 1. That the cysts are incidental to a chronic interstitial ne- phritis. This explains the bilateral nature of the disease, but does not show why it should be associated with a similar cystic condi- tion in other organs, notably the liver. 2. That they are the result of congenital malformation in that the kidney pelvis does not become properly apposed to the paren- chyma. 3. That they are cystadenomata. So much for the theories. From the clinician’s point of view the facts, though definite enough, are equally confusing. The disease appears at all ages. In the fetus the kidneys have been known to be so much enlarged as to obstruct labor. Certain writers have endeavored to distinguish congenital cystic degeneration from that which occurs in adults, but there is no foundation for this distinc- tion. The condition is always bilateral. Among 62 cases collected by Lejars only 1 was unilateral, and even in that one there was a single small cyst in the opposite kidney (Morris). Another peculiarity Fig. 99.—Polycystic Kidney. 1 ArcMv f. Tdin. Chir., 1901, lxv. 112. CYSTS 447 of the disease is the frequency wfith which the liver is involved. Of Ritchie’s 88 cases 86 were bilateral, the liver was cystic in 21, and the thyroid gland, the uterus, and the ovary each cystic in one case. Pathology.—The most striking feature of the fully developed cystic kidney is its size. The organ grows so large as to fill the entire lumbar region and to project anteriorly almost to the median line (Fig. 100). The disease usually progresses more rapidly upon one side than upon the other, so that one kidney may be so much enlarged as to form a visible abdominal tumor, while the other can not he palpated. The largest recorded specimen weighed 16 pounds (Hare). Apart from its size, the most striking characteristic of this growth Fig. 100.—Outline of Polycystic Kidney and Spleen. Duration 8 years; death six months later. Right kidney and liver also involved. is its irregularity of surface. When the kidney has grown to such a size as to cause a surface tumor palpation reveals the existence over the growth of larger or smaller rounded lumps, some hard, some elastic, and some even fluctuating. This characteristic irregularity of surface is all but pathognomonic of cystic disease of the kidney. On section the cystic kidney shows an infinite number of cysts of varying sizes. With the naked eye it may be impossible to detect any normal renal tissue. The contents of the cysts are liquid, viscid, col- loid, or caseous. They are usually amber-colored, rarely dark and hem- orrhagic, and exceptionally suppurating. The cyst contents are not urinous, and the cysts do not communicate with the sinus of the kidney. Exceptionally calculi are found in the cysts, and in the kidney pelvis. Symptoms.—The symptoms of the disease are habitually those of chronic interstitial nephritis, and, unless the tumor grows to such a size CYSTS AND TUMORS OP THE KIDNEY 448 as to attract attention, the disease runs its course and terminates as chronic nephritis. The urine is albuminous and contains casts. There is polyuria. The surgical symptoms are hematuria, which occurs in 25 per cent of all cases (Newman1), tumor, and pain. Pyuria from secondary in- fection is occasionally associated with calculus. The course of the disease is slow. Morris estimates the expectation of life at from one to ten years, although Ritchie has recorded a case living twenty-two years after the diagnosis had been made. Diagnosis.—So rarely does the renal condition attract attention that only 5 of Lejar’s 62 cases were correctly diagnosed during life. According to Morris, the tumor is discovered during life in 25 per cent of cases, and about 50 per cent complain of symptoms closely resembling those of chronic interstitial nephritis. When there are hemorrhage, pain, or pyuria and slight enlargement of the kidney this is likely to be mistaken for one of the surgical diseases of that organ. The diagnosis can usually be made by palpation. (I was once misled by a symptomless bilateral calculous hydronephrosis. The pa- tient dropped dead the next day.) In one of my cases radiography dis- closed the cystic nature of two moderately enlarged kidneys. (The patient insisted upon pyelography, which I refused. It was done by another surgeon and caused such alarming symptoms that nephrectomy was immediately performed.) Braasch states that “the pelvic outline of bilateral cystic kidney is characterized by flattening of the calices, giving a general oval contour to the pelvis, in contradistinction to the retracted calices of tumor. Occasionally, however, a retraction of the calices may also be found with the bilateral cystic kidney, but it then is broad and open, not slit-like or narrow.” Treatment.—Cystic degeneration of the kidney is not a surgical disease; in its clinical aspects it is a chronic interstitial nephritis. Rovsing 2 has had some success in temporarily relieving pain and improving kidney function in 3 cases by multiple incision and punc- ture of cysts until the kidney is reduced to a normal size. Lund 3 reports four cases of improvement following this operation. Nephrectomy does not cure. Its immediate mortality is very high (33 per cent of 62 cases reported by Sieber4). 6. Echinococcus Cysts.—Echinococcus cysts of the kidney are rare. Houzel5 collected the statistics of Finsen (Iceland), Thomas (Aus- tralia), Neisser, and Davaine, a total of 2,111 cases of echinococcus 1 Glasgow Med. Jour., 1897, i, 324, and ii, 42. 2 Am. Jour. Tirol., 1912, viii, 120. 8 Jour. A. M. A., 1914, lxiii, 1083. *Deutsch. Zeitsclir. f. Chir., 1905, Ixxix. 5Bevue de chir., 1898, xviii, 689, 811. Cf. also Carta-Mulas, Gas. d. Osp., 1915, xxxiv, 609. SOLID TUMORS OF THE KIDNEY 449 cysts in men, with only 115 (5 per cent) instances of renal echinococcus. The cyst arises in the cortex of the kidney and grows slowly, with' out producing symptoms, until it reaches such a size as to form an ob- vious tumor, or ruptures. When left to itself the cyst habitually bursts into the pelvis of the kidney, and its contents are discharged with the urine. This occurs in 52 of the 63 cases collected by Roberts.1 In 3 of these cases the cyst ruptured into the intestines as well, once into the stomach, once into the lungs; and of the 11 remaining cases 8 did not rupture, 2 were incised, and 1 burst into the lungs only. In only 18 of these cases was the tumor distinguished during life. Suppuration of the cyst may occur after it has ruptured. The results of rupture are not necessarily good. The cyst may for years continue to discharge without ever emptying itself. The symptoms of the disease are lumbar tumor, growing slowly, with little fever or pain, and no constitutional symptoms. The tumor itself simulates a hydronephrosis, and the hydatid fremitus can rarely be obtained. Later in the disease rupture of the cyst is betokened by a renal colic and followed by the discharge of hydatid vesicles through the urethra. Treatment.—Twenty of Roberts’s cases recovered and 19 are known to have died. The only treatment of the disease, and often the only means of making a diagnosis, is nephrotomy. After the cyst has been incised and thoroughly washed out a cure may be expected. It is scarcely necessary to excise the entire cyst, and in a number of cases nephrectomy has proved fatal. 7. Dermoid Cysts.—Baldwin2 has collected seven reported cases of renal dermoid cysts. SOLID TUMORS OF THE KIDNEY BENIGN TUMORS Benign tumors of the kidney are extremely rare. The commonest of them is the renal “lipoma,” the benign type of “hypernephroma.” True lipoma and fibroma have been described. These benign growths have no clinical features. They do not give rise to any symptoms and the diagnosis is only made post mortem. Their sole interest lies in the fact that most of them are liable to malignant degeneration. Frequency.—Nine cases of primary renal tumor were recorded in 4,505 autopsies. Secondary deposits were found in the kidneys 10 MALIGNANT GROWTHS 111 Urinary and Renal Diseases,” 2d Edit., Phila., 1872, p. 566. 2Surg., Gyn. Obstet., 1913, p. 219. 450 CYSTS AND TUMORS OF THE KIDNEY times in 126 cases of carcinoma, and 10 times in 69 cases of sarcoma. While these secondary deposits are commonly bilateral the primary malignant disease is habitually unilateral.1 Penal growths are about equally frequent in the two sexes and on the two sides. The distribu- tion of the disease throughout life is rather striking. Kuster has tabu- lated 422 cases as follows: From birth to 5 years 128 Six to 10 years 41 Forty to 50 years 125 Over 50 years 128 Thus the malignant tumors of the kidney may be considered clin- ically as the tumors of childhood and those of adult life. In child- hood they are most common from birth to the fifth year, exceptional after the tenth year. In adults they occur most commonly between the forty-fifth and the sixtieth year. The malignant tumors of the kidney may be divided pathologically as well as clinically into two age groups, viz., the embryomata (Wilms’s tumors) of childhood and a variety of tumors, chief among which are the so-called “hypernephromata” of adult life. Trauma and heredity have not been shown to influence tumors of the kidney while nephritis, suppuration and stone are accidental and secondary rather than primary. (Though epithelioma secondary to stone has been noted.) Tumors C Wilson rses Watson “Hypernephroma” 71 45 Hypernephroma of the adrenal 2 4 Papillary adenoma 2 — 4 Papillary cystadenoina 2 — 11 Sarcoma 7 2 Carcinoma 4 3 Fibroma 1 '14 Lipoma — 5 Embryoma 3 — Epithelioma of the pelvis 1 — Papilloma of the pelvis 3 1 Totals 92 89 1 Wagner (Folia TJrol., 1912, vi, 619) reports a case with primary tumors in each kidney and quotes Kiister’s statistics which showed post mortem 42 (out of 261) cases of metastasis of a renal tumor in the opposite kidney. * Should doubtless be classed with “ hypernephroma. ’ ’ SOLID TUMORS OF THE KIDNEY 451 The relative frequency of these tumors may be roughly estimated from the preceding table (p. 450) made up of reports by Watson and Wilson.1 Embryoma.—The renal tumors of childhood were usually spoken of as sarcomata, adenosarcomata or mixed tumors until properly classi- fied by Wilms.2 These tumors, like most other malignant growths, re- Fig. 101.—Adenocarcinoma of the Hypernephroma Type. main relatively incapsulated within the kidney, so that one usually finds portions of renal tissue uninvolved in the growth even after this has reached twenty pounds’ weight. Like other embryomata these growths are mixed in character, and, while the sarcomatous elements predominate, especially in the large tumors, areas resembling carcinoma and bits of enchondroma, osteoma, etc., can be found in the growth unless these have been overrun by the more malignant tissue. These 1 Ann. of Surg., April, 1913. 2 ‘ ‘ Mischgesehwuelste der Nicrc, ’ ’ Leipzig, 1899. 452 CYSTS AND TUMORS OF THE KIDNEY growths extend by lymphatic continuity into the perirenal tissue and by venous metastasis. They reach an enormous size. “Hypernephroma.”—The propriety of this title has been gravely questioned of late years. But inasmuch as they are widely known under this name, and as the pathologists have not yet reached any unanimity in their interpretation of the nature of these tumors, we may still continue to call them “hypernephromata.” They destroy life before reaching anything like the size often attained by the tumors of infancy; but like them they usually occupy only a portion of the kidney even after they have extended into the vessels and the perirenal tissue. The early pathol- ogists described them as malignant lipomata be- cause, in their growth as well as in t li e i r mi- croscopic characteristics, they show a certain re- semblance to fatty tu- mor. Grawitz, however, gave them the name of “hypernephroma ” after showing that their structure closely resem- bles that of the tumors of the adrenal glands. He inferred that they were due to adrenal inclusions,1 within the kidney, such as have occasionally been found.2 Of late years this theory has been questioned by various writers, notably by Wilson, who maintains that they are “mesotheliomata derived from the nephrogenic vesicles which had failed in the early embryo to form a tubular connection with the renal pelvis.” Others are satisfied to classify them simply as carcinomata. The striking microscopic characteristic of these growths is their great variety of structure. In places they exhibit a structure which suggests the cortex of the adrenal gland; they are very vascular; indeed, as Watson remarks, their stroma may he said to be formed of capillaries, so that in places they suggest angiosarcoma and endothelioma. The cells are polygonal or columnar in shape, and their large lightly staining Fig. 102.—Carcinoma op the Kidney. 1 Ann. of Surg., April, 1913. 2 Dunn (Jour. Path, and Bacteriol., 1913, xvii, 515) classifies them as (1) true adrenal rests, (2) adenopapillary tissue and (3) papilliferous cysts. SOLID TUMORS OF THE KIDNEY 453 bodies have given rise to the French title “carcinoma with clear cells.” With the breaking down of certain parts of the tumor one may see pictures absolutely characteristic of papillary cystadenoma while other specimens show a narrow tubular development which has suggested the title “adenoma.” The larger cells often contain fat or become vacuolated when this disappears. The larger tumors usually show a necrotic center. Carcinoma—Perhaps the above tumors are but one form of renal carcinoma. There is, however, a rare clinical type of carcinoma, usually an adenocarcinoma, which involves the whole of the kidney (Fig. 102). Sarcoma.—Spindle-celled, round-celled, and mixed sarcomata are described. The latter are actually embryomata, hut the spindle and round-celled varieties, though rare, usually occur in adult life. Wilson states that “most of the few true sarcomata of the kidney develop primarily in adult tissue of the renal capsule and involve the cortex secondarily.” Other Tumors.—The papillary cystadenomata are doubtless all variants of the “hypernephroma,” so are the adenomata, benign or malignant. Tumors of the Renal Pelvis.—See page 457. Symptoms of Malignant Growths The symptoms of renal tumor are: Hematuria. Urinary symptoms. Tumor. Compression symptoms (varicocele). Pain. General symptoms. Hematuria.—Hematuria, is usually the first symptom of renal tumor in the adult. This was the first symptom in 138 out of 257 cases studied by Albarran.2 Hematuria occurred during the course of the disease in 235 out of 357 cases. The hematuria is characteristically abundant, painless, spontaneous, and not influenced by motion or rest. Renal colic may result from the passage of clots through the ureter. These clots may sometimes be discerned in the urine by their wormlike shape. The bleeding may be so free that the blood only clots after reaching the bladder. I have seen four cases that required catheterization to free the bladder of clots. The hematuria may occur many years before any other symptom. Thus Hildebrand has reported cases in which the intervals between the appearance of blood and any other symptom of tumor were eight to twelve years. The hematuria may be so profuse as to cause grave anemia. 1Cf. Kretschmer, Surg., Gynec. and Obstet., 1914, xix, 766. 2<. f. Kinderh., 1911, lxxiv, 1 (by Jour. A. M. A.), 510 MALFORMATIONS OF THE BLADDER AND URETHRA With perineal hypospadias the scrotum is bifid, and the penis is usually very imperfectly developed, imperforate, and looks like a large clitoris. The bifid scrotum passes very well for a vulva. This is a common type of pseudohermaphrodite. Etiology.—Hypospadias is a simple arrest of development in a portion of the lower wall of the urethra, its lateral halves failing tc unite in the median line. In favor of this view are the manifest hereditary tendency to this deformity seen in some cases, and the fact that at two months the embryo has hypospadias normally. The scrotum has not yet united, and if natural development ceases here the last degree of hypospadias results. It may be urged that this theory does not explain the incurvation of the penis, nor its adhesion to the scrotum, nor the scarlike contracted appearance of the orifice. To explain these facts Kaufmann 1 advanced the theory that hypospadias and epispadias are examples of congenital fistula dependent upon imperfect union of the penile and the balanitic urethra. These two portions of the canal, it is known, are developed separately, and if imperfectly approximated atresia at the penobalanitic junction may result. How, Kaufmann sup- poses that the urine secreted by the fetus may break either through the obstruction, leaving congenital fistula, or through the floor of the canal, producing hypospadias, or through its roof, thus causing epi- spadias. This theory explains incurvation and adhesion hut not mal- position of the urethra in epispadias, or exstrophy of the bladder, with nonunion of the symphysis pubis—phenomena so closely related to epi- spadias that no theory which does not elucidate them can be invoked to account for the urethral deformity. Symptoms.—Balanitic hypospadias is unimportant; many patients have it without being aware of the fact, while the greatest inconvenience it produces is a slight imperfection in erection and a dribbling at the end of urination. With penile or perineal hypospadias, however, the patient may be forced to urinate in a squatting posture to keep from wetting himself, erection may be very imperfect, and there may be im- potence from inability to throw the semen into the vagina. An associated inconvenience is the necessity of enlarging the con- tracted meatus, in order to introduce dilating instruments, in case of stricture. Treatment.—For balanitic hypospadias no treatment is actually necessary unless a meatotomy to permit the introduction of instruments into the urethra. But if the patient demands radical operation, Beck’s procedure should he employed. For penile and perineal hypospadias operation is always required (p. 742). 1 “Deutsche Cliirurgie,” 1886, 1 (a), 60. MALFORMATIONS OF THE URETHRA 511 EPISPADIAS Epispadias is a fissure of the superior wall of the urethra with ectopia of the canal (Guyon). It is extremely rare. According to Baron,1 epispadias occurs once for 150 cases of hypospadias, but Mar- shall did not find a single case of epispadias in examining GO,000 conscripts.2 The epispadias may be balanitic or penile, or the urethra may be entirely laid open. This complete epispadias is almost always accompanied by exstrophy of the bladder. The epispadic orifice is large, and sometimes the finger may even be passed through it into the bladder. The prepuce forms a knob of loose tissue below the glans. The penis is short and thick, or small and more or less deviated. It is usually adherent to the scrotum, sometimes practically buried in it. The pubic bones may be separated even when there is no exstrophy of the bladder, and there may be hernia of that organ without exstrophy. Etiology.—The observations made upon the etiology of hypospadias apply equally well to this condition. Epispadias is certainly an arrest of development in the upper wall of the urethra, but it is still a matter of hypothesis how the urethra gets above the united corpora cavernosa; for even when the genital buds which are to form the corpora cavernosa are still separate at the fortieth day of fetal life, the urethra is beneath them. With exstrophy of the bladder, where the lower portion of the abdominal wall is lacking and the pubic bones do not come together, it is easier to understand how the roof of the urethra may be wanting throughout. Symptoms.—The symptoms consist in the functional derangement of micturition, erection, and emission, as in hypospadias; but it is to be noted that incontinence of urine, which never complicates hypospadias, is usually the main feature of severe cases of epispadias, and this cries out for operation more loudly and incessantly than even the most aggravated symptoms of hypospadias. Unfortunately, it is precisely here where operations are most in demand that they accomplish least. Treatment—For the milder cases, uncomplicated by the loss of sphincter power, the counsel to bear their woes patiently is a good one. The methods hitherto employed to relieve this condition—even the fa- vored procedures of Thiersch and Duplay—are tedious and fraught with failures. In view, however, of the success of the Eove-Josserand operation for hypospadias, I should be tempted to try it for simple penile epispadias. In addition to the changes obviously necessary to adapt the operation to epispadias it would be necessary to divert the 1 Dolbeau, op. cit., p. 11. 2 Englisch (Bull, med., Paris, 1895, ix, 153) has reported a case of complete separation of the penis into lateral halves, each corpus cavernosum forming a penis by itself, and the urethra opening between them. 512 MALFORMATIONS OF THE BLADDER AND URETHRA stream of urine, and it might seem advisable to connect the new and the old urethra by continuing the graft into the outer extremity of the epispadic urethra previously denuded. When the sphincter is lost it cannot be replaced. The complicating adhesions, torsion or flexion of the penis, must be dealt with here, as in hypospadias, by liberating incisions of the skin and the sheaths of the cavernous bodies. Young’s operation seems to have superseded all others. He has even employed it on a case with incontinence of urine. CHAPTER LTV DISEASES OF THE SCROTUM ANATOMY The scrotum is a pouch formed of skin and of muscular and con- nective tissue. Its function is to contain and support the testicles. It is developed from lateral halves which unite centrally in the raphe, a raised line continuous with the raphe of the penis and that of the perineum. The integument of the scrotum is delicate in structure, covered with a few hairs, and likely to become pigmented at puberty. The sebaceous glands are very large. The dartos is a layer of unstriped muscle firmly attached to the integument, and reflected inward from the raphe, to form the septum scroti. On exposing the scrotum to the air, the vermicular contractions of this muscle can be readily seen. They occur under the influence of cold or fright, and during the venereal orgasm. In youth, especially in winter, the dartos is habitually contracted and holds the testicles well up under the pubes. The ancient sculptors did not fail to notice that contraction of the scrotum was a mark of general as well as of sexual vigor. In the aged and infirm, however, especially during the summer, the muscle relaxes, allowing the testicles to hang low. The septum scroti is pervious to fluids, so that serum or infiltrated urine can find its way readily from one side to the other. The lym- phatics of the scrotum are large and numerous and lead to the inguinal glands. The connective tissue within the scrotum, like that of the penis, is practically devoid of fat. The muscular dartos, described above, is the only layer of importance. The space between it and the testicle is filled with a loose mesh of fascia within which run the scattered fibers of the cremaster muscle, and beneath which the infundibuliform fascia, derived from the transversalis fascia, forms the investment of the spermatic cord. ANOMALIES The scrotum develops independently of the testicles, but if the latter fail to descend it remains rudimentary. 513 514 DISEASES OF THE SCROTUM Failure of union between the lateral halves of the scrotum consti- tutes one of the features of pseudohermaphroditism. CUTANEOUS DISEASES The scrotum may be affected by most of the diseases of tlie skin. Only those that are modified by their position deserve notice. Eczema—Eczema attacking the scrotum and the surrounding parts is sometimes excessively obstinate and prone to relapse. Acute eczema, urticaria and dermatitis venenosa result in an enor- mous edematous swelling. Intertrigo.—Intertrigo occurs in children and in fat men of rheu- matic habit. Much can he done to prevent it by scrupulous cleanliness, and the use of a suspensory bandage to keep the cutaneous surfaces apart. To overcome the hyperemia, rest, cleanliness, and exposure of the parts to the air are speedily effective in mild cases. If the surface is moist and excoriated, it should be dusted with equal parts of finely powdered oxid of zinc, camphor, and starch, or it may be dressed with the oxid of zinc ointment or with a solution of sulphate of zinc. A strip of old thin linen should be used to sling up the scrotum and keep the cutaneous surfaces apart. Later, when the parts are dry, compound tincture of iodin, at first considerably diluted with water, locally, will hasten the cure. Pityriasis.—In men with a delicate skin, especially in summer, there is often a slightly brown discoloration of the thigh and the scro- tum, where the two surfaces lie habitually in contact, caused by a vegetable parasite in the upper layers of the epidermis. It sometimes gives rise to a mild local erythema and considerable itching. A few applications of the compound tincture of iodin diluted to half strength, and painted on after the affected skin has been washed with soap and dried (to remove the fat from the scales and spores), will cure the dis- coloration and the itching. Sulphurous acid does well. Eczema Marginatum—This is another parasitic disease, affecting the scrotum, thighs, mons veneris, and buttocks. It is not an eczema, but a herpes tonsurans vesiculosus—a combination of herpes tonsurans and intertrigo, as proved by Pick.1 The eruption commences in one or more small, round patches, red, elevated, and itchy, just where the scrotum habitually lies in contact with the thigh. It spreads circum- ferentially, healing in the center. The border of the eruption is sharply defined, and forms the distinctive feature of the disease. It is com- posed of papules, vesicles, excoriations, and crusts. The parts within this festooned border over which the disease has passed are left of a 1 Archiv f. Berm, und Syph., 1, iii, 443. INJURIES OF THE SCROTUM 515 brown color. Often, little heaps of dried-up scales lie here and there upon this surface. Patches of eruption break out in the neighborhood or within the border, and behave exactly like the patches first consti- tuting the disease. The affection is slow in getting well and tends to relapse. Friction and moisture of the parts, together with the parasite, are necessary for its production. Among the scales scraped from the margin, the microscope may detect the moniliform filaments and spores of the tricophyton of Malmster. In certain stages of the disease the parasite is difficult to find. Treatment. —Dilute lead-water or oxid of zinc ointment may be used locally at first if there be much inflammation of the skin, to be followed by parasiticide lotions, or the latter may be commenced with at once. The best of these is a mild solution of corrosive sublimate (1: 10,000), which should be kept constant- ly applied. Sulphurous acid, pure, is an ex- cellent parasiticide; or compound resorcin ointment (N. F.). Treatment should he kept up for some time after apparent cure, as relapses are the rule, and can only be averted in this way. Pediculi Pubis These parasites may be found upon the scrotum, as they may, in fact, upon any part of the body from which the hairs of puberty grow. They exist in greatest abundance, however, about the genitals, and particularly on the mons veneris. They are plainly visible to the naked eye, as are their eggs attached to the hairs (Fig. 116). Mourson,1 a French naval surgeon, first pointed out the relation between certain blue spots on the skin and pediculi pubis, and Douguet confirmed the relationship by inserting a bruised pediculus under the skin and producing a spot. Mallet proved that the coloring matter resides in the salivary glands of the pediculus. bio treatment is better than the old-fashioned blue mercurial oint- ment, which may be rubbed into the hairy parts about the pubes and perineum and somewhat down the thighs, the patient going to bed in drawers and sleeping covered with the ointment all night. Two such applications, at a few days’ interval, usually destroy the colony. The treatment is a very dirty one, and much soap and hot water form essen- tial parts of it. Fig. 116.—Pediculus. a, Nit attached to hair. INJURIES OF THE SCROTUM Wounds.—Wounds of tlie scrotum, whether surgical or accidental, give rise to free bleeding. This must be entirely controlled by ligature 1 Lancet, 1882, ii, 454. 516 DISEASES OF THE SCROTUM before the wound is sutured, for in the lax scrotal tissues an insig- nificant oozing may give rise to an enormous hematoma extending to penis, thighs, and abdomen. As a further precaution, the scrotum should be compressed beneath the adhesive plaster dressing described on p. 539. Loss of Tissue.—When any considerable portion of the scrotum is destroyed by gangrene, accident, or the knife, the rapidity with which the defect covers in is little less than marvelous. Castration need never be performed, however great the loss of in- tegument. Kocher’s 1 case, in which both testicles were practically covered over by skin in the short space of three weeks, shows what brilliant results may be obtained by expectant treatment. The surgeon need only help with tension sutures and aseptic dressings. Hematoma and Hematocele.—Contusions of the scrotum give rise to extensive ecchymosis and edema quite comparable to the familiar black eye. If seen early the hemorrhage may be checked by adhesive plaster compression and an ice-cap. Later heat promotes absorption. The hematoma may have to be incised. INFLAMMATIONS OF THE SCROTUM Inflammatory Edema.—Extensive edema may complicate any in- flammation of the scrotum on account of the laxity of its tissue. Where edema is excessive, and the tension so great that injury to the skin seems imminent from pressure, a few punctures may be made on each side of the raphe, at the most dependent point of the scrotum. These punctures should he protected by a wet dressing to encourage oozing, to improve the circulation, and to prevent infection. In milder cases, strapping (p. 539) will quickly reduce the edema, if the cause has been removed and a suspensory bandage is applied. Cellulitis and Abscess.—Cellulitis and abscess of the scrotum are encountered clinically as phenomena of urinary infiltration (p. 227). Erysipelas and Gangrene.—Erysipelas and fulminating gangrene of the scrotum and penis are apparently one and the same. Clinically the lesion begins as an erysipelatous dermatitis, which spreads, usually within 24 hours, over the whole of the external genitalia. The scrotum and penis are enormously swollen and tense. The temperature is not necessarily high, though there may be chills. By the second day gangrene has set in and this too spreads with great rapidity, the patient becomes toxic, and within a few days dies, unless the mass of gan- grenous skin and subcutaneous tissue is promptly excised. Careful examination distinguishes scrotal ervsipelas from passive Chirurgie,” 1887, 1 (b), 8. ELEPHANTIASIS, LYMPH SCROTUM, LYMPH YAR1X 517 scrotal edema in the early stages of the inflammation, and from periurethral gangrene later. The treatment is excision of the gangrenous tissue, weak perman- ganate of potassium wet dressings, and general stimulation. With prompt surgery the patient’s prospects are excellent. With incredible speed the small remnant of scrotum covers the nude testacies and healing is usually complete in about two months. Diphtheria.—Le Clerc1 has observed and collected a number of cases resembling, clinically, an acute erysipelas, and which he attrib- utes to diphtheria, the Klebs-Loefiler bacillus having been cultivated, either pure or in mixed culture, from the wound discharges. Emphysema.—This occurs with general subcutaneous emphysema and with scrotal gangrene. Scrotal Fistula and Calculi.—These are of urethral origin. ELEPHANTIASIS, LYMPH SCROTUM, LYMPH VARIX Elephantiasis is a condition of chronic distention of the lymph vessels of any part of the body, whereby the skin and subcutaneous tissues become thickened and indurated and the part often enlarges to an incredible size. It occurs usually in the lower extremity and in the penis and scrotum. Etiology—The cause of elephantiasis is obstruction of the lymph channels. Thus scrotal elephantiasis may follow extirpation of the inguinal glands.2 Severe chronic inguinal adenitis may have the same unhappy effect. But the enormous elephantiasis, so frequent in the tropics, is due almost always to the filaria sanguinis hominis. The fascinating life history of the filaria has been studied by Lewis,3 Man- son,4 Le Dentu,5 Mastin,6 Lothrop and Pratt,7 and many others. Born in some marsh or swamp, the embryo enters a man’s alimentary canal in a sip of water. Thence it makes its way to the lymphatics, where it settles down for life and attains its full development. Here it is impregnated and pours into the blood current an infinite stream of embryos. By night the blood is alive with them, by day not one can be found where, a few hours before, were myriads. Where they hide no one knows. But in the human host they cannot develop. To reach 1Gayon’s Annales, 1898, xvi, 1102. s Cf. Bull. soc. frangaise de dermat. et syph., 1898, ix, 292. !(, Gynec. and Obstet., March, 1911, p. 230. TUMORS OF THE TESTICLE 559 coma probably arises in the testicle, but is rare and its exact origin is uncertain. Alveolar, large round cell, perivascular, and other forms of so-called sarcoma testis are of epithelial and teratomatous origin. Adenoma arising from the spermatic tubule cells is a rare tumor occurring in atrophic undescended testes. Considerable hyperplasia but no true tumors of the interstitial cells have been observed. The commonest tumor of the testis is an embryonal carcinoma alveolar or diffuse with polyhedral or rounded cells and often with lymphoid stroma. These tumors are probably one-sided developments of teratomata. . . . That adrenal tissue may appear in true teratomata is shown by one of Ohkubo’s cases and in the writer’s case 16, a teratoma testis in its second recur- rence was indistinguishable from many adrenal tumors. Further evidence would therefore seem necessary to establish the occurrence of a true testicular tumor arising from pure adrenal tissue. . . . Standing out prominently from the maze of speculation in this difficult field are two main facts of observation. Teratoma testis arises almost invariably where the spermatic tubules enter the rete testis and where some sex cells must fail to realize their full develop- ment into spermatogonia. Here is one of those transitional areas where tumors are prone to develop from superfluous and isolated cells. Teratoma testis arises at all ages,1 often after trauma, in testicles that appear to have been normal. The reasonable deduction is that all normal testicles contain the potential cells of origin of teratomata and that such rare accidents as isolation of blastomeres and fertilization of polar bodies are not concerned in their origin. It must be urged that no one has ever seen anything in the testicle which would directly connect teratomata with isolated blastomeres or polar bodies. The existence of such things in the testicle is purely hypothetical. Influenced by these considerations the writer concludes from this study that teratoma testis arises from sex cells in the neighborhood of the rete, whose normal development into spermatogonia has been suppressed but whose potencies remain intact and ready to express themselves in the various forms of simple or complex teratomata. The gross characteristics of the growth may be those of a dermoid cyst, or of a tumor of mixed tissue, solid or cystic, or of a rapidly growing malignant growth. Secondary hydrocele is a relatively unimportant feature. Metastases occur early by way of the lymphatics. Later the whole pampiniform plexus of veins may become involved in the growth. SYMPTOMS Since malignant tumors of tlie testicle often appear benign at the outset, and since apparently benign tumors may at any time become malignant, tumor of the testicle should always be regarded as menacing its possessor’s life. Thus in one of Conche’s cases (Sturgis) the tumor 1 The great majority, however, between the ages of 15 and 30. 560 DISEASES OF THE TESTICLE began to grow after having been quiescent for five years. On the other hand, in a case recorded by Socin, in six months the tumor attained the size of a man’s head, and Sturgis’s case of sarcoma grew in a year to the size of a child’s head. Kocher collected 32 cases, 25 of which came under observation within a year and a half of the beginning of the disease, and of which only 1 had lasted six years—an average of one year and four months; while 83 of Kober’s “sarcoma” cases show an average of two years and eight months from the beginning of the disease to the time of Fig. 125.—Carcinoma of Testicle. The organ is completely destroyed by the growth There is hydrocele. (Case of Dr. G. D. Stewart.) operation. The pain is often slight throughout, though it may well be- come severe in the later stages. Testicular sensation is lost. The oval shape of the testicle is preserved. As the tumor grows it may be evenly elastic or uneven, nodular, elastic in places, perhaps fluc- tuating when there are large cysts or a flaccid hydrocele. Finally, the scrotal veins enlarge, the iliac and lumbar glands can be felt by deep abdominal palpation, and, ultimately, the tunica albuginea gives way and elastic masses can be felt projecting through it. Thence the fascia and skin are involved and the tumor eats its way through the tense in- tegument, forming the malignant fungus, the fungus hematoides of the testicle. This occurred only once in Kober’s 114 cases. The inguinal glands do not enlarge until the scrotum becomes invaded by the growth, for the lymphatics from the testicle run directly up the cord to the iliac and lumbar glands. TUMORS OF THE TESTICLE 561 DIAGNOSIS AND TREATMENT Xodulpr, slow growing, and bilateral neoplasms of the testicle may be mistaken for syphilis. The Wassermann reaction is an almost infallible guide to the diagnosis, for this is almost always positive, as in conditions of active visceral syphilis. In the absence of this reaction the tumor should be treated as such. If the Wassermann is positive, treatment for syphilis should result in the subsidence of the swelling within a month; otherwise treat as tumor. Very early cases, with the tumor at its beginning, between testicle and epididymis, may be mistaken for tuberculosis. There is a special type of very rapidly growing tumor that so closely simulates hydrocele or hematocele as to deceive even the most erudite. Hence the absolute rule that no hydrocele should be tapped unless it transmits light. Treatment.—The treatment must be by a combination of radiation and surgery. Either alone almost always fails, the two combined give a very fair promise of success, and curiously enough some of the most malignant tumors yield most brilliantly to the combined treatment. For example, a patient consulted me in 1917 for a tumor of the right testicle with a metastasis on the iliac glands so large that when he lay down it could be seen to bulge out his abdominal wall. Dr. Janeway gave the abdomen a treatment with a radium pack and a week later I removed the testicle which Dr. Ewing pronounced a typical malig- nant teratoma. At the time of operation the abdominal tumor was no longer visible but was distinctly palpable. Two weeks later, when the patient left the hospital, the abdominal tumor could no longer be felt. In 1922 the patient was alive and apparently entirely well. The “complete” operation, following the spermatic vessels to the renal vessels in the search for metastases, is very unsatisfactory. Either one finds no glands or those found are so large and adherent that nothing can be done with them. CHAPTER LIX HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE IIyduocele is usually defined as an accumulation of serous fluid in the tunica vaginalis. Hydrocele may also occur in the funicular process of the peritoneum (encysted hydrocele of the cord). Varieties.—Hydrocele may be idiopathic or symptomatic. It may be acute or chronic. While all idiopathic cases are chronic, not all symptomatic cases are acute, therefore the terms are not quite inter- changeable. SYMPTOMATIC HYDROCELE As its name suggests, symptomatic hydrocele occurs only as a symp- tom of disease in the testicle and epididymis. It is often acute, and is especially common with acute epididymitis and tuberculosis. A fibrous adhesive vaginalitis has been identified post mortem or during opera- tion. It gives no clinical symptoms. Treatment.—The treatment of symptomatic hydrocele is, in some degree, comparable to the treatment of serous pleurisy. If the primary disease is acute and the hydrocele insignificant, it may be disregarded and allowed to be absorbed as the acute disease abates. If large and tense, or its absorption too slow, it may be aspirated one or several times. But if the primary disease is chronic, while aspiration may hold the hydrocele in check, some more radical procedure is often de- manded. The treatment by injection usually fails. The need of a more radical procedure may prove the surgeon’s opportunity to induce the patient to submit to an operation upon his testicle from which he otherwise would shrink. IDIOPATHIC HYDROCELE Most French writers maintain that there is no such thing as idio- pathic hydrocele, that every vaginalite sereuse is symptomatic. This theory does not explain why idiopathic hydrocele is so common in the tropics, or why idiopathic hydrocele does not often follow acute epididy- mitis, a disease which leaves far greater changes in the epididymis than those alleged as cause of idiopathic hydrocele. 562 IDIOPATHIC HYDROCELE 563 Varieties.—Hydrocele is usually confined to tlie tunica vaginalis (Fig. 126). In infants, however, it may occur before the funicular process has begun to close (congenital hydrocele), so that the cavity of the hydrocele communicates with the peritoneal cavity, yet by such a small opening that there is often no hernia and the fluid does not spon- taneously drain off into the abdomen (Fig. 129). A more frequent variety is infantile hydrocele, occurring when the funicular process has quite closed at its upper end, so that the fluid distends both vaginalis and funicular process (Fig. 130). Hydrocele occurring in a retained testis is termed inguinal hydrocele. These and other varieties mentioned above will be dealt with later. Etiology.-—Hydrocele does not oc- cur as a dropsical phenomenon, and it has already been distinguished from inflammatory or symptomatic vaginal- itis. It is possible that certain cases are due to the bursting of an epididy- mal cyst into the tunica vaginalis,1 but beyond this we are quite in the dark as to its cause. Hydrocele is most common in the middle-aged. In the tropics it is said to afflict one man in ten. It is far less common in temperate climes. Pathology—The Character of the Fluid.—The fluid of hydrocele is viscid, odorless, straw-colored, clear, or opalescent. It looks like blood serum. Its specific gravity is about 1.024. It contains about 6 per cent of organic matter, notably fibrinogen, to which it owes its property of coagulating blood serum. The alkaline carbonates and sodium chlorid are present in some quantity. The reaction is neutral. The presence of fibrinogen and inorganic salts distinguishes it from ascitic fluid. It may contain a few flakes and strings resembling urethral shreds. It is sometimes full of bacteria, sometimes brown from the admixture of blood. These bacteria and this blood are usually the result of previous punctures. The microscope reveals blood and epithe- lial cells and leukocytes. Cholesterin crystals are usually present, not often in any numbers. Suppuration is rare. The Quantity of Fluid.—A good-sized hydrocele contains some 200 or 300 c.c. of fluid. Mr. Cline removed 6 quarts from the scrotum of Gibbon the historian. Breisson, after removing 16 liters on one occa- Fig. 126.—Usual Form of Hydrocele, 1 Lancet, 1885, i, 748. 564 HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE sion, drew 26 liters from the same patient ten months later. It takes from three months to a year for a good-sized hydrocele to refill after tap- ping. The largest hydroceles I ever operated upon held 2,500 c.c. and 1,500 c.c. (right and left sides of the same patient). The Tunica Vaginalis.—The sac of a hydrocele may remain nor- mal in structure even after the disease has existed for some time. Fig. 127.—Radiogram op Calcified Tunica Vaginalis. Support to the testicle and systematic tapping may prolong this condi- tion indefinitely. But if the scrotum is not supported, the slight bruis- ing which the tumor continually suffers may produce a chronic thicken- ing in the tunica vaginalis; the surface loses its gloss and becomes wrinkled and irregular, while the vaginalis becomes thick and leathery. Adhesions and masses of fibrin result from inflammation. Obliteration of some part of the sac may subdivide it, causing the rare multilocular hydrocele. I have twice met with calcification of the vaginalis, a very rare condition, which has been exhaustively described by Roswell Park.1 1Jour. of Cut. and Gen.-Urin. Diseases, 1895, xiii, 361. IDIOPATHIC HYDROCELE 565 The Testicle and Epididymis.—Unless inverted or displaced by adhesions, the testicle lies below and behind the hydrocele. In mild cases the testicle remains normal, but after evacuation of the fluid one or more areas of induration may commonly be found in the epididymis. These are points of intertubular edema due to the interference with circulation. In old and inflamed cases of hydrocele, both testis and epididymis may be quite sclerosed and so atrophied as to be scarcely recognizable in the sac wall. Sometimes the tunica vaginalis forces its way between the testicle and epididymis, forming quite a pouch there. Multilocular Hydrocele.—Multilocular hydrocele is quite rare. It may be produced in one of three ways: 1. Several varieties of hydrocele exist simultaneously (e. g., hydro- cele of the vaginalis and hydrocele of the cord). 2. The sac becomes subdivided by adhesions. 3. There is hernia of the sac between testis and epididymis. Fibrous Bodies.—The so-called fibrous bodies occasionally met with upon opening a hydrocele are concretions of earthy phosphates or carbonates covered with fibrin. Probably they are for the most part due to a deposition of the hydrocele salts upon some w7arty growth, followed by atrophy of the little nucleus, after which the concretion breaks free. Wendlung met with concretions 6 times in 109 opera- tions (Peraire1). They do not exceed the size of a pea—though Chassaignac found one 2 cm. long and 12 mm. wide—and are usually single. Symptoms,—Idiopathic hydrocele is always chronic. The effusion takes place slowly and painlessly, and the swelling is only discovered after it has attained some size, for which reason the patient fancies it has appeared suddenly. The accumulation of fluid is slow and inter- rupted, but continues indefinitely. After tapping, the reaccumulation is at first rapid and then slow until the tumor reaches its original size, usually several months after tapping. Thus I have a patient who, re- fusing any radical measures, returned twice a year for 11 years to be tapped, having, for a number of years previous to that date, visited other surgeons for the same purpose. There are no subjective symptoms attached to hydrocele, except the sensation of dragging felt in the loin and groin from the weight of the tumor. Signs.—Hydrocele is usually pear-shaped, larger below than above; or it may be oval, and, if very large, sausage-shaped. It cannot he re- duced by pressure. Fluctuation can usually be made out. The tumor is generally tense, the scrotum often stretched and shining. The cord, of natural size and feel, can be grasped above the tumor. The testicle 1 Bull, de la soc. anat., 1899. 566 HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE is usually situated behind, a little below the center (Fig. 126), and pressure on this point gives rise to the peculiar sensation experienced when the testicle is squeezed. Occasionally the testicle is found below and in front, more rarely in the center, in front, from plastic adhesion. Its position should always be ascertained before operating on a hydro- cele. Pressure on a hydrocele does not produce pain; there is no heat or redness of the skin unless the tumor be large enough to keep it con- stantly on the stretch. There is flatness on percussion. There is no Fig. 128.—Hydrocele. impulse on coughing, unless the hydrocele extends into the inguinal canal or is complicated by hernia. The weight of the tumor is a criterion that has been much depended upon to distinguish solid from fluid tumors. It is absolutely unreliable. Varicocele and hernia may complicate hydrocele, and the pressure on the testicle may render it sterile. But if the hydrocele is cured the testicle will resume its functions unless it has become atrophied. Diagnosis.—The diagnosis is made by three tests: 1. The light test. 2. Isolation of the tumor. 3. Puncture. The Light Test.—Most hydroceles are so thin-walled that if an electric bulb or a candle is held close to one side of the tumor and the opposite side inspected through a tube (e. g., a roll of paper), the whole mass glows with a pinkish light. The position of the testicle may even be discerned by its shadow. CONGENITAL HYDROCELE 567 This test rules out hematocele, most spermatoceles, and solid tumors of the testicle, btit does not exclude a complicating hernia. If the walls of the hydrocele are thickened, the light test fails. If the test fails in a case that has every other aspect of hydrocele, it is doubtless a spermatocele. Isolation of the Tumor.—If the fingers can be brought together above the tumor and feel nothing but the normal tissues of the cord, hernia is excluded. If the tumor runs into the inguinal canal and gives no impulse on coughing, there is probably no hernia. Puncture.—The tumor should not be punctured unless hernia can be absolutely excluded by isolation, and tumor by the light test. It is, in other words, both dangerous and unnecessary. Prognosis.—Hydrocele in the adult does not get spontaneously well. Suppuration and transformation into hemato- cele are rare. Curling cites the case of a Spaniard who had ruptured his hydrocele thirty times by horseback riding and other violent exercises; yet the swelling always returned after a few months. In- fants often get well spontaneously, and expectant treatment is therefore most suitable for them. Treatment.—Tapping.—This is appropriate to symptomatic hydrocele, for children—for whom it is often curative—and for patients refusing radical measures. Before tapping for hydrocele the testicle must be accurately located by the testicular sensation or the light test, and hernia and tumor must be absolutely excluded. Hydrocele in the adult will usually refill after this operation, but for children it often suffices, especially if the internal surface of the sac be scratched. If the cyst wall be thick tapping will never effect a cure. The patient can put on a suspensory bandage and resume work at once after tapping. Radical Treatment.—Of the many methods of treating hydrocele only two need be detailed—namely, injection and open operation. The choice between these operations is discussed in Chapter LXXX. Fig. 129. — Congen- ital Hydrocele. CONGENITAL HYDROCELE In congenital hydrocele there has been no obliteration of the peri toneal prolongation, and the tunica vaginalis is continuous with the peritoneum (Fig. 129). It occurs in infancy. 568 HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE Diagnosis.—The diagnosis is usually easy, but there is some danger of confusion with hernia. Congenital hydrocele and hernia usually coexist. Congenital hydrocele may be found in adults, but is rare. Horwitz met with it once in 110 cases. Kocher estimates that it occurs 4 times in every 100. Treatment.—Open operation; never injection. INFANTILE HYDROCELE Infantile hydrocele is far more common than the congenital variety. Horwitz met with 22 cases. The hydrocele occupies the tunica vaginalis and the funicular process up to the inguinal canal, where it is shut off from the general peritoneal cavity (Fig. 130). It resembles a con- genital hydrocele, but is quite irreducible. Treatment.—Since these hydroceles are usual- ly complicated by hernia, they should never be injected, always subject to open operation. Abdominal Hydrocele (Bilocular hydrocele hydrocele en bissac).—This is a very rare variety of infantile hydrocele, in which the hydrocele is partly in the scrotum, partly in the abdomen. The abdominal portion, which may grow to an enor- mous size, usually lies between the general peri- toneal cavity and the anterior abdominal wall. By pressing the abdominal muscles the patient can force the fluid violently into the scrotum. Treatment.—Excision of the sac. I have operated upon one case in which the tumor reached to the umbilicus. The sac was readily freed through an abdominal incision. It was then readily drawn down and excised through an incision over the inguinal canal. The canal was then repaired by the Bassini method. Fig. 130.—Infan- tile Hydrocele. ENCYSTED HYDROCELE OF THE CORD Conditions commonly grouped as encysted hydrocele of the cord are: 1. Hydrocele of the processus funieularis. 2. Pedunculated cysts of the epididymis. 3. Hydrocele of an old hernial sac. 1. Hydrocele of the Processus Funieularis.—The sac is shut off below from the tunica vaginalis, above from the peritoneum. The hydrocele may be single or multiple. Usually single, it presents the MULTILOCULAR HYDROCELE OF THE CORD 569 features of a hydrocele of the tunica vaginalis, but is situated above the testicle and about the vas. Sometimes it may be reduced into the inguinal canal, but never into the abdomen. Although it usually occurs in children, I have several times seen it in the adult. 2. (See below.) 3. Hydrocele of an Old Hernial Sac.—This occurs in the process of peritoneum left behind by a hernia which has been reduced and the neck of the sac closed, either spontaneously or by the use of the injec- tion cure for hernia. The hydrocele is usually mistaken for a recurrence of the hernia. Tbeatment.—The sac should be incised and its parietal layer removed. Hematocele.—Hematocele of the cord is rare, but may occur in the same way as hematocele of the tunica vaginalis, usually after injury. Indications for treatment are the same (p. 572). MULTILOCULAR HYDROCELE OF THE CORD Multilocular hydrocele of the cord was first described by Pott and Scarpa as diffuse hydrocele of the cord, and most authors retain that title. The pathogenesis of this rare affection is habitually misunder- stood. Koclier,1 however, after a critical survey of the literature, con- cludes that an actual diffuse hydrocele can be due only to a rupture of some hydrocele or spermatocele, a temporary accumulation of fluid in the connective tissue about the cord. All other cases he classifies under five heads, viz.: 1. Echinococcus cyst. 2. Spermatocele. 3. Encysted hydrocele of the cord subdivided into loculi by ad- hesive inflammation. 4. Cysts of fetal remains (Muller’s Duct, Wolffian Body, Organ of Giraldes). 5. Cystic lymphangioma. Symptoms—The symptoms are characteristic, whatever the nature of the disease. The tumor extends about the cord from the testis up or into the spermatic canal. It is smooth, rounded, translucent, and boggy rather than fluctuating, though a difference in this regard may be made out in different parts of the tumor. It may be partly reducible. There is a slight impulse on coughing. Diagnosis—The diagnosis from encysted hydrocele of the cord is established by the boggy feel and the irregular, indistinct outlines of the tumor. In fact, it resembles an incarcerated omental hernia in every- 1 Op. cit., pp. 170, 180. 570 HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE thing but its translucency and its fluctuation in places. Incision may be required to establish the diagnosis. Treatment.—The tumor may safely be let alone. To cure it incision has usually been employed. Pott’s classical case of lymphangioma died of lympliorrliagia after incision. CYSTS OF THE EPIDIDYMIS—SPERMATOCELE This condition, commonly known as spermatocele or encysted hydro- cele of the testicle, is a collection of fluid “contained in a cyst or cysts, distinct from but close to the cavity of the tunica vaginalis” (Jacob- son). These cysts are developed in and about the epididymis, very exceptionally in the testicle itself, and should be classified as epididymal cysts. Two classes may be recognized: 1. Small cysts developing (usually) about the epididymis. 2. Large cysts originating within the epididymis. 1. The small cysts are rarely encountered before middle age, while they are very common in later life. They usually project more or less distinctly from the head of the epididymis. They do not attain any notable size; they rarely contain spermatozoa—in short, they have little clinical significance. 2. The large cysts usually appear before middle age and commonly contain spermatozoa. They are often multiple and grow between the epididymis and the testicle, separating them and unraveling the former. Thus they form irregular fluid tumors about the top of the gland. Ex- ceptionally, the cysts are pedunculated and grow upward, simulating hydrocele of the cord. I have seen four cases that precisely simulated hydrocele of the tu- nica vaginalis in every respect except translucency. The sac lay in front of the testicle with the vaginalis between. These cysts rarely contain more than 100 c.c. of fluid, though Curl- ing drew off 32 ounces from one individual and 40 ounces from another. Jacobson mentions a case from whose right side 49 ounces were drawn, and 58 from the left. Frost’s1 cases yielded 52 ounces. The nature of these large cysts is identified by the fact that the fluid is milky and swarming with spermatozoa or else absolutely watery. Pathogenesis.—Since the smaller cysts are met with later in life than the larger, and less frequently contain spermatozoa, many authors attribute the larger cysts to persistent fetal remains, such as the vasa aberrantia, the hydatid of Morgagni, or the paradidymis (organ of Giraldes), and the smaller cysts to dilatations of the seminal canals. The recent tendencv, however, has been to discredit the claims of the 'Lancet, 1878. ii, 48A CYSTS OF THE EPIDIDYMIS—SPERMATOCELE 571 fetal elements, and to attribute the earlier and larger cysts to dilatation of the vasa efferentia or of the epididymis itself behind an obstacle more or less impervious,1 and the later, smaller tumors to a cystic enlarge- ment of the tubules due to senile changes after the organ has passed the height of its activity. The presence of spermatozoa in' the cysts is explained by those who cling to the theory of embryonal rests upon the ground that the cyst has burst into the epididymal canal. The absence of spermatic elements is explained by those of the opposite camp on the ground that the cysts become occluded from the main channel and their seminal ele- ments gradually disintegrate. The communication between a cyst and a seminal duct has been observed a number of times. Symptoms.—The small cysts are occasionally met with in older men. They produce no symptoms. The large cysts have peculiar features. If seen early, an undefined sense of thickening, with extra resistance, is distinguishable by tbe fin- ger in the region of the top of the testicle. This goes on increasing, usually at so slow a rate that the patient soothes himself with the idea that it will become no larger. It grows constantly, however, and may attain a large size. There is no pain, except a slight dragging on the cord. The cyst keeps its position at the upper end of the testicle, or ex- tending down in front of it. It may be “heart-shaped,” the testicle lying below the cyst which is notched above. The walls are usually thin and tense, so that fluctuation cannot always be distinguished. Translucency is rarely present. The cyst tends to increase in size indefinitely. It may coexist with hydrocele and be masked by it. It may be broken into the vaginalis by accident, and, continuing to secrete, form spermatic hydrocele, or it may be punctured when a supposed simple hydrocele is tapped. Diagnosis.—The heart shape of the cyst, though pathognomonic when present, is not constant. The diagnosis is usually made by the irregular shape and position (above the testicle) of the tumor or the absence of translucency in a supposed hydrocele. Aspiration usually completes the diagnosis by withdrawing a milky fluid full of sperma- tozoa. If the fluid is limpid it may be distinguished from hydrocele fluid by its watery limpidity (whereas hydrocele fluid is straw-colored), its neutral reaction, its low specific gravity (less than 1.010), and its low percentage of albumin (about per cent against 4 per cent to 7 per cent in hydrocele). 1 Griffiths {Jour, of Anat. and Phys., 1893-94, xxviii, 107) maintains that, like hydronephrosis, these dilatations are caused by partial obstruction due, in this case, to catarrhal inflammation. He also maintains that the hydatid of Morgagni is always a solid body, never cystic, and that there is no evidence that embryonal remains are in any way connected with spermatocele. 572 HYDROCELE, HEMATOCELE, SPERMATOCELE, CHYLOCELE Treatment.—The cyst should be excised. There is no object in dis- turbing small cysts. HEMATOCELE The term hematoma is applied to a tumor caused by the effusion of blood into the tissues, whether of the testis or the scrotum. If the effu- sion becomes encysted, or if it*occurs within a cyst or the serous tunic of Fig. 131.—Hematocele. The sac is filled with hardening jelly; hence the mosslike fringe. The slight thickening at the bottom is all that remains of the testicle. testicle or cord, hematocele results (Fig. 131). I have seen a hemato- spermatocele. Etiology—The most common cause is a crushing injury. Any op- eration upon the testis may result in hematocele. Scrotal hematocele and testicular hematocele are always traumatic. Vaginal hematocele is usually traumatic, but, exceptionally, may have a spontaneous origin. CHYLOCELE 573 Symptoms.—There are consequently two varieties. The one comes on rapidly after injury and is attended by scrotal hematocele. If there has been a pre-existing cyst or hydrocele this becomes suddenly larger, more tense, and painful. In the other, or spontaneous variety, the tumor increases slowly in size and simulates hydrocele, except in regard to translucency. The blood in hematocele may be found red and fluid, but is usually black or brown, and it may be mixed with pus if severe inflammation has followed its effusion. The walls of the cyst may be coated with layers of fibrin, and they tend to thicken and become adherent to the surrounding connective tissue, while the inner surface becomes rough and uneven, resembling anything but a serous surface. Diagnosis.—The diagnosis of hematocele of the second or spontane- ous variety presents many difficulties. Here there is no guide in the history nor any local signs of injury. The records of surgery possess many cases where perfectly healthy testes, surrounded by a hematocele inside of a thickened tunica vaginalis, have been extirpated as can- cerous. The diagnosis cannot be made without an exploratory incision. In the traumatic variety, the diagnosis is made at once from the history. It is unimportant, often impossible, to distinguish between traumatic hematocele of testis, vaginalis, and scrotum. Treatment.—For hematoma all that can be done is to keep the pa- tient upon his back, with the testicle supported and covered with cold lotions, administering an anodyne if the pain be severe. If the quantity of blood effused is not too great, the pain will soon begin to subside, and the patient may be allowed to go about with a suspensory bandage. The blood will gradually be absorbed. If, in spite of these means, the pain becomes excessive, and the tension of the parts great, the tumor should be incised and drained. Ancient hematocele demands castration. CHYLOCELE Chylocele (fatty, milky, chylous hydrocele, galactocele) is an ac- cumulation in the tunica vaginalis of chyle or fatty lymph. It is a feature of lymph scrotum, and is caused by the rupture of a dilated lymph vessels into the tunica vaginalis. Filarial embryos have been seen in the fluid by Martin and Davies. Chylocele may also be due to traumatic rupture of a lymphatic into the tunica vaginalis. False chylocele is due to a fat- or cholesterin-producing degeneration in the fluid or in the epithelium of a hydrocele. Chylocele when occurring without lymph scrotum resembles hemato- cele. The treatment is excision. CHAPTER LX DISEASES OF THE YAS DEFERENS AND SPERMATIC CORD ANATOMY The cord is made up of the vas deferens, the habenula or remains of the funicular process of the peritoneum, and certain vessels and nerves, all held together by meshes of connective tissue containing un- striped muscular fiber (internal cremaster of Henle). Surrounding these is a continuous layer of connective tissue (tunica vaginalis com- munis) adherent to the tunica vaginalis below and continuous with the fascia transversalis above. Outside of this the cremaster muscle lies in loops, some of them embracing the testicle, others extending only a short distance down the cord. The arteries are, the spermatic from the aorta, the deferential from the superior vesical, and the cremasteric from the epigastric. The veins from the testicle and epididymis unite in the pampiniform plexus which constitutes the bulk of the cord. The larger veins have valves; they usually unite within the abdomen to form one large trunk, which empties, on the left side into the renal vein, on the right side into the vena cava. A much smaller bundle of veins accompany the vas and the spermatic artery. The spermatic plexus of nerves is derived from the renal, the aortic, the superior mesenteric, the hypogastric, and the lumbar plexuses of the sympathetic, the genital branch of the genito- crural nerve, and the inguinal branch of the ilio-inguinal. The cremaster muscle varies in size and power in different subjects. Its function is to assist in sustaining the testicle by its tonic contrac- tion, and to compress the organ during the sexual orgasm. The muscle is subject to painful spasmodic contraction in kidney colic, in neuralgia of the testicle, and sometimes in connection with prostatic, or vesicular irritation. The cremasteric reflex is the retraction of the testicle excited by irritation of the adjoining portion of the thigh. The Vas.—The vas deferens is the excretory duct of the testicles. It runs upward from the tail of the epididymis to form one of the main constituents of the spermatic cord. It lies in the inner and posterior portion of the cord, where it may be identified as a rigid tube, the only element of the cord that does not slip almost insensibly from between 574 VARICOCELE 575 the examining fingers. After passing through the inguinal canal the vas curves obliquely downward and backward over the base of the bladder, crosses behind the ureter and runs to the inner side of that duct, separated from it by the seminal vesicle. At this point it becomes markedly sacculated, forming the ampulla of the vas, then narrows to its original dimensions, and is joined by the duct of the seminal vesicle to form the ejaculatory duct, which pierces the prostate and opens into the posterior urethra just in front and to one side of the verumontanum. The vas deferens is lined throughout with columnar epithelium. Its muscular coat consists of two layers, the inner circular, the outer longitudinal. Surrounding all is a dense fibrous tissue. Relations.—The chief relations of the vas have been described above. In the scrotum it is closely surrounded by its owm artery and one or two small veins. These vessels and the nerves run near it, and, except for a few veins to the inner side, the whole pampiniform plexus lies to its outer side. Anomalies.—Curling 1 relates a number of cases reported by various authors, in which the vas deferens was absent wholly or in part, on one or both sides. When the testicular end is missing the epididymis may or may not be missing as well. Wounds.—Wounds of the cord may cause profuse hemorrhage and rupture of the vas. The hemorrhage may be checked readily enough. If the vas is cut it should be united by Belfield’s method (p. 751). If some such operation is not performed, the duct becomes occluded, and, although this does not cause atrophy of the testicle, yet it shuts off the spermatozoa of that side from the urethra. Complete division of the cord may cause atrophy of the testicle. Division of the pampiniform plexus causes only a temporary edema. Torsion of the Cord.— (See p. 553.) Inflammation.—See p. 532.) Hydrocele and Hematocele.—(See p. 568.) VARICOCELE 2 Varicocele is varicosity of tlie veins of the pampiniform plexus. It may be either symptomatic or spontaneous. Symptomatic Varicocele.—Symptomatic varicocele is rare. It is caused by the pressure of some intra-abdominal growth obstructing the spermatic veins. The tumor is usually of renal origin and malignant (p. 456). 1(‘ Diseases of the Testis,” 4th ed., 1878, p. 7. 2Cf. Istomin, Deutsche Zeitschr. f. Chir., 1909, xcix, 1. 576 DISEASES OF VAS DEFERENS AND SPERMATIC CORD Diagnosis.—Symptomatic varicocele cannot be mistaken for spon taneons varicocele. It develops very rapidly, late in life, on either side; is painless, attains large proportions, and is associated with a palpable abdominal tumor, against which the treatment should be directed. Spontaneous Varicocele—Varicocele in a mild form is perhaps the most common affection of the genital organs. It has been esti- mated that about 10 per cent of males have slight varicocele.1 It occurs almost invariably on the left side; when very marked on this side it may exist slightly on the right. Brescliet, in 120 operations, operated only once on the right side. I have never operated on both sides. Most slight varicoceles are encountered in young unmarried men; the affection rarely commences after twenty-five; it is unusual to find it in a married man whose sexual relations are satisfactory. The chief factor in its production is ungratified sexual desire, unrelieved erotic fancies, or, less often, the opposite condition, abuse of the sexual powers, by which the veins are kept constantly engorged. The slight turgescence of the veins constituting varicocele in a young bachelor and often causing him needless alarm, disappears after marriage, together with the uneasy sensations which accompanied it. Old men whose testicles are inactive rarely have varicocele, though their legs show many tortuous veins. This fact is of the utmost im- portance. That slight varicocele is often a sexual derangement, a func- tional disorder depending upon vicious sexual hygiene, is not suf- ficiently appreciated by practitioners. In many cases young men dis- tress themselves unceasingly, and importune their surgeons for an operation to cure a disorder which would be more speedily and effectu- ally removed by marriage. The degree of varicocele alluded to above may be dismissed briefly. The vessels are a little full, the cord loose, feeling like a small bundle of earthworms, no one vessel being exceptionally large; the testicle is perhaps oversensitive, and there is usually a slight dragging sensation in the groin, but beyond this nothing except the fancied ills and the hypochondriacal complainings of the young man who is cheating Na- ture or abusing her gifts. The proper treatment of such cases is sexual hygiene. The patient’s mind must be diverted, he must be dissuaded from an operation, told to wear a snugly fitting suspensory bandage, and as far as possible to forget his sex until marriage affords him an opportunity to get well. The free local application of cold water daily is a very useful adjuvant. Yet varicocele serious enough to constitute a disease and to demand active surgical measures for its relief does occur. It is an exaggera- 1 Bennett estimates 7 per cent., while Senn states that among 9,815 recruits 2,075 were affected with varicocele. VARICOCELE 577 tion of the milder form; it comes on in early manhood, and has no connection with varices of the legs or anus (hemorrhoids). Pathogenesis.—Any theory to be adequate must explain the preva- lence of the disease among the adolescent and its occurrence, almost entirely, upon the left side. Many authors look for an anatomical predisposing cause. Thus certain French writers invoke a pre-existing phlebitis. Bennett 1 and Spenser 2 suppose a congenital anomaly of the veins. Such predis- posing causes are not generally accepted. Sufficient anatomical pre- disposition is found in the position of' the veins, dependent, unsup- ported, surrounded by the loosest kind of a fascial envelope. To this add the congenital congestion set up by the untamed and pampered passions of youth, and no further predisposing cause is necessary. But why should the varicocele occur upon the left side? To an- swer this question an infinite variety of theories has been proposed. There is space to enumerate only the more important ones. The left testis hangs lower than the right, and the left renal vein is higher than the opening in the cava which receives the right spermatic vein, hence the left vein is longer than the right. To this add the fact that the left spermatic vein, enters the renal vein at right angles, and is not affected by suction as is the right vein which enters the cava at an acute angle. So far we are on safe anatomical ground; beyond all is theory. Perhaps, as . has been alleged, right-handed men transmit the force of their exertions to the left foot by means of the abdominal muscles of the left side. Bat I have seen left-handed men with vari- cocele, always on the left side. Perhaps the sigmoid flexure, over- loaded with feces, presses upon the veins. But this is as rare in youth when varicocele is common, as it is common in old age when varicocele does not occur. Curiously enough the ovarian veins are very rarely varicose, except on the left side. A violent strain may induce acute varicocele. Pathology.—In mild cases the veins are merely tortuous and di- lated. But in a full-formed varicocele the vessels are elongated, their valves broken down, their walls affected by fatty atrophy, and thickened. The veins sometimes contain phleboliths, or become thrombosed throughout, as a result of phlebitis. Symptoms. —I have seen a number of cases of acute varicocele re- sulting from straining, or coming on spontaneously. Except in acute cases, such as those just detailed, varicocele comes on gradually, and is discovered by accident. The amount of pain com- plained of varies greatly; a very large varicocele is usually attended by absolutely no pain, while a very slight enlargement of the veins 1“0n Varicocele,” London, 1891. 2 St. Barthol. Eosp. Rep., 1887, p. 137. 578 DISEASES OF VAS DEFERENS AND SPERMATIC CORD may give rise to considerable uneasiness extending up the back and down the thigh, perhaps amounting to neuralgia of the testis. The only general symptoms of varicocele besides pain are those of hypochondria and defective morale. The impotence often alleged by physicians of an incredible “years’ experience” to result from vari- cocele is the veriest fiction. When impotence and varicocele co-exist they are due to the same causes; hut neither is the impotence due to the varicocele nor the varicocele to the impotence. The local conditions are typical. The left testicle hangs consider- ably lower than the right, borne down, and perhaps completely sur- rounded by the mass of dilated veins. The mass feels soft, like a bunch of earthworms. The scrotal veins may be similarly affected. The scrotum is thin and relaxed, the dartos powerless. In long-standing cases of severe varicocele the testis gradually atrophies because of the interference to its circulation. This result is in no way due to the weight of the mass of veins. The course of the disease is usually not progressive. Of the many men who have slight varicocele, only the smallest percentage fail to get well under the regulated sexual exercise of married life. Excep- tionally, however, the veins do grow and enlarge indefinitely. Diagnosis.—There are few diseases more readily recognizable than varicocele; the peculiar appearance and wormy feel of large tortuous veins can scarcely he confounded with anything else. Treatment. —If the varicocele be small and its symptoms inconsid- erable, the patient should be advised as to his sexual hygiene, perhaps instructed to wear a suspensory bandage and treated for neuralgia of the testicle, if this is a feature of his condition. If these measures fail, or if the patient insists upon more radical treatment, surgery must be employed (p. 751). TUMORS OF THE CORD Cystic Tumors.—See Hydrocele of the Cord (p. 568). Solid Tumors.—Solid tumors of the cord are rare. Fibroma, fibromyoma, and sarcoma, all of the vas deferens, have been observed in isolated instances. Gumma is very rare (Goldenberg).1 The only tumor of clinical importance is lipoma of the cord. The frequency of lipoma of a hernial sac lends color to the theory that lipoma of the cord is secondary to hernial lipoma. In structure the tumor may be a pure lipoma, a fibrolipoma, or a myxolipoma. These tumors are usually small and reducible into the inguinal canal, simulating epiplocele, from which thev are only differentiated 1Jour. of Cut. and Gen.-Urin. Diseases, 1901, xix, 113. TUMORS OF THE CORD 579 by operation, unless they can be drawn entirely out of the canal. Ex- ceptionally, however, they attain an extraordinary size. Nove-Josse- rand 1 reports a specimen weighing kilos, and cites two others weigh- ing respectively 20 and 15 pounds. The larger tumors may be patho- logically benign and yet clinically malignant. 1Lyon med., 1897, lxxxiv, 237. CHAPTER LXI DISEASES OF THE SEMINAL VESICLE ANATOMY The seminal vesicle (Fig. 132) is a reservoir connected with the vas deferens. Each vesicle lies to the outer side of its vas, its apex buried in the prostate, where it joins the vas at an acute angle to form the ejaculatory duct. The body of the vesicle is directed obliquely upward and outward, lying along the upper border of the prostate and projecting beyond it laterally. The fundus of the vesicle lies just external to the termination of the ureter in the bladder. Each ves- icle is bound close to the bladder and prostate by the fascia of Den- onvilliers, a dense envelope. This fascia is the relic of that portion of the peritoneum that in the fetus separates the budding bladder from the rectum. It begins at the apex of the prostate, covers the posterior surface of this gland, forms the posterior sheath of the seminal vesicles and merges into the peritoneal reflection above. Within this fascia ramify numer- ous large branches of the prostatic plexus of veins. The relation of the vesicles to the peritoneum is variable. The rectovesical pouch touches the fundus of each vesicle; when the bladder is full there is a triangular extraperitoneal space between the vesicles, just above the prostate. The vesicle is elliptical in shape, flattened anteroposteriorly.. Guel- liot1 gives 49, 18.5, and 10 mm. as its average length, breadth, and thickness. The lumpy surface of the vesicle has been compared to the convolutions of varicose veins or of the intestine. By a tedious and Fig. 132.—Seminal Vesicles. *“Des vesicules seminales, ” Paris, 1883, p. 27. 580 PHYSIOLOGY 581 delicate dissection the vesicle may be unraveled. It is a canal 10 to 15 cm. long. From this canal spring numerous small diverticula, one of which, originating near the orifice of the organ, may be almost as long as the vesicle itself. The blind end of the vesicular tube may he doubled back, so that the tube actually terminates near the orifice of tlie vesicle, and the fundus represents its middle. The tube is quite as irregular within as without. Here and there the orifices of diverticula loophole the tortuous wall. The vesicle is made up of three coats: a thin outer fibrous coat, a thick middle layer of circular and longitudinal muscular fibers, and a mucous membrane. This contains many elastic fibers. Its epithelium is cylindrical in youth, cuboidal or flattened in old age. The epi- thelial cells often contain granules of brownish pigment, masses of which are occasionally found in the semen. Guelliot denies the exist- ence of special glands in the vesicle, and affirms that the epithelium is identical throughout the organ. Rehfisch recognizes vesicular glands. The arteries of the vesicle are derived from the inferior vesical and the middle hemorrhoidal. The veins join the prostatic and lateral ves- ical plexus. The lymphatics empty into the pelvic ganglia. The nerves are derived from the hypogastric plexus of the sympathetic. The ejaculatory ducts begin at the junction of the vas deferens and seminal vesicle. Becoming smaller and of even caliber, these ducts run obliquely forward and upward through the prostate, approaching each other until they nearly touch in the median line. Yet they are quite separate in their openings on the lips of the prostatic utricle. They are closely surrounded by a dense elastic tissue and contain a few straggling muscle fibers derived from the longitudinal muscle of the vesicle. PHYSIOLOGY The functions of the vesicle are three: 1. To store the secretion of the testis. 2. To dilute it. 3. To expel it into the prostatic sinus just before ejaculation. 1. Rehfisch,1 in a detailed study of the comparative anatomy and physiology of the seminal vesicles, showed that in rats, guinea-pigs, and some other mammals, the vesicles empty by a separate duct into the urogenital sinus and at no time contain spermatozoa. But he confirmed on man De Graaf’s experiment of injecting the vas deferens, showing that the vesicle fills with fluid before the ejaculatory duct is forced open. Hence it is fair to assume that the vesicle, as well as the ampulla of the vas, is a place of storage for the spermatozoa. 1 Deutsche med. Wochenschr., 1896. 582 DISEASES OF THE SEMINAL VESICLE 2. The secretion of the seminal vesicle dilutes the semen and prob- ably has some obscure function of stimulating the vitality of the sper- matozoa. This secretion is albuminous, alkaline, and odorless. It con- tains a large proportion of mucin. Besides blood cells, leukocytes, and epithelia, the fluid contains many little hyaline pellets rarely visible to the naked eye. These bodies (sympexions, globulin kbrner) appear under the microscope as hyaline spheroids showing radiating lines of cleavage. They may contain masses of spermatozoa or pigment gran- ules, and may attain a size sufficient to obstruct the ejaculatory duct. 3. The vesicle becomes distended with fluid by the accumulation of its own secretion and the influx of testicular fluid. Unless there is spermatorrhea, little or none of this fluid escapes, except during the sexual orgasm. This act occurs as follows: after a period of sexual excitement, during which the verumontanum becomes erect, the mus- cular coat of the vesicle and the ampulla of the vas contract peristal- tically, driving the fluid into the ejaculatory duct, which, very probably, is relieved of the elastic pressure that usually occludes it by a simul- taneous muscular contraction of the prostate. The semen is thus ejacu- lated into the prostatic sinus, where it mingles with the prostatic secre- tion. Thence the prostatic and urethral muscles eject the fluid by jets. Regurgitation of semen into the bladder is prevented, not by the erect verumontanum but by the force of the stream issuing from the ejacu- latory ducts. Science and experience agree that the seminal vesicles are not emptied by a single orgasm. ANOMALIES Anomalies of the seminal vesicles are usually part of some general genital malformation. Guelliot has analyzed and refused to accept the alleged cases of multiple seminal vesicles. When the vesicle is absent the corresponding testicle may yet be present. Extreme dilata- tion of the vesicles is probably always acquired. The ejaculatory ducts may empty into the ureters instead of on the edge of the prostatic utricle. In a few cases they have been found to continue forward alongside of the urethra the whole length of that canal to the meatus. WOUNDS OF THE VESICLE Guelliot recognizes only one ease of undoubted accidental wound of the vesicle. The patient had suffered a fracture of the ischium. CONCRETIONS AND CALCULI 583 Operative wounds of the ejaculatory ducts are very frequent. The patency of the ducts is imperiled by all perineal cystotomies and pros- tatotomies, including lithotomy, Bottini’s operation, and prostatectomy. Two results follow: inflammation (acute vesiculitis and epididymitis) possibly, obstruction probably. Fistulae of the spermatic duct have resulted from the old-fashioned lateral lithotomy operations. The resultant spermatic fistula heals kindly unless the parts are cancerous or tuberculous. EXAMINATION AND INFLAMMATION (See pp. 8, 133, 144, 150.) TUBERCULOSIS (See p. 402.) CYSTS Prolonged inflammation sometimes causes gradual dilatation of the vesicles until they become two or three times their normal size and even overlap in the median line. Such cysts have only a pathological sig- nificance. Echinococcus cysts occurring between rectum and bladder have been attributed, without convincing proof, to the vesicle. CONCRETIONS AND CALCULI While it is not unusual to find a number of concretions or small cal- culi in the vesicles of the aged, they have, as a rule, no clinical symp- toms. It is only very rarely that they give rise to spermatic colic or attain a noteworthy size (Fig. 32). Symptoms.—Spermatic colic may occur at the moment of ejacula- tion or during sleep. The pain is very sharp, colicky, in fact, and nauseating. It is centralized about an inch up the rectum, or at the neck of the bladder, and thence radiates up the posterior wall of the pelvis or to the testicles. The pain is caused by the impaction of a concretion or a mass of inspissated semen in the duct. The obstruction may be forced, and a painful and deficient emission ensue after a few moments of colic, or, if it occur without sexual sensations, during the 584 DISEASES OF THE SEMINAL VESICLE night, it lasts from ten to twenty minutes and then gradually dies away. Treatment.—The hot rectal douche (p. 208) is an excellent remedy to relieve the pain and to shorten the attack. Many persons who are subject to mild attacks of nocturnal spermatic colic obtain relief by introducing a finger into the rectum and pressing upon the offending organ. Relapses are prevented by massage of the vesicle. MALIGNANT GROWTHS Guelliot recorded but one authentic case of primary carcinoma of the seminal vesicle. Secondary involvement occurs from the prostate, bladder, or rectum. CHAPTER LXII DERANGEMENTS OF THE GENITAL FUNCTION IMPOTENCE Impotence is inability to accomplish the sexual act. It is a com- plaint not infrequently submitted to the physician; not always frankly and openly as such, but often by implication, as though it should be recognized and inquired about in answer to remote indications which the patient has scantily furnished. The physician who would meet the daily wants of his fellow-men in reference to troubles of this sort, must possess an accurate knowledge of the physiology of the sexual func- tion and of its various derangements, and be ready to anticipate the reticence of patients; otherwise he will fail to sound many of the depths of human nature where suffering lurks—which suffering is for the most part preventable or relievable. Impotence must be carefully distinguished from sterility, which signifies inability to beget offspring on account of d.efect in the semen, whether the individual can have sexual intercourse properly or not. The two are often associated in the same individual, but they may be totally distinct, as the following examples will illustrate. Thus, in the East, there are two methods of making eunuchs: either the penis is removed together with the testicles (and such a eunuch is necessarily both impotent and sterile), or the testicles alone are removed (and such a eunuch, though sterile, may be still potent, and does not bring so high a price as the eunuch who has no penis). It is a well-known fact that both animals and men, from whom the testicles have been removed after puberty, still retain sexual desires, and may have inter- course, with venereal orgasm and ejaculation, during a period of many years. A cryptorchid is not impotent, but is very apt to be sterile, and such is the case of many patients after double gonorrheal epididymitis; while, as causes of impotence without sterility, may be mentioned de- formities preventing sexual intercourse, though the spermatic fluid is normal, such as exstrophy of the bladder, extreme incurvation of the penis, and hypospadias. Impotence may be organic or functional. 585 586 DERANGEMENTS OF THE GENITAL FUNCTION ORGANIC IMPOTENCE This is exceedingly rare in the male. Anyone who can perform the sexual act is potent. This act implies two conditions, namely, suffi- cient erection to make intromission possible and a subsequent seminal ejaculation. That lack of desire before the act and pleasure during its accom- plishment are not absolute essentials to sexual intercourse is exemplified by the two conditions: priapism from cantliarides in which there is no desire, and yet intercourse is possible with perfect intromission and ejaculation, and certain diseases of the cord attended by more or less priapism, where intercourse followed by conception may take place, and yet the patient be unconscious at what moment ejaculation occurs. Conditions Involving True Impotence—1. Absence of penis. If there are healthy testicles, the patient cannot be called sterile. 2. Minute size of penis may involve impotence. That small size is only relatively a cause of impotence is evident, and that it by no means involves sterility is shown by Orfila, in a case where an action for rape was brought against a man with only a stump of a glans in place of the entire penis, by a woman who was impregnated by him. Orfila decides that impregnation may take place under these circumstances, but only through the consent of the woman, and that consequently rape is im- possible. The numerous cases on record where impregnation has taken place without rupture of the hymen show that a deposit of semen within the ostium vaginae may fertilize an ovum, and such a deposit of semen might be accomplished by the smallest possible penis. Intromission and ejaculation might take place, and impotence, though possible, is not essential. 3. Extreme size of the penis is a relative cause of impotence. 4. Extreme epispadias and hypospadias, or incurvation, likewise involve impotence, without sterility. Slight hypospadias may, but does not necessarily, involve impotence. The semen is not properly ejacu- lated into the upper part of the vagina, and impregnation sometimes fails to take place on this account. 5. Large size of the prepuce, or excessively tight and narrow orifice of the same, may involve impotence, as may also any tumors or growths upon or about the penis, elephantiasis, fatty tumor, hydrocele; or neigh- boring deformity (faulty position of the thigh from ankylosis of hip, excess of abdominal fat, etc.), which may mechanically interfere with copulation without in the least implying sterility. 6. Very tight stricture of the urethra, especially if there be large and multiple fistulae behind it, involves impotence if the semen does not escape by ejaculation, but dribbles away after erection subsides. A similar cause of impotence exists in a vicious direction of the orifices of IMPOTENCE 587 the ejaculatory ducts, by which during ejaculation the semen is turned backward into the bladder and escapes afterwards with the urine. Ac- cording to Grimaud de Caux, such a condition of things may be caused by the action of prostitutes, who, fearing pregnancy, watch for the moment of ejaculation, and then press forcibly upon the urethra of their partner just in front of the prostate, by inserting a finger into his rectum, thus causing the semen to he ejaculated into the bladder. A similar condition has been known to result from prolonged posterior urethritis and is not infrequent after prostatectomy. When, from these or any other causes, there is no ejaculation, the condition is known as aspermatism. I have known two patients who alleged complete aspermia to beget children. 7. Imperfect, irregular, or bent erections, due to inflammation, in- jury, or tumor of one of the erectile cylinders of the penis, may some- times prevent intromission and entail impotence. 8. Eunuchs, and those having atrophy of both testicles, are usually impotent, always sterile. 9. Injuries or diseases of the central nervous system may cause impotence by interfering with either erection or ejaculation. Impotence may be symptomatic—not to speak of the physiological impotence of childhood and old age—and then is only conditional or temporary, and usually disappears with the removal of its cause. In symptomatic impotence there is lack of erection, and often also tem- porary sterility. Such impotence is always associated with severe acute febrile diseases and with conditions of lowered vitality, whether due to wasting disease, to shock, or to other causes. Long-continued sexual excess, whether by masturbation or otherwise, produces impotence, though this is commonly a false impotence, an inability of the jaded body to keep pace with the lecherous mind. Finally, all drug habits— opium, tobacco, cocain, alcohol, etc.—tend to produce impotence. When a man is thoroughly drunk he is impotent; when a steady drinker, his sexual powers are always diminished, sometimes lost. FUNCTIONAL IMPOTENCE Functional impotence is properly defined by Hiihner1 as “that form of impotence in which there exists no gross pathological change in the structure of the sexual apparatus.” It may be considered under three heads: 1. Imaginary impotence. 2. False impotence. 3. Impotence depending upon disease of the sexual organs or abuse of the sexual function: usually both together. 1 Medical Becord, October 23. 1915. 588 DERANGEMENTS OF THE GENITAL FUNCTION Imaginary Impotence.—Tlie first class may be passed over lightly. Unhappily, there will always be among us a class of men, of splendid physique and infinite endurance, who elect to spend their lives in ignoble homage to Venus. And such men have their followers, their admirers —puny, dyspeptic, rabbit-eyed creatures—whose sole ambition is to flog their bodies on to wondrous feats of venery and bestiality. And since Nature never cast them in this mold, they come crying out be- cause their bellies are not so big as their appetites, instead of thanking God for it. False Impotence.—False impotence is that purely psychic condition which may result in a perfectly normal individual from sexual indif- ference or from such emotions as grief, joy, fright, repugnance, etc. It is only rarely that persons so afflicted consult a physician, and they can then usually be relieved by a proper interpretation of their symptoms. A second type of false impotence, however, exists in the sexual pervert whose abnormal habits have engendered a method of thought which renders normal cohabitation repulsive or impossible. Such patients require the most careful psychotherapeutic treatment which, with the help of psycho-analysis, and a sympathetic under- standing of their condition, often works wonders. Sexual Neurasthenia—Sexual neurasthenia, inasmuch as it implies pain and discomfort, has been dealt with on page 181. But the lesions there described centering about the verumontanum and utricle form the physical basis of the great majority of cases of impotence. The patient may attribute his trouble to gonorrhea, but it is doubtless always due to some sexual aberration. In early life the dominant cause is masturbation, later excessive sexual activity of any kind, and in married life coitus interruptus. Ungratified sexual excitement is a cause of impotence only when carried to great lengths and resulting in prolonged erections without emission. As a result of these conditions there may be impairment of desire, psychic impotence, disturbances of the orgasm, usually in the nature of pain, and associated with other evidences of inflammation of the veru- montanum (such as painful urination, etc.). Finally, and most impor- tant, are the disturbances of erection and ejaculation. The condition begins with frequent nocturnal emissions due to hypersensibility of the sexual reflex (usually caused by verumontanitis) ; and premature ejaculation soon results. If the patient exercises prudence and intelli- gence in the management of his sexual affairs the progress -of his con- dition may be slow or he may at any time have the wit to cure himself. As the conditions grow worse the emission becomes so premature that it actually occurs before full erection takes place. Functional Impotence.—In diagnosing functional impotence it is to be remembered that every case has its psychic basis, most cases a IMPOTENCE 589 moral and a physical one. The following suggestions will be of assistance: 1. True continence, chastity of thought as well as of act, never causes impotence. 2. Delay and lack of sensation in erection is likely to he psychic rather than due to sexual excess. 3. The intense reticence of these patients, while perfectly natural, interferes with a proper understanding of the case. Some form of psycho-analysis is often necessary to obtain all the facts, hut once the physician has these in his possession he is in a position to treat the case intelligently; without the facts, he can do nothing. 4. The condition may continue to develop after its cause, e. g., mas- turbation, has long since stopped. Treatment.—The treatment is threefold: 1. The Patient’s Sexual Coefficient Must Be Discovered.— The sexual coefficient is the amount of sexual power with which he is endowed by Nature. Mankind at large is possessed of the notion that, although men’s noses and digestions need not all he cut of the same pattern, it is to be expected that the sexual capacity of everyone should be all-embracing. Thus, while it is no disgrace to be dyspeptic about the stomach, it is to the last degree shameful to be dyspeptic about the genitals. Theoretically, such a distinction is absurd; but practically, no man is willing to brand himself a sexual laggard. In some way, by dint of enumerating emissions, copulations, masturbations, the physi- cian must learn what ideal he can set before the patient. If a man’s natural capacity for sexual congress is only once a month, it is hopeless to try and tune him up to three times a night. 2. The Patient Must Be Encouraged.—The first point of en- couragement must be to depress him by bidding him look for a pro- tracted and relapsing convalescence. Then he must be made to under- stand that his sexual possibilities are just so great and no greater; and that, however well he may get, overstepping his allotted bounds will call down swift retribution upon him. Finally, he must really be encour- aged to feel that his malady is a functional disorder, a dyspepsia, which, like other dyspepsias, is curable, but only at the cost of a prolonged fast. He must abstain from coitus, from masturbation, from lewd companions, from obscene thoughts and things. The more thoroughly he abstains, the more certain his cure. Usually he will try to adopt halfway measures, caring more for his “pot of ale” than for body and soul together. But such a course may not be countenanced. The ideal of absolute purity must be forever set before him and, as it were, hammered into him. If a strong moral influence, as that of father, brother, or priest, can be brought to bear, so much the better. But all these measures are frankly palliative. When a man has 590 DERANGEMENTS OF THE GENITAL FUNCTION once got into the habit of concentrating his whole mind upon his sexual organs, it is not to be expected that he should be entirely diverted to higher things. Chastity all can aim at, but celibacy is beyond the reach, beyond even the understanding, of the many. Hence, the proper cure for such a man, if he can be got into such a condition that he has an erection ever so rarely, is to instruct him in sexual physiology and hygiene, to acquire his confidence by sympathy, and to get him married, with the advice to attempt no intercourse, to be entirely frank and hon- est with his wife (who will more than equal him in timidity and ignorance), and, awaiting some morning when awaking with a vigorous erection, to accomplish coitus promptly without delay, as a matter of imperious duty. The act once accomplished, the spell is broken. He knows he is a man and his confidence in himself returns. 3. He Must Be Assisted Physically.—When possible, an entire change of scene with hard physical work presents the best opportunity for a man to get out of his old rut. Local treatment of the urethra by instillations, urethroscopic cau- terization, massage of prostate and vesicles, sounds, etc., quite empiric- ally, as in the treatment of sexual neurasthenia (p. 172). Hiihner speaks well of bromids, 1 gm., p. c. (and 0.0025 (1/20 gr.) of strychnin in four doses, q. 2 h., immediately preceding intercourse). STERILITY Sterility is an inability to beget children on account of absence or imperfection of the semen. The spermatic fluid, though ejaculated, may contain no spermatozoa (iazoospermia). Without enumerating all the possible causes of azo- ospermia, three may be especially designated: 1. Obliteration of both epididymes or both vasa by inflammation. 2. Such temporary influences as debilitating disease and mental or physical exhaustion. The latter is the cause of temporary sterility in many business men. They can impregnate their wives only after a vacation has supplied them with surplus energy. Chemical toxemias may produce the same result, and although alcoholics are famous for having large families, Simmons 1 estimates that 01 per cent of alco- holics are sterile. 3. The x-ray 2 deserves special mention. Brief exposure to this may entail brief sterility. The constant exposure to the influence of the ray to which radiographers are subjected results in a prolonged and perhaps a permanent sterility. 1Deutsch. Archiv f. Min. Med., 1898, Ixi, 412. 2 Of. Brown and Osgood, Trans. Am. Assn. G.-U. Surg., 1907, ii, 365. STERILITY 591 4. Inflammation of the prostate and vesicles. If the inflammation is severe the spermatozoa may he killed in transit, bet even a mild catarrh may so alter the qualities of these secretions as to render the spermatozoa infertile. Oligospermia is a rare and apparently congenital condition in which the semen instead of swarming with spermatozoa contains but few of these. They are usually deformed. Such a condition entails sterility just as much as does azoospermia. Aspermia means absence of ejaculation owing to defect or deformity or scar about the orifices of the ejaculatory ducts; these project the semen backward into the bladder instead of outward along the urethra. The patient recognizes no ejaculation, but usually there is a slight seepage from the meatus and such patients are by no means inevitably sterile. Diagnosis—The diagnosis of sterility is a much more complex problem than the above paragraphs suggest for the problem includes, not only the question of masculine, hut also that of feminine sterility. Moreover sterility is often relative. The diagnosis of sterility, due to such gross lesions as azoospermia, oligospermia or aspermia, is readily accomplished by the examination of a condom specimen. The difficult problem is that in which both man and woman are apparently normal though their union remains infertile. Careful microscopic examination of a condom specimen of semen is the first step in diagnosis. The chief information obtained by such an examination is the number of sper- matozoa. If these are very numerous the semen is doubtless fertile even though many of the spermatozoa are deformed. Indeed it is usually a waste of time to endeavor to estimate the motility of the spermatozoa in a condom specimen. This can only be fairly studied in a specimen obtained by massage of the seminal vesicles (and unfor- tunately massage does not always expel the spermatozoa) or by an examination of the secretions in the woman’s vagina a few hours after coitus. Reynolds,1 basing his work on that of Hiihner, comes to the following conclusions: 1. When the spermatozoa are abundant in number, normal in form and appearance, furnished with long- cilia and capable of rapid movement through the semen the male is satisfactorily fertile. 2. When normal spermatozoa ai’e killed or lose vitality overrapidly in the secretions of the individual woman the chemieophysiologic character of her secretions furnishes an effective cause of sterility. 3. The alterations in a secretion which make it fatal to the spermatozoon may be localized in the vagina, in the cervix, in the body of the uterus, or in one or both tubes; and any one of these alterations may exist with normal secretions above it; but an alteration in the secreting surface in any of these localities 1Jour. A. M. A., 1915, lxv, 1151. 592 DERANGEMENTS OF THE GENITAL FUNCTION usually vitiates all the secretions below it, probably by their necessary ad- mixture. 4. When the spermatozoa are observed to penetrate without apparent loss of vitality to the fundus of the uterus and to survive there for a normal length of time, deficient quality of the ova may be considered the probable cause of the sterility. Throughout the management of every case of sterility it must be remem- bered that the failure is the failure not of one individual, but of a couple, and that the condition of both partners must be studied. For the performance of the Hiihner test1 we must ask to see the woman as soon as possible after coitus has taken place. She may come to the office for this examination, since it is only very exceptionally, if ever, that the vagina does not contain sufficient spermatozoa for this test even after she has walked about for some time. With a normal vaginal secretion the spermatozoa should show active motility in the vagina for about an hour and sometimes much longer, but if circumstances permit it is desirable that the patient should be seen within half an hour of coitus. A specimen of the vaginal mucus is taken by a sterile platinum wire from the culdesac, exposed by a speculum, and this examination may be repeated if desired, whenever convenience permits, until the spermatozoa are found to have lost their activity. A specimen of the cervical mucus is next obtained in the same way, after the surface of the cervix has first been carefully wiped clean of semen by the repeated use of cotton swabs (no anti- septic should be used). With a normal cervical secretion and a normal os a few spermatozoa will usually be found in the lower part of the cervical cavity almost immediately after coitus, but will appear there in larger numbers at the end of half an hour to an hour. They are never so numerous here as in the vagina, but under normal circumstances, at the end of an hour, there should be several actively moving spermatozoa in each slide from the cervical mucus. The greatest care should be used to avoid the infliction of anj7 trauma in the ex- amination of the cervical cavity, since overthorouglmess here may readily vitiate the use of the remaining portion of the test at that sitting. When the cervical cavity has not been unduly disturbed, when the spermato- zoa are of full vitality, and when the secretions of the woman are nonnal throughout, an examination of the secretions of the cavity of the uterine body should disclose the presence of a few actively motile spermatozoa in the uterine mucus at the end of from two to three or four hours. This examination must, however, be made with a specially devised syringe, since the platinum loop can neither be introduced with certainty to the fundus nor made to retain the uterine mucus during its withdrawal from the cervix. Even with the use of a syringe it is difficult to be absolutely sure that spermatozoa which are observed in the fluid withdrawn from the uterus are not due to an admixture from the cervix, but if the piston is not withdrawn until the tip of the syringe is well up in the uterine cavity, if the outside of the syringe is carefully wiped after withdrawal, if it is properly designed, and especially if the spermatozoa are found several times in succession, their probable location in the uterine mucus can be predi- cated. In some cases it will be found that actively motile spermatozoa have disappeared from the cervix after the lapse of a number of hours but are still found in the uterine mucus. In these cases the test is practically complete. The saddest commentary upon the prevalent state of the med- ical mind in reference to the diagnosis of sterility is reported by 1 Urol and Cutan. Review, 1914, xvii, No. 11; also “Sterility,” 1913. MASTURBATION 593 Barney.1 He collected statistics from a large public hospital on 108 women who were diagnosed as sterile; 71 of them were actually oper- ated upon, or advised to be operated upon, and yet in only 5 of the whole number was the husband’s semen examined. Treatment.—Ten per cent of sterility is said to be due to the male, and it is only with the treatment of sterility in the male that we shall concern ourselves. I can recall only three classes of cases that have consulted me: 1. Aspermia after operation is likely to be only temporary, or at worst partial. I have twice tried to correct it by operation, but have not succeeded. It is, as above stated, not an inevitable cause of sterility. 2. Azoospermia due to alcohol or overwork. Cases of the latter sort are, I believe, not infrequent. I have twice seen impregnation follow a vacation in Europe; one of these coiiples had been married five years, the other twenty. In hotli the semen was apparently normal while the husbands were at work, and the wives had been duly and vainly mutilated by the gynecologist. 3. Azoospermia, due to bilateral gonorrheal epididymitis. For these the proper treatment is the Martin operation; without it there is no hope, with it there is a small prospect (perhaps 20 per cent), of cure. I have never seen a case in which the vitality of the semen appeared to be interfered with by suppuration in the prostate or seminal vesicles. Many persons with chronic prostatitis and seminal vesiculitis have all the children they want. Oligospermia seems a more incurable condi- tion than azoospermia, for in the former case the deficiency is probably congenital, though Martin regards it as a partial obstruction. MASTURBATION Self-abuse is the production upon one’s self of the venereal orgasm. The term masturbation signifies that an orgasm is produced by means of friction with the hand. Masturbation is not a malady. It does not necessarily produce disease unless carried to excess. Its practice is not confined to man. Monkeys are often masturbators; bears have the same habit; goats, making use of the mouth, indulge in it; turkeys sometimes practice it. In the human being it is practiced by both sexes at all ages, females being less addicted to it than males. The majority of women have little passion, and suffer the first approaches of a lover or husband largely as a matter of complaisance. Undoubtedly there are numerous exceptions to this rule, but still a rule it is that the female, naturally 1 Boston Med. Surg. Jour., 1914, clxx, 943. 594 DERANGEMENTS OF THE GENITAL FUNCTION modest, retiring, refined, learns wliat passion is only as the result of experience. With the male it is different. His passion is natural. He has erections while yet a child, and sexual yearnings long before puberty. Rarely does a hoy escape initiation into forbidden pleasures by his schoolfellows or his elders, and, though he escapes these, he is still very likely, when handling himself during erection, to find the sensation agreeable, and to go on, really ignorant of what he is doing, until he has become a confirmed masturbator. Male babies are some- times handled by their nurses to keep them quiet, a practice which is certain to beget the habit even in the earliest years of life. Stone in the bladder, irritation of the prepuce from retained smegma, ascarides, etc., lead a child to handle himself, and end in masturbation, if long continued; indeed, there are so many causes, natural and unnatural, why a boy should masturbate that few escape. But the most common cause is instruction received from other boys at school. Self-abuse is not confined to youth; middle and old age are not free from it. It may be safely assumed that a large proportion of mankind have masturbated more or less at some period in their lives, and it is equally safe to assert that at least 90 per cent of such masturbators are not physically injured by the habit. If carried to excess, sexual indulgence in the natural way will produce evil effects, yet sexual intercourse is not only harmless, but even beneficial in moderation, as it can be only in the married state. It is not the loss of seminal fluid which is of the first importance in producing disease from sexual excess, but the nervous shock of the oft-repeated orgasm. Babies and young children lose no seminal fluid, women have none to lose; yet, in all of these, evil results follow excess as certainly as they do in the male after puberty. It is probable that any succession of nervous shocks as sharp and decisive as the sexual orgasm, even although purely intellectual, such as joy or fear, would shatter the vitality and nervous tone of an individual as much as masturbation. Such writers as Lallemand, Acton, Belliol, make too much of the solitary vice, while quacks find here the largest and most lucrative field for their nostrums. These men scatter their books and circulars broad- cast over the land, and often, under alluring titles, thrust them within the eager grasp of the young, the inexperienced, the hypochondriacal, the nervous, overworked, unmarried youth, whose sexual needs, stimu- lated by his impure thoughts, find no adequate relief. Their tenets find ample faith and ready acceptance in the ingenuous mind, and errors are implanted which years of sober after-thought and experience, aided by the physician’s careful and conscientious advice, are scarcely able to eradicate. The use of tobacco, alcohol, and, it might be added, tea, is as wide- MASTURBATION 595 spread as the habit of masturbation; and each of these, or certainly the first two habits, probably inflicts as much injury upon the human race as does the secret vice. Yet who would affirm that every man who smoked would have headache, dyspepsia, heartburn, neuralgia, intermitting pulse, or would become thin, depressed, nervous, sleepless —all of which effects may be produced by an excess of tobacco; or that another who drank liquor would necessarily have delirium tremens, cirrhosis of the liver and kidney, and die with ascites and Bright’s disease ? As with whisky and tobacco, so it is with masturbation car- ried to excess. Masturbation may contribute in producing the most serious results, among which idiocy, insanity, epilepsy, dementia, phys- ical prostration, hypochondria, impotence, and sterility are prominent; hut in such it will be found that some mental deficiency was the funda- mental difficulty, masturbation hut one of its expressions. Hence it is evident that, while the intelligent physician must recognize the physical evils masturbation may produce, he should boldly oppose himself to that sickly sentimentality which shrouds in mystery'one of the failings of our physical nature because it involves the sexual function, and should try to face the subject honestly and to handle it as a scientific problem. The majority of mankind who indulge in masturbation do so just before and after puberty. At first most of them are ignorant that they are harming themselves, but they soon find it out by one means or another, and then sooner or later give it up. The longer and the more frequently they yield to the vicious habit the stronger does its hold become, so that in case they escape the mental and physical dis- orders to which excessive venery in extreme cases may give rise, still they may pay the penalty of excess by some diminution of vigor in after-life, by upsetting their sexual hygiene, and by establishing sexual necessities which they find it difficult to satisfy; and, finally, they may continue on through life victims to a perverted sexual sense, shunning women, from whom they aver that they derive no pleasure, totally wrecked as to their morale, hypochondriacal, and suffering from all sorts of functional distress, physical and intellectual, real and fancied. The chief reason why so much is said of venereal excess by mastur- bation, and so little of sexual excess in the natural way is that the former is so much more common, and not that the act itself is physic- ally more harmful. The solitary vice, as it is aptly styled, may be practiced on all occasions. On the other hand, sexual intercourse re- quires the consent of two individuals and opportunities which are com- paratively hard to find. In married life excess is the exception; sexual hygiene is more apt to be correct, man is in his natural condition. Other emotions enter largely into his daily life, and it is rare that a man happily married complains of any disorder of the genito-urinary system, except those of 596 DERANGEMENTS OF THE GENITAL FUNCTION a purely physical nature. On the other hand, the old rounder, who flatters himself upon the number of women he has ruined, but lays the blame upon Dame Nature, is usually a masturbator and, not infre- quently, a pervert. Symptoms.—A young child who has been taught to masturbate will be seen constantly at work at his genitals, and observed to have erections with unnatural frequency. No further signs are needed. Such chil- dren are fretful, peevish, thin, nervous, excitable, sleep badly, and have a haggard look. Boys who masturbate to excess usually incline to melancholy brood- ings, to staying apart and reading rather than to joining their com- panions at play. Their palms are apt to be cold and moist. They lose the innocent frankness of youth. The young man is oversliy, unambitious, he shrinks from a steady gaze, blushes readily, and seems to be conscious of having done some- thing unmanly. Adult masturbators often show no sign of the habit, though they are apt to be cowardly, mean-spirited, poor specimens of humanity. But it is rare for adults to practice masturbation to great excess, and, if they suffer from any of the supposed evil consequences of the habit, it is either on account of excess in earlier life, of imperfect sexual hygiene, or of irregularly gratified sexual desire. Their symptoms assume a multiplicity of expression, and are generally hypochondri- acal, and manifestly not entirely dependent upon masturbation; for the same symptoms are very common in patients who do not masturbate. As to atrophy of the genitals, varicocele, etc., these are not due to masturbation. Masturbation is a symptom, rather than a cause, of insanity. The physical damage done by masturbation (or any other form of sexual excess) is confined to the internal genitals. Its most patent expression is verumontanitis (cf. Iliihner x). The foregoing remarks are not intended to palliate in the least degree the baseness of the practice of self-abuse, or to deny that lack of physical and sexual vigor, spermatorrhea, neuralgia of the urethra, etc., may be caused by its excessive indulgence; but they are intended to combat the prevalent idea that very few men indulge in the secret vice, and that all who do so suffer; and they are also intended to ad- vance the proposition that in the vast majority of instances masturba- tion does little harm to the individual, except in regard to his morale. It unmans him, makes him untrue to himself, and cowardly; and most sensible boys find this out before a great while, and give up the prac- tice, which they feel to be sapping their manhood and self-esteem. Treatment—It is infinitely better that a bov should never mastur- *N. Y. Med. Jour., Feb, 17, 1912. MASTURBATION 597 bate if he can be prevented. Prophylactic instruction may save him. No instructor can equal a parent, whose moral influence outweighs all consideration of amateurishness. Every child has a right to know the essentials of sexual life. Indeed every hoy, at least, will learn from an evil source all he fails to learn from a pure one. The parent’s chief duties are two, viz., to answer all questions with absolute frankness (for they are asked in that mood), and to warn the child of approaching phenomena of emissions, etc., as well as of the need of keeping his hands off his own genitals and those of others. In the case of babies who do not do well, nurses should be watched and discharged if they are found handling the child. If the infant has already acquired the habit, his hands must be tied when he sleeps, and at all other times he must be watched until he grows out of the habit. Circumcision often helps to check masturbation whether of boy or girl. Boys should always be made to sleep alone, never allowed to consort secretly with any other one boy. All close intimacies between boys of different ages should be broken up, and, on the appearance of any of the signs of masturbation, a close watch should be maintained. In most cases it is not good policy to ask a boy if he fingers his privates. lie will be pretty sure to say no, and then to tell other lies to substantiate the first. To assume the fact after a careful study of the case is the safest course, and the boy, thrown off his guard by the statement that he does masturbate, will rarely deny it, or will do so in such a lame manner or with such overpositiveness as to convict him- self. Finally, when the patient has confessed his folly, it is not wise to terrify him out of his habit by brilliant and exaggerated statements of the possible misery he may bring upon himself if he does not desist. This is appealing to a base motive, and, although sometimes successful, it is often inadequate to the proposed end, for a healthy boy cannot realize what it means to he sick; he cannot understand it, and conse- quently is not afraid of it. The method of treatment that is most effective, but requires the most force to carry out, is to elevate the boy out of his bad habit, to shame him, to make a man of him, to reason with him, and to talk to him honestly and openly, without reserve or mysticism. When a man comes complaining of the results of masturbation, an attentive study of the symptoms will prove his disease to be hypochon- dria, and his malady ungratified sexual desire, often with congestion of the verumontanum. Ilis training should consist in encouragement to continence, with absolute purity of thought, and subsequently mar- riage, to regulate his sexual hygiene. After marriage we hear no fur- ther complaint from these cases, always provided there is really nothing more than functional derangement at the bottom of the patient’s com- plaint, as is the case in the vast majority of instances. 598 DERANGEMENTS OF THE GENITAL FUNCTION Treatment of the inflamed prostate and vesicles by massage and of the verumontanum by instillations or uretliroscopic applications is an essential part of the treatment of the adult. Medicines are of little or no value; camphor, bromids, or lupulin may be given as placebos, but it is doubtful if they have any efficacy. Cold sponge-baths, outdoor sports, physical fatigue, sleeping in a cool room on a hard bed with a light covering, are all useful; eating lightly at night, not retiring until very sleepy and rising immediately on waking in the morning, are powerful assistants in breaking up the habit. POLLUTION Pollution is a term applied to involuntary emissions of semen in ejaculation, attended by a more or less marked venereal orgasm. Pol- lutions are nocturnal or diurnal. NOCTURNAL POLLUTIONS Nocturnal pollutions are exceedingly common. They usually ac- company an erotic dream, and the patient wakes just as the ejaculation is occurring. When sleep is profound, the patient may not wake, or, if he does, he forgets liis dreams, so that the sensation of pleasure accom- panying ejaculation is faint and forgotten. Occasional nocturnal emis- sions are entirely natural and by no means a sign of disease. Their frequency compatible with health varies with the purity of mind and the sexual vigor of the patient. A man who is happily married rarely has nocturnal emissions while living with his wife, but, if he leaves her for several weeks, it is natural that there should be a formation and collection of semen which, distending the seminal vesicles, excites erotic fancies and escapes at the conclusion of a dream. Any man suffering from ungratified sexual desire is normally in a condition demanding relief for his overdistended seminal vesicles and, if that relief be not afforded in some other way, it comes spontaneously during sleep. This is all the more certain to be the case if he has established a habit of ex- cessive sexual intercourse, or masturbation. Occasionally nocturnal emissions may be overfrequent, and indicate a condition of irritation in the deep urethra which requires treatment. Treatment.—When emissions do not exceed one a week they should be disregarded, and attempts made only to purify the patient’s thoughts, to elevate his physical tone, and if possible to get him happily married. The patient should exercise and develop his muscular system. He should endeavor to tire himself out by physical work so as to sleep soundly. Locally, cold baths and cold douches are useful. He should PRIAPISM 599 sleep on a hard bed, lightly covered. The stomach should not be full on retiring. Most patients have involuntary emissions toward morn- ing, and waking, find themselves lying on their backs. This position, with the bladder somewhat distended, tends to beget erection, and, by avoiding it, pollution may be escaped. This end may be accomplished by tying a towel round the waist on retiring, with a hard knot in the back of the spine. When the patient lies upon this knot it awakens him. If these measures fail, or if the emissions recur so frequently as really to do harm, local treatment for vesiculitis, prostatitis or veru- montanitis is required. From time to time different mechanical devices appear for treat- ing pollution, their object being either to prevent the patient from handling himself during sleep or to awaken him before emission when he gets an erection. I believe them valueless and as likely to do harm as good, by keeping the patient’s mind concentrated upon his malady and leading him to attach too much importance to the physical act of emission. DIURNAL POLLUTION Diurnal pollution is rare. Some impressionable patients acquire so intense a prostatic irritability from venereal excess that the sight or thought of certain women or the lightest friction upon the glans penis will produce ejaculation. Such injuries to the spine as are caused by the garrote and the gallows commonly cause ejaculation; and sexual perverts find in shoes, hats, odors, and various abominations sufficient cause for pollution. PRIAPISM Priapism is a condition of prolonged erection independent of tho will or emotion of the patient. Such erections may be transitory, in which case they are usually due to some local inflammation or to cerebral or spinal disease (e. g., tabes). But in severe cases the priapism may be of very lung duration. Hinman 1 distinguishes the cases due to nervous causes, and those due to local mechanical causes. Among the former 3 were due to peripheral irritation (phimosis, fissure in ano) ; 4 were toxic, 3 due to cantharides and 1 to diabetes; 5 due to nasal polypi and cured by their removal, 13 to fracture of the spine, 1 to myelitis, and another to tumor of the spinal cord. Among the cases due to mechanical cause, 64 followed sexual excess and in 55 of these there was thrombosis of the corpora cavernosa, 6 other cases of thrombosis followed a systemic infection, in 2 cases there was 1 Annals of Surgery, December, 1914. 600 DERANGEMENTS OF THE GENITAL FUNCTION infiltration with neoplasm, while 2 others were attributed to angio- neurosis. Injury produced the thrombosis in 7 cases; “45 cases showed a definite relationship to leukemia.” Hinman states that priapism is most common between the twentieth and the fiftieth years, and that it may continue for from a few hours to two years. The nervous cases of functional origin are usually repe- titious and brief. Pain may be absent or severe. There may be some disturbance of urination; sexual desire is usually absent. Many of the cases have gotten well spontaneously or by treatment of a recognized etiological factor. TIinman suggests operative relief by division or in- jection of the internal pudic nerve, by ligation of the dorsal arteries, or by dividing the ischiocavernosi muscles. For priapism due to throm- bosis of the corpora cavernosa incision has been employed with success in 31 out of 33 cases. Ilinman suggests that incision in one corpus is likely to drain both, since the vascular anastomosis is free. CHAPTER LXI1I DISEASES OF THE PENIS—ANATOMY—ANOMALIES—INJURIES— INFLAMMATIONS ANATOMY The penis is a genital organ. Its urinary function is purely sec- ondary. It is conformed anatomically to subserve the genital function. In the adult it measures, when at rest, from the root of the scrotum to the meatus urinarius, from 6 to 10 cm. to 4 inches) ; when erect, from 12 to 17 cm. (5 to 7 inches). It consists essentially of three segments—the two corpora cavernosa, lying together like the barrels of a gun, and the corpus spon- giosum, like the ramrod, beneath them (Fig. 133), the whole surrounded by in- tegument. The Corpora Cavernosa.—The corpora cavernosa arise on each side from the tuberosities and ascending rami of the ischium. They come together under the symphysis pubis, and continue side by side, forming the main bulk of the penis. They terminate anteriorly in a conical ex- tremity, over which the glans penis (the terminal expansion of the corpus spongio- sum) fits like a cap. There is no vascular communication between the corpora caver- nosa and the glans penis, or the corpus spongiosum. The corpora cavernosa are surrounded by fibrous sheaths which are so dense and strong that they will support the weight of the cadaver.1 These sheaths are plenti- fully supplied with elastic fibers. The an- terior portion of the partition between the corpora cavernosa is per- forated by numerous apertures, to insure symmetrical erection. The Fig. 133.—Transverse Sections of Penis (Cruveilhier). A, flaccid. B, in erection. 1, 2, dorsal vein and artery; 3, cor- pora cavernosa; 4, tunica al- buginea; 5, integument; 6, tun- ica albuginea of corpus spon- giosum; 7, erectile tissue; 8, urethra. 1 Cruveilhier, ‘ ‘ Traite d ’anatomie descriptive, ’ ’ Paris, 1865, ii, I, 386. 601 602 DISEASES OF THE PENIS tissue proper of the corpora cavernosa consists of large venous spaces, known as spongy or erectile. The Corpus Spongiosum—The corpus spongiosum urethrae is also composed of erectile tissue, it surrounds all that portion of the urethra lying in front of the triangular ligament, anteriorly forming the glans penis, which caps the conical extremity of the corpora cavernosa, pos- teriorly terminating in the hulb, which lies just in front of the triangu- lar ligament in the angle of the converging corpora cavernosa and below the urethra. The Gians.—The glans penis (Fig. 13) is covered by a semimucous membrane endowed with peculiar sensibility, especially around the raised posterior border—rthe corona glandis. The epithelium covering the glans is fine, the papillae minute, the sebaceous glands (of Tyson) large and numerous, and most plentiful about the frenum. These glands secrete the white material (smegma) that collects behind the corona. The function of the glans penis is to furnish a soft-skinned expansion for the distribution of the terminal filaments of the nerves of sexual sensibility. Muscular Action.—One important function of the corpus spon- giosum is acquired through its bulb—namely, that of assisting in the expulsion of the last drops of urine or semen from the urethra. The prostate, the levator ani, and the deep urethral muscles—especially the compressor urethrae—contract upon the fluid remaining in the canal after micturition in a spasmodic “piston-stroke.” This forces the last few drops beyond the bulb of the urethra. Now the fibers of the accel- erator urinae surrounding the bulb and adjacent portions of the corpus cavernosum contract, and drive the blood contained in the areolae of the bulb forward along the corpus spongiosum, distending that body, and thus bringing the walls of the urethra more closely into contact in a progressive wave. If there is organic stricture the last few drops of urine do not escape promptly, but dribble away; for the scar tissue which constitutes stricture obliterates the areolae of the erectile tissue and thus obstructs the free passage of the wave of blood along the corpus spongiosum. Fascia.—The three erectile bodies which have been briefly described are surrounded by the fascial sheath of the penis. This fascia (called Buck’s fascia) arises from the symphysis pubis by a triangular bundle of fibers, the suspensory ligament of the penis, and from the pubic rami at the attachment of the anterior layer of the triangular ligament. Thence it runs forward, surrounding the corpora cavernosa and the corpus spongiosum in two separate compartments. The lower plane of this fascia is in its posterior part identical with the deep layer of the perineal fascia. The cavity of Buck’s fascia is bounded anteriorly by the base of the glans penis and posteriorly by the triangular ligament. ANOMALIES OF THE PENIS 603 Hence peri-urethral cellulitis and extravasation are habitually confined within these limits for an indefinite time, unless at the root of the penis where the fascia blends with that covering the pubes, and leaves a loop- hole of escape into the subcutaneous tissue of the abdominal wall. Vessels.—The lymphatics and veins of the penis run along the dorsum, and receive in their course branches from the corpus spon- giosum. The lymphatics lead mainly to glands lying along and above Poupart’s ligament on each side. The arteries arise from the internal pudics. Connective Tissue.—The connective tissue between the skin and Buck’s fascia is very loose and elastic, and, like that of the eyelids, does not contain fat. Skin.—The skin of the penis, except that it tends to become pig- mented after puberty, does not differ essentially from ordinary in- tegument. Over the glans penis it folds back upon itself, forming a nonadherent sheath for the glans (the prepuce), evidently intended to preserve the delicate sensibility of this portion of the member. The Prepuce—The prepuce is composed of two layers, a cutane- ous (external) and a more delicate semimucous (internal). The point of junction of these two is called the orifice of the prepuce. Between these layers is a very loose and elastic connective tissue, without fat, which permits the two surfaces to be entirely separated from each other, and the prepuce effaced, by drawing back the integument of the penis until the glans is entirely uncovered. The mucous layer of the prepuce is supplied with glands (of Tyson). It is much less elastic than the cutaneous layer. The prepuce is attached to the lower angle of the meatus urinarius by a triangular fold of mucous membrane called the frenum preputii— analogous to the frenum linguae. The frenum contains a small artery. ANOMALIES OF THE PENIS Deformities of the urethra are described on p. 507. Double Penis.—Double penis is excessively rare. It is analogous to double uterus and vagina in the female, but by no means so common. Un- doubtedly it is not so rare as the records of surgery imply, for the exist- ence of this deformity naturally leads the patient to shun observation; and, as the defect is not necessarily accompanied by any injurious symp- toms, he does not voluntarily subject himself to the inspection of a physi- cian. Hence the cases usually reported, such as those of Hart1 andGorre,2 accompany grosser malformations of fetal inclusion. The case reported 1 Lancet, 1866, i, 71. 2Compt. rend, de l’Acad, des Sciences, 1844. DISEASES OF TIIE PENIS 604 in the first edition of this treatise 1 is a notable exception. Similar ones are reported by Drs. Alan P. Smith,2 J. Lorthior,3 and Carl Beck.4 Smith’s patient had a stone in one of his bladders, was cut and cured. lie could urinate from either bladder at will. Torsion of the Penis—With epispadias and hypospadias the penis may be more or less completely twisted upon itself. Jacobson5 has collected a number of cases. In Caddy’s c case the torsion was unaccom- panied by any urethral defect. Absence of Penis—The various amputations of the penis, surgical, traumatic, or gangrenous, do not concern us here. The congenital de- formity is a rare one, and usually unaccompanied by any faulty devel- opment of the testicles or of other parts of the body. The scrotum, how- ever, is usually small and may be bifid. In either case the external genitals closely resemble those of a woman. This is male pseudoher- maphroditism. The line of pubic hair is said to be an infallible sign of the sex of such a person if an adult. If a female, the upper border of the hair forms a transverse line across the hypogastrium, while the hair of the male rises up in a curved line toward the umbilicus. The urethra opens in the median perineal raphe or on the anterior rectal wall. In the latter case there is danger of ascending infection (Matthews7). Harris8 collected 6 cases, including 1 of his own, omitting 2, Revolat’s 9 and Wright’s.10 More recently Preston11 has reported a case. Apparent Absence of Penis.—Congenital dislocation or apparent absence of the penis exists when the penis, lacking its proper sheath of skin, lies buried beneath the integument of the abdomen, thigh, or scrotum. Boutelier 12 reports such a case. Under the skin above the scrotum a movable body was felt, liberated by incision, and discovered to be the penis. Another case, reported by J. Murphy,13 would seem to be rather a penile adhesion to the hypogastrium, for the child could urinate through a hole in the lower part of the abdomen. The treat- ment of such a condition implies the immediate liberation of the incar- 1Case I, Van Buren and Keyes. 2 Trans Med. and Cliir., Faculty of Maryland, April, 1878. 8 Centralbl. f. d. Krarikh. d. Ham. u. Sex. Org., 1901, xii, 381. 4 Med. News, 1901, lxxix, 451. 6 “Diseases of the Male Organs of Generation,” 1892, p. 612. 6 Lancet, 1894, ii, 634. 7 Phil a. Med. Jour., 1898, i, 71. 8 Amer. Practitioner and News, 1894, xvii, 27. °J. de Sedillot, xxvii, 370; Demarquay, Maladies cliir. du penis, Paris, 1879, p. 538. “Ashby and Wright, “Diseases of Children,” p. 531. 11 Med. Record, 1898, liv, 315. 12 Union med. de la Seine infer., 1875, xi, 27. u Brit. Med. Jour., 1885, ii, 62. ACCIDENTS TO THE PENIS AS A WHOLE 605 cerated member to avoid urinary infiltration. In this emergency any method of covering the denuded penis with skin may be employed, the simpler the better, leaving until later years the task of affording a more satisfactory envelope to the organ. Congenital incurvation of the penis and scrotal concealment of that organ occur as phenomena accessory to hypospadias, and will be consid- ered as such. Hermaphroditism.1—Accepting Klebs’s definition of true hermaph- roditism—viz., the existence of dissimilar genital glands (i. e., at least one testis and one ovary) in one individual—there is still some doubt whether any such individual has existed. Dr. Blacker and Mr. Law- rence 2 maintain the positive side of the question, and find in the litera- ture foundation for their belief. In no case has it been recorded that the person was, functionally, both male and female, producing both spermatozoa and ova. On the contrary, as a general rule they are sexu- ally neuter. These true hermaphrodites resemble clinically the pseudo- hermaphrodites—persons whose sex can with difficulty he determined— and they sometimes come to the surgeon asking him to make them dis- tinctively male or female, whichever he may deem more appropriate. In deciding such a question, if the external genitals are quite indeter- minate—as they often are—the chief characteristics to be considered are the shape of skeleton, the disposition of the superficial fat, the growth of hair, facial and pubic (see above), the voice and the shape of the larynx, and, finally, the sexual sentiments of the individual. The process of “making a man of him” or “a woman of her” may be long and tedious, but may prove successful, as in a case reported by Gruber,3 in which amputation of the hypertrophied clitoris, posterior colpotomy to enlarge the rudimentary vagina, and electric epilation of the facial hair sufficed to establish the external female characteristics. ACCIDENTS TO THE PENIS AS A WHOLE Wounds.—The penis is liable to be wounded by accident or by de- sign. In the latter case insanity, or the melancholy depression pro- duced by masturbation, induces the patient to mutilate himself; or the injury may be inflicted by a jealous woman. Superficial cuts are unimportant, but wounds extending through the sheaths of the corpora cavernosa may give rise to troublesome, possibly fatal, hemorrhage, while the cicatrices left after healing may distort the penis and render erection imperfect and painful. 1 Cf. Hart, Edinb. Med. Jour., 1914, xiii, 295. 2 Trans. Obstet. Soc., Lond., 1896, xxxviii, 265. 2 Centraibl. f. d. ges. Therap., Wien. 1897, xv, 385. 606 DISEASES OF THE PENIS Treatment.—Cleanse the wound. Endeavor to obtain primary union by immediate suture. Introduce tlie sutures just deep enough to bold the fibrous sheath. Employ moderate pressure in dressing. Erec- tions, which are sure to occur, since the local inflammation induces a flux of blood, retard healing. Even in cases seemingly desperate, where the penis has been almost wholly severed from the body, an attempt should be made to save it. A remarkable success in a case of this sort, where the whole penis was severed except a portion of one corpus cavernosum, is related by Ar- taud.1 Erectile power is not regained after such a recovery. Contusions.—The escape of blood under the skin after superficial contusions of the penis is often excessive, on account of the laxity of the connective tissue and the large size of the superficial veins. Deeper contusions give rise to localized swelling from circumscribed effusion of blood. This swelling fluctuates and deforms the penis more or less, sometimes causing it to deviate when erect. Inflammation of the cor- pora cavernosa may result, terminating in suppuration or gangrene. Severe contusions involving the urethra may lead to infiltration of urine and urethral fistula. The introduction of the penis into a ring is a classical accident. The penis swells, the patient is ashamed to seek relief, and serious inflam- matory mischief—even gangrene, urinary fistula—may ensue. Guillot in such a case conceived the happy idea of dissolving the ring, which was of gold, in a bath of mercury. Demarquay 2 narrates many curi- ous instances of a similar character. Subcutaneous hemorrhage may be controlled by the application of cold and pressure, with due regard for the possibility of sloughing if the treatment is overdone. Later, simple pressure to promote absorp- tion will suffice, or the clots may be evacuated through an incision made under local anesthesia with the usual aseptic precautions. If gangrene occur, the penis should he kept absolutely dry and clean by applying a mildly antiseptic powder and a gauze dressing. The gangrenous tissue may be removed piecemeal, after which the gaps may be filled in by skin-grafting or by a plastic operation. Injuries involving the urethra are described on p. 488. Fracture of the Penis.—When the fibrous sheaths of the corpora cavernosa are ruptured by sudden forcible flexion of the erect penis, a sort of fracture of the member is produced, with extensive extravasa- tion of blood, sometimes amounting to traumatic aneurysm. Valen- tine Mott 3 reported two interesting cases of this accident, where the only treatment employed was rest and cold locally applied. Both re- 1 Bull, de la Soc. de Chir., vii, p. 451. 8 “Maladies chir. du penis,” Paris, 1877. * Trans, of the N. Y. Acad, of Med., vol. 1, Part I, 1851, p. 99. ACCIDENTS TO THE PENIS AS A WHOLE 607 covered with a useful organ and no deformity. Demarquay has cited many others. Treatment.—A catheter is passed into the bladder to insure the patulousness of the urethra. Upon this the penis is bandaged and an ice cap applied. If the pressure proves unbearable or if gangrene, ex- travasation, or cellulitis threaten, the clots must be evacuated and the bleeding checked by suture. The urine should be diverted through a hypogastric opening. After recovery an indurated spot may remain permanently to mark the site of the injury, perhaps resulting in priapism or stricture. Fracture of Corpus Spongiosum.—Fracture of the corpus spongi- osum is generally occasioned by “breaking the chordee” in gonorrhea. The inflamed tissue gives way, yielding urethral hemorrhage as an immediate and traumatic stricture as a remote result. The healthy corpus spongiosum may be fractured during erection. Dittel1 gives one such case. My father has seen another.2 Dislocation of the Penis.—When the integument of the penis is violently dragged upon, as, for instance, when the clothes are caught and torn away upon a revolving wheel, the entire penis may be shot out of its investing cutaneous sheath and lodged in the scrotum, the peri- neum, the groin, or under the integument of the abdomen. In such cases, the semimucous membrane of the prepuce gives way either at the preputial orifice or just behind the corona. A number of instances of this curious luxation have been recorded.3 The penile injury is usually not discovered until retention of urine or the passage of urine by some opening at a distance from the preputial orifice directs attention to the contused genitals, when the penis is found to be only a sheath of in- tegument containing clotted blood. Sometimes it has been difficult to find the penis at all; but an intelligent search will always reveal it, and then the surgeon’s obvious duty is to replace it in its sheath, incising the integument about its root as far as may be necessary to attain the de- sired result. In dislocation, the urethra is often ruptured low down, and, after the organ has been replaced in its sheath, operation for urethral rupture may be called for. In one case, a six-year-old child, Uelaton reduced a dislocated penis through the preputial orifice by means of an aneurysm needle, assisting its hook action by external manipulation. 1 Wien. med. Blatter, 1885, Nr. 2. 2 Van Buren and Keyes, 1st ed., p. 7. 3 Cf. Goldsmith, Lancet, 1898, ii, 387. 608 DISEASES OF THE PENIS CUTANEOUS AND MUCOCUTANEOUS AFFECTIONS OF THE PENIS Many common skin diseases involve the skin of the penis as well as other integumentary parts. As a rule, they present no special charac- teristics and require no comment here. Venereal sores, true chancre and chancroid, are common, as also are soft venereal warts. These re- ceive mention elsewhere. Hutchinson 1 circumcised a hoy for lupus of the prepuce and obtained a perfect result. Kake, of Trinidad,2 has performed circumcision on 1G lepers, and, even though the incision actually traversed a leprous patch, it always healed kindly. Scabies.—Sometimes scabies produces papular, crusted and con- fluent lesions on the glans or skin of the penis, closely resembling the venereal sores. The lesion is crusted rather than ulcerative, typical burrows may be found, and the effect of sulphur ointment is magical. Herpes Progenitalis—This affection consists in the development of clusters of vesicles upon reddened patches on the mucous covering of the glans, or on either layer of the prepuce, or on other portions of the neighboring skin, attended by a slight sensation of heat and tingling. When occurring on the cuticular layer, herpes runs its course as it does elsewhere on the body, but when vesicles develop within the preputial orifice the epithelium of the vesicles is soaked off, little ulcerations re- sult, more or less general inflammation is likely to arise from retention of the secretions, and balanitis, with posthitis, vegetations, and inflam- matory phimosis, may be the ultimate result. Exceptionally the ulcera- tions become deep and angry, and the diagnosis from chancroid difficult, while the glands in the groin may inflame and suppurate. The affection shows a marked tendency to recur. A tight prepuce and contact of irritating discharges act as predisposing causes. Diagnosis.—Vesicles, usually in groups, always precede the ulcera- tions, while the latter are irregular in shape, superficial, and very rarely complicated by suppurating bubo. The pus is not auto-inoculable. Treatment.—Until the vesicles break there is no treatment. There- after the ulcers should be dusted with any mild antiseptic powder. Recurrence may sometimes be prevented by circumcision; but often it cannot be prevented. Herpes Zoster.—Zoster may occur upon the penis as elsewhere. Lichen Planus. —This occurs on the glans penis, simulating almost precisely a squamous syphilid. They may be distinguished by the Wassermann reaction and by biopsy. Elliott states that the syphilitic eruption is never wholly confined to the glans. 1 Arch, of Surg., 1890, ii, 17. 2 St. Louis Med. and Surg. Jour., 1893, lxiv, 221. CUTANEOUS AND MUCOCUTANEOUS AFFECTIONS 609 Balanoposthitis.—Balanitis (/?«Xavos, a gland) is an inflamma- tion of the surface of the glans penis. Posthitis ( the prepuce) is an inflammation affecting the mucous surface of the prepuce chiefly. Neither can exist for any length of time without becoming more or less complicated by the other. For practical purposes they must be consid- ered together. Etiology.—Persons of irritable skin and gouty habit are predis- posed to this disorder. A long and tight prepuce is always a predis- posing cause. The exciting causes are mechanical irritation or unclean- liness from retention of smegma, or from contact with diabetic urine, gonorrheal, leukorrheal, menstrual, or other irritating fluids. Symptoms.—The membrane at first becomes reddened, then mottled and moist; next the epithelium comes off in patches, leaving irregular excoriations which soon ulcerate and discharge a purulent fluid. The ulcerations are not preceded by vesicles. There is a burning soreness with itching at the end of the penis, usually scalding on urination. The entire prepuce may inflame, become red and infiltrated, producing in- flammatory phimosis. The ulcerations rarely become deep, and the inguinal glands do not often suppurate, but they may grow somewhat large and tender. In chronic balanitis with phimosis, the mucous sur- face of the prepuce is granular and even condylomatous. R. W. Taylor 1 has described a peculiar ringed affection of the pre- puce and glans—narrow rings of reddened mucous membrane covered by a thin layer of epithelial scales. The inclosed area is normal, the rings vary from \ to | inch in diameter. The affection is sometimes painful or itching. The rings remain stationary for a time. They may come out in successive crops. They get well without scar, slowly, under the use of arsenic internally. They should not be confounded with lichen planus of the glans penis. Diabetic balanoposthitis is caused by contact of the saccharine urine. Erosive and gangrenous balanitis 2 is a specific infection caused by a spirocheta and a baciTus quite similar to those found in Vincent’s angina. The infection, if mild, results in superficial erosions about the corona or the adjacent portions of the prepuce, rarely on the glans penis. This infection may lead to ulceration, cellulitis of the prepuce, and even to gangrenous ulceration with perforation of the prepuce. Erosive meatitis of little boys is a circumscribed lesion about the meatus described by Goldenberg.3 It lasts a few months and heals spontaneously. The scab may close the meatus. Any mild ointment will prevent this. 1 Arch, of Med., 1884, vol. xii, No. 3. 2 Cf. Corbus and Harris, Jour. A. M. A., 1909, lii, 1474. 3 Am. Jour. Surg., 1910, xxiv, 218. 610 DISEASES OF THE PENIS Adhesions due to balanitis are uncommon after early childhood. In elderly persons the possibility of epilheliomatous degeneration in a patch of chronic balanitis must be borne in mind. Diagnosis.—Balanitis occurs only under a long or a tight prepuce. Simple balanitis must be distinguished by urinalysis from diabetic balanitis. Ulcerative balanitis cannot be distinguished from inflamed herpes in many cases. It also closely resembles chancroid, from which it can often only be distinguished by examination of the organisms found in the satellite glands. Fortunately the treatment of severe cases of the three conditions is the same. Treatment.—If the prepuce can be easily retracted without caus- ing paraphimosis, simple balanitis may be speedily relieved. Cleanli- ness is of the first importance, but soap should not be used. Warm water and peroxid, aa, will remove all the discharges. After washing, the parts should be dried by gently touching them with a soft cloth, and dusted (by the aid of a dry camel’s-hair brush from which the powder may be evenly shaken) with bismuth and calomel, or any fine powder. A piece of old linen, just large enough to cover the glans, and with a hole cut in its center so that it may be slipped like a collar around the corona, is now to be moistened in a mild antiseptic solution (acetate of aluminum 2 per cent, or aromatic wine and water, equal parts) and laid over the glans, leaving the meatus uncovered. The prepuce is then pulled forward to its natural position. In this way friction between the inflamed surfaces is avoided, all the discharges are absorbed, and a mildly stimulating fluid is kept in constant contact with the ulcerated or abraded surfaces. The dressing should be re- peated two to four times daily, according to the discharge. After recovery a dry piece of linen should be kept between the glans and the prepuce for some weeks, renewed twice daily. Argyrol, sol. saturat., is an almost infallible application. It should be employed in all severe cases. If the prepuce cannot be retracted, it should be incised, as for chan- croid, and sores and wounds bathed lavishly in 20 per cent argyrol solu- tion. If chancroid be present, inoculation of the wound is inevitable. Yet chancroidal cases require operation most urgently in order to expose the sore, whose ravages (perhaps upon the glans penis) are progressing uncontrolled. A large chancroid exposed is better than a small one concealed. Circumcision.—In chronic and inveterate cases, or where insignifi- cant causes produce constant relapse, circumcision affords a certain cure. Circumcision of diabetics, while almost certain to prove curative, may result in gangrene. ACUTE INFLAMMATORY AFFECTIONS 611 ACUTE INFLAMMATORY AFFECTIONS OF THE PENIS Cellulitis.—Cellulitis arises from chancroids, balanopostliitis, trauma, or gonorrheal peri-urethritis. The inflammation may spread to the abdomen, scrotum, or thighs, or it may involve the erectile bodies. Lymphangitis.—Lymphangitis is comparatively benign. A lym- phangitis of the large dorsal lymphatic may be differentiated from phlebitis of the dorsal vein by the fact that the cord of induration ex- tends outward, at the root of the penis, toward a group of enlarged glands, instead of disappearing beneath the symphysis pubis. Erysipelas.—Erysipelas of the penis is rare. It usually spreads to the penis from the adjoining regions. It is likely to he virulent and complicated by cellulitis (phlegmonous erysipelas). Treatment.—Prophylaxis, by careful treatment of the causes of inflammation, is of the first importance. If the penis has already be- come inflamed it should he elevated, with the scrotum, and wet dressings of sublimate (1:10,000) or aluminum acetate (2 per cent) applied daily. Pest in bed, free purgation, and a light diet are essential in the more severe cases. Tension may be relieved by incision, abscesses must be opened and drained, and sloughs speedily removed. Cavernitis and Penitis.—Inflammation of the corpora cavernosa or of all three erectile bodies arises from cellulitis or its causes, espe- cially inflammation in the bulb of the corpus spongiosum. Course.—The course of the disease is that of an acute inflammation with constant priapism and edema added to the usual local symptoms. While the inflammation may be walled in by occlusion of the vascular spaces, pyemia is “a terribly frequent complication” (Jacobson). Treatment.—The treatment should therefore be most energetic. Indurations in the erectile bodies should be freely incised, packed to check the hemorrhage, and later irrigated frequently. OTHER DISEASES OF THE PENIS AS A WHOLE Chronic Edema.—Chronic edema may be caused by elephantiasis or by general anasarca. The swelling of the scrotum usually overshad- ows that of the penis and may be so great as practically to obliterate that organ. In the penis the edema is greatest in the prepuce and especially about the frenum. This edema may offer a mechanical impediment to urination, and the low vitality of the tissues renders them especially liable to become inflamed by contact with the urine that dribbles over them. Treatment.—The prepuce must be kept dry and dusted with a 612 DISEASES OF THE PENIS soothing powder. Multiple punctures or incisions may liberate the exu- date sufficiently to keep the swelling within bounds, and, these failing, a dorsal incision will succeed. Light edema may be controlled by band- aging and elevation. Dilatation of the Lymphatics.—This condition is secondary to trauma or inguinal adenitis. The dilated lymphatics appear as white, subcutaneous cords encircling the penis behind the corona or extending along the sides or dorsum. "There are no subjective symptoms and the obstruction may be relieved spontaneously. For esthetic reasons mul- tiple ligation or total excision may be resorted to, but a lymph fistula may result from such treatment. Elephantiasis.—(See p. 517.) Gangrene is usually the result of inflammation. It may, however, come on independent of any local inflammation. Spontaneous gangrene usually occurs in connection with the acute exanthems. Cases have been reported from typhoid, typhus, intermittent fever, and small-pox. Senile and diabetic gangrene also occur. Cases following prolonged priapism, iliac thrombosis, atheroma of the dorsal artery, exposure to cold, and acute alcoholism are also cited by Jacobson. Treatment.—The prophylactic measure—incision of inflammatory and edematous areas—has already been noted. When gangrene has once declared itself, attention to the patient’s general condition, the preservation of dryness, asepsis, and warmth locally, and the prompt removal of all frankly gangrenous tissue are the therapeutic indications. Later, plastic work may be required to cover areas left bare of integu- ment. Cicatricial deformity of the erectile bodies can be remedied only by time. TUBERCULOSIS Tuberculosis of the penis is a rare lesion. I have seen but three or four cases in the last ten years at Bellevue Hospital, though the class of patients seen there is precisely that among whom the lesion should be most common. It begins primarily in the skin of the penis or extends to the surface from the urethra. Tuberculosis following ritual circumcision is extremely rare now that the custom of sucking the wound has been given up. If an extension from the urethra, the lesion first appears about the meatus. Ritual tuberculosis begins in the cut edges of the prepuce. Otherwise the lesion usually begins about the plans penis or prepuce. The lesions I have seen were irregular ulcers, very chronic, indurated, with hard base and everted edges, rather less sloughy than a gumma, but closely resembling a carcinomatous ulceration. The lesion extends very slowly and irregularly over the skin, not involving the deeper structures, usually taking several years to in- GRANULOMA INGUINALE 613 volve a square inch or so. In so doing it usually heals in one spot as it extends to another. The two clinical characteristics whereby tuberculosis may be dis- tinguished from carcinoma are its chronicity and the fact that the tuberculous lesion usually heals in one part as it extends in another, which carcinoma never does. The diagnosis should always be confirmed by biopsy. The lesion should be treated like tuberculosis elsewhere. It yields slowly to the X-ray or Finsen light and cures have been reported fol- lowing thorough cauterization with the actual cautery. GRANULOMA INGUINALE This condition lias been believed to be exclusively a tropical disease until the report of Symmers 1 of cases found in Bellevue Hospital. Since then many others have reported cases of the disease which could not be traced to a tropical infection. It is evidently endemic in the United States. It occurs almost exclusively among negroes, affecting both sexes; method of infection is not known though it is believed that the Donovan organisms, found in mononuclear cells, are the exciting cause. Randall claims to have cultivated these organisms. He described them as having well-defined capsules but appearing in nests occupying a rounded area within a cell and revealing no capsule. The organisms appear as small rounded bodies which, under Wright’s stain, are pink with a blue cocoid central body or oval with a bacillary or diplococoid dark blue central body. The outer zone has a capsule; the central bodies are metachromatic granules. The lesion itself appears first on the genitals or in the groin. It begins as a papule, relatively insensitive, which ruptures, exudes a watery pus, refuses to heal and slowly spreads. The character of the ulcer is quite definite grossly from any other genital ulceration. Its base is gelatinous, looks reddish, exuberant, overgrown, soft, so that in making cultures the loop can be pushed deeply into this tissue. The edges are quite the opposite to those seen in chancroid; instead of being undermined they turn out and overlap the healthy skin. The lesion may heal in some spots and spread in others, secondary foci spring np and all sorts of cicatricial and ulcerating distortion of the parts result. The lesion is destructive and also causes lymph block. Symptoms are few; pain, slight discharge, unimportant in com- parison to the size of the lesion; the patient ultimately dies from secondary anemia and the infection of the large lesion. The diagnosis i Journ. A. M. A., May 8, 1920, p. 1304; also Campbell, Journ. A. M. A., Mar. 5, 1921, p. 648; also Randall, Surg., Gynec. Obst., 1922, xxxiv, 717. 614 DISEASES OF THE PENIS is readily made if the condition is but thought of as a possible cause of any chronic genital ulcer. The Donovan bodies are usually found quite readily. The condition can be cured by intravenous injection of tartar emetic 0.1 gm. in 10 c.c. of sterile normal saline solution sterilized in the autoclave (it can not be boiled). Injections are given daily beginning with the dose 0.04 gm. and increasing to 0.1 gm. As the higher doses are reached the patient may have chills and joint pains in which case the interval between injections is lengthened. About twenty injections are needed to effect a cure and apparent cures must be followed closely for several months in order that results may not be overlooked. CHAPTER LXIV PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS Preputial Deformities.—Practically, the deformities of the fore- skin (phimosis and atresia of the orifice excepted) are unimportant. The prepuce is sometimes bifid, enlarged into a pouch, redundant, or rudimentary. When the prepuce is deficient, the epithelium of the uncovered glans penis becomes hard and tough, mere nearly resembling ordinary cuticle. Under these circumstances its sensibility is di- minished, but it is less liable to become excoriated or inflamed. Hence, absence of the prepuce is not to be regretted, and the operation for its restoration (posthioplasty) need not be described. PHIMOSIS Phimosis exists where the orifice of the prepuce is so small that the glans penis cannot be uncovered. The orifice of the prepuce may be congenitally absent (atresia preputii). Phimosis is congenital or ac- quired, simple or inflammatory, or complicated by other diseases or by adhesions. In young children preputial redundancy is so common that it may be considered normal. The foreskin of an infant is developed out of all proportion to the rest of the penis, taking the member after puberty as a standard of comparison. V/henever the prepuce can be fully retracted there need be no anxiety about the future; the preputial orifice will enlarge sufficiently before or at puberty. Phimosis may be brought about secondarily through induration and inelasticity of the skin caused by frequent attacks of preputial inflam- mation. The meshes of the connective tissue, at first distended with serum, become secondarily thickened and hypertrophied, leaving a thick, indurated, inelastic prepuce that cannot be retracted. This condition is known as inflammatory phimosis. Another common cause of acquired phimosis is the cicatrization of multiple chancroids around the orifice of the prepuce. Infrequently, diabetic eczema produces phimosis. Demarquay quotes a case where a passionate and jealous woman made her lover wear a gold padlock with which she secured the preputial orifice, keeping the key herself. 615 616 PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS The victim of her charms carried his padlock, which was replaced from time to time through new punctures, during four or five years, until such a degree of irritation had been set up that Petroz and Du- puytren, when consulted, diagnosticated cancer, and removed the pre- puce. Ho relapse of the cancer is recorded. Tkeatment.—Circumcision in infancy will leave the patient less subject to venereal disease and to sexual irritability in later years. For this reason the operation has of late years attained great popularity. I favor it for all infants whose foreskins are long or tight. A positive indication for operation upon a child does exist, how- ever, when the preputial orifice is smaller than that of the urethra. This condition is evinced by ballooning of the prepuce during micturi- tion, for the urine flows into the cavity more rapidly than it can escape from the orifice. The retention of a drop or two of urine in the cavity of the prepuce after each act of urination leads to balanitis, suppuration, the growth of vegetations, formation of the preputial stone, or incrus- tation of the glans. When the adult prepuce is tight, an operation may be called for, even though phimosis, strictly speaking, does not exist. For example, the collection of smegma, or repeated attacks of herpes, may necessitate operation. Again, if an individual with a tight prepuce gets chancre, chancroid, or gonorrhea, serious inflammatory complications are likely to arise. PARAPHIMOSIS Paraphimosis exists when the prepuce is retracted behind the corona glandis and cannot be replaced. Causes.—An unnaturally tight preputial orifice is a predisposing cause to paraphimosis. Inflammatory paraphimosis may depend upon balanitis, gonorrhea, herpes, chancroid, chancre, etc. Symptoms.—The glans penis is swollen and livid. Behind the corona, most marked below, rises a tense, shining, edematous belt of the mucous layer of the prepuce. Behind this there is a deep sulcus or furrow, most marked above, often the seat of superficial ulceration. Here lies the stricture; behind it there rises another edematous fold, usually smaller than the one in front (Fig. 134). If the stricture of the prepuce is tight enough to arrest the circula- tion, it may finally cause the destruction by gangrene of all tissues lying in front of it. Treatment—Reduction may almost invariably be accomplished without incision, if the following details are observed, viz.: 1. The stricture must first be pulled well back. Exceptionally the Fig. 134.—Paraphimosis. Fig. 135.—Paraphimosis. The edema is squeezed out preparatory to reduction. 618 PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS mucous membrane is unfolded at the dorsum; this must be smoothed out by still further retracting the prepuce. 2. The edema must be thoroughly squeezed from in front of the stricture to the shaft of the penis behind it. Until one has patiently squeezed such a penis for several minutes, it is quite incredible how fully the edema may thus be reduced and shifted to the shaft of the penis (Fig. 135). 3. Reduction is then accomplished by forcing the stricture slowly over the head of the penis—so slowly as to squeeze out the remaining edema. It is futile to attempt to pry the stricture over the glans until the edema has been reduced. The following is the best method of re- duction: Seize the penis behind the strio- tured prepuce in the fork of the index and middle fingers of both hands, one placed on each side. Row make pressure with the thumbs on both sides, in such a direction as to compress the glans laterally, rather than from before backward, and at the same time pull the strictured portion of the pre- puce forward, the effort being rather to pull the stricture over the glans than to push the glans through the stricture (Fig. 136). If a prolonged, careful attempt at reduction fails, the strictured point must be divided. This may be done under local anesthesia. After reduction, the treatment consists in elevation of the penis within a jock strap, and syringing the preputial cavity with a mild anti- septic solution. Fig. 136.—Reduction of Para- phimosis. TUMORS OF THE PENIS Gumma.—Gumma occurs often in the glans or the prepuce, very rarely in the urethra and the corpora cavernosa. The so-called relaps- ing chancre is a gummatous deposit in the scar of the initial lesion. The history, the influence of treatment, and, if necessary, the exam- ination of a section of the growth determine the diagnosis. In the corpora cavernosa gumma resembles circumscribed fibrosis, but is deeper, less cartilaginous, and almost always occurs in the posterior third of the organ (Zeissl). BENIGN TUMORS OF THE SKIN AND CONNECTIVE TISSUE Cysts.—Implantation, and sebaceous cysts occur. The last originate in the sebaceous glands of the skin or in Tyson’s glands. Cysts occur TUMORS OF THE PENIS 619 almost always in the prepuce and are readily enucleated. (Cf. Geru- lanos.1) Benign Neoplasms.—Lipoma, adenoma,2 and angioma have been described. They are rare, and their removal is a question of judg- ment involving a recognition of the function of the penis as an intro- mittent organ, and the possible loss of this function from the formation of a cicatrix. Papilloma.—More important because of their frequency are the papillomata (condylomata acuminata) of the penis. They are commonly denominated venereal warts. This title, however, is not exact, since there is no necessary connection between them and any venereal disease. They are papillary overgrowths, often highly vascular, and composed of epithelium. They may be prominent and peduncu- lated, or flat, and growing from a considerable surface. They are nearly always multiple. They are caused by inflammation, or simply by lack of cleanliness. Consequently the most favorable condition for their production exists in gonorrhea, in balanitis, or when mucous patches occupy the cavity of the prepuce. Their favorite seat is just behind the corona glandis, but they are also encountered anywhere within the cavity of the prepuce, at its orifice, upon its cutaneous sur- face, or even within the urethra. They are found also upon the scro- tum, and frequently around the anus. They are, when numerous, bathed in a fetid, puriform secretion, and may grow large enough within the prepuce to cause phimosis. They occur upon young chil- dren, and are found in their greatest luxuriance within and around the vulvae of women affected wflth irritating discharges—discharges not necessarily venereal in any sense. Implantation warts also occur after circumcision. Diagnosis.—Warts should be differentiated from mucous patches and condylomata lata by the typical flat appearance of the syphilitic lesions and the accompanying symptoms of the disease. From commencing epithelioma the diagnosis may be extremely dif- ficult. When in doubt examine a snipping under the microscope, and if it appears benign, treat it as such, but remove it in any case. If it recur, and the patient is over fifty, it is safest to exsect it as though it were epitheliomatous, whatever the findings of the pathologist. Radium is very efficient for this class of cases. Prognosis.—Unless kept scrupulously clean, warts sometimes ulcer- ate, and they may even suppurate, light up suppurating buboes, and even cause gangrene of the penis. Simple cleanliness, on the other hand, often causes them to atrophy. Epitheliomatous degeneration may take place, and is always to be 1 Deutsche Zeitschr. f. Chir., 1900, lv, 326. 2“Morrow’s System,” 1893, i, 58. 620 PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS feared. Implantation warts are especially liable to hypertrophy and become horns. Treatment.—Repeated washing with soap and water followed by the application of calomel often causes vegetations to shrink up and disappear. In any case this is essential. In case vegetations are com- plicated by balanitis, treatment of the latter will often at the same time triumph over the warts. But circumcision is usually required. The most valuable local application is a 10 per cent mixture of sali- cylic acid in acetic acid.1 This forms a chalk and water mixture of which the moist chalk is smeared over the warts. One or two applica- tions cause the growths to wither away and drop off. If they persist, however, all the pedunculated growths may be removed with curved scissors, and the surface from which they grow cauterized with nitric acid or any other escharotic. The x-ray, the high frequency current, and radium are efficacious for obstinate cases. Lactic acid—pure for small lesions, in one per cent solution for extensive ones—is highly spoken of by Watson.2 Horns.—Horny growths may spring from the glans or the in- tegument. They begin as warts and are very prone to epitheliomatous change. Brinton 3 has described a curious case and collected others from the literature. Baldwin 4 and Bruce Clark 5 mention others. BENIGN TUMORS OF THE ERECTILE BODIES The benign tumors of the erectile bodies of the penis are four: cir- cumscribed fibrosis, enchondroma, osteoma, and calcificatiori. The first is comparatively rare, the others extremely so. Circumscribed Fibrosis.—I have come to prefer this name for the malady heretofore usually known as chronic circumscribed inflam- mation of the corpora cavernosa, for the condition is a fibrosis, not an inflammation. The malady is gouty in origin, comparable to Dupuytren’s contrac- tion of the palmar fascia. It usually appears between the ages of thirty- five and fifty. Pathology.—The growth occurs in the sheath of the erectile body. It is a fibrosis which may show patches of enchondroma (Stopczanski 6). Symptoms.—The affection comes on insidiously, without apparent cause, although the patient sometimes ascribes it to injury. The first symptom is a bending or a slight pain at a certain point in the penis 1Not glacial. 2 Lancet, Apr., 13, 1913, No. 4624. 3 Med. News, 1887, li, 141. 4 Ibid., 449. 6 Lancet, 1894, i, 219. 6 Wien. Min. Wochenschr., 1908, xxi, 318. TUMORS OF TIIE PENIS 621 when the organ is erect. Examination detects a hard, flattened mass with sharply defined margins, occupying one or both corpora cavernosa near the surface, and feeling like cartilage—elastic, springy, not as bony as a calcareous plate. The corpus spongiosum does not participate in the disease. The penis bends during erection at the affected point, and along the edge of the hardness a little pain is experienced. This indurated mass, which is usually irregularly oval in shape, may remain stationary for an indefinite period; or it may progress slowly backward or forward, sometimes retaining its size and shape, sometimes growing larger, sometimes smaller. A slight tenderness is perhaps felt along the line of advancing in- duration, and moderate uneasiness is usually produced by pressing the induration between the fingers or by erection. The seat of election is the septum and adjacent portions of the sheath on the dorsum of the penis, not far from the glans. Prognosis.—The prognosis is negatively good in that the fibrous mass never ulcerates or becomes cancerous, may get spontaneously better, even possibly well, or may, and sometimes does, develop back- ward until it gets so low down toward the root of the penis that it no longer seriously interferes with upright erection. I have seen more than one patient who, at one time being debarred from sexual intercourse, has by a shifting of the position of the induration again become potent. I have met one person with a distinct plaque of some size, of which he had no knowledge whatever. The distinction between fibroma and en- chondroma can only be made pathologically; clinically it is unim- portant. The tendency to ossification manifests itself so rarely that it is a negligible quantity. Treatment.—An effective treatment of this singular malady is yet to be discovered. Thus far time only has seemed to help it. Thiosinamin, antisclerosin injections, blisters, oleate of mercury, tincture of iodin, the iodids, and electrolysis, have uniformly failed. Excision only replaces the fibrosis by scar tissue. Piperazin is well spoken of. Calcification and Ossification.—Both of these conditions are usually, probably always, secondary to fibrosis, or enchondrosis of the erectile bodies. Calcification of small patches is quite rare, ossification is even more unusual. Cases of this latter condition have been reported by von Lenhossek,1 Demarquay,2 Porter,3 Jacobson,4 and Chetwood.5 In Chet- wood’s specimen certain spots were simply fibrous, others were cartilagi- 1 Virchow’s Archiv, 1874, lx, i. 2 Op. cit., p. 354. 3N. Y. Med. Record, 1882, 270. 4 Op. cit., p. 683. 5 Jour, of Cut. and Gen.-Urin. Bis., 1899, xvii, 231. 622 PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS nous, while the bulk of the growth was true bone. To compare penile osteoma with the bony development normal in the penes of certain monkeys is scarcely logical. Prognosis.—Calcification or ossification may cease after more or less of each corpus cavernosum has.suffered, or it may involve the whole organ pretty generally. Sexual intercourse may be seriously interfered with, if not prevented altogether. Treatment.—Medicine holds out no hope to the sufferer. If the disease has come to a standstill and the deposit is superficial and small, it may be removed with the knife—an operation which has been per- formed with success by Regnoli, MacClellan, and Iluitfeldt.1 MALIGNANT NEOPLASMS OF THE PENIS The primary malignant new growths of the penis are sarcoma and epithelioma. The former is very rare. It arises from the erectile bodies, usually the corpora cavernosa. The latter, much more common, begins on the glans or on the prepuce. (Epithelioma of the urethra is considered with the other diseases of that canal.-) Secondary new growths present no peculiar features. They either form part of a disseminated carcinosis or are mere extensions of the tumor from an adjoining region, usually the scrotum. Sarcoma.—With or without previous trauma a tumor appears in one of the erectile bodies. The fact that it is a distinct lump and not a flat indurated patch readily distinguishes it from the benign tumors of these structures. Moreover, sarcoma usually appears in early man- hood and develops with characteristic rapidity and early involvement of the inguinal glands. Exceptionally, however, it grows slowly and the glandular involvement occurs late. Of the 13 cases recorded by Jacob- son 2 some arose from the erectile tissue, some from the fibrous sheath, and one—a melanotic sarcoma—apparently originated in the urethral mucous membrane. The earlier cases were reported as fibroma or carcinoma. As the tumor grows it causes priapism by occluding the cavernous spaces, and may also occlude the urethra and so cause retention of urine. Early amputation of the penis is the only treatment. The prognosis is absolutely bad. Epithelioma.-—Epithelioma of the penis (Fig. 135) begins on the prepuce or glans, both of which are usually involved when the patient presents himself for examination. Though Ereyer 3 has reported a case in a youth of seventeen, and Kaufmann places 6 per cent of the cases in the third decade, here, as 1 Norsk Mag. f. Laegevid., 1910, lxxi, No. 1. 2 Op. cit., p. 738. 3 Brit. Med. Jour., 1891, i, 1173. TUMORS OF THE PENIS 623 elsewhere, epithelioma is usually a disease of later life. One case de- veloped in the scar of a liorse-bite, others have arisen from the scars left by venereal sores, a few from urethral fistula; but warts and chronic balanitis are the most fruitful sources of epithelioma, the former espe- cially if neglected and allowed to remain foul and moist. Indeed, 29 out of 33 cases collected by Kaufmann began as apparently benign warts. Finally, phimosis is a marked predisposing cause of epithelioma. By retention of the smegma and urine it predisposes the patient to Fig. 137.—Epithelioma of the Penis (Wyeth). balanitis, vegetations, and fissures of the foreskin, and these processes once set up are kept concealed and constantly bathed in an acrid and irritating fluid. Demarquay noted phimosis in 42 out of 59 cases, and it is claimed that the circumcised Jew is exempt from penile epitheli- oma. The question of inoculation from cervix uteri is agitated from time to time, but the extreme rarity of the cases adduced indicates that they represent nothing more than a curious coincidence. Symptoms and Course.—Although epithelioma of the penis is not often seen until well under way and absolutely characteristic, the vari- ous aspects under which it first presents itself must be appreciated in order that intelligent radical treatment may be resorted to early. In about 5 out of 6 cases the disease begins as a wart situated on the 624 PHIMOSIS—PARAPHIMOSIS—TUMORS OF THE PENIS glans or on the inner surface of the prepuce. This wart is intractable to ordinary methods of treatment, and recurs if cut or burned away. As it grows it assumes a lobulated, cauliflower appearance, and soon begins to ulcerate in places, and to exude the characteristic foul ichorous discharge. Then the base gradually takes on the hard induration of the epitheliomatous ulcer with everted edges. By this time the inguinal glands are probably involved and may he felt as shotty subcutaneous nodules in either groin. (For the lymphatics of the penis so anastomose that a so-called crossed bubo—the sore on the one side of the penis and the bubo in the opposite groin—occurs not infrequently.) More rarely epithelioma begins as a raw spot or an indolent ulcer, and still more rarely it appears first as a subcutaneous nodule or as a patch of leukoplakia. In whatever way the disease begins, it comes after a time to the frankly cancerous stage. The ulcer advances, involving all the tissues in its path; the discharge is thin, sanious, fetid; the ulcer deep, irregu- lar, unhealthy, its edges hard, livid, and everted. At the same time the exuberant warty growth progresses, either of these conditions predominating to make the case clinically a warty or an ulcerative lesion. The inguinal glands now become prominent and partake of the py- ogenic as well as of the cancerous infection, so that they become matted together, and may even suppurate or produce an epitheliomatous ulcer in the groin. Locally, the growth may spread over quite a large superficial area without involving the corpora cavernosa, but when these become in- vaded secondary growths develop to their very depths. Involvement of the corpus spongiosum results in stricture. Lancinating pain is a prominent symptom only late in the disease. The chief inconveniences to the patient in the earlier stages are the presence of the growth, the foul discharge, the tendency to annoying hemorrhage after the slightest abrasion, and urethral stricture. As the disease advances the strength of the patient fails. The tumor spreads up over the penis to the pubes, abdomen, and thighs, joining the ulcer- ated inguinal glands and extending down over the scrotum to the peri- neum, anus, and buttocks, until, finally, the patient dies of sepsis, cachexia, or hemorrhage. Diagnosis.—The diseases which may be confused with epithelioma of the penis are warts, chancre, chancroid, tuberculous ulcers, and ulcers from chronic balanopostliitis. As we have seen, the appearance of epithelioma is characteristic enough after its base has become indurated and the infection has begun to spread to the inguinal glands; but it is of the greatest importance that the diagnosis be made before that time, while the disease is yet emi- TUMORS OF THE PENIS 625 nently curable. To this end all growths or ulcers that prove intractable should be regarded with suspicion, and if that suspicion is confirmed by microscopical examination of a snipping from the diseased tissue, im- mediate operation should be insisted upon. Prognosis.—Before the inguinal glands become involved the oper- ative prognosis is good. Afterwards it is bad, yet not absolutely so, for cures are reported in cases where unmistakable gland involvement had occurred. Treatment.—If the growth be seen before induration has occurred it may usually be removed by circumcision if on the prepuce, or by thorough cauterization if upon the glans. Patches of leukoplakia upon the glans penis or the foreskin should be promptly destroyed by knife or cautery. The patient should, however, be warned of the danger of recurrence, and should this appear, or should there be some induration about the base of the tumor, the penis must be amputated behind the corona, and the inguinal glands of both sides extirpated, whether they are palpably enlarged or not, for the microscope has repeatedly shown these glands to be the seat of malignant deposits though their gross appearance was quite normal. If the glans is extensively involved, the penis must be amputated close up to the pubes, or else extirpated entirely. Jacobson claims that simultaneous castration adds to the comfort of these patients, though most men refuse to part with their testicles even when their function has thus ceased. Barney reported 100 cases.1 Though 80 recurred within five years (and 12 thereafter), 11 out of 26 cases operated upon for recurrence re- mained well five years thereafter. Though excision of the inguinal glands is imperatively required for all but the earliest cases, it is note- worthy that 20 were cured by primary, and 8 by secondary, amputation without adenectomy, while only six were cured after the combined op- eration: in other words, almost all the advanced cases die in spite of operation. 1 Ann. Surg., Dec., 1907, p. 890. CHAPTER LXV CHANCROID—SUPPURATING BUBO Chancroid (or soft chancre) and hard chancre are no more akm than measles and leprosy; and it is unfortunate that the ancient con- fusion of the local and the general infection has left us this legacy of misleading terms; but it is now too late to change them. Chancroid is a specific, local, contagious, auto-infectious venereal ulcer. It is specific in that it is caused by a specific microorganism, the streptobacillus of Ducrey.1 This bacillus is dumb-bell shaped, thick and rounded or square at the ends, constricted in the middle. It varies in length from 1.5 to 2 /*• It groups in parallel chains, and oc- curs both inside and outside the cells (Fig. 138). It stains readily with the ordinary dyes (methylene-blue, or violet, or fuchsin), and is decol- orized by the Gram stain. For many years after its discov- ery in 1889, in spite of the confirma- tory observations of TTnna, Kretling, Dubreuilli, and Lasnet, etc., and in face of the manifestly specific char- acter of chancroid, the pathogenic action of the streptobacillus was doubted until proven by the culture and inoculation experiments of Istamanolf and Askpianz,2 Lincoln Davis,3 Lancret,4 and Tomasczew- ski.5 But chancroid is peculiarly liable to mixed infection. A smear taken from the surface of the ulcer usually shows numerous pyogenic and other bacteria, and few if any of the pathogenic bacilli. Hence such a smear cannot he depended upon for diagnosis. Fig. 138.—Streptobacillps op Ducrey. (Lincoln Davis.) 2 Biforma medica, 1889, vol. v, p. 98. 2 J ahresbericht d. Path.—Microdrg., 1898, vol. xiv. s Jour, of Med. Besearch, 1904, vol. ix, p. 401. 4 Bull, med., 1898, vol. xii, p. 1051. *Zeitschr. f. Hygiene u. Infect., 1903. vol. xiii, p. 327. 626 FREQUENCY 627 Chancroid is a local lesion, causing no systemic infection or reaction. It is, therefore, indefinitely auto-inocidable. Indeed, the marked tend- ency to auto-inoculation is one of the most striking clinical character- istics of the ulcer. That it confers no immunity whatever was amply proven by the disciples of sypliilization. Lindemann, for example, in- oculated himself 2,700 times with chancroidal pus in the vain hope of immunizing himself against syphilis. But a local and temporary im- munity does exist; for after many inoculations a given region becomes temporarily immune, though the virus will still take on other parts of the body. Clinically, however, such immunity has no significance. Finally, chancroid is a contagious venereal ulcer. Hot once in a hundred cases does one see a chancroid except about the genitals. This is as much as to say that it is practically always acquired by sexual contact. Although many cases of mediate contagion have been reported (the virus being usually conveyed by the hand), such cases are proportionately extremely rare. Indeed, chancroid will not “take” upon the integument unless it is abraded. Cullerier’s experiments show that this must oftentimes be true of the vagina as well. In two cases he deposited pus from a chancroidal bubo in a clean vagina, and let it re- main there between half an hour and an hour. Then some of the vaginal secretion was collected and inoculated upon the thigh, after which the vagina was thoroughly cleansed. In both instances typical chancroids developed on the thigh while the vagina remained clean. Hence, be it noted, a woman may convey chancroid from one man to another without herself becoming infected. Yet auto-inoculation of chancroid upon the healthy skin or mucous membrane lying in contact with it is extremely common. But it takes many hours of intimate contact to effect the inoculation. FREQUENCY In the clinic, chancroids outnumber true chancres two to one. In private practice the preponderance is reversed, and we see five, or even ten, chancres to one chancroid. The reason for this is twofold. In the first place, chancroid can never make headway among cleanly per- sons, for it is so foul and disgusting that no decent citizen infected with it would attempt sexual intercourse until it is cured, and half a cure— such as so commonly conceals the infectiousness of syphilis and gonor- rhea—is here impossible. In the second place, in most instances, a little soap and water at the time of exposure is an absolute safeguard against it. Chancroid flourishes only where soap and water are not esteemed. 628 CHANCROID SITUATION AND NUMBER Chancroids upon the male genitals are most common in the coronary sulcus, especially in the little pocket on each side of the frenum. Ure- thral chancroid is extremely rare. In women the sores usually occur about the introitus, rarely higher up. From these regions the ulcers may spread by contact or by direct extension over external genitals, anus, thighs, abdomen, and even far- ther afield. Chancroid commonly begins as a single ulcer; but no sooner has this appeared than secondary ulcerations begin, so that by the time the physician is consulted several sores are usually present. SYMPTOMS AND COURSE Incubation.—The disease has an incubation period varying from one to ten days, usually three to five. A protracted incubation is proba- bly due to the fact that the virus is retained some days within the prepuce (or vagina) before inoculation occurs. Onset—The symptoms of chancroid are best ob- served by studying the course of the artificial ulcer produced by inoculation. Within twenty-four hours after such an inoculation a reddish blush surrounds the puncture. This soon changes to an inflamed areola which, in the third day (rarely sooner or later), becomes a pustule. This extends quite rapidly, and within a few days breaks and becomes a char- acteristic chancroidal ulcer (Fig. 139). The Ulcer.—The typ- ical chancroid is a round ulcer with undermined or perpendicular edge. The Fig. 139.—Chancroids of Prepuce, Preputial Frenum, and Glans Penis, in Various Stages of Development. (Kaposi.) COMPLICATIONS 629 ulcer is usually rather deep. Its base is irregular, grayish yellow, and covered by a pultaceous false membrane. It is surrounded by a non- indurated, inflammatory areola. The secretion is abundant and puru- lent. It bleeds readily. It may he intensely painful. Course.—If untreated and uncomplicated the ulcer increases in size for a week or two. Then, having attained a diameter of about 1 cm., it remains stationary for about two weeks, and then gradually heals by cicatrization from the edges toward the center. So rarely, however, is the ulcer both uncomplicated and untreated that the stage of spontaneous healing is not seen in the clinic. COMPLICATIONS The common complications of chancroid are mixed infection with syphilis (mixed sore), mixed infection with pyogenic microbes (in- flamed chancroid), destruction of the frenum, phimosis, gangrene and phagedena, balanoposthitis and venereal warts, lymphangitis, adenitis (bubo). The Mixed Sore.—So long as your patient has chancroid you may never he sure that he has not chancre. This rule is without exception. A chancroid may readily conceal a chancre from the most experienced eye. A chancroid may refuse to heal because of complicating gumma. A very large proportion of sores treated in the clinic as chancroids are actually chancres, for many cases of unsuspected syphilis date back to a “chancroid.” The Inflamed Chancroid.—While every chancroid is more or less irritated by its own secretions and contaminated by ordinary pyogenic microbes, the resulting inflammation is often insignificant unless ac- centuated by friction. The chancroid at the preputial orifice is usually an interminable while getting well. The friction of shirt and drawers, or even the rub- bing of the softest dressing, so irritates the sore that, though it may lose all its chancroidal characteristics and become a simple, sluggish abrasion, it lingers on week after week, taxing to the utmost the victim’s patience and the physician’s skill. Chancroid underneath a long prepuce, however loose, usually ex- cites so acute a cellulitis in the connective tissue of the foreskin as to cause inflammatory phimosis. This retains the secretions of the chan- croid, which, bathed in this irritating pus and protected from effective treatment, promptly invades both glans and prepuce, and instead of healing tends rather to eat its way through the glans penis into the urethra or through the foreskin, at the same time setting up an intense inflammation, which may terminate in abscess, erysipelas, or gangrene. 630 CHANCROID If the prepuce is retracted in a desperate effort to get at the suppurating cavity, paraphimosis complicates matters. Destruction of the Frenum.—One of the commonest complications of chancroid is destruction of the preputial frenum. The frenum is destroyed in the following manner: a chancroid ap- pears in the sulcus at one or both sides of the frenum; as it enlarges it eats a hole in the frenum, leaving a narrow string, which soon gives way as well. Gangrene and Phagedena.—The terrible phagedena which, until the era of antisepsis, was an imminent possibility for every case of chancroids, has almost passed into oblivion with hospital gangrene and such ancient horrors. One can no longer imagine such a case as Ricord treated for several years, and which, commencing as a chancroidal bubo fourteen years before, was still an open ulcer at the knee—indeed, this may well have been a gumma. On the other hand, gangrene foudroyante is still occasionally en- countered as the complication of stricture, or of chancroid. Thus Mar- tin 1 relates and depicts the case of a man who lost two-thirds of his penis by gangrene in thirty-six hours. Happily, such cases are ex- tremely rare. Most “phagedenic chancroids” are gummata with a negative Wasser- mann reaction. Lymphangitis—Acute inflammation of the lymphatics running along the dorsum and sides of the penis toward the inguinal glands is a rare complication. Suppuration therein is much rarer. Inguinal Adenitis.—Chancroid of the genitals causes inguinal ade- nitis or bubo. This complication occurs about once in every three cases. The bubo when bilateral is usually moie severe on the side upon which the sore lies; but, on account of an abnormal lymphatic supply, the glands in the opposite groin may be the more inflamed. This is the so-called “crossed bubo.” The chancroidal bubo may be a simple inflammatory adenitis, the glands becoming large and quite tender, so remaining for a week or more, and then slowly resolving. It may go on to peri-adenitis. The glands become matted together in irregular, tender masses adherent to the skin and to the subjacent tissues. When the inflammation reaches this stage it terminates by suppuration. When the abscess is incised or breaks, it usually forms a chancroidal ulcer. This is the so-called virulent bubo. It has long been known that chancroidal pus, although it would remain virulent for many weeks if kept in a sealed tube, promptly lost its virulence when heated to a temperature of 105° F. It is, therefore, to be inferred that both “simple” and “virulent” buboes are due to 1 Morrow’s “System,” p. 875. DIAGNOSIS 631 infection by the streptobacillus, but that the heat engendered in the in- flamed gland is sufficient to reduce its virulence sometimes to the point of rendering it temporarily innocuous; so that it only requires a few days of cooling off, as it were, in the open ulceration to regain its prim- itive vigor.1 DIAGNOSIS The diagnosis of chancroid may be made by the microscope (which gives no negative assurance), by culture on blood agar, by the ancient and very trustworthy method of auto-inoculation,2 or by confrontation (examination of the person from whom the sore was contracted). Generally speaking, however, no test is required to establish the diagnosis of chancroid. The multiple, virulent sloughing ulcers, spread- ing by contact inoculation, the characteristic bubo, and the history of very recent exposure form a typical clinical picture. Inflamed herpes or simple ulcer may, however, very closely simulate beginning chancroid. Moreover, the chancroid may originate in the orifice of a sebaceous gland of the scrotum or penis (follicular chancroid), and so be mis- taken at first for a small boil or an acne pustule. Bullous and ecthyma- tous forms of chancroid are extremely rare. But the really important point in the diagnosis of chancroid is its differentiation from true syphilitic chancre. The details of this differ- entiation are considered elsewhere (p. 821) ; but it is not amiss to re- peat once again that no matter how sure you may he that a given sore is a chancroid, you cannot thereby make a negative diagnosis of syphilis; for the same coitus that transmitted the chancroid may have transmitted syphilis, the chancre of which might not develop until after the chan- 1 Thus Dubreuilh {Jour, de med. de Bordeaux, 1893, vol. xxiii, p. 573) has reported an epidemic of chancroids producing 136 buboes. Of these, 27 did not suppurate; 43 were incised, the pus was sterile to culture and they healed rapidly; 51 became virulent, though sterile when incised; only 3 were virulent at the time of incision; and 12, which were open on admission to the hospital, were all virulent. 2 To perform auto-inoculation, cleanse a spot on the outer side of the patient’s thigh with alcohol; then with a clean bistoury or pin wipe a little pus from the suspected sore; twirl the point of the instrument into the skin at the point to be inoculated just deep enough to draw the most minute drop of blood, smear the spot well with the virus, and clap on a vaccination shield. A “take” is announced by the appearance of a typical chancroid on the third day. This should promptly be destroyed by cauterization. The mere appearance of a pustule or an ulcer after inoculation proves nothing. It must be chancroidal in type to be considered trustworthy evidence. If, after inoculation, there is still some doubt of the nature of the ‘ ‘ take, ’ ’ its secretions may be examined for the Ducrey bacillus with better prospect of success than in the original sore, or the diagnosis may be confirmed by hetero-inoculation (inoculation of another person). 632 CHANCROID croid was cured, or might develop on the chancroid, and be so insignifi- cant as to escape the most careful scrutiny. TREATMENT Abortive Treatment.—A chancroidal nicer not more than three or four days old may be completely destroyed by the application of pure nitric acid after anesthetization with 10 per cent cocain solution. But the opportunity to apply such treatment is extremely rare. The ulcer can only be thus aborted when it is palpably very superficial. Unless every bacillus is reached and killed by the acid, such cauterization man- ifestly does more harm than good. The presence of older lesions in the vicinity, therefore, contra-indicates this treatment. Curative Treatment.—Three rules sum up the routine treatment of chancroid. 1. Establish the best possible surgical conditions by the treatment of complications (see below). 2. Clean the ulcers and dust twice a day with argyrol crystals. This is almost a specific. 3. Always suspect old, rebellious, or phagedenic sores of syphilis. Treat them locally by cauterization with carbolic acid or silver nitrate, if mild; by the actual cautery (under general anesthesia), if phage- denic. Prevention of Bubo.—Warn the patient to avoid all violent exer- cise, and to walk about as little as possible in the hope of preventing suppurating bubo. Watch the groins carefully, and with the first sign of peri-adenitis (matting together of the glands) clap him into bed with a liot-water bag on his groin. Do not, under any circumstances, paint the groin with iodin. It does no good and causes irritation of the skin, so that, if the bubo does eventually suppurate and burst, the surrounding skin is ready for inoc- ulation. Treatment of Complications.—Cellulitis and suppuration call for wet dressings, rest in bed, elevation of the penis, and incision, secundum artem. Phimosis, whether congenital or inflammatory, is the most annoy- ing complication of chancroid. A chancroid under a tight foreskin, unless aborted by argyrol, demands prompt liberating incision. Dorsal incision sometimes suffices; but a bilateral incision affords much more satisfactory access to sores in the region of the frenum. After the chancroids have healed a secondary circumcision is usu- ally required. Above all things, do not pull back a tight prepuce. The para- SUPPURATING BUBO 633 phimosis which will probably result is not easy to reduce, and is the most fertile cause of gangrene. Partial erosion of the frenum forms a pocket which is very hard to clean. Tie a thread-tightly around the remaining band, and it will cut through within forty-eight hours. SUPPURATING BUBO Suppuration in the inguinal lymph nodes is clinically so much more common as a complication of chancroid than of any other lesion that it seems well to consider it in this place, if for no other reason than to bring out the fact that the lesion should not be attributed to chancroid unless the association can be clearly shown to exist. Chancroidal Bubo.—Chancroidal infection of the inguinal nodes is a suppurative adenitis and periadenitis. The nodes enlarge and become sensitive and painful. They become matted together into an inflammatory mass, which breaks down into a multilocular abscess, which in turn bursts through the skin and forms a chancroidal ulcer of the groin. The adenitis is occasioned by trauma to the chancroid through the friction of the clothes, or by retention of the secretions under a long foreskin. It usually appears after two or three weeks, and not infrequently begins just as the genital chancroid is healing, so that by the time the adenitis comes under observation the original lesion is healed. Indeed the French maintain that a period of weeks may elapse between the healing of the chancroid and the appearance of the adenitis; hut I have never recognized this. Treatment consists in rest, as complete as practicable to prevent suppuration. But once this has occurred it can only be controlled by the following treatment: The points of suppuration are punctured with a bistoury (a scalpel makes too wide an incision), the pus squeezed out, and the cavities injected with a 10 per cent, emulsion of iodoform in vaseline and this injection repeated every second day until the incisions heal, which they always do in a week, if the inci- sions are small enough to retain the vaseline. But failure results and chancroidal ulceration of the groin ensues, if the incisions are too large. Chancroidal ulceration of the groin should be treated by thorough curetting of the lesions followed by thermocauterization repeated as often as seems necessary. Spontaneous Suppurative Inguinal Adenitis.—Acute or chronic suppuration in the inguinal nodes occurring spontaneously (i.e., not due to chancroid or other lesion of genitals or lower extremity) is 634 CHANCROID almost always tuberculous, though the acute onset (perhaps due to mixed infection) does not in the least suggest tuberculosis. Treatment is by multiple incisions as small as may be, followed by curettage. The ensuing ulcerations are treated by Bier cups. Any attempt at complete enucleation of the infected nodes in the hope of getting a clean wound and. prompt healing is almost certainly fore- doomed to failure, and leaves, just as the curetting does, an ulcer that may well take eighteen months to heal; but wdiereas the ulcers fol- lowing curettage are small and scarcely interfere at all with locomo- tion, the ulcer following complete adenectomy is large enough to result in almost complete disability. The hygienic treatment for tuberculosis is of course obligatory, unless the prompt healing of the lesion and absence of tuberculosis in the scrapings shows that the lesion was not after all tuberculous, and this we repeat is very rarely the case. Gonorrheal Suppurative Inguinal Adenitis.—Suppuration in the inguinal nodes due to gonorrhea might be said never to occur in civil practice, though it is common enough in the Army. The difference may be accounted for on physiological grounds. The lymph stream from the urethra (except from its balanitic portion) leads to the iliac nodes, not to the inguinal. Inguinal adenitis is therefore not a com- plication of urethritis, but of the balanitis accompanying urethritis, and this is never neglected and irritated by hard marches in civil life as it is in the military. Treatment is by incision and drainage. Suppuration in the Iliac Nodes.—At Bellevue we have had several cases of suppuration in the iliac nodes, usually a complication of sup- purative inguinal adenitis. The condition is readily recognized as an inflammatory mass in the inguinal region, beneath the abdominal muscles. It is to be treated by incision, curettage and drainage. Excision of the mass is, of course, out of the question, since it is everywhere adherent to the iliac vessels. CHAPTER LXVI THE INITIAL LESION OF SYPHILIS The initial lesion (primary lesion) of syphilis consists of the chancre and the adjacent adenitis. It must not be forgotten that the in- flamed lymph glands form as essential and characteristic a part of the initial lesion as does the chancre itself. THE CHANCRE The chancre is an eroded or ulcerated, painless neoplasm, arising at the site of syphilitic inoculation. The chancre is primarily a neoplasm. By hearing this in mind we distinguish it instinctively from chancroid, which is primarily an ulcer. The one is a lump, the other a hole. This neoplasm is commonly called the induration. The induration may be very extensive; it may form a large hard lump, projecting mark- edly above the surrounding tissues and having a diameter of perhaps an inch. But usually (in eight cases out of ten) it is small—one might almost say minute—and instead of projecting above the integument it is embedded in it. Thus, it may be felt rather than seen, and in ap- pearance is rather insignificant than impressive. The surface of this insignificant neoplasm is almost always eroded and moist, but it may be ulcerated, or it may be covered by an unbroken reddened integument. It is peculiarly hard and elastic, as though a piece of cardboard were embedded in the integument. In order to appreciate this one must pick it up from the surrounding tissues and palpate it from side to side. Pathology—The chancre has the general characteristics of syphi- loma. We find in a connective-tissue framework a mass of plasma cells, leukocytes—all the elements of an acute localized exudative inflamma- tion. The vessels, especially the arteries, are infiltrated, irregularly thickened, and occluded by the characteristic “coat-sleeve” infiltration. The surface of growth is more or less necrotic, whence the erosion or ulceration. Proper staining shows spirochetes in the substance of the chancre. 635 636 THE INITIAL LESION This inflammation diminishes insensibly toward the border of the induration and extends into the surrounding tissue far beyond the apparent limits of the growth. The infiltrations in the vessel walls, in particular, extend beyond the palpable seat of the disease. Yet the depth of the chancre is almost nil. It occupies chiefly the epidermal layer of the skin, encroaching but little on the true derma and the sub- jacent tissue. Hence it leaves no scar. Multiple Chancres.—The most striking characteristic of chancre is its insignificance; next in order of importance is its uniqueness. Yet too much stress may be laid upon this. The chancre is usually single, to be sure, yet Papagaey,1 who collected 14,004 reported cases, found that in from 25 per cent to 33 per cent the chancres were multiple. This confirms other Continental statistics; yet multiple chancres are cer- tainly much fewer in my practice. My records show only 56 among 549 case?, examined—i. e., 1 in 10. But whether 1 in 10 or 1 in 3, the multiple chancre must be counted with, and it is a grave clinical error to insist on the uniqueness of chancre as a diagnostic factor. The number of multiple chancres is 2 in 78 per cent of cases (Pa- pagaey). My father has recorded 1 case of 11 and 1 of 12 chancres (4 on the left breast, 8 on the right). Fournier has seen a patient with 23 (7 on the left breast, 16 on the right). The location of multiple chancres is almost exclusively genital. Only 2 per cent of extragenital chancres are multiple (Fournier). Chancres of the breast are quite frequently multiple. The existence of multiple chancres brings up the question, When does syphilitic immunity begin ? Is reinoculation possible ? Although in many instances the several inoculations are indubitably simultaneous, in others they doubtless succeed one another, perhaps after an interval of several days. Indeed, Queyrat 2 has proven that it is sometimes possible to auto-inoculate chancre if the inoculation is performed before the lesion is ten days old, and experimental inocula- tion bears this out. Types of Chancre—The three chief types of chancre are: 1. The eroded chancre. 2. The ulcerated chancre. 3. The indurated papule. The Eroded Chancre.—From 60 to 80 per cent of chancres as- sume this form. It is most characteristically exemplified by chancres within the preputial cavity. The mduration is rounded, circumscribed, and thin, sometimes so thin as to be scarcely perceptible except to the most delicate touch 2 La syphilis, 1906, iv, 64. 2 Bull, de la soc. Franc., de derm, et de syph., 1906, vol. xvii, p. 66. THE CHANCRE 637 (parchment chancre). Exceptionally the parchment chancre ulcerates deeply. Its color is usually a dark, vinous, or “raw-meat” red. Rarely it is of a dusty gray color (the color of lard). It may he covered with little petechiae. Its surface is usually flat. It may he a little elevated above the surrounding integument, or a trifle sunken below it, or surrounded by a slightly elevated ring of induration. The eroded surface is smooth and polished. It emits a slight sero- purulent discharge. It may be cov- ered by a crust or a false membrane (from infection by skin cocci). The Ulcerated Chancre.—■ This is the type of chancre described by Hunter, and to it the title “hun- terian chancre” is, therefore, pe- culiarly applicable. It is far less common than the eroded chancre. It has a relatively large in- durated base topped by a distinct ul- cer. The ulcer is due to extensive necrosis, and the necrosis is propor- tional to the interference with circu- lation; thus the thinner induration forms an eroded chancre, while the more nodular mass ulcerates. The ulcer extends into the true derma. Its edges are sloping (not undermined) and give the sore a sort of funnel shape; the base is granulating and may be covered by a false membrane ; the discharge is slight and serosanguinolent. The clinical picture of ulcerated chancre is that of a neoplasm eaten out by an ulcer, not that of an ulcer surrounded by an inflammatory ring. The neoplasm may be embedded within the skin; but pick it up, and you will realize that it is a distinct lump with an ulcer in the center. The Indurated Papule.—This is the rarest type of chancre. It occurs usually in situations where the integument is so dense and thick as to prevent very extensive development of the neoplasm. The indura- tion consequently remains a small, dark-red, flat papule. As it begins to heal the surface becomes scaly. Exceptional Varieties.—The induration may he so slight as to he clinically imperceptible. Eournier noted this absence of induration 7 times in 300 cases. Fig. 139A.—Large Ulcerated Hunter- ian Chancre. (Kaposi.) 638 THE INITIAL LESION As a result the lesion appears to be either *. 1. A superficial herpetiform ulceration or group of ulcerations (her- petiform chancre), or 2. A grayish or silver-white spot of thickened epithelium. This is seen only on the glans penis. Both these types are extremely rare. On the other hand, the induration may be very extensive, and extend far beyond the ulceration. Complications of Chancre.—The chief complications of chancre are: 1. Lymphangitis and edema. 2. Chancroid (mixed sore). 3. Simple inflammation. 4. Phagedena (gangrene). 5. Transformation into a mucous papule. 6. Vegetations. Lymphangitis.—Corded lymphatics, running from the chancre to the adjacent glands (e. g., along the dorsum of the penis), are not often seen. But in certain localities, such as the prepuce and the labia majora, a great mass of lymphatic induration may surround the chancre, or small similar masses may lie adjacent. Such a complication obstructs the lymphatic flow and causes considerable edema. It is sometimes spoken of as indurative edema. “Mixed” Soke.—As chancroid itself is rare among the upper classes, so is the mixed sore, the combination of chancroid and chancre. Among the chancres seen in the dispensary, however, fully one-tliird are “mixed sores.” The possible combinations of chancre and chancroid are three: 1. The chancroid may appear, flourish, and be cured, and from its remains the chancre may arise. 2. The chancroid may overlap and overshadow the chancre, so that the latter is suspected only from the induration remaining after the sore heals, or proven by the appearance of secondary syphilitic lesions, or a positive Wassermann reaction. 3. A true chancre may become chancroidal. Of the three types, the second is the one commonly observed. The presence of chancre is not even suspected until the chancroid in healing begins to take on a suspicious hardness, or until a roseola breaks out all over the patient. While the patient has an active chancroid, therefore, one can never assure him he has not true chancre. Inflamed Chancre.—The friction of clothes, or any other form of trauma, may so irritate the chancre that it becomes acutely inflamed; yet this is unusual. As a rule, the pyogenic microbes have no effect upon chancre beyond encouraging ulceration. THE ADENITIS OF CHANCRE 639 Gangrenous and Phagedenic Chancre.—The obstruction to cir- culation in the indurated base of a chancre is habitually sufficient to excite desquamation and exudation from its surface. Exceptionally, it is so marked as to cause gangrene of the dermis. Such a complica- tion is of no great importance. Phagedena is far rarer. Indeed, the occurrence of phagedena is presumptive evidence that the sore is not chancre. It is probably gumma. Transformation into a Mucous Papule.—-Chancre upon the mucous membrane or between moist folds of skin may, at the time of the first, general, secondary outbreak, become a typical mucous papule. The fact requires no further comment. Vegetations.—Soft warts may surround the chancre. Their pres- ence is accidental, and can scarcely be called a complication. Duration.—The chancre usually lasts four to six weeks, though some trace of induration may remain many months. Reinduration of the chancre, which simply means recurrence of syphilitic inflammation in a chancre partially or wholly cicatrized, may prolong its duration indefinitely. Fournier relates that he has seen a chancre run its whole course in two weeks. This must be about the minimum. Yet patients will often say that their chancres only lasted a few days, for they are careless observers. Their testimony merely bears witness to the clinical in- significance and painlessness of this lesion so fraught with grave con- sequences. Diagnosis—During the first week of a chancre spirochetes may readily be found in its secretion (p. 803). During the ensuing weeks they become less numerous here but may often be obtained by aspira- tion of the inguinal glands. The Wassermann reaction often becomes positive in the second or third week, almost always in the "fifth week, and always between the eighth and the tenth week following the appear- ance of the chancre. Treatment.—A daily wash with warm water, protection from fric- tion of the clothes, and the application of any simple dusting powder is all the treatment the chancre needs. But the disease requires instant and energetic specific treatment. THE ADENITIS OF CHANCRE Syphilitic inflammation of the group of lymph glands adjacent to the chancre is part of the initial lesion. It is as constant and typical as the chancre itself. Indeed, Fournier failed to find it only thrice in 5,000 cases. It appears in the second week after the outbreak of the sore. 640 THE INITIAL LESION Inguinal adenitis may be bilateral or unilateral; if the latter, it is usually on the side corresponding to the chancre. Exceptionally the lymphatics so anastomose that the adenitis is on the opposite side {crossed bubo). As a rule, however, both sides are affected. Symptoms.—The adenitis appears in the second week after the appearance of the chancre, usually on or about the tenth day. It reaches maturity in two or three days, and presents the following character- istics: multiplicity, moderate size, absence of peri-adenitis and of all acute inflammation, hardness, slow resolution. Multiplicity.—There is always a group of glands involved; in- deed, inguinal adenitis usually shows • involvement of a group in each groin, but the one rather more enlarged than the other. This group, or pleiad, as Ricord appropriately termed it, is made up of one (rarely more) large gland surrounded by a group of lesser ones (clinically the large node often predominates the scene, the lesser ones being scarcely discernible). Size.—The larger gland scarcely attains the size of a cherry and may be much smaller; the lesser ones are the size of peas. Absence of Inflammation.—Unless there is mixed infection the glands are neither painful nor tender. They are freely movable be- neath the skin, upon the subjacent parts, and upon one another.1 The skin over them is not discolored; they do not suppurate. This com- plete absence of peri-adenitis is one of their most striking characteristics. Hardness.—“The hardness of the glands is the hardness of the chancre;” such is the routine statement. The clinical facts do not quite bear it out. Though the glands may be as hard as the chancre, and when so are typical, in the larger number of cases they are distinctly more elastic. Slow Resolution.—The great virtue of syphilitic bubo is that it persists many weeks after the chancre has disappeared and may lead to the discovery of the scar of a healed chancre. It usually persists three months. Unusual Varieties—The bubo may be abnormal, inflamed, or “mixed.” Abnormal Bubo.—Exceptionally the bubo consists of a single very large gland, or the large gland is altogether lacking. Inflamed Bubo.—Inflamed bubo is much more common than in- flamed chancre. The pyogenic bacteria multiply upon the chancre and from it enter the lymph current, yet may not cause much local irrita- tion. The common clinical causes of inflamed bubo are genital filth and cohabitation. The bubo of labial or buccal chancre is habitually a large, tender, inflamed mass. 1 Unless they are inflamed, in which case they adhere to one another. THE ADENITIS OF CHANCRE 641 “Mixed” Bubo.—Syphilitic adenitis may be complicated by chan- croid or by tuberculosis. Chancroid and chancre combine to make a “mixed” sore and a “mixed” bubo. In both instances the characteristics of the chancroid lesion overshadow the other. Tuberculosyphilitic glands l have never seen. They are said to assume the tuberculous type. Diagnosis.—The typical group of one large uninflamed gland sur- rounded by a lot of little ones—all of them hard, insensitive, and not adherent—is so unmistakable that a discussion of its differentiating characteristics is all but superfluous. Certain varieties of herpes or balanitis excite a bubo quite similar to that of syphilis; but the exciting lesion is so dissimilar that a mistake is scarcely possible. The insensitive, hard, movable glands of syphilis can scarcely be confused with the inflamed, tender, adherent nodes of chancroid; though, as we have already said, the latter may conceal the former. The diagnosis is certified by the discovery of spirochetes or by the Wassermann reaction. CHAPTER LXVII GENERAL CONSIDERATIONS IN OPERATING ON THE URINARY ORGANS The major operations upon the urinary organs are often performed upon patients whose kidneys are gravely diseased, and whose constitu- tions are more or less undermined, both by infection and by renal in- sufficiency. The following considerations are of importance, in the order given: Complete diagnosis. Improvement of the kidney action and reduction of sepsis. Choice of anesthetic. Choice of operation. After the operation, the important special considerations are: Facilitating the action of the kidneys. Drainage (retained ureteral or urethral catheter). DIAGNOSIS The pathological conditions in the urinary organ of a patient who is about to submit to operation are often both multiple and complex. A patient with an enlarged prostate, for instance, may have both stone and tumor in his bladder (I once came upon one of my assistants en- deavoring to do a litholapaxy under these circumstances) ; or he may have a saccule. If so, the removal of his prostate affords only partial relief. Pain and blood seen issuing from a ureter, with an x-ray shad- ow showing a stone on that side of the pelvis, might seem sufficient for a diagnosis of renal stone or ureteral stone. So it did in one of my cases; but the stone was in the appendix and had I taken the trouble to do a careful functional test I should have realized that it could not be in the urinary tract. When a patient passes a great deal of blood in the urine and has a very large kidney there seems little question but that the blood comes from that kidney; yet in one of my cases that had no pus whatever in the urine this free bleeding came from an ulcer on the papilla of a tuberculous kidney whose fellow was enor- mously hypertrophied but otherwise normal. A pain in the side preced- ing a calculous anuria would seem to justify operation upon that kidney. 642 PREPARATION FOR OPERATION 643 I once followed this suggestion and, although I came upon a diseased kidney, at the post mortem examination the opposite kidney was found acutely obstructed by a stone in the orifice of its ureter. Had I operated upon the other side the patient would have been saved. A patient with advanced pulmonary tuberculosis and symptoms of surgical renal disease might be expected to have a tuberculous kidney. Yet from one such patient I have removed a kidney almost totally destroyed by tumor, and from a second a kidney containing the largest stone I have had to deal with. The tests made in this case showed a pyonephrosis with tubercle bacilli; omission of the x-ray led to overlooking of this very large stone. Such are some of the many pitfalls which may be avoided only by employing before operation every device to accomplish the most complete diagnosis possible. The routine examination of every major urinary case includes the following items: 1. Complete urinalysis and physical examination. 2. Blood pressure. 3. Renal function test. 4. Radiography. 5. Cystoscopy and ureteral catheterization with kidney function test. 6. Other tests, such as pyelography or cystography, as may be sug- gested by the results of the preceding examination. PREPARATION FOR OPERATION General Preparation.—If the preceding examination has shown that the patient’s general condition is such as to permit operation and that no special contra-indications exist the general preparation of the patient differs little from that for any other type of operation. A few points may be specified as follows: 1. The patient’s skin should always be prepared by scrubbing, never by tincture of iodin. This must he the general rule for hospital cases inasmuch as a great many of them have to do with the genitals, and it is quite impossible to clean the skin of the scrotum by chemicals. It re- quires a thorough scrubbing after the patient has been anesthetized and is on the operating table. 2. The use of morphin either before or after operation is not con- tra-indicated by any renal condition with which I am acquainted. The drug does interfere with the activity of the kidney, but only temporarily. The advantage of the use of morphin often far outweighs its disadvan- tages. For instance, I have at present under my care a patient who is dying of cardiac decompensation in connection with a chronic pyelone- 644 GENERAL OPERATIVE CONSIDERATIONS pliritis due to a stricture of the urethra. He recently passed but 2 ounces in 12 hours; he was then given grain of morphin, slept 9 hours, and passed 10 ounces of urine in the subsequent 12 hours. For several years past I have used hyoscin and morphin as almost a routine preliminary to operation. 3. Appropriate pre-operative treatment is required for diabetes, decompensated heart cases, high blood pressure and edema, etc. Rest in bed with appropriate drugs and diet will uften put such patients in a condition in which they can be operated upon. The indications and contra-indications are in no way special for operation upon the urinary tract. Preparation of Patients with Urethral Retention of Urine The pre-operative problem presented by the patient with urethral retention of urine has become classic in the treatment of sufferers from pros- tatism. But the prostatic is only a type, though often the most extreme type of this condition. Urethral stricture presents precisely the same problem, so does large vesical calculus; so, indeed, do certain renal condi- tions with low phenolsulphonephthalein output. But the problem of the prostatic summarizes all of these. The preparation required by the prostatic depends upon the pre- liminary diagnosis; the following rules may be laid down: 1. The prostatic should never he operated upon while in acute reten- tion. This retention must first he relieved by the retained catheter or by suprapubic drainage until the patient has passed through the acute reactionary congestion of the kidneys and the acute renal infection which inevitably ensue. This period used to be put at about one week. It is safer to prolong it until all subjective evidence of acute renal disturbance such as fever, dry tongue and disturbed mentality have disappeared, and further until the phenolsulphonephthalein test has shown a recovery from the first depression, which recovery may carry it back to a point even higher than it was at the time the catheter was first introduced into the patient’s bladder. 2. We are accustomed to consider absence of infection almost as dangerous as the presence of retention. But this is probably only because the absence of infection and the presence of acute retention is a combination often seen, and an extremely dangerous one. If one operates between attacks upon a patient with a clean bladder and a retention of no more than 3 or 4 ounces of urine no undue inflammatory reaction or failure of the kidneys may be expected unless the phenol- sulphonephthalein test before operation is extremely low. But the combination of an uninfected bladder and considerable retention is an extremely dangerous one. Prostatectomy upon such patients results in a very high mortality. On the other hand the patient with a chronic retention and in so- DIURESIS 645 called catheter life is the safest possible risk for prostatectomy, unless his heart or his kidneys are worn out. The Phenolsulphonepiithalein Test.—The use of the phenol- sulphonephthalein test as a pre-operative indication of the patient’s con- dition is almost universal among American urologists today. As has already been insisted, however, the findings of the test are not absolute. If the phenolsulphonepiithalein output in one hour after intramuscular injection is as high as 25 per cent and the patient is in no acute inflam- matory or retentive condition, he may be estimated a good operative risk as far as his kidneys are concerned. If there is considerable retention or acute infection, however, this must be overcome before the phenolsulphonepiithalein assurance is accepted. Yet a fine disregard of the findings of the phenolsulphonephthalein test may be expected of any accomplished surgeon. For in some cases the phenolsulphonephthalein output becomes and remains inexplicably low. This indicates damaged kidneys to be sure, yet the damage of the kidneys may not be so great as to prohibit operation. If such a patient has neither subjective nor objective symptoms of any acute condition, if his heart is reasonably sound or fortified by rest and digitalis, if the surgeon is skillful enough to perform his operation rapidly, and with a minimum of hemorrhagic and anesthetic shock, almost any operation may be performed in spite of almost any failure of the phenolsulphone- phthalein test. Nitrogen retention, if present, is a far more evil omen than low phthalein. The low phthalein merely shows that the kidneys are not functioning well. The nitrogen retention shows that as a result toxic substances have already accumulated in the blood. Eliminative treat- ment must be undertaken, by diuresis, catharsis, diaphoresis, rest, and a low diet until the nitrogen retention is overcome, or at least reduced to a minimum and there stabilized. Diuresis.—Special insistence must be laid upon diuresis. The object of diuresis is to keep the urine at a maximum dilution until the following results are achieved: 1. Renal function tests brought as near to normal as possible and there stabilized. 2. Dry tongue made moist. The means of diuresis are chiefly two: 1. Administration of water by mouth or hypodermoclysis, and by rectum. Each surgeon will follow his own rules as to the preferred method of water administration, and will vary his procedure to suit the emergency. In extreme cases it will be noted that the patient’s mouth is so dry he actually cannot be persuaded to drink. He must be fed water under skin and in rectum. As much as 500 c.c. may be 646 GENERAL OPERATIVE CONSIDERATIONS given by hypodermocylsis twice a day for weeks on end. It must not be forgotten, however, that such excessive diuresis is a strain both upon heart and kidneys. After it has achieved its purpose of reducing the toxemia, the patient is not in condition for operation until he has been given an opportunity to convalesce with special attention to . . . 2. Stimulation of the heart function by digitalis and graduated exercise. It is to be noted that the impaired kidneys do not secrete digitalis as well as do normal organs. The degree of nocturnal polyuria is an excellent index of the patient’s general vitality. CHOICE OF ANESTHETICS It is futile to lay down rigid rules on the subject of anesthesia. Every anesthetic is dangerous and each surgeon will succeed best with the anesthesia to which he and his assistants are most accustomed. General anesthetics are said to be better given in this country than in Europe. The favorite anesthetic in this country at the present time is the gas oxygen method usually administered by the technic of Crile and often preceded by 1/200 of a grain of hyoscin and i of a grain of morphin one hour before operation. I favor this preliminary nar- cosis as being free from danger and making the subjective operative shock much less for the patient; but I have unfortunately not yet met the ideal anesthetist to administer gas and oxygen without admix- ture of ether. It has been my experience that if this anesthetic is to be successfully administered it is best to anesthetize the patient with gas followed by ether (the so-called ether induction method) and then to proceed with gas and oxygen and as little ether as possible. But a truly skillful etherizer will do almost as well as the expert in gas- oxygen. Though excellent authorities can be cited on either side, the prevail- ing surgical view today seems to be that ether is less disturbing to the kidney action than chloroform. Local anesthesia should be substituted for general anesthesia wherever the skill of the operator with this method permits. Most scrotal operations can be performed under local anesthesia, though for inflammatory conditions 1 still prefer ether. Suprapubic cystotomy and lithotomy may perfectly well be done under local anesthesia and several surgeons have successfully performed prostatectomy by this method. I have not yet been converted to it. Local anesthesia is of no value for kidney operations excepting for the puncture of large hydronephroses or pyonephroses. European surgeons are employing paravertebral anesthesia for this purpose, and I have performed one DRAINAGE 647 nephrectomy by this technic. I am not convinced of its advantage over a good general anesthetic. Spinal anesthesia is safe only in the most expert hands. Sacral, parasacral and regional anesthesia are now being popularized in this country, largely through the work of Labat. POSTOPERATIVE CARE The requirements of the patient after operation are much the same as before. It is routine practice in many clinics to administer a hypodermoclysis as a routine measure after major operations upon the urinary organs, and even after minor operations upon patients in retention. Morphine may be administered freely during the first few days. DRAINAGE Drainage is provided for in a special manner by tlie operative tech- nic of each procedure to be described. The Retained Catheter.—One of the most valuable ways of provid- ing drainage for the bladder, both before and after operation, is by the retained catheter (indwelling catheter, catheter tied in, catheter d demeure). The retained catheter or sound is employed either for dilatation or for drainage. For the former purpose, filiform bougies are tied into the urethra; for the latter purpose, silk or rubber catheters are em- ployed. No metal instruments should he tied into the urethra, for fear of causing severe ulceration of the walls of the canal. Antisepsis.—Before introducing the retained catheter, the anterior urethra should be thoroughly irrigated with a 1: 4,000 solution of per- manganate of potash, and the glans penis scrupulously cleansed with soap and water and bichlorid. The technic of the retained catheter has been minutely explained by Guyon.1 His rules may be summed up as follows: 1. The instrument employed should be large enough to permit u free outflow of urine, and small enough not to make any pressure along the canal. Its eye must be near the end. Metal and olivary instruments are useless. The simple rubber catheter or woven catheter should be employed.2 1 “Lemons cliniques,” 1897, iii, 328. “We may add that special forms of self-retaining catheter are irritating to the male bladder,- though they are favored for drainage of the bladders of women. 648 GENERAL OPERATIVE CONSIDERATIONS 2. The instrument must be introduced so far as to have its eye well within the bladder. When the catheter is properly placed the urine flows continuously from it, drop by drop. When the retained catheter proves irritating this is usually because it has been introduced too far or not far enough, and is not draining the bladder properly. 3. The method of fixation is described below. 4. While the catheter is to remain in place the penis should be laid up over the groin, to prevent ulceration at the penoscrotal angle.1 5. Cleanliness is insured by using a clean cathe- ter in the first place, by changing the catheter and cleansing it and the urethra every five days, by using daily irrigations of the bladder, by wrapping the penis in a wet dressing of bichlorid (1: 10,000), and by using an aseptic urinal. An ordinary glass bed urinal will suffice. A rubber tube is led into it from Fig. 141.—Filiform Bougie Tied On. the catheter, and a little (1:40) carbolic solution kept in the vessel. The urinal is to be scoured and boiled daily. When the retained catheter acts efficiently it re- duces urinary fever and septicemia. When it acts inefficiently it produces them. Inefficient action may he due to plugging of the catheter by pus or blood, to malposition of the catheter, or to an idio- syncrasy of the patient. Fixation.—The female urethra is so short that an indwelling catheter in it must be of the self- retaining type (Fig. 140). Self-retaining catheters are of no value in the male urethra. In the female, the catheter is held in place by tying a number of silk strings to it as it issues from the vulva and fixing these to the pubic hairs in front, and by means of adhesive strapping to the lateral gluteal creases behind. Fig. 140. — Pezzer Self - retaining Catheter. 1 This is not necessary if a soft rubber catheter is used. DRAINAGE 649 Fixation in the male varies according to the instrument used. Fixa- tion of a filiform may he accomplished by tying a silk suture about it as it issues from the meatus, tying the ends of this suture together at a point about 1 cm. distant from the bougie, and then running the ends about the coronary sulcus and tying them above (Fig. 141). A catheter is, however, too heavy to be held by this method. It may best be retained by the dressing devised by Dr. Sinclair. Two pieces of adhesive plaster are cut into small rectangles, of which the long diameter will just surround the catheter, and the short diameter is about 1 cm. From the long edge of this rectan- gle two strips extend for about 10 cm. and are infolded so that they will not stick. The resultant product resembles a pair of trousers. The rectangles are af- fixed about the catheter close to the meatus, so that the “trouser legs” extend over the body of the penis at four equal angles. The shaft of the organ is then sur- rounded without compression by a band of adhesive plaster about 2 cm. in width, the legs of the cathe- ter bands pulled down over this (Fig. 142) and fixed by means of another strip of adhesive plaster. Before this is made adherent, each of the legs is pulled taut. Brief compression then fixes the outer band of adhesive plaster over these. The solidity of the fixation is insured by wrapping a silk string three or four times about the adhesive plaster on the catheter and tying it tightly. Position of the Penis.—If a silk catheter is used, the penis must lie over the groin; otherwise ulceration at the penoscrotal angle will result. If a rubber catheter is used, no attention need be paid to this detail, but the end of the catheter may be permitted to drop into a urinal situated between the patient’s thighs. Requisites for Success.—In order that the catheter shall work properly, it is necessary that it should fit loosely but snugly in the Fig. 142.—Sinclair’s Method of Fixing Retained Catheter. 650 GENERAL OPERATIVE CONSIDERATIONS urethra (about size 17 French) ; that its tip should remain in the blad- der ; and that it should he changed every three to six days, according to the irritation it excites. While the catheter is in place, the bladder should be irrigated at least once a day, and when it is changed the anterior urethra should be thoroughly flushed with permanganate solution. The catheter always excites a mild urethritis, and sometimes great protestations of pain from the patient; but if the urine drips from it regularly, it is well to quiet the patient for the first twenty-four hours by assurances and narcotics, after which his objections will usually cease; but if the bladder persistently expels the catheter, or if the pa- tient protests too loudly, or if fever results, it cannot be employed. CHAPTER LXVIII OPERATIONS UPON THE KIDNEY SURGICAL ANATOMY Gross Anatomy.—Although familiarity with the minute anatomy of the kidney is an essential part in the equipment of every practitioner, be he physician or surgeon, it is quite impracticable to enter upon this intricate subject here. A brief survey of the gross anatomy of the organ must suffice. The rest we leave to the histologist. The kidney is ovoidal in shape, flattened anteroposteriorly, and with a deep notch, the hilum, in its inner border. The renal vessels and nerves enter the organ through the hilum, the vein lying in front of the artery, while behind these is the conical pelvis, terminating below in the ureter. The sinus of the kidney is the irregular cavity of which the hilum is the orifice. The normal kidney is 11 cm. long, 6 cm. wide, and 4 cm. thick. It weighs from 125 to 200 grams. The kidney is closely surrounded by a fibrous capsule sending fine processes between the secreting tubules. A thin, irregular layer of un- striped muscle lies between the capsule and the kidney. When the organ is healthy its capsule may be readily stripped from it, but inflammation causes the capsule to become adherent. A vertical section through the kidney (Fig. 143) shows its secreting structure to consist of two parts: an outer (cortical) portion and an inner (medullary) portion, the latter made up of rounded cones (pyra- mids) whose apices (papillae, mammillae) project into the sinus of the kidney; while between the medullary pyramids the lighter-colored cor- tical portion of the organ also abuts on the sinus. The Renal Arteries.—The renal arteries are given off one from each side of the abdominal aorta, and proceed directly outward to the kidney, lying behind the veins (the right renal artery runs behind the inferior vena cava). As the artery enters the hilum of the kidney it divides into several branches, which enter the cortical substance and are thence distributed throughout the organ. The arterial supply of the kidney is peculiar in that the vessels do not anastomose. The small vessels subdivide from the main branches that enter between the pyra- mids and are terminal. 651 652 OPERATIONS UPON THE KIDNEY Ilyrtl has shown that the arterial system is divisible into two parts: a more important anterior system, supplied by the main branches of the renal artery, and a posterior system, supplied usually by a single branch, the retropyelitic, that passes around the posterior edge of the hilum, running down upon the posterior surface of the pelvis, and sends branches into the posterior part of the kidney. The terminal distri- bution of the anterior and posterior branches of the renal artery is neither definite nor fixed, but, generally speaking, the anterior branches sup- ply a little more than the anterior half of the organ. Therefore, in order to incise as few arterial branches as possible, the kidney should be opened in a vertical line about 0.5 cm. back of the median plane of the organ. Veins, Beeves, Lymphatics.—The renal veins accompany the ar- teries, lying in front of them,1 and empty into the inferior cava. On the left side, the spermatic, infe- rior phrenic, and supra- renal veins are tributaries of the renal. Within the kidney the veins anasto- mose freely. The nerves of the kid- ney are derived through the renal plexus from the solar plexus, the semilunar ganglion, and the lesser and smallest splanchnic nerves. The spermatic plexus is derived from the renal plexus. The lymphatics accompany the blood vessels and empty into the lumbar glands. Position.—The kidneys lie on each side of the spine in the upper lumbar region, behind the other viscera and outside of the peritoneal Fig. 143.—Frontal Section through the Kidney, Pelvis, and Calices (Henle). A, branch of the renal artery; U, ureter; C, calyx; 1, cortex; 2', me- dulli; 2" boundary zone; 4, fat of sinus of kidney; 5, arterial branches. Nuzurm {Jour. A. M. A1914, Ixii, 1238) has studied cases with retro-aortic left renal veins. SURGICAL ANATOMY 653 cavity (Fig. 144). They rest on the diaphragm and the psoas magnns and quadratus lumborum muscles between the twelfth dorsal and the third lumbar vertebrae. Their upper extremities lie nearer to each other than the lower, and the internal borders face a little downward and forward, the outer borders upward and backward. The right kid- ney often lies rather lower than the left on account of the position of the liver above it. The average normal variation in the posi- tion of the kidneys is well expressed by Brew- er’s 1 statistics obtained in the dissecting-room. He found the upper end of the right kidney opposite the eleventh rib in 78 cases, opposite the twelfth rib in 62 cases, and lower still in 9 cases. The upper end of the left kidney was opposite the tenth rib in 1 case, opposite the eleventh in 100 cases, opposite the twelfth in 43 cases, and below the ribs in 6 cases. Yet it must be borne in mind that dur- ing life the kidneys move up and down with every respiration, and are peculiarly suscepti- ble to downward dis- placement. Fatty and Fascial Envelope.—The kidney, surrounded by its fibrous capsule and topped by the adrenal, lies embedded in a mass of loose cellular tissue, usually containing a considerable amount of fat, and calculated to permit slight changes in its size and position. This fatty envelope (perirenal fat) quite fills the hollow of the loin, and is surrounded and held in place by a distinct fascia. This fascia has been Fig. 144.—Diagram Showing Relation of the Viscera to the Parietes; Posterior View (Treves). S, stomach; L, liver; K, kidney; SP, spleen, R, rectum. 1Med. News, 1897, lxxi, 129. 654 OPERATIONS UPON THE KIDNEY studied by Ziickerkandl, Gerota, and Glantenay and Gosset.1 It com- pletely surrounds the kidney, the suprarenal capsule, and the perirenal fat. In front it blends with the subperitoneal fascia, internally it ad- heres to the vertebral column, and above to the diaphragm. It sends a few fibers to the aponeurosis of the quadratus lumborum which lies immediately behind it. It thus forms a distinct sac firmly anchored to the diaphragm and the spine. It is everywhere closed, except at its Fig. 145.—Situation, Direction, Form and Relations of the Kidneys (Sappey). 1, 1, the two kidneys; 2, 2, fibrous capsule; 3, pelvis; 4, ureter; 5, renal artery; 6, renal vein; 7, suprarenal capsule; 8, the liver lifted up; 9, gall-bladder; 12, spleen; 14, abdominal aorta; 15, inferior vena cava; 16, left spermatic artery and vein. lower extremity, where the posterior layer thins out and sends only a few fibers across to the subperitoneal fascia. Below and behind this fascial envelope lies another mass of fat, practically continuous with the perirenal fat, hut distinguished as the pararenal fat. Relations.—Behind, the kidney is in relation with the diaphragm and the psoas and quadratus muscles. The last dorsal nerve runs trans- versely between the muscles and the perirenal fascia, and the pleura usually descends between the ribs and the diaphragm low enough to cover the upper third of the organ. 1 Guyon’s Annalcs, 1898, xvi, 113. SURGICAL ANATOMY 655 In front of the right kidney lie the duodenum and the ascending colon. A fold of peritoneum separates kidney and liver above the colon, while lower down a peritoneal fold separates colon and duodenum. The left kidney is crossed by the tail of the pancreas and lower down by the descending colon, while its upper portion is separated from the stomach by the lesser sac of peritoneum. The upper extremity of each kidney is capped by the adrenal. In fetal life this is closely adherent to the kidney and almost completely envelops it, but after birth the adherence becomes slight. Tiie Pelvis of the Kidney.—The pelvis belongs anatomically to the ureter, of which it is the dilated upper extremity, but surgically to the kidney, of whose secretion it is the reservoir and in whose sur- gical disease it participates. At the bases of the renal pyramids the epithelium of the uriniferous tubules joins with the fibrous covering of the cortex, the one to form the inner, the other the outer, coat of a tube surrounding one or more papil- lae, and called a calix (infundibulum). The calices unite to form the pelvis, an irregularly funnel-shaped pouch which protrudes from the lower and back part of the hilum, whence it runs downward, narrowing rapidly to become the ureter proper at a level with the lower end of the kidney. The structure of the pelvis resembles that of the ureter (p. 415). The radiographs, Figs. 36 and 37 and Plate V, illustrate the great diversity in shape and size of the normal kidney pelvis. Generally speaking, the pelvis splits up into two main calices; the upper one long and thin, extending obliquely upward to the top of the kidney, the lower one shorter and thicker, extending transversely. Each of these subdivides into several secondary calices, as the illustrations show. Manifestly, therefore, when the kidney is incised for the purpose of reaching the pelvis, it is wiser, other things being equal, to make the incision in the lower pole, both because the lower calix is broader and more readily accessible, and also because it is usually large enough to admit the finger, which the upper calix may not be. Relations of the Vessels to the Kidney Pelvis.—The main renal vessels lie in front of the kidney pelvis and extend from the kidney in a direction upward and inward, while the pelvis, which lies behind, drops almost directly downward. The only vessel of importance lying behind the pelvis is the retropyelitic artery, which, as stated above, supplies the posterior portion of the kidney. Inasmuch as there are no internal anastomoses in the renal arteries, division of this artery may occasion necrosis of almost half the kidney. It is, therefore, im- portant to be on the lookout for it whenever the pelvis is incised. It usually skirts the upper edge of the pelvis within the hilum of the kidney, so that, ordinarily speaking, it is not seen. 656 OPERATIONS UPON THE KIDNEY PREPARATION FOR OPERATION The preparations for operation upon the kidney are, generally speaking, those for any major, general operation. The patient’s general condition should be in the best possible state, and the diagnosis of the state of the renal function, of the pathological condition of the kidneys and of the condition of the other vital organs, should be most carefully studied. The study of the renal function should be made as previously laid down, and it is an excellent rule to perform radiography, ureteral catheterism, and study of the renal function upon every patient whose kidney is to undergo operation. Under certain circumstances any or all of these tests may have to be omitted, but one can never tell before- hand which is the case that may absolutely require every diagnostic test. The recent confession of a noted surgeon that, in his second series of 100 operations upon the kidney, he was mistaken in his diagnosis quite as many times as in the first 100 cases, is but an expression of the great uncertainty of renal surgery, which uncertainty can only be lessened by familiarity with and constant application of every device for accurate diagnosis before the patient conies to the operating table. (See Chapter LXVII.) LUMBAR INCISION Position of the Patient.—For sucli minor operations as drainage of perirenal accumulations of pus and urine, or nephropexy, the patient may lie upon the abdomen, since the operation may be performed through a vertical dorsal incision, but the only advantage of this posi- tion is that it saves a little time if both kidneys are to be operated upon. The almost universal custom is to place the patient upon one side, with the hip and knee of the under leg well Hexed so as to prevent the trunk from tumbling over, and the knee and hip of the upper leg extended, for the purpose of retaining the balance and of still further increasing the size of the lumbar recess. To increase the size of this space still further, and to push the kidney upward and make it more accessible in the loin, it is necessary to place some form of pillow or bolster underneath the opposite loin of the patient. A large sand bag or pillow will serve this purpose; the Edebohls kidney bag serves better; and the appliances for this purpose fitted to all modern operating tables serve best of all, since these may be raised or lowered and the patient, placed upon the flat table, may be raised into proper position during the opera- tion, and dropped back upon the table again when the muscles are to be sutured. The elevation should be such as to put the upper loin upon the stretch, but not really to lift the weight of the patient’s body from Fig. 146.—Patient Lying on Side, Showing Proximity of Free Border of Ribs to Crest of Ilium. Fig. 147.—Patient as in Fig. 146, but Elevated by “Kidney Suppobt.” Note how the ribs are drawn away from the iliac crest. The space between is widened by the interval included in the Q • 658 OPERATIONS UPON THE KIDNEY the hip and shoulder resting on the table. The arms should be disposed in front of the patient. The Incision.—Three incisions are in favor. In the order of impor- tance they are: The oblique incision. The transverse incision. The vertical incision. The Oblique Incision.—The surgeon, standing behind the patient, determines the position of (1) the tip of the last palpable rib (which may be the eleventh or the twelfth); (2) the outer edge of the mass of spinal muscles; and (3) the upper border of the iliac crest. The incision is begun over the rib at the point where it disappears under the erec- tor spinae, and carried obliquely down and for- ward to pass two or three fingers’ breadths above the upper edge of the iliac crest, from which it can be carried still farther down and forward parallel with that crest, if necessary. The incision should always be long enough to admit the whole hand. It may be curved slightly with the concavity upward. After incising the superficial tissues, the external oblique is reached and divided; though if an easy operation is anticipated, this muscle may be thrown forward and the dissection continued between it and the spinal muscles1 in Petit’s triangle. The next plane reached is that of the internal oblique and transversalis. If the kidney is known to be very loose, these muscles need not be divided, but may be separated on a plane parallel with their fibers. This muscle-splitting operation gives, however, a very restricted field, and in the great majority of instances it is necessary to divide all the abdominal muscles in line with the external incision, the trans- versalis being split parallel to its fibers. If the division is made suf- ficiently far back, the twelfth dorsal nerve is not seen; if the incision is sufficiently oblique and high above the iliac crest, the ilio-inguinal and iliohypogastric nerves are either not seen at all, or are seen to run parallel with the incision and below it. Xone of these nerves should be divided. Fig. 148.—The Oblique “Kidney” Incision. 1, cos- tomuscular angle; 2, quadratus and spinal muscles; 3, iliac crest; 4, last dorsal nerve; 5, iliohypogastric nerve; x, xi, xii, ribs. LUMBAR INCISION 659 Unless the kidney is very low the incision should now he carried upward along the lower border of the twelfth rib (after making sure that it is the twelfth and not the eleventh—otherwise the pleura will be torn). The latissimus dorsi is divided, and the rib freed from the serratus posticus inferior and the erector spinae and finally from the ligament of llenle, a fibrous band binding it down to the first lumbar vertebra. (These structures should be incised at a little distance from the rib; otherwise the last dorsal vessels will be repeatedly incised. They may then be divided and tied once, well away from the rib.) With the cutting of this ligament the rib will be felt to spring away from the vertebrae, thus greatly enlarging the lumbar space. ISTow a mass of retroperitoneal fat appears in the incision. This is pushed down and blunt dissection made in a backward and upward direction. This brings the perirenal fat into the wound, surrounded by its fascial capsule. Since this fascial capsule closely resembles the peritoneum, the surgeon will do well to thrust his hand into the incision along the muscles of the back, and then, palpating forward, he will feel the kidney, and be sure that the tissue behind it is its fascial capsule. This fascial capsule is incised and split longitudinally by the fingers. If the kidney is quite loose, it may be drawn into the wound by catching the perirenal fat which now bulges out, and drawing it out, both in front and behind, while the fingers strip it from the surface of the kidney; but if the kidney is adherent, this procedure is of no avail. The hand must be plunged into the loin and blind, blunt dis- section made with the fingers. The first object sought is to clear away the upper pole of the kidney. With the fingers close to the organ, adhesions are broken up and the perirenal fat pushed aside until the upper pole is reached; then the fingers are swept around this, both behind and before, until it is quite free. The upper pole is then released and the lower pole much more readily freed in like manner. In freeing the poles one should delay a moment to feel for aberrant vessels. An attempt is then made to draw the kidney up into the wTound, either by traction upon the perirenal fat and capsule, or by traction upon the kidney itself. If the maneuver is difficult, it may often be facilitated by turning the kidney backward, inspecting its anterior sur- face, and carefully incising adhesions that bind it to the surrounding tissues, pushing these away and so advancing, little by little, until the hilum is reached. The same procedure is then employed for the pos- terior surface of the kidney, and for its extremities as well. Finally, when all adhesions have been freed, the kidney readily pops out of the wound, unless bound down by considerable inflammation about its hilum. 660 OPERATIONS UPON THE KIDNEY The Transverse Incision.—This incision is employed for the removal of unusually large kidneys. It is carried parallel to the last rib, and a finger’s breadth below it from the edge of the spinal muscles to the edge of the rectus. Nephrectomy is then performed as described on p. 697. The Vertical Incision.—The vertical incision, running directly downward from the twelfth rib to the iliac crest, gives a field too re- stricted for most operations. It may be employed for nephropexy, and has the advantage of sparing the lateral and anterior abdominal walls. Variations in the Operation.—Many other types of incision have been suggested, but the three mentioned above are the only ones cur- rently employed. The oblique incision may be extended downward, for extraperitoneal exploration of the ureter, as far as the brim of the pelvis. If intra- peritoneal complications are suspected, the peritoneum may be deliber- ately incised and the gall-bladder, the intestines, or even the appendix, inspected, while the hand may be run across for intraperitoneal palpa- tion of the opposite kidney—a procedure, by the way, which very rarely discloses anything worth knowing. That the opposite kidney seems sound on palpation is no evidence that it has any appreciable functional capacity. Accidents in the Operation—The peritoneum may be torn, but this is an unimportant accident, even if it cannot be adequately sutured. If the kidney or the perirenal tissues are infected, peritonitis may be prevented by adequate drainage. Injury to the pleura is prevented as described above. Its occurrence is characterized by the whistle of the air drawn in at inspiration and the bubbles that appear in the wound at expiration. The tissues should be quickly clamped and the rent closed by suturing the diaphragm. Other operative accidents relate to the kidney and are mentioned in the succeeding chapters. THE TRANSPERITONEAL INCISION Deliberate transperitoneal nephrectomy through a vertical incision at the outer edge of the rectus muscle is no longer an approved opera- tion. It is employed only when the surgeon, ignorant of the precise nature of the abdominal mass he is attacking, enters the peritoneal cavity before he recognizes that tlie kidney is the organ at fault. Tinder these circumstances if the mass is not infected it may be attacked in the way most convenient. If it is infected the peritoneal cavity may be readily walled off either by suturing the parietal peritoneum and then dissecting it laterally until the tumor is reached extraperitoneally, THE TRANSPERITONEAL INCISION 661 or by making a vertical incision in the peritoneum, just lateral to the ascending or descending colon, and suturing this layer of parietal peri- toneum to the inner edge of the peritoneal incision of the anterior abdominal wall. For a proper handling of a renal growth under these conditions it is usually necessary to enlarge the vertical incision by a transverse one extending to the loin. A much more common form of intraperitoneal operation is that which begins as an extraperit'oneal procedure in the loin, but enters the peritoneum either accidentally or deliberately on account of difficulties in removing the kidney. Such an opening in the peritoneum need not be deplored since it often gives more ready access to the inner side of the mass, and guarantees the safety of the colon and the vena cava. The intestines are simply walled off, and the operation proceeds in the usual manner as described on page 068. CHAPTER LXIX OPERATIONS UPON THE KIDNEY (