•\, -*► ^ V:; &-;jj&tf \ \ ■ • ■„. y ■. . * ; r/ \ ■W# m-.x- &jjjff * :'i* %...t &: ^-*^sS •'4 ■ *■ r **- NLM 0510T73M 7 ■"*riOK»L LIBR»«Y OF MEDICINE nwjPTi"*/ SURGEON GENERAL'S OFFICE LIBRARY. Section, Xo. I m-1i ;/" ^ V* manual ot Genito-Urinary Di lseases by Ellwood R. Kirby, M. D. Clinical Professor of Genito-Urinary Diseases in the Medico-Chirurgical College, Philadelphia ; formerly Instructor of Clinical Surgery in the University of Pennsylvania; Surgeon to St. Mary's Hospital; Genito-Urinary Surgeon to Medico-Chirurgical Hospital; Surgeon to Out-Patient Department St. Agnes' Hospital, Etc. 17& Philadelphia F. W. S. Langmaid, M. D. 202 South Thirty-sixth Street 1899 VVT Copyright 1899 ^ by F. W. S. Langmaid All rights reserved To J. William White, M. D. Professor of Clinical Surgery in the University of Pennsylvania In Remembrance of his Kindness and Counsel By His Friend and Pupil The Author Preface. This little manual has been published in response to the repeated requests of the author's pupils, from notes used by him in teaching and quizzing. Effort has been made to present the matter briefly and clearly, therefore, authorities have not been cited nor cases quoted, and debatable points have been omitted. It is believed that the manual will be found abreast of the times and useful to those for whom it is intended. Ellwood R. Kirby, 1202 Spruce Street. February, 1899. 4 Contents. The Kidney. PAGE Anatomy of the Kidney—Relations of the Kidney—The Position of the Kidney—Anomalies of the Kidney— Examination of the Kidney — Examination of the Urine separately from the two Kidneys—Contusions of the Kidney—Wounds of the Kidney—Movable Kidney — Floating Kidney — Nephrorrhaphy — Renal Calculus — Nephro-Lithotomy — Tuberculosis of the Kidney— Hydronephrosis— Pyelonephritis—Pyonephro- sis or Surgical Kidney—Perinephritic Abscess—Tumors of the Kidney—Nephrotomy—Nephrectomy . . 1-20 The Ureter. Anatomy of the Ureter—Subcutaneous Rupture of the Ureter—Wounds of the Ureter—Ureteritis—Ureteral Calculus — Ureteroplasty—Uretero-Lithotomy—Ureter- ectomy — Uretero-Ureterostomy — Uretero-Enterost- omy—Uretero-Cystostomy—Ureterorrhaphy . . . 20-22 The Bladder. Anatomy ot the Bladder—Exstrophy of the Bladder— Cystocele—Hsematuria—Frequency of Micturition— Residual Urine—Suppression of Urine—Retention of Urine—Incontinence of Urine—Atony of the Bladder —Catheterization — Sterilization of Catheters — Tech- nique of Catheterization—Cystitis—Chronic Cystitis— Tuberculosis of the Bladder—Tumors of the Bladder —Vesical Calculus—Median Lithotomy—Lateral Lith- otomy—Suprapubic Lithotomy—Lithilopaxy—Rupture of the Bladder—Cystotomy—Puncture of the Bladder 22-43 The Scrotum, Cord and Testicles. Anatomy of the Scrotum—CEdema of the Scrotum—Gan- grene of the Scrotum—Elephantiasis of the Scrotum —Wounds of the Scrotum—Tumors of the Scrotum —Epithelioma of the Scrotum—Anatomy of the CONTENTS PAGE Spermatic Cord—Contusions and Wounds of the Cord—Inflammation of the Cord—Tumors of the Cord—Varicocele—Hydrocele of the Spermatic Cord —Congenital Hydrocele of the Spermatic Cord— Diffuse Hydrocele of the Spermatic Cord—Encysted Hydrocele of the Spermatic Cord—Anatomy of the Testicles—Undescended Testicle—Orchitis—Tubercu- losis of the Testicle—Syphilis of the Testicle— Tumors of the Testicle—Hydrocele—Hematocele— Spermatocele — Epididymitis — Seminal Vesiculitis — Castration—Vasectomy ...... 43-64 The Prostate Gland. Anatomy of the Prostate—Relations of the Prostate— Prostatitis—Prostatorrhcea—Hypertrophy of the Pros- tate — Prostatomy — Prostatectomy — Castration for Hypertrophied Prostate—Tuberculosis of the Prostate —Prostatic Calculi—Tumors of the Prostate . . 64-79 The Penis. Anatomy of the Penis—Phimosis—Circumcision—Paraphimo- sis—Balano-posthitis—Herpes Progenitalis—Venereal Warts—Erysipelas of the Penis—Cavernitis—Tubercu- losis of the Penis—Priapism—Tumors of the Penis— Epithelioma of the Penis—Amputation of the Penis —Extirpation of the Penis ...... 79-88 The Urethra. Anatomy of the Urethra—Hypospadias—Epispadias—Rup- ture of the Urethra—Meatotomy—Foreign Bodies in the Urethra—Gonorrhoea—Gleet—Gonorrhceal Arthritis —Stricture of the Urethra—Internal Urethrotomy— External Urethrotomy—Perineal Section—Urethral Fistulae — Urethral Fever — Cowperitis — Periurethral Abscess ......... 89-120 Chancroid. Causes—Varieties—Symptoms—Complications — Diagnosis —Treatment ........ 128-131 Syphilis. Causes—Methods of Infection—Periods of Syphilis— Chancre—Skin Eruptions—Tertiary Syphilis—Treat- ment of Syphilis—Hereditary Syphilis . . . 131-143 • Cucliac axis ami plexm '(/&,, \ Right 10th n. t)ci | co -*< io | coi^ao i oiowwio 1-3 PQ EH W •qs;i2na •neoTjaniY H|«inii'|io|o|t.|ao|C5| •qanaj^ i-> | CI CO 1 "* liOWt- IQCCiO 1 ,-h OS 00 I-^IOCO 1 1 1 H 1 HHi-l 1 HHH 1= •qsr[3aa MM 1-1 I 1 I °* I " 1 r,<10 I ° I I ^ I °° I •nBouatuy !-< I« | |eo|^jio|co|fc.|oo|o>jg| o 3 O 5 O 6 O 8 O 9 OOOOOoooon ^ 22 21 20 18 17 15 U 12 Catheter Scales, French and American Gauges Compared. 3i The Bladder. 31 Treatment.—The patient should be placed in bed, with the hips elevated, leaches to the perineum, belladonna and opium sup- positories, a milk diet, and the internal administration of jfr. Tincture aconiti . . gtts. xxiv Tincture belladonnas . f3i Acid boracic Sodii bromidi . . aa 3" Liq. potassi citratis q. s. ad fgvi M. S. fs*ss every four hours. At the end of from three to five days the acute symptoms will have subsided, then intravesical irrigations may be employed with benefit. (1) Nitrate of silver, 1 to 10,000 gradually increased. (2) Corrosive sublimate, 1 to 30,000 (3) Carbolic acid, 1 to 2,000 (4) Permanganate of potash, 1 to 8,000 " (5) Boracic acid, 2 per cent, solution (6) Thiersch's solution (salicylic acid Sss, boracic acid Siiiss and water to make a quart). These irrigations should be given daily, as hot as can be comfortably borne, and gradually increased in strength according to the effect produced, As a general rule, permanganate is to be recommended in the more acute conditions, and nitrate of silver for the chronic In the later stages, the reparative process may be somewhat hastened by the internal use of the balsams, copaiba, cubebs, etc. Chronic Cystitis. Is caused by such conditions as interfere with the incomplete evacuation of the bladder, as tight stricture, enlarged prostate, atony, tumors, and stone. Symptoms.—The symptoms are similar to those of the acute, but not so marked. The urine is cloudy, containing mucus and pus in abundance, and a thick tenaceous, ropy or stringy, muco-purulent substance. It is alkaline in reaction, due to ammon- iacal fermentation, with deposit of phosphates. Prognosis.—Chronic cystitis of long standing is very prone to infect the kidneys by continuity of tissue, as pyelitis, and pye- lonephritis. 32 Genito-Urinary Diseases. Treatment.—For the successful treatment of chronic cystitis the predisposing cause (stricture, enlarged prostate, stone, tumor) must be searched for and removed. The diet must be regulated so as to avoid all highly-seasoned food, pastries, red meats, tea, coffee, etc. Alcohol in all forms is to be strictly interdicted. The patient should partake freely of mineral waters, and saline diu- retics (citrate of potash) should be given in such doses as to render the urine neutral. Relief is often given by the balsams in chronic cystitis, and the following prescription may be tried: J&. Salol, .... grs. iii Oleii santali . . . gtts. xv Balsam copaiba . . gtts. x Oleii cinnamomi . . gtts. ii M. Ft. capsula i. S. From four to six to be taken daily. For the local treatment, instillations may be employed when the inflammation is limited to the vesical neck. Nitrate of silver is to be used with an Ultzman's syringe, fifteen drops of a half to a five per cent, solution being placed in the prostatic ure- thra every third or fourth day. Irrigation may be used as for the acute variety of the dis- ease, with the exception that the quantity of fluid used at first should be small owing to the contraction of the bladder. Nitrate of silver is to be preferred, beginning with a strength of i : 8,000 and gradually increased in strength according to the effect pro- duced. The urine must first be drawn off, and the bladder washed out with a boracic solution before the nitrate of silver is used. When the bladder is thickened and contracted, a median perineal cystotomy should be performed and a permanent cath- eter fixed in place for drainage, to bring about the atrophy of the hypertrophied bladder wall by disuse. Tuberculosis of the Bladder. Tuberculosis of the bladder is rarely a primary condition, being usually secondary to tuberculosis of the prostate or kidneys. The trigone is the part usually affected. Symptoms.—Gradually increasing frequency of micturition in a young man; haematuria at the end of urination; some Bawlick's Bladder Endoscope. Cystiscopes for vesical exploration of the male and female bladders. 32 A soft vascular, spongy Tumor of the fundus of the bladder. (Villous.) Polypoid growths from the mucous membrane of the bladder. 33 The Bladder. 33 vesical tenesmus; pain at the end of the penis; sudden arrest of the stream from involuntary contraction of the compressor urethrse muscle to relieve pain caused by the passage of urine along the urethra. The urine contains pus, blood and tubercle bacilli. A cysto- scopic examination will usually reveal the cause of the trouble. Treatment.—In the early stages, general antituberculous treatment should be instituted, such as cod-liver oil, iodide of iron, change of climate, etc. Locally, the bladder should be emptied of urine by careful catheterization, gently irrigated with boracic acid solution, and an instillation of twenty drops increasing to two fluid ounces of a solution of bichloride of mercury 1 : 5,000 gradually increased to 1 : 1,000, should be given every second or third day. Occa- sionally the instillation of two or three drachms of a 10 per cent, emulsion of iodoform in glycerine may prove useful. In more advanced cases, a suprapubic cystotomy should be done, and the diseased surface freely curetted; the raw surface left is to be cauterized with carbolic acid 1 to 5, in glycerine, or when the lesion is small pure acid may be employed, followed by a liberal dusting of iodoform powder. The fistulous opening should not be allowed to close until all symptoms of pain and cystitis have disappeared. Tumors of the Bladder. These are extremely rare and may be either primary or secondary. Varieties.—(1) Papillary fibroma (most common), (2) car- cinoma, primary and secondary, (3) mucous polyps, (4) myomata, (5) myxomata, (6) sarcomata, (7) adenomata, and (8) dermoids. Symptoms.—Hemorrhage may extend over a long time, occur spontaneously and suddenly, and without any attending symptoms; residual urine, retention of urine, and intermittent stream. Pain becomes pronounced when cystitis develops ; pus is then found in the urine. Tumors are often associated with secondary calculus formation. Diagnosis.—The use of the cystoscope will reveal the true nature of the case in the majority of instances. 34 Genito-Urinary Diseases. Treatment.—Suprapubic cystotomy. In exposing the interior of the bladder a Watson speculum will be found useful. The removal of the growth is effected by sharp spoons, curette forceps and ecraseur, the base of the growth being cauterized with the Paquelin cautery. In extensive disease the entire bladder may be removed and the ureters transplanted into the colon. Hemorrhage is usually severe and must be controlled by pads and ligatures. The wound in the bladder may be closed immediately or allowed to granulate, depending upon the condition of the mucous membrane at the time of operation (cystitis). Vesical Calculus. Stone in the bladder. Varieties. — Calculi may be classified under the following headings : (i) Those formed from the natural saline constituents of the urine (uric and phosphatic stones). (2) Those formed of elements often, but not necessarily, found in healthy urine, but never in excess except as a result of disease (oxalic stone). (3) Those formed from elements which are foreign to the urine altogether, being excreted by renal action in certain mor- bid states of the body (cystine and xanthine). When the salts of the urine are deposited in a solid form as crystaline particles, the condition is described as sand. When about the size of a hemp-seed or pea they are termed gravel. When as large as the kernel of a hazel nut, they are termed concretions, and when too large to pass through the urethra they are termed calculi. Causes.—The common varieties, in the order of their fre- quency, are uric, phosphatic, and oxalic. A large number of vesical calculi (uric and oxalic) begin in the kidney ; these in time pass into the pelvis of the organ, and are transferred along the ureter to the bladder, where, if not expelled from the viscus, they constantly attract to them- selves the salts of the urine until they attain a sufficient magni- tude to create the usual symptoms of calculus. /^W3K Lateral operation of lithotomy. Sounding bladder for calculus, varieties of vesical calculi. •v^4'.; ^" ^r -5) Urates Uric Acid v & ^«i? Urates of Amonium Phosphates Oxalates Vesical Calculus Urethral Calculus in the membraneous Urethra. Calculus in the Bulb of the Urethra. 35 The Bladder. 35 The phosphatic calculus is not often found in the kidney, being more commonly produced in the bladder (phosphate of lime). Phosphate of lime in the mucus of a diseased bladder meeting with phosphate of magnesia, a triple phosphate results. This combined with more phosphate of lime, makes a fusible calculus, the commonest form. Stone in the bladder is not confined to any period of life ; it may exist before birth, and is met with from infancy to extreme old age. A very large proportion, however, occur in early life In a table of 8574 cases collected by Gross, 4986 were under twenty years, 748 between twenty and thirty, 438 between thirty and forty. 588 between forty and fifty, 685 between fifty and sixty, 772 between sixty and seventy, and 338 between seventy and eighty. The formation of stone is supposed to be favored by drink- ing hard water of limestone districts. Insufficient food (lack of milk), clothing, and, fresh air, the necessary accompaniments of poverty, appear to encourage calcu- lus formation among children, but not among adults. Habits of self-indulgence, full diet, and lack of exercise, encourage calculus formation, especially in elderly adult males. Chronic inflammation of the bladder, atony of the bladder, stricture of the urethra, enlarged prostate, vesical tumors, and foreign bodies, all predispose to the formation of a vesical calculus. Symptoms.—Increased frequency of micturition, especially during the day ; the patient, when in the erect posture, frequently experiences the desire to empty his bladder, because the stone falls down in the base of the bladder in contact with the vesical neck. There is pain at the end of micturition referred to the end of the penis; sudden stoppage of the stream, the cal- culus acting as a ball-valve; blood, pus and mucus in the urine, priapism, and reflex pains in perineum, thighs, and loins. Diagnosis.—The diagnosis is made by instrumental explora- tion of the bladder. The sound should be a metallic instru- ment, and adapted by its form to freely explore the bladder. It should possess a short, curved beak, so that it can be turned to the right, left, above, and below. (See Figure 10.) 36 Genito-Urinary Diseases. When the stone is encysted the surgeon may not be able to demonstrate the metallic click. When exploring a bladder for stone it is well to do it in a systematic manner. The method commonly adopted is to first explore in the median line, the beak of the instrument pointing towards the fundus of the bladder. The instrument should now be turned so that the beak points to the right side of the patient, then to the left, and finally the post-prostatic pouch and bas-fond. It is advisable to have the bladder partially dis- tended with boracic acid solution before making the examina- tion. The presence of a calculus can always be demonstrated by the X-Ray. Treatment.—As preventive measures, regulation of the diet, avoidance of alcohol, spices, peppers, etc; and the removal of all predisposing causes located in the bladder, prostate and urethra. Operative Treatment.—(i) Lithotomy, median, lateral, supra- pubic. (2) Lithilopaxy or crushing. Before operating upon any case of vesical calculus the patient should be subjected to a preparatory treatment for at least a week. This consists in the use of a milk diet, daily irrigation of the bladder with warm boracic acid solution, and the internal administration of five grains of salol with ten grains of boracic acid, thrice daily. During this period the condition of the kidneys should be ascertained by frequent quantitative, chemical and microscopical examinations of the urine. Median Lithotomy.—Median lithotomy is indicated in very small hard stones with or without strictures of the deep urethra. Disadvantages.—Very little room for the manipulation of instruments; great difficulty in introducing the finger into the bladder for purposes of exploration; there is great danger of wounding the rectum and bulb of the urethra, and finally, hem- orrhage may be troublesome. Operation.—Before operating upon any case of stone in the bladder always introduce a vesical sound and ascertain whether the stone is still present, as it is possible that the stone may have escaped from the bladder during urination. r & Old No. Fig. u. Stone Scoops. Lithotomy Staff. Old No Fig. 10. Stone Searcher. Old No. Fig. 13. Perineal Tampon. Old No. Fig. 14. Colpeurynter / Lateral operation for vesical calculus, showing lithotomy position, line of incision, and methods of grasping and removing the stone. 37 The Bladder. 37 Place the patient in the lithotomy position (legs flexed on the thighs, thighs on the abdomen, and buttocks brought well to the edge of the table). One assistant should have charge of each leg, and the one on the left side of the patient should hold the staff in his right hand. A catheter is introduced, and the viscus filled with six or eight ounces of boracic acid solution ; the patient must be well etherized or the bladder will not retain the fluid. A curved staff with a wide groove is introduced into the urethra, and so held that its handle inclines towards the umbilicus, and exactly in the median line. (See Figure 11.) An incision is now made in the median line of the peri- neum, beginning one and a quarter inches in front of the anus, and extending to the external sphincter. The point of the knife is made to enter the groove of the staff and the following structures divided from before backwards:—Skin, superficial fas- cia, perineal center, external sphincter, Colle's fascia, lower border of the anterior layer of the triangular ligament, com- pressor urethrse muscle, membraneous urethra, posterior layer of the triangular ligament, and apex of the prostate. The finger should now be introduced into the bladder and the staff with- drawn. Forceps or scoop are to be introduced into the bladder along the finger as a guide, and the stone removed. (See Figure 12.) A full-sized Nelaton catheter is to be introduced into the bladder through the perineal incision, and the viscus thoroughly irrigated with boracic acid solution. If hemorrhage occur, the perineal wound may be packed with iodoform gauze around a catheter. A light antiseptic dressing with a T bandage should be applied. (See Figure ij.) The catheter should be changed every second day for a week and then removed altogether. While in place, the end should be kept in a urinal filled with 1 to 20 carbolic acid solution to prevent infection. Lateral Lithotomy.—Lateral lithotomy is indicated in medium sized hard stones with stricture of the deep urethra. The preliminaries of this operation are similar to those for the median. 38 Genito-Urinary Diseases. The perineal incision should be begun at a point one-and- a-quarter inches in front of the anus in the median line, and extend to a point midway between the anus and the left tuber ischii. The finger is introduced into the wound and the staff located, and the point of the knife made to enter the groove of the staff, the handle depressed, the blade at the same time being turned a little to the left, and pushed steadily along the groove until a gush of urine announces that the neck of the bladder has been sufficiently divided. The following structures are divided in this operation :—Skin, superficial fascia, transversus perinsei, muscle, vessel, and nerve; Colle's fascia; the anterior layer of the triangular ligament ; external hemorrhoidal vessels and nerves ; compressor urethral muscle; membraneous urethra ; posterior layer of the triangular ligament ; levator ani muscle, and left lateral lobe of the prostate. Introduce the index finger into the bladder; remove the staff; introduce the forceps along the finger as a guide, and remove the stone. The after treatment is now similar to that for the median operation. Suprapubic Lithotomy.—Suprapubic lithotomy is indicated in very large hard stones; when calculi are complicated by enlarged prostate ; in encysted calculi; when the hips are anchylosed so that the patient cannot be placed in the lithotomy position ; and when the patient has a very deep perineum. Operation.—Introduce a colpeurynter bag into the rectum and distend with from six to ten ounces of fluid, so as to push the bladder forward and displace upwards the prevesical peritoneal layer. (See Figure 14.) Introduce a catheter into the bladder and distend the viscus with from six to ten ounces of boracic acid solution. If the bladder will not retain the solution an elastic ligature may be placed around the penis. An incision three inches in length is made in the linea alba, beginning at the pubic symphisis; the subcutaneous fat, often plentiful in amount, being divided, and any vessels secured, the linea alba is identified and divided. The transversalis fascia is now picked up and divided at the lower angle of the wound. Retractors should now be introduced, and the edges of the The high or suprapubic operation for vesical calculus. 38 9 Bigelow's Evacuator. Bigelow's Lithotrite. Various forms of Lithotrites, and instruments for crushing a stone when found too large to remove through the lithotomy incision. 39 The Bladder. 39 wound drawn wide apart. A layer of loose fat, frequently having large veins in it, next comes into view, lying over and concealing the bladder. This must be carefully divided, and all bleeding points ligated. A spot on the anterior surface of the bladder having been selected about three-quarters of an inch from the pubes is punctured, and the left index finger introduced into the bladder and the calculus located. Forceps or scoop should be introduced along the finger as a guide and the stone removed. When cystitis is present a catheter should be introduced into the bladder through the urethra, and Guyon's double tubes (two long drainage tubes having a caliber of 15 F.) introduced through the suprapubic wound into the bladder. The wound in the bladder and in the subcutaneous structures should be sutured together around the catheter, leaving room for a small piece of iodoform gauze to drain the lower part of the space of Retzius. The skin incision should be closed in a similar manner. As soon as the urine flows clear the tubes may be removed, and the remaining fistula allowed to close by granulation. When little or no cystitis exists the wound in the bladder should be closed by suture as follows: A continuous suture of fine catgut for the mucous coat, then a layer of interrupted catgut sutures, not going deeper than the mucous membrane; finally the skin and deeper structures are closed with silkworm gut. A catheter should be passed into the bladder through the urethra and retained in place until the wound is completely healed. Lithilopaxy.—Crushing and removing a stone at one sitting. It is the operation of choice in all cases of vesicle calculus unless contra-indications are present, the contra-indications being the indications for the various forms of lithotomy. Indications.—Medium-sized soft stone, when uncomplicated by enlarged prostate, when the stone is not encysted, when there is no stricture of the urethra, when the urethra is not acutely inflamed, and when the caliber of the urethra is suffi- cient to admit a lithotrite. The operation should never be undertaken except by those 4° Genito-Urinary Diseases. who have had considerable experience in the handling of ureth- ral and vesical instruments, as great damage may be done to the bladder. Complications.—The prolonged use of a lithotrite may occa- sion an epididymitis or urethral fever unless the operation be done in a thoroughly aseptic manner. Operation.—Irrigate the bladder thoroughly with boracic acid solution, allowing six or eight ounces of the fluid to remain in the organ. The catheter is now withdrawn and the lithotrite introduced as you would a steel sound; this may be a little difficult because of the sharp angle by which the beak joins the shaft. (See Figure ij.) Keep the instrument exactly in the median line, open the jaws and attempt to catch the stone ; if not caught in this position turn to the right, then to the left, and finally to the bas-fond. In whatever position the stone may be caught by the lithotrite, the instrument should always be brought to the median line, and the beak gently rotated from side to side, in order to prevent the wall of the bladder being caught in the jaws. The instrument should now be held firmly, and locked; the handle being turned slowly at first until the jaws bite well into the stone, then more and more until the stone is crushed. These manipulations are repeated until all fragments are crushed; the lithotrite is then withdrawn and an evacuating tube, straight or curved, having a caliber of 30 F., with a large eye on its anterior surface, is introduced into the bladder, and attached to the Bigelow evacuator, the latter having previously been filled with boracic acid solution. The instrument consists of a rubber bag, and a glass ball at the bottom for collecting the fragments. The evacuating connection which extends into the interior of the rubber bag is open at the end, and its circumference perforated with a number of small holes, so that as the water is pumped back into the bladder, it passes through the minute perforations rather than through the end of the tube, because the sum total of the diameter of these perforations is greater than the diam- eter of the tube, hence the water flows through the sieve and the fragments of calculus must fall into the glass bulb at the bottom. (See Figure 16.) Anterior layer of deep perineal fascia removed, showing ^^COMPRESSOR URETHRC. 'nternal pudic artery. Artery of the bulb. Coivper's gland. Artery of Corpus Cavernosam Dor teaIArtsry of Pent.* Artery of JBuli Tnt^rnetl Pudic Arteru Cowper's GZetnc/ 40 The Bladder. 41 While the left hand supports the evacuator, the surgeon with his right hand being very careful not to use too much force, but yet quickly squeezes the bulb sufficiently to send into the bladder about two ounces of fluid; on releasing the rubber bag, the return flow of fluid carries with it the fragments of stone. Occasionally during the manipulation of the evacuator the surgeon experiences a sensation resembling a fish-bite. This indicates that the mucous membrane of the bladder is being caught in the eye of the evacuating tube, and more water must be intro- duced into the bladder. When no more fragments come, the evacuator is withdrawn, and a vesical sound introduced to see if any fragments too large for evacuation remain ; if so, they are to be recrushed and evacuated in the same manner. The bladder is now to be irrigated with warm boracic acid solution. The diet should consist of milk. Ten grains of boracic acid with five grains of salol should be administered thrice daily. The patient may be allowed to get out of bed in a week. Rupture of the Bladder. Causes.—Traumatism to the lower abdomen, especially when the bladder is distended; fractures of the pelvis; and finally it may be ruptured by the lithotrite or colpeurynter in operations for vesical calculus. Varieties.—(i) Intraperitoneal. (2) Extraperitoneal. Extraperi- toneal into either the space of Retzius or recto-vesical space. Symptoms.—Intraperitoneal rupture—Inability to urinate (this power is occasionally preserved in both varieties of injury) ; some bloody urine drawn off by the catheter; difficulty of manipulat- ing an instrument in the contracted bladder. If the urine is healthy, peritonitis may not develop for from thirty-six to seventy- two hours, otherwise it is immediate and rapidly fatal. There may be fluctuation and dulness in the flanks, hypogastric pain, and always profound shock. Extraperitoneal rupture.—Inability to urinate ; a little bloody urine is withdrawn by the catheter; manipulation of the beak of the catheter will show that the bladder is contracted. When the rupture is anterior, the extravasation of urine will occur in the 42 Genito-Urinary Diseases. prevesical space, when posterior, into the recto-vesical space, along the rectum, appearing at the side of the anus. There is always more or less shock. Diagnosis.—Catheterize and withdraw the urine, then inject a known quantity of boracic acid solution, withdraw fluid, and see if the quantity corresponds with amount injected. Treatment.—Intraperito?ieal rupture. A laparotomy should be done and the rent in the bladder located and closed by a Czerny-Lembert suture. Then inject boracic acid solution to see if the line of suture is water-tight. Flush out the abdominal cavity with boiled water or Thiersch's solution and close the abdominal wound with drainage. A catheter should be introduced into the bladder through the urethra and retained in place for at least five days. Extraperitoneal rupture into the Space of Retzius.—Open the prevesical space as for a suprapubic operation, and if blood stained fluid wells up from the anterior surface of the bladder, the organ should be thoroughly explored for the tear, and the wound closed in a manner similar to that described in suprapubic lithotomy. Close the abdominal incision, leaving sufficient room for an iodo- form gauze, drain to aid the escape of urine if the sutures give way. A catheter should be retained in the bladder for at least five days, and twice daily the bladder should be gently irrigated through this instrument. Recto-vesical space.—Introduce a staff into the bladder, first placing the patient in the lithotomy position, and then doing a median perineal cystotomy (see median lithotomy). A large Nelaton catheter should be introduced into the bladder through the perineal wound and retained in place for ten days. Areas of extravasation about the rectum should be freely opened to prevent cellulitis. The bladder should be irrigated with boracic acid solution night and morning. Cystotomy.—The operation for opening the bladder apart from such cases as exploring for growths, foreign bodies, etc.. Varieties.—(i) Suprapubic. (2) Median perineal. Indications.—In cases of cystitis when the urine is extremely foul and there is danger of ascending infection (kidneys). In Methods of puncturing the bladder with a trocar for retention of urine. 43 The Scrotum. 43 turberculosis of the bladder; as a palliative measure (rest). In rupture of the urethra or traumatic stricture with fistula and for retrograde catheterization. For description of operations see median lithotomy and suprapubic lithotomy. Puncture cf the Bladder.—It is sometimes necessary to puncture the bladder to relieve over-distension in cases of acute retention of urine. Methods.—(:) Suprapubic. (2) Subpubic. (3) Cock's operation (perineal). (4) Through the rectum above the prostate. Either a straight or curved trocar and canula may be used according to the position elected. The Scrotum. Anatomy.—The scrotum a pendulous, membraneous pouch containing the testicles, is composed of the following tissues: (1) the skin, (2) the dartos, (3) the external spermatic fascia, (4) the cremasteric or middle spermatic fascia, (5) the internal sper- matic fascia, and (6) the tunica vaginalis. Owing to the attachments of the dartos to the skin, it must be remembered that when operating upon the scrotum, the skin edges must be carefully everted, as, like in the neck, there is a constant tendency towards inversion. (Edema of the Scrotum. Causes.—(1) Rupture of the bulbous portion of the urethra (extravasation of urine), (2) general anasarca from heart, liver, and kidney lesions, and (3) septic inflammations. Symptoms.—Bilateral uniform enlargement, the scrotum pre- serving its normal outline, with pitting on pressure. Diagnosis.—(Edema of the scrotum must be distinguished from hydrocele, as in rare instances, the oedema may be unilateral. CEdema of the Scrotum. Hydrocele. 1. Usually bilateral. 2. Outline of scrotum preserved. 3. Pits on pressure. 4. Not translucent. 5. Rugae obliterated. 1. Usually unilateral. 2. Outline altered. 3. No pitting on pressure. 4. Translucent. 5. Rugse not obliterated. Treatment.—Remove the cause, and relieve tension by numerous small incisions under strict antiseptic precautions. 44 Genito-Urinary Diseases. Gangrene of the Scrotum. Gangrene of the scrotum is an extremely rare condition. Causes.—Uninary infiltrations; erysipelas ; thrombosis and embolism; as a complication of grippe, typhus and diabetes; traumatism, and frost-bite. Treatment.—The same general rules apply here as for gangrene in any other part of the body. After the slough separates the testicles must be covered by a plastic operation, or by bringing together the granulating edges. Elephantiasis. A condition rarely seen in this country. Causes.—Some obstruction to the flow of lymph, which may be either inflammatory in origin or result from the invasion of the tissues of the body by the filaria sanguinis hominis. Symptoms.—The growth consists of a hypertrophy of the tissues of the scrotum, the penis usually participating in the disease. The surface of the skin becomes thickened, indurated, sometimes rugus or knotty, and crossed with deep fissures. The scrotum sometimes attains enormous dimensions (fifty to one hundred and fifty pounds). In consequence of this great weight, the spermatic cords are much elongated, and the cre- master muscle much thickened. The testicles usually remain unaffected. Treatment.—In the early stages the administration of large doses of the iodide of potash is frequently of great service. When the bulk of the tumor becomes so great as to seriously interfere with the comfort of the patient excision is the proper remedy. As these operations are often extremely bloody, the base of the tumor should be surrounded with an Esmarch band, the testicles exposed, and all diseased tissue cut away. If suffi- cient tissue is not at hand for closing in the testicles, they will be entirely covered with granulations if left exposed. As these cases are occasionally complicated with rupture, the surgeon should remember the possibility of encountering a hernial sac. Elephantiasis of the scrotum. X<:cfb. Cvstic disease of Testicle. Tuberculosis of Testicle. Abscess of Testicle. 44 &—■ Spermatic Cord and Suspensory Ligament of the penis. 45 The Spermatic Cord. 45 Wounds of the Scrotum. Wounds of the scrotum may be either incised, contused, lacerated or gunshot. Wounds of the scrotum are similar to like injuries of other parts of the body and are treated upon the same general princi- ples. The surgeon should see that all hemorrhage is controlled before closing the wound, as these vessels may continue to bleed in the loose cellular tissue, and large accumulations of blood result. Tumors of the Scrotum. With the exception of epithelioma, tumors of the scrotum are rare. Cysts, fibromata, lipomata, enchondromata, and der- moids have been reported. Epithelioma of the Scrotum. This condition was formerly known as "chimney sweepers' cancer" because of its frequency among people engaged in this work. Symptoms.—It begins usually as a small papule or nodule, becoming excoriated, and finally covered by a scab. When this scab is removed it will be found that the original excoriation has increased in size and become an ulcer. The edges become indurated, hard and raised above the level of the surrounding tissue; the base of the ulcer is uneven; granulations, when present, are unhealthy, and an acrid, irritating, watery pus exudes. As the disease advances the tissues of the scrotum are progressively destroyed, and finally the inguinal lymphatic glands become involved. Treatment.—Early and complete excision of the growth, carrying the incision well into the healthy tissues. All enlarged inguinal glands must be removed. Spermatic Cord. Anatomy.—The vessels and nerves, to, and the excretory duct from the testicle, make up the so-called spermatic cord. It is composed (1) the spermatic artery, (2) the spermatic plexus of veins, (3) the vas deferens, (4) lymphatics, (5) sympathetic nerves, (6) the artery of the vas, (7) the cremaster muscle, (8) the artery of the cremaster, (9) the genital branch of the genito-crural nerve, 46 Genito-Urinary Diseases. and (10) the obliterated processus vaginalis. It extends from the internal abdominal ring, through the inguinal canal, and into the scrotum as far as the summit of the testicle. Contusions and Wounds of the Cord. These may result from wounds inflicted over the pubis, and from kicks and blows applied over the same region. If the vessels are divided the hemorrhage may be free, and if the cord is ruptured, the ends may retract within the canal, the escaping blood forming an elongated, sausage-shaped tumor, parallel to and above Poupart's ligament (hematocele). Treatment.—Ligature of all bleeding points, with rest, ele- vation, and pressure. Inflammation of the Cord. Funiculitis or inflammation of the spermatic cord is of rare occurrence. Causes.—Extension of inflammation from the posterior urethra and from phlebitis. Symptoms. — Swelling, induration, great tenderness, and a sense of weight and dragging experienced along the course of the inguinal canal and in the back. Treatment.—Rest in bed, the use of leeches or the appli- cation of cold or lead water and laudanum, with sufficient sup- port to the testicles to prevent dragging on the cord. Tumors of the Cord. Fatty tumors of the cord are quite common, and may develop in the inguinal canal or scrotum. Symptoms.—Tumor of slow growth, irregular in outline, sometimes lobulated, moving up and down by traction on the cord. Diagnosis.—A fatty tumor must be differentiated from an epiplocele. This may be exceedingly difficult without an explora- tory incision. It must be remembered that the epiplocele is within the peritoneum, the lipoma without; the hernia forms from above, the lipoma from below. The presence of an impulse on cough- ing in a hernia, and its absence in a lipoma, may make it possible to distinguish between the two. o "3- The anatomical relations of the lower genito-urinary tract. Ecchymosis of, scrotum from con- tusion. Method of Strapping a Testicle. Method of Tapping a Hydrocele. Section of testicle Fungus of showing chronic orchitis. testicle. "Chimney sweaps" cancer (epithelioma of scrotum). 47 The Spermatic Cord. 47 Treatment.—When the tumor becomes inconvenient or trou- blesome from its size, excision will be necessary. In performing this operation the greatest care should be observed not to wound any of the components of the cord. Myomata and sarcomata are but rarely seen. Varicocele.—A varicose condition of the veins of the pam- piniform plexus. The condition is most frequently seen in the young from the fifteenth to the thirtieth year, and usually involves the left side. Causes.—Owing to the absence of a valve in the left sper- matic vein at the point where it empties into the renal, varicocele almost invariably occurs on the left side. The left side is still further predisposed by the angle (right) which the left spermatic forms with the left renal, and by the relation which the vein bears to the sigmoid flexure (posterior). The left spermatic vein is much longer than the right, consequently the weight of the column of blood is greater on the left side than on the right. Landouzy examined 5639 army recruits, and states that 87 per cent, of the cases of varicocele were on the left side, 6 per cent, on the right side, and 7 per cent, on both sides. Besides the mechanical conditions favoring the development of varicocele, there are a number of other causes—heavy lifting, straining efforts in defecation on account of constipation, pro- longed standing or walking, excessive venereal indulgence, mas- turbation, and tumors situated in the abdominal cavity pressing upon the veins. Symptoms.—It develops gradually, and as it progresses there is experienced a sense of weight and dull, aching pain, extend- ing along the cord and to the small of the back. As the veins increase in size they form soft, doughy, convoluted masses com- parable to a bunch of earth worms, extending from the base of the scrotum to the external abdominal ring-. The scrotum, in consequence of additional weight, becomes relaxed and elongated, the color of the blood in the veins being quite visible through the skin. When the varicocele becomes large it is not infrequently associated with atrophy of the testicle from pressure. 48 Genito-Urinary Diseases. These patients frequently suffer from (sexual neurasthenia) mental depression, impotence, headache, nervousness, dyspepsia, and emaciation. Diagnosis.—Varicocele may be confounded with scrotal hernia and congenital hydrocele. A hernia cannot return when once reduced and the finger placed over the ring while a varicocele can. A congenital hydrocele transmits light while a varicocele does not. Treatment.—The treatment may be palliative or radical. The palliative treatment indicated in mild cases consists in the regulation of the bowels, cold douches, the avoidance of all exciting causes, and the use of a properly fitting suspensory. The radical treatment consists in a resection of the veins, and is indicated when the varicocele is progressing and the testicle atrophying. Operation.—The vas deferens is isolated, and either kept so by two fingers of the left hand, or handed over to an assistant who stands opposite to the surgeon. In either case the latter makes the veins prominent by grasping the affected side of the scrotum and protruding the varicocele. An incision about one and a half inches long, is then made over the now prominent varicocele, care being taken to keep well above the level of the tunica vaginalis. The veins are exposed by a few touches of the knife; any formal dissection of the veins being unnecessary. An aneurism needle threaded with catgut is passed below the veins at the lower angle of the wound, and the needle withdrawn. The same procedure is repeated at the upper angle of the wound, only about two-thirds of the veins being included in the ligature, otherwise gangrene will follow. Both ligatures are tied down tight and the intervening portion of the veins cut away. One end of each ligature is now cut close to the knot, and tie the two remaining long ends together so as to approximate the stumps of the divided veins thus shortening the cord on that side. The wound is closed by two or three silkworm gut sutures, dressed antiseptically, and the patient kept in bed for at least one week. Dartos. External spermatic fascia. Cremasteric fascia. Infundibuliform fascia. Parietal tunica vaginalis. Visceral tunica vaginalis. Tunica albttginea. A lobule of the testicle.. A septum___ Mediastinum.. Digital fossa.. Spe, ■'tic vein.. Epididymis.. I'as deferens... Artery to vas.- Spermatic artery.. Internal muscular. tunic of Kolliker. Tunica vaginalis. parietal layer. Anatomy of the Testicle. Tunica Vaginal Tunica Albuginea. Minute Anatomy of the testicle. Varicocele. Orchitis. 48 The Spermatic Cord. 49 When the scrotum is preternaturally long, the redundant portion should be excised, using a clamp for the operation Hydrocele of the Spermatic Cord. Hydroceles of the cord are less frequently met with than the periorchitic variety, and consist of an accumulation of clear fluid similar to that of the tunica vaginalis. Varieties.—(i) Congenital. (2) Diffuse. (3) Encysted. Congenital Hydrocele of the Spermatic Cord. This is a rare affection, the result of an anatomical defect; the funicular process being closely adherent to the cord at the external abdominal ring, but remains open above communicating directly with the abdominal cavity. Symptoms.—The presence of a soft, fluctuating tumor in the canal, prominent when the patient is in the erect posture and diminished or slowly disappears with the patient in the recumbent posture. When the patient resumes the erect posture the tumor slowly returns. There may be an impulse on coughing in this variety of hydrocele. When prominent enough the surgeon may be able to apply the transmitted light test. Diagnosis. — Congenital hydrocele must be distinguished from an inguinal hernia. In hernia the tumor disappears suddenly and completely and with the characteristic flop and a gurgle when taxis is applied; coughing brings it back quickly. Hydrocele disappears slowly and requires considerable time for its complete return. The transmitted light test is pathognomonic of hydrocele. Treatment.—A truss may be applied, and is occasionally followed by cure; failing in this an antiseptic seton should be employed. Diffuse Hydrocele of the Spermatic Cord. A collection of fluid in the cellular tissue which surrounds the cord. Symptoms.—An elongated, cylindrical or ovid swelling, usu- ally extending from the testicle to the internal abdominal ring, filling the inguinal canal. The swelling is soft, compressible and fluctuating, and the tumors move with the spermatic cord. When of sufficient size translucency may be observed by the proper use of the light test. 50 Genito-Urinary Diseases. Diagnosis.—Diffuse hydrocele must be distinguished from omental hernia. Omental Hernia. Diffuse Hydrocele. Impulse on coughing. No impulse on coughing. Reducible. Irreducible. Doughy to the touch. Fluctuating to the touch. Does not transmit light. Does transmit light. Treatment.—When of sufficient size to cause some inconve- nience to the patient, the aspiration and iodine injection may be tried. In the majority of cases it is better to open the sac and drain as for hydrocele of the tunica vaginalis. Encysted Hydrocele of the Spermatic Cord. An accumulation of fluid between the funicular and vaginal processes. Symptoms.—It appears as a circumscribed ovoid swelling at some point of the cord, projecting chiefly in front of the latter, transmitted light shows the tumor to be translucent. Diagnosis.—Encysted hydrocele may be mistaken for hernia ; there is no impulse on coughing, gurgling, nor resonance, besides being irreducible. The light test will usually clear up the diagnosis. Treatment. — Encysted hydrocele occassionally disappears spontaneously, otherwise the open operation with drainage should be carried out. The Testicles. Anatomy.—The testicle is a compound tubular gland, sur- rounded by a serous pouch known as the tunica vaginalis, and contained in the scrotum. The left testicle is usually placed somewhat lower in the scrotum than the right. The epididymis, composed of about twenty feet of convoluted tubes, is about one and a quarter inches in length, attached to the posterior border of the gland, is divided into a globus major or head, above, a body, and a globus minor or tail, below, which is continuous with the vas deferens. The testicle is at first an abdominal organ, lying below the kidney. It is connected by unstriped musular fibres, the guber- Hydrocele of the cord communi- cating with the tunica vaginalis testis. The in- strument is pas- sed through the membrane which separ- ates the fluid from the peri- tonaeum, a, Testis. Hydrocele of the cord communi- cating with the peritoneal cavi- ty, a, Testis. Encysted hydro- cele of the cord. Hydrocele of the tunica vaginalis testis. Bilocular hydrocele. Tc, Parietal layer of tunica. S, Spermatic cord. N h, Epididymis. H, Testis. D, Cavity of diverticulum. 7 v, Cavity of the tunica vaginalis proprius. Z %, Inflammatory new. formation between the visceral and parietal layers. Usual form of hydrocele. 50 The Testicles. 51 naculum, with the pillars of the external ring and the base oi the scrotum. It begins to descend in the early part of the third month of foetal life, reaching the internal abdominal ring within the sixth month. At the eighth month, it appears at the exter- nal ring, and reaches the base of the scrotum shortly before birth. Undescended Testicle.—The absence of one or both testi- cles from the scrotum is no evidence that these organs do not exist, as they remain undescended, either in the abdomen or in some part of the inguinal canal. The left testicle is more frequently undescended than the right. In several reported cases the testicle has been found in the perineum, and in the femoral canal. When the testicle is permanently detained in its unnatural position, it generally remains undeveloped, and is particularly liable to such complications as inflammation, and malignant disease, especially sarcoma. Diagnosis.—When the testicle is in the inguinal canal it may be confounded with hernia, the absence, however, of the testicle from the scrotum, its ovoid shape, irreducibility, and the sickening sensation produced when the tumor is compressed will distinguish it from hernia. When situated in the region of the groin it might be con- founded with bubo, especially when the seat of inflammation. If the scrotum were found empty on the affected side, the swelling, in all probability, would be testicle. Treatment.—When the gland still remains in the abdomen, nothing can be done by surgical intervention, as its attachments are so short that it could not be dragged down into the scrotum. When situated in the inguinal region, an effort should be made to cause its descent by gently dragging it downward. Its return to the canal is prevented by protecting the ring with a truss having a very soft pad. Should a hernia follow the testicle, the truss will answer the double purpose of retaining the hernia and preventing the retraction of the gland. If the testicle cannot be brought down into the scrotum by the sixth year, operation must be considered. Operation.—An incision is made over the testicle; the 52 Genito-Urinary Diseases. exposed gland is then brought out of the wound, the fibres of the cremaster muscle divided transversely, and the cord gently stretched until the testicle will hang free beyond the external abdominal ring. The finger is now forced through the loose areolar tissue of the scrotum to its base. The latter is invaginated and fastened to the base of the testicle with two chromacized catgut sutures. The invaginated scrotum is now drawn out, carrying with it the anchored testicle, the deeper tissues closed with catgut, and the tissues of the cord sutured to the pillars of the external ring. A firm antiseptic dressing should be applied. In the femoral variety of the trouble, the testicle should be reduced into the abdominal cavity and retained in place by a truss. The perineal variety can occasionally be cured by operation similar to that for the inguinal misplacement. When high up in the inguinal canal, it should be protected from injury by an appropriate pad or truss. When seen late in life, castration is always advisable, as the organ is, in all probability, functionally useless. Orchitis. An inflammation of the testicle. Causes.—Gonorrhoea, mumps, tuberculosis, syphilis, and trau- matism. Symptoms.—The testicle rapidly swells, but retains its nor- mal ovoid form, with the exception of being somewhat more flattened. The pain is of a dull, sickening character, often radi- ating to the hips and back. It may be complicated by acute hydrocele. Occasionally suppuration follows an acute inflammation. Diagnosis.—Orchitis must be distinguished from epididymitis. In epididymitis the swelling is confined to the posterior aspect of the scrotum, and careful palpation will reveal the enlarged indurated organ behind. Treatment.—The patient should be confined to bed, the scrotum elevated, and lead water and laudanum freely applied. The bowels should be kept loose by the use of salts, and the pain should be controlled by the use of sufficient morphia. The Testicles. 53 When an acute hydrocele is present, tapping with a tenotome, allowing the escape of a few drops of fluid, will often instantly relieve the intense pain. After the acute symptoms have subsided, the testicle should be strapped with strips of adhesive plaster, so as to hasten absorption. Tubercular Orchitis. Tubercular orchitis is usually secondary to a like affection of the epididymis, but the organisms may reach the gland through the blood vessels and produce so-called primary infection. It is met with at all ages, although commonly between twenty-five and thirty-five. The disease is often bilateral. Symptoms.—The gland becomes hard, knotty and irregular in form ; there is little or no pain in the early stages of the dis- ease. There is a sense of dragging and weight and a sense of discomfort referable to the back. Sooner or later these nodules become adherent to the skin, soften, and finally rupture spontan- eously, leaving fistulous openings, which remain sometimes for years, exhibiting little or no tendency to heal. Not infrequently the disease of the testicle has been preceded by tuberculosis of the lungs. Diagnosis.—Tubercular testicle is to be distinguished from syphilitic orchitis. Tubercular Orchitis. 1. Usually begins in the epidid- ymis. 2. Occurs between twenty-five and thirty-five. 3. Irregular and nodular. 4. Suppuration frequent. 5. Sometimes painful. 6. May be larger than the fist. Syphilitic Orchitis. 1. Usually begins in the tes- ticle. 2. May occur at any age. 3. Uniform and hard. 4. Seldom if ever suppurates. 5. Painless. 6. Always smaller than the fist. Prognosis.—Occasionally, under favorable circumstances, reso- lution takes place, which will leave the testicle without serious damage. It may undergo encapsulation and cause no further trouble, or the disease may progress from bad to worse until the entire testicle is destroyed. 54 Genito-Urinary Diseases. Treatment.—The treatment of tubercular testicle consists in the use of iodide of iron, cod liver oil, good food, fresh air, and plenty of sunlight, combined with the local use of iodide of lead ointment. When not benefited by this treatment, one of the following may be tried : (i) Lannelongue's injection of chloride of zinc; from three to five drops of a one per cent, solution being injected around the periphery of the tumor every third or fourth day. (2) Injections of a ten per cent, emulsion of iodoform in gly- cerine are sometimes valuable. From twenty to thirty drops are injected into the focus of the disease, the needle being introduced at several points, five drops being deposited at each point. These injections are to be repeated every fourth or fifth day, depending upon the violence of the reaction. (3) The diseased focus when circumscribed may be curetted or excised with good results, except the loss of function of the testicle. (4) When the disease is progressing, or other measures have failed, castration is to be recommended. Metastatic Orchitis. An inflammatory orchitis complicating mumps. One testicle is usually involved, and atrophy is not uncommon. The symptoms and treatment are similar to acute orchitis. Syphilitic Orchitis. A complication of the tertiary stage of syphilis. Symptoms.—A hard, indurated, somewhat irregular, painless swelling, usually smaller than the fist, and often bilateral are all that are noted. Treatment.—Internally the biniodide of mercury should be given in doses of one-twelfth of a grain with twenty grains of iodide of potash thrice daily. The iodide should be pushed, and local inunctions of mercurial ointment given. Tumors of the Testicle. Tumors of the testicle are rather uncommon, but cysts, ade- nomata, carcinomata, chondromata, fibromata, myxomata, sarco- mata, and dermoids are occasionally found. The Testicles. 55 Carcinoma is by far the most common tumor affecting the testicle. Symptoms.—The disease is unilateral, beginning after middle life, first as a uniform swelling, which soon becomes nodular and irregular, growing with great rapidity, and quickly breaking down and ulcerating, leaving a protruding fungus mass. As the disease advances, the inguinal lymphatics become involved (drain scrotum), and also the lumbar (drain testicle) ; there is dull, aching pain; the general health rapidly fails, the face becomes cachectic, and the body emaciated. Diagnosis —Cancer of the testicle must be distinguished from tubercular orchitis. Cancer of Testicle. i. Occurs about age of 50. 2. Begins in the testicle. 3. Growth rapid. 4. Becomes adherent to skin early. 5. Pain sharp and severe. 6. Attains great size. 7. Painless on pressure. 8. Unilateral. 9. Course rapid and fatal. the Tuberculosis of the Testicle. Occurs between 25 and 35 years. Begins usually in the epi- didymis. Growth slow. Adhering to skin later. 5. Little or no pain. 6. Never very large. 7. Painful on pressure. 8. Often bilateral. 9. Course slow,extending over a period of months or years. Treatment.—Early and complete extirpation. Hydrocele. A collection of fluid in the tunica vaginalis testis. Varieties.—(1) Acute. (2) Encysted. (3) Congenital. Acute Hydrocele. This condition usually results from an extension of inflam- mation from the epididymis or testicle. Symptoms.—Owing to the prominence of the symptoms of the primary disease, the characteristic symptoms of hydrocele are not pronounced. Pain is often extremely severe, and is due to pressure. 56 Genito-Urinary Diseases. Diagnosis.—The diagnosis usually presents no difficulty if the light test be employed. Treatment.—Rest in bed, elevation of the scrotum, and the local use of lead water and laudanum, are usually sufficient. After the acute symptoms have subsided a well fitting suspen- sory should be worn. When the pain becomes very severe, the sac may be punc- tured with a fine tenotome and a few drops of serum allowed to escape. Uusually this is followed by instant relief. The local use of belladonna and mercurial ointments will often hasten the absorption of the fluid. Encysted Hydrocele. This is the ordinary form of hydrocele, the fluid being con- tained within the cavity of the tunica vaginalis. Causes.—In many cases the cause is not appreciable, often it can be traced to traumatism, strains, anatomical defects, or is a complication of orchitis or epididymitis. Symptoms.—A swelling of slow formation ; swelling begins below and ascends ; pyriform in shape; smooth, tense, and fluctuating; elastic on pressure, but does not alter its size; dull on percussion ; stands away from the body, and cannot be reduced. When examined by the light test the swelling will be found to be translucent. The patient should be examined in a dark room; a candle or lamp is held on one side of the swelling, the surgeon stoops down on the other side, making the scrotum tense with one hand, while the other is placed in a vertical position on its upper surface, in order to intercept the peripheral rays of light. Diagnosis.—A hydrocele must be distinguished from a hernia, varicocele, hematocele, sarcocele, and encephaloid of the testicle. Hydrocele. Hernia. i. Begins at the most depend- ent part. 2. Irreducible. 3. Flat on percussion. 4. Stands away from the body. 5. Translucent. 6. No impulse on coughing. Swelling commences at the top. Reducible. Tympanitic (gut). 4. Does not stand away from the body. 5. Not translucent. 6. Impulse on coughing. 0 Method of applying adhesive straps to the testicle. Evacuating a hydrocele. with a trocar and canula, showing how to avoid the testicle. 57 The Testicles. 57 i. 2. Hydrocele. Unattended with pain. Does not disappear with pa- tient in the recumbent posture. Tumor smooth and regular in outline. Hydrocele. Appears idiopathically. 2. Stands away from the body. 3. Transmits light. 4. Fluctuating and elastic. Varicocele. 1. Pain in testicle, inguinal canal and loins. 2. Does disappear. 3. Feels like a bunch of worms. Hematocele. 1. Generally results from trau- matisms. 2. Falls between the legs and feels heavy. 3. Does not transmit light. 4. Solid and doughy. Treatment.—The treatment of a hydrocele is either palliative or radical. Palliative treatment consists in tapping the sac with a trocar and canula, drawing off the fluid, and repeating this procedure as often as the sac refills. In tapping a hydrocele the surgeon should grasp the neck of the tumor with the fingers of the left hand so as to make it tense; with the other hand a trocar and canula is plunged into the sac with a firm, quick motion, at the junction of the middle and lower thirds of the scrotum, and in a direction inward and upward, so as to avoid wounding the testicle. It is always well to select a spot on the scrotum free from veins, so as to avoid the possibility of hemorrhage into the loose tis- sue of the scrotum. Radical treatment is carried out either by injections or by cutting operations. Injection.—This method has for its object the causation of an aseptic, adhesive inflammation which will obliterate the sac by adhesions between the walls. Injection is only indicated in thin- walled hydroceles. The patient should be placed in the recumbent posture, the parts having been prepared antiseptically. A trocar and canula 58 Genito-Urinary Diseases. is plunged into the sac in the usual manner, the trocar with- drawn, and the fluid allowed to escape. It is necessary for the success of this treatment that all fluid be removed from the sac. From one drachm to an ounce of pure tincture of iodine, depend- ing upon the quantity of fluid withdrawn, is to be injected into the sac by means of a syringe with a nozzle accurately fitting the canula. The canula and syringe are now withdrawn as one instrument, the finger placed over the puncture, and the scrotum thoroughly manipulated in order to bring the iodine in contact with all parts of the sac. The puncture is now sealed with gauze and collodion. The patient should be confined to bed for at least a week, and lead water and laudanum applied locally for a few days, in order to counteract the excessive inflammatory reaction, which necessarily follows this plan of treatment. So soon as the acute symptoms subside, the testicle should be strapped to hasten resolution. The open operation is performed by making an incision about one and a half inches in length through the skin, subcu- taneous structures and sac. The fluid is allowed to escape ; the edges of the sac are sutured to the skin incision, and the cavity packed with a small strip of iodoform gauze to act as a drain. The drain is to be shortened each day, until the cavity is entirely obliterated. The open operation is indicated in thick-walled hydroceles, and when the iodine method has failed. Excision of the sac, that is the parietal layer of the tunica vaginalis, is sometimes recommended. An incision two and a half inches in length is made over the centre of the swelling dividing all structures down to the sac. The sac is then opened and the edges caught with haemastatic forceps, and split up with a pair of scissors. It is now separated from the tissues of the scrotum by sponging, and then cut away as close to the epi- didymis and testicles as possible. All hemorrhage is now con- trolled, and the wound closed without drainage. A large anti- septic dressing should be applied, and firm compression maintained by the use of a crossed perineal bandage. The open operation and excision do not necessitate confine- ment to bed as is the case with the iodine method. The Testicles. 59 Congenital Hydrocele. In this form of hydrocele there is a direct communication between the base of the scrotum and the abdominal cavity, the funicular and vaginal processes having failed to close. Like con- genital hernia, it may appear at birth or later in life. Sypmtoms.—History of a tumor of slow formation, dull on percussion, beginning at the lowest point of the scrotum, disap- pearing when the patient assumes a recumbent posture, but returning slowly when in the erect posture. The light test will reveal translucency. Such hydroceles are frequently complicated by hernia (con- genital hernia). Diagnosis.—Congenital hydrocele must be distinguished from inguinal hernia. i. i. 3- 4- 5- Congenital Hernia. Begins at external ring. Impulse on coughing Tympanitic (gut). Not translucent. Disappear with a a gurgle. flop and 6. Hernia is retained. Congenital Hydrocele. Begins in the most depend- ent part. No impulse on coughing. Flat on percussion. Translucent. Disappears slowly with pa- tient in the recumbent posture. 6. Finger over the ring does not prevent the hydrocele from reforming. Treatment.—Occasionally these cases may be cured by the application of a truss, which is often necessary for a co-existing hernia. If this fails, an aseptic seton (seton introduced with all antiseptic precautions) may be tried, or a small drainage tube may be introduced through the sac from side to side. A large antiseptic dressing should be applied and changed quently. The surgeon should be scrupulously clean in management of these cases to avoid infection either from urine or the faeces. fre- the the 6o Genito-Urinary Diseases. Hematocele. A collection of blood in the tunica vaginalis. Causes.—Traumatism, disease, and as a sequel to aspiration for hydrocele. Symptoms.—The tumor is ovoidal or globular in shape, the largest circumference being below; does not fluctuate; does not transmit light; feels heavy and solid when palpated, and is dull on percussion. Treatment.—Rest in bed, elevation of scrotum, and the local application of lead water and laudanum. After the acute symp- toms have subsided, the testicle should be strapped with adhe- sive plaster so as to hasten absorption. When the above measures fail, the tunica vaginalis should be opened as for hydrocele, all clots cleaned out, the cavity irri- gated with bichloride solution i to 2,000, and the wound packed with iodoform gauze, so that healing takes place from the bottom up. Spermatocele. A collection of milky white fluid in the tunica vaginalis con- taining spermatozoa. Symptoms and treatment are similar to those applicable to hydrocele. Epididymitis. An inflammation of the epididymis. Causes. — Commonly results from the extension of gonor- rhceal inflammation from the posterior urethra through the vas deferens to the epididymis, usually appearing about the fifth or sixth week. Symptoms. — One of the earliest symptoms is tenderness along the cord, and a hard, swollen state of the vas deferens, and pain in the back. The testicle swells, and becomes exceed- ingly tender, the patient walking with a stooping posture, with the legs somewhat separated. On examination, the swelling will be found confined to the posterior aspect of the scrotum, most marked at the inferior border of the gland (tail of the epididymis). Often the disease extends by continuity of tissue to the vaginal tunic, and an acute hydrocele results, with increase in severity of the symptoms. The Testicles. 61 Suppuration is rare in these cases, the general tendency being always toward resolution. Traces of the attack often remain for a long time after the infection has disappeared, the regular outline of the epididymis being interrupted by masses of lymph. Prognosis.—The prognosis is always good as regards a cure, but bad as regards the future functional activity of the organ. In the majority of cases of double epididymitis, the patients remain sterile, as the plastic lymph which blocks the tubules is never entirely absorbed. Treatment.—The patient should be confined to bed, the scrotum elevated, and lead water and laudanum freely applied. In the meantime all treatment directed to the posterior urethra should cease. When the symptoms are severe the hydrocele may be punctured. After the acute symptoms subside the testicle should be strapped with adhesive plaster, or equal parts of belladonna and mercury ointments applied to hasten the absorption of the lymph, and at the same time from ten to fifteen grains of iodide of potash should be given three times daily for its absorbative action. Syphilitic Epididymitis. An inflammation of the epididymis late in secondary syphilis, consisting- of small orumatous lesions. Diagnosis.—Distinguish from tuberculosis of the epididymis. (See tuberculosis.) Treatment.—Internally, mercury with iodide of potash com- bined with the local use of inunctions of mercurial ointment. Tuberculosis of the Epididymis. The epididymis is a frequent seat of primary tuberculosis, although it often follows tuberculosis of the prostate. When primary, the infection takes place through the blood. Its preference for the epididymis is explained by the fact that the arteries break up into a fine capillary network to supply the spongy tissue of the epididymis, the current of blood is slowed and the tissue soft. Symptoms.—The disease usually begins in the head of the organ as a series of nodules of slow growth, which finally soften, become adherent to the skin, break down, discharging their con- 62 Genito-Urinary Diseases. tents spontaneously, and leaving a sinus. The testicle is often secondarily involved. The disease is often bilateral. Diagnosis.—Tuberculosis is to be differentiated from syphil- itic epididymitis. Syphilitic Epididymitis. j Tubercular Epididymitis. i. Usually affects the right. 2. Usually unilateral. 3. Appears at any age. 1. May affect either. 2. Often bilateral. 3. Appears between 25 and 35. 4. Usually a single nodule. 4. Usually several nodules 5. Usually break down. 6. Sinus formation common. 5. No tendency to degeneration. 6. No sinus formation. Treatment.—Same as tuberculosis of the testicle. Seminal Vesiculitis. An inflammation of the seminal vesicles. Causes.—It may be either gonorrhoeal or pyogenic, the former being by far the most common cause of the trouble. Symptoms of acute are those of posterior urethritis. Diagnosis.—Thfe diagnosis can readily be made by a care- ful palpation through the rectum, the patient being in a stooping position over a chair. The usual termination of this affection is in a chronic inflam- mation, although it sometimes disappears spontaneously when the inflammatory condition of the posterior urethra is cured. The Symptoms of Chronic Seminal Vesiculitis are those of chronic posterior urethritis. (See gonorrhoea.) Diagnosis.—The diagnosis is to be confirmed by a rectal examination and the "three glass test." Take three ordinary conical urine beakers, and have the patient fill the first, then the vesicles are milked by the finger in , the rectum, then the second glass is filled, and finally the third; shreds in the second glass will indicate inflammation of the vesicles. Treatment.—The treatment is that appropriate for acute and chronic prostatitis. In the chronic variety of the affection, the vesicles should be milked by the finger in the rectum every third or fourth day according to the effect produced, and should be continued over a period of three or four months. The Testicles. 6^ Tuberculosis of the Seminal Vesicles. Tubercular seminal vesiculitis is rarely a primary affection, being usually secondary to involvement of the prostate. Symptoms.—The disease is usually bilateral and is charac- terized by the formation of irregular nodular, indurated masses, readily detected by rectal palpation. There may be some fre- quency of micturition, painful pollutions, discharges of bloody semen, and finally sterility. Diagnosis.—The diagnosis can be readily made by rectal palpation, and the examination of the urine and semen for tubercle bacilli. Treatment.—Occasionally they break down and suppurate, discharging through the rectum, then to heal spontaneously. In the early stages of the affection, the bowels should be kept regular, the urine should be rendered bland and unirritating, and the same general measures should be adopted as are appro- priate for tuberculosis in other parts of the body (cod liver oil, iron, fresh air, etc.). \ When the above measures fail and the disease is progress- ing, excision of the affected vesicle is indicated. Castration. The operation for the removal of the testicle. Indications.—(i) Tumors; (2) tuberculosis; (3) occasionally gumma ; (4) extensive suppuration ; (5) for the relief of enlarged prostate, and (6) certain cases of undescended testicle. Operation.—The testicle being made to protrude with the left hand, an incision is made over it from the external ring to the base of the scrotum. When the skin is involved by a growth, two eliptical incisions should be made and the affected skin removed. The testicle with its tunics is now quickly freed from the sur- rounding tissue and the cord exposed and freed. An aneurism needle threaded with a double catgut ligature is passed through the cord as high up as possible, the loop cut, and the needle withdrawn. The cord is now ligated in each half and once around, and divided fully one-quarter of an inch below the liga- ture. The divided end of the cord should now be cauterized by an application of pure carbolic acid to prevent infection of 64 Genito-Urinary Diseases. the wound. A few scrotal vessels will require ligature ; the wound is then closed with silkworm gut sutures being careful to evert the skin edges (dartos causes inversion). Vasectomy. An operation for the excision of a portion of the vas deferens. Indications.—For the relief of prostatic hypertrophy. Partial excision might occasionally be indicated for the relief of local tubercular deposits. Operation.—Have an assistant to hold the vas between the thumb and finger of each hand, at the same time making it prominent on the posterior aspect of the scrotum. An incision one inch long is made over the vas, and the latter pulled out of the wound by means of a blunt hook. Two catgut liga- tures are thrown around the vas about half an inch apart, then tied down tight, and the intervening portion of the tube resected. The ends of the divided tube are cauterized with pure carbolic acid, and the wound closed. The wound may be sealed with a gauze and collodion dressing and the testicles supported in a suspensory bandage. The Prostate Gland. Anatomy.—The prostate is a solid body, partly glandular and partly muscular, embracing the neck of the bladder and surrounding the first portion of the urethra. It weighs about eighteen grammes. It consists of a median and two lateral lobes ; the two lateral lobes meeting in front of the urethra are sepa- rated from the median lobe, which lies behind the urethra, by the prostatic fissure. The ejaculatory ducts and the uterus mas- culinus are found in this fissure. Relations.—By its anterior surface the prostate is in relation with the symphisis pubis. Posteriorly it is in relation with the rectum, through the wall of which it can be felt (corresponding in size to a horse chestnut.) Laterally it is in relation with the levatoranni muscles. The base of the gland is in relation with the bladder, and its apex rests against the posterior layer of the triangular ligament. Diagram of pan= UJnud triangular ligament ot urethra Anterior fibres of elevator of anus are hooked down toshow part of prostate; the rest is tracked by dotted Iidc 1. root of cavernous body; ? bulb; 3, compressor muscle of urethra; 4, membranous part of urethra surrounded by compressor muscle; 6, prostate gland; 6, anterior border of elevator muscle of anus; 7, elevator muscle of anus; 6, artery of bulb; 9, internal pudic artery. Anatomical relations of Prostate and Seminal vesicles. 64 Colles'. Ant. layer. Subpubic fascia. Perineal body. Superior vesical r'aseiti Superior true lirjament. Fascial sheath for vesiculce teminalea. \fascia transversal's.. __rectovesical \pm. culdesac puboprostatic ligament. -posterior layer of /riangularlhjl- ™US/ii \Jf%r\~\Collasfascia-~ pmnealbodf\W JanferiorlaytrJlnayuh tramiyhptk^J ligament peririet \flanaofLonper * Vesical Sphincter. 65 The Prostate Gland. 65 Prostatitis. Inflammation of the prostate gland. Varieties.—(1) Acute. (2) Chronic. Causes.—Acute—exposure to cold and wet; acute gonorrhoeal infection; as a complication of acute febrile diseases ; pyaemia; septic thrombo-phlebitis of the prostatic plexus of veins ; trauma- tism ; the introduction of dirty instruments, and by contiguity of tissues from the rectum. Chronic.—Repeated attacks of acute inflammation; chronic posterior urethritis ; vesical and prostatic calculi, and masturbation. Symptoms.—Acute—feeling of weight and fulness in the perineum (sensation of a hot ball) ; frequency of micturition with vesical tenesmus, followed by dysuria and often retention. There is pain on urination and defecation; tenderness in the perineum on pressure, and mild constitutional symptoms (fever, malaise, etc.). Examination per rectum produces intense pain, and the prostate is found to be enlarged, soft, and hot. When an abscess forms fluctuation can often be detected by palpation of the gland through the rectum. The majority of prostatic abscesses rupture spontaneously into the urethra; they may rupture into the rectum, bladder, or recto-vesical space, The chronic variety is usually associated with frequency of micturition; vague pains through the perineum, the discharge of a few drops of a clear, viscid fluid, especially after defecation. There is some pain during defecation ; nocturnal pollutions ; impo- tence, and sexual hypochondriasis. Palpation through the rectum shows the prostate to be large, soft, and flabby. Diagnosis.—Acute prostatitis is to be distinguished from cyst- itis (see cystitis), and cowperitis. In cowperitis there will be two indurated swellings on either side of the median line of the perineum, and the absence of all rectal symptoms which are associated with prostatitis. Chronic prostatitis may be mistaken for chronic posterior urethritis, but may be distinguished in the following manner: Request the patient to empty about one-third of the urine con- 66 Genito-Urinary Diseases. tained in the bladder into a conical urine glass; then milk the prostate and the second third to be passed into a second glass, the last portion into a third glass. The first glass will contain the washings of the anterior urethra; the second, the secretion of the prostate, and the third, shreds from the posterior urethra. Treatment.—(i) Acute—Rest in bed with the hips elevated ; leeches, ice or hot fomentations to the perineum; milk diet and the internal administration of J£. Tincturae aconiti . . gtts. xxiv Tincturae belladonnae . f3i Acidi boracici Sodii bromidi . . aa 5ii Liq. potassii citratis q. s. ad fgvi M. S. fgss every four hours. If retention should occur, it should be relieved by the intro- duction of a very small Nelaton catheter. When an abscess forms, a median perineal incision should be made and the pus evacuated. Chronic—All sources of irritation should be removed; full sized steel sound should be passed at intervals of three or four days, combined with prostatic massage and the instillation of ten drops of a one per cent, solution of nitrate of silver in the prostatic urethra. The strength of the silver solution .may be gradually increased to five or even ten per cent.. The general health should always be looked after; the diet regulated; constipation relieved; moderate exercise, cold baths, tonics, etc.. Prostatorrhcea. A condition of chronic congestion of the prostate gland, characterized by the discharge of colorless mucoid fluid, which is passed after urination, or from the straining effort necessary to expel the contents of the rectum. Symptoms.—The most prominent symptom is the discharge of a thin, more or less milky fluid from the meatus, following straining at stool, during the forcible expulsions of the last drops of urine, or even during sneezing or laughing. The quantity Showing the relations of the floor of the bladder to the prostatic urethra in the normal condition of this body. The bristle is passed from the ejacul- atory duct into the urethra. Section through the symphysis pubes, showing relations of prostate to surrounding strictures. i, pubes; 5, pubo-prostatic ligament: 9, middle lobe of, 10, prostate : 12, left vas ; 13, left vesicula ; 14 com. ejaculatory duct; 16, prostatic plexus receiving 17, dorsal vein of penis; 19, bulb; 20, Cowper's A Vertical Section of the Union of the Vas Deferens and Vesiculae Seminales so as to show their Cavities. i,r. Vas Deferens with thick Parietes and narrow Cavity. 2.2. Portion of the same where the Ca- vity is enlarged. 3.3. The Extremities of the Vas Deferens from each side where they join the Vesiculae Seminales and Ductus Ejaculatorius. 4.4, Vesiculae Seminales distended with air and dried. Bas fond of bladder, ureteral orifices and mouths of the ejaculatory duct. 66 1 1. Prostate at birth. Width, at base,4 lines; a little above middle, 5 lines; at apex, 2 lines; Inngth along middle, 4 lines, and at edge, 4%; thickness at base,, 2 lines; at middle, 3'4. and at api-x, \%. Weight, 13 grains. 2. Prostate at 4 years. Breadth, at base| 6 lines; just above middle, 7; and at apex, 2}/2\ length along middle, 6lines; and 7 lines at margin; thickness at base, 2% lines; at middle, 4; and at apex, 2. Weight, 23 grains. 3. Prostate at 12 years. Width, S^ lines, at base; 9% above middle, and 3 at apex; length, along middle, 8 lines, and 8% at edge; thlckn-ss at base, 3; niiddlo, 4^; and at apex, <&/.. Weight, 43 grains.. 4. Prostate at 14 years. Width, at base, 11 lines; at middle, 9^; at apex, 4; length, along middle, 8 lines, and 10 at margin; thickness, 3>^ at base; 5at.middle, and 3 at apex. Weight, 58 grains. S. Prpstate at 25 years. Width, at base, 18 lines; middle, 20; and apex, 5; length, along mid- dle, 15 Unes; and at edge, 18; thickness afr. base, 9 linesj middle, 10; at apex?4. Weight iU drachms, ° ' Hypertrophy of median and oflateral lobes of prostate ; bladder dilated and thickened ; ' prostatic' catheter. The Prostate Gland. 67 secreted may vary from a slight moisture of the meatus to a teaspoonful in twenty four hours. It may be increased by riding, bicycling, and by over-indulgence in alcoholic and malt liquors. The escape of fluid is occasionally attended by pleasurable sen- sations. There is usually some irritability, as indicated by the frequency of micturition, and a sense of weight and fulness in the rectum and perineum. Treatment.—It is a most obstinate affection unless subjected to early and persevering treatment. All sources of local irritation, such as internal and external hemorrhoids, stricture, phimosis, etc., must be removed. The same general hygienic regimen should be followed as is indicated for chronic prostatitis. Internally atropia and ergot have proven of great value, and when combined with prostatic massage and instillations of silver nitrate, a cure usually follows. In order to bring such a case to a successful termination, it is often necessary to assure the patient that the discharge is not seminal fluid. Hypertrophy of the Prostate. An enlargement of excessive nutrition independent of inflam- matory changes. Essentially senile, rarely seen under fifty years, although it may begin earlier. Frequency.—Although hypertrophy of the prostate is often met with in aged persons, its relative frequency is greatly over- estimated ; about one in three men over fifty-five have some enlargement of the postate, but only about one in seven have any symptoms of obstruction; not more than one in fifteen or twenty men who live beyond fifty-five years of age can be expected to require treatment for this affection. Causes.— Guy on claims that hypertrophy of the prostate is a part of a general condition peculiar to advancing years, charac- terized by extensive degenerative changes, and by the over production of fibrous tissue; a general arterial sclerosis, not limited to the vessels of the genito-urinary system, but when occurring in them, producing both the prostatic hypertrophy and the rigid feeble bladder. 68 Genito-Urinary Diseases. In opposition to this theory we have the statement of Griffiths and Moullin that the original growth is glandular and that the fibroid changes seen are in the nature of degenerative changes ; therefore, while fibroid changes are consistent with atheroma, glandular . hypertrophies do not occur as a result of arterial sclerosis. Harrison says the primary changes take place in the bladder, and the depression of the posterior wall, which is said to occur as the bladder sinks into the pelvis with advancing years, pre- cedes prostatic obstruction, and is compensated for by the development of a muscular ridge between the orifices of the ureters, tending towards the obliteration of this pouch. As these muscular fibres are continuous with those of the prostate, hyper- trophic changes affecting these muscles must also affect the prostate. Such a theory must be incorrect because from an embryo- logical study of the prostate, it is undoubtedly a sexual and not a urinary organ. Velpeau supposed the enlargement to result from a form of fibro-myoma analagous to those of the uterus. The third theory seems to suggest the most probable cause of the enlargement, especially if we consider the prostate belong- ing to the sexual and not the urinary group. Varieties.—Hypertrophy of the prostate may be one of three kinds:—(i) Overgrowth of the glandular elements (adenoma). (2) Overgrowth of the stroma (myoma). (3) A combination of the two (adeno-myoma), the muscular elements being finally converted into true fibrous tissue, and the glandular acini destroyed. In rare cases, hypertrophy is complicated by cystic changes in the remains of the Ducts of Miiller. The second or myomatous enlargement is the most common, the hypertrophied muscle fibres rapidly becoming converted into fibrous tissue. The part affected with enlargement very much influences the results in relation to the function of micturition. It is by no means necessary that the natural size of any portion should be much exceeded in order to produce severe symptoms. On the other hand, you may have a very large prostate, and may have almost no symptoms. Transverse section of normal prostate, showing microscopical stricture. The relative Position of the Prostate, Vesiculae Seminales and Bladder, as seen after the removal of the Perineal Muscles. r. Section of the Urethra. 2. Prominences formed by the Bulb of the Urethra. 3. Membranous Portion of the Urethra. 4. Prostate Gland. 5. Vesiculae Seminales. 6. The Bladder lying upon the the Rectum. 7. Section of the Rectum. 8. Portion of the Coccyx. Longitudinal section of hypertrophied prostate, in a patient seventy-four years of age ; showing a false passage tunneled by a catheter, b, Line of transverse sec- tion shown in Fig. COO. a, Duct of vesicula seminalis 68 Two instruments appear transfixing the prostate, of which body, the, three lobes, a, b, c, are much enlarged. The instrument d perforates the third lobe a, while the instrument e penetrates the right lobe c, and the third lobe a. This accident occurs when instruments not possessing the proper prostatic bend, are forcibly pushed forwards against the resistance at the neck of the bladder. The prostate presents four lobes of equal size, and all projecting largely around the neck of the bladder. The prostatic canal is almost completely obstructed, and an instrument has made a false passage through the lobe a. The sound passing around the nor- mal curve of the urethra. j Showing the increase in the curve of the urethra in prostatic hyper- trophy, and the necessity of a longer curve'in the catheter. 69 75 The Prostate Cland. 69 The enlargement may vary from that of a plum to that of a cocoanut; it may involve the entire organ ; it may be limited to one lobe; to two lobes, and may extend backwards and upwards towards the bladder or towards the rectum. In 60 per cent, of cases, the enlargement is symmetrical ; in 15 per cent. the median lobe is involved ; in 8 per cent., the left lobe, and in 6 per cent., the right lobe ; in 4 per cent., both lateral lobes ; in 2 per cent, the anterior commissure. Effect on Urethra and Bladder.—As the apex of the prostate is attached to the posterior layer of the triangular ligament, any enlargement of it is followed by an increase in its long diameter. As a result, the prostatic urethra must be lengthened, and the neck of the bladder is carried upwards and backwards, producing the so-called post-pro static pouch. It, there- fore, follows that the urine which collects in this pouch cannot be voided by voluntary efforts. The constant desire to micturate occa- sioned by this collection of urine, causes a hypertrophy of the muscles of the bladder, and a sacculation of those parts of the organ not supported by muscle fibres. In many cases the increase in pressure on the bladder results in a preternatural thinning of bladder walls and atony. The presence of residual urine predisposes to cystitis and the development of calculus, and, if not relieved, will cause ascend- ing pyelonephritis, Symptoms.—(1) Undue frequency of micturition, particularly at night. The residual urine and the congestion about the neck of the bladder are the causes of this symptom. It is not pro- nounced during the day, even though the patient may occupy the same position as in sleeping. It is highly probable that as a result of the enlargement the function of the vesical sphincter is somewhat interfered with, so that the relaxation during sleep allows a few drops of irritating urine to escape into the pros- tatic urethra, which, being in a congested and hyperaesthetic state, occasions the urgent desire to urinate. (2) Difficulty in starting the stream, due to irritability of the vesical sphincter. (3) Loss of the parabolic curve. In enlarged prostate the 70 Genito-Urinary Diseases. stream drops vertically from the penis ; is due first, to the obstruc- tion caused by the enlarged gland, and secondly, to the paralysis of the detrusor muscles from over-distension. (4) Interrupted stream, due to the ball valve action of an enlarged middle lobe. (5) Dribbling at the end of micturition, because the wave of contraction, which should be continuous from the bladder, is interrupted by the enlarged gland, and the stream is broken. As the prostate increases in size the incontinence of retention or complete retention of urine may follow. As the enlargement progresses the bladder becomes invaded with virulent organisms, either from the introduction of dirty catheters, or from the kidneys, or by contiguity of tissue, from the rectum, and cystitis results. The urine undergoes ammoni- acal fermentation, becomes exceedingly foul, and is loaded with pus and mucus. With the local symptoms, the patients often complain of pain on urination and defecation, and vague pains about the loins, hypogastrium, and inner side of the thighs. Objective symptoms.—(1) Residual urine.—The patient should be requested to urinate, and then a Nelaton catheter should be introduced into the bladder; the urine that is drawn off is termed residual urine. (2) Palpation by the rectum.—The patient should be placed in the semi-recumbent posture with the legs drawn up and the thighs separated, the middle finger of the right hand being prepared, is inserted into the rectum and the gland carefully explored. Digital exploration will only show the amount of lateral and posterior enlargement. (3) By the use of instruments, the length of the prostatic urethra, the seat and nature of the obstruction, and the tonicity of the bladder may be ascertained. Treatment.—The treatment of enlarged prostate may be considered under the following headings: I. Palliative. A. Hygienic. B. Medicinal. _„ ,. _ _ , II. Radical. C. Instrumental. D. Miscellaneous. r A. Prostatotomy. B. Prostatectomy. C. Castration. v D. Vasectomy. "The lateral lobes of the prostate, e d, are enlarged, and contractthe prost- atic canal. Behind them, the third lobe, of smaller size, occupies the vesical orifice, and completes the obstruction. The walls of the bladder have hence become fasciculated and sacculated. One sac, a, projects from the summit of the bladder ; and another, b, con- taining a stone, projects laterally. When a stone occupies a sac, it does not give rise to the usual symptoms as indicating its presence, nor can it be always detected by the sound." "The two sacs appear projecting on either side of the base of the bladder. The right one, e, contains a calculus, f; the left one, c, larger dimensions, is empty. The rectum lay in contact with the base of the bladder, between the two sacs. "The three lobes, a, b, c, of the prostate are „ enlarged, and of \ equal size, moulded against each other in such a way that the prostatic canal and vesi- cal orifice ap- pear as met clefts be- tween' them. The three lobes are ei crusted c their vesical surfaces with a thick calca- reous deposit. The surface of the third lobe, a, which has )een half denuded of the calca- •eous crust, b, in order to .how its real character, appeared at first to be a stone impacted in the neck of the bladder, and of such a nature it certainly would seem to the touch, on striking it with the point of sound, or other instru- ment." 70 The Prostate Gland. 71 Hygienic.—The general or constitutional treatment of the patient is not to be disregarded. One of the main objects is to prevent the local congestion of the organ, such as would be induced by chilling of the surface, wet feet, sitting on cold seats; too much excitement, sexual or otherwise. The bowels should be kept regular by regulating the diet, moderate exercise and the occasional use of salines or mercurials. The diet should be good, plain, but nutritious, avoiding tea, coffee, spices, highly seasoned articles, pastries, rich dressings, and very acid fruits. In the majority of cases the use of alcohol had better be inter- dicted, especially malt liquors ; in certain cases where the patient is feeble, with a tendency to hypostatic congestions, the moderate use of well diluted Scotch whisky will probably do the minimum amount of harm. Medicinal.—With the exception of ergot, there is no remedy on which the slightest reliance can be placed to influence the hypertrophy in the smallest degree. It should be administered through a long period, and when the urine is irritating, it may be combined to advantage with salol and boracic acid. When there is much vesical irritability the following may be administered: i& Tr. Belladonnae . . . f3ss Acid boracici Sodii bromidi . . aa 3ij Liq. potassii citratis q. s. ad fgvi M. S. fgss every four or six hours. As is the case with all obstructive conditions, there is great danger of the loss of vesical tonicity. This should be prevented by the use of strychnia 1/20 of a grain three times daily. When the urine is hyperacid it should be corrected by the use of citrate of potash, bicarbonate of soda, the proper regulation of the diet, and the rather liberal use of pure water. When the urine is alkaline, benzoic acid should be given in doses of fifteen grains three times daily. Instruments.—These include the regular use of a full-sized sound passed at intervals of a week, so as to maintain the normal caliber of the prostatic urethra. The same result can be attained by the use of one of the various prostatic dilators. 72 Genito-Urinary Diseases. In the majority of cases of prostatic hypertrophy more or less urine which collects in the post-prostatic pouch, can- not be passed by the voluntary efforts of micturition. It is therefore necessary to have recourse to catheterization, the best instruments being the Nelaton or the Mercier. These instru- ments should be used with great care and with the strict pre- cautions as to antisepsis as are given under the head of cathe- terization (see page 27). As a routine the catheter should be passed half as many times a day as there are ounces of residual urine. When cystitis is present, it should be treated according to rules given under that heading (see page 29). Miscellaneous.—Under this heading are included the various parenchymatous injections (ergot, acetic acid, etc.), electro-punc- ture, massage, etc. Although these measures may be followed by temporary reduction in the size of the prostate, they are exceedingly dangerous, and may even be followed by abscess formation or sloughing. Radical treatment.—Under the head of radical treatment, are included all those forms of operations applicable directly or indirectly to the enlargement. Prostatomy. An incision into the prostate was first devised for the relief of a condition known as "bar at the neck of the bladder," and may be done either through the urethra or through the perineum. Method of Bottini.—An instrument shaped not unlike a litho- trite, having a concealed platinum knife, which may be heated by electricity, is incased in double tubes through which a stream of water flows to keep it cool. It is introduced into the bladder like an ordinary sound, then the beak turned around one hundred and eighty degrees, and brought in contact with an enlarged mid- dle lobe or bar. The knife is now heated and pulled through the median line of the hypertrophied mass for two or three cen- timeters, and then pushed back into the bladder until cool. This same manipulation may be repeated upon the superior aspect ol the growth. Many successful cases are reported by Bottini, but the method has not yet been generally adopted in this country. Section through an enlarged prostate and vesical neck, showing obstruction (a) and the post-prostatic pouch. Hypertrophy of the prostate, showing the asymmetrical development of the middle or third lobe, a a, Openings of ureters. 72 The Prostate Gland. 73 The perineal method consists in opening the urethra at the apex of the prostate gland through the perineum, and dividing the obstruction by a blunt pointed knife. Prostatectomy. Excision of the prostate may be done in three ways, urethral, perineal, and suprapubic. Perineal Prostatectomy. This operation is indicated for the removal of suburethral growths, in extra-vesical enlargements of the lateral lobes, where the patient is feeble, where the bladder is atonic and contracted, and rigid, and where there is cystitis, in cases where the sur- geon desires to secure drainage. It has the serious drawbacks of giving very little room ; by it the operation is performed in the dark ; in patients with a deep, fat perineum the "perineal distance" may make it quite impossible for the operator to get into the bladder and do anything to the obstructing median and lateral lobes. Operation.—The ordinary median or transverse perineal incision may be made and the prostate exposed as in the operation of perineal lithotomy. The prostate should be explored through the artificial opening, and if a median outgrowth or isolated tumors are discovered, the prostatic sinus should be dilated or the prostate incised laterally and enucleate or excise according to the conditions present. Pedunculated outgrowths can be removed with the small wire snare. A large Nelaton catheter should be introduced through the perineal wound into the bladder and retained in place for from three to five days. Suprapubic Prostatectomy. This operation is indicated (i) where one or more calculi co-exist with enlarged prostate ; (2) in the firm fibrous varie- ties of hypertrophy, and (3) when a patient refuses double castration. Operation.—The preliminaries are similar to those for any ordinary suprapubic cystotomy. The quantity of water injected into the rectal bag (especially when the prostate is abnormally hard), should not exceed six or eight ounces. Where the -bladder is contracted, with thick, non-distensible walls, it is 74 Genito-Urinary Diseases. usually inadvisable to perform this operation. A catheter left in the bladder, until the latter is opened, expedites the operation. Enucleation is to be performed as far as possible by the finger ; this not only prevents hemorrhage, but the finger will turn out far more intelligently, safely, and quickly, much larger pieces than any forceps. The edges of the bladder incision are secured to the subcutaneous abdominal structures by two sutures on each side. The mucous membrane over the growth is divided with a pair of long-handled scissors, then the index finger of the right hand is slipped into this opening, while at the same time an assistant makes firm counter-pressure against the perineum. With the finger in the bladder the obstruction is enucleated en masse, or piece by piece. The operation should be continued in every case until all the lateral and median hypertrophies, as well as all hypertrophies along the line of the prostatic urethra, have been removed. After the operation has been completed, Guyon's double tubes (two long drainage tubes caliber of fifteen French), are introduced into the base of the bladder through the abdominal incision, and the latter united around the tube by a superficial and deep row of sutures, leaving sufficient room for the intro- duction of a strip of iodoform gauze behind the symphisis pubis in order to drain the Space of Retzius. This should be removed in from forty-eight to seventy-two hours. The after treatment consists in keeping the wound thoroughly aseptic and daily irrigations of the bladder with warm boracic acid solution (15 grains to the ounce). If the enucleation of the prostate occasions excessive hemor- rhage, Cabot's tampon may be used. This is a long strip of gauze, of appropriate width (the edges of which should be rolled in and stitched to avoid loose, frayed edges), should be folded back and forth upon itself to form a pad of sufficient size. The folds are shorter each time so as to produce a conical shaped pad; for the same reason the strips of gauze should be broader at one end than the other by two inches. A silk thread attached to a button, is passed through the centre of all the layers of "Exhibits the lobes of the prostate greatly increased in size. The part a, b, girds irregularly, and obstructs the vesi- cal outlet, while the lateral lobes, c, d, encroach upon the space of the prostatic canal. The walls of the bladder are much thickened." Sarcoma of the prostate and neck of the bladder, with ob- struction. The catheter has tunneled the neoplasm. On the left side.—"Two bougies, d, e, are seen to enter the upper wall of the urethra, c, anterior to the prostate, a, b. This accident happens when the handle of a rigid instrument is depressed too soon, with the object of raising its point over the enlarged lobe of the prostate." "In this case an in- strument, d d, after passing beneath part of lining membrane e e, anterior to the the bulb, penetrates b, the right lobe of the prostate. A second instrument, cc, pene- trates the left lobe. A third instrument, ff, is seen to pass out of the urethra an- terior to the prostate, after transfixing the right vesicula semina- lis external to the neck of the lobe, enters this viscus at a point beh ind the prostate. 74 The Prostate Gland. 75 the pad from the surface, having the smaller to that having the larger diameter, so that the button is at the extremity of the gauze strip representing the last fold. The thread is to be car- ried through a perineal opening or through the urethra and securely tied around a roll of gauze at the meatus to keep the pad in place. The pad should have another thread attached to its upper extremity to facilitate its removal. Urethral prostatectomy should never be advised, as it necessi- tates working in the dark, and is necessarily limited as a sur- gical procedure. Castration for Hypertrophied Prostate. In 1892 it was suggested by White that there existed an analogy between uterine fibro-myomata and prostatic overgrowth, and that castration might have the same effect upon the prostate gland as oophorectomy does upon the uterus, causing a shrink- age or atrophy, resulting in a practical disappearance of the enlargement. At the request of Prof. White, I carried out a series of experiments with the following result; For control experiments thirty-five dogs and their prostates were weighed, and the average weight taken as a standard. The average weight of the atrophied prostate gland in the eleven dogs experimented upon was 3.920 grammes. If we compare this average with the average weight of the nor- mal gland, which was 15.347 grammes, we find that the average loss of weight consequent upon castration to be 11.458 grammes, and later operations on the human subject were followed by like otraphic changes. All of the most troublesome symptoms are relieved, in seven out of eight cases. The cystitis is relieved in over half. The bladder regains its tone in about two-thirds. The cases in which it fails to lessen the size of the prostate are very few. It is reduced much below normal in many and to normal in half. Before recommending castration ascertain (a) the general con- dition of patient; (b) age; (c) sexual power; (d) condition of kidneys ; (e) amount of pain; (f) size and consistency of pros- tate ; (g) examine urine (character, amount, etc.) ; (h) has the catheter been used; how often; amount of pain; was introduc- tion difficult ? (z) what is the amount of residual urine ? 76 Genito-Urinary Diseases. Indications for Castration. Castration is indicated in large soft prostate, when the patient is advanced in years, with absence of sexual power, large amount of residual urine, marked cystitis and catheteriza- tion difficult. If castration is refused, vasectomy may be tried, although the results are not as prompt or as satisfactory. In case of calculus and prostatic hypertrophy co-existing without other complication, if castration or vasectomy is indi- cated, the operation should be performed first and after the prostate has atrophied, the stone dealt with according to the indications of the case. If prostatectomy is indicated remove both by suprapubic operation. Prostatectomy is indicated when catheterization is difficult or painful in the younger class of cases in good general condition, kidneys sound, sexual power retained, and in the fibrous variety of hypertrophy. Vasectomy is indicated in low state of vitality, old age, bad kidneys, etc., where other operations would not be well borne. Palliative treatment is indicated when prostate is not much enlarged; pain not severe; urine normal; catheter has not been used; residual urine less than four ounces ; general health good; sexual power retained. Palliative treatment consists in diet; general hygiene ; dilatation of prostatic urethra; use of catheter when amount of residual urine is excessive; use catheter only when necessary, as, unless thor- oughly aseptic, cystitis will be added to the other troubles, or may cause hyperaesthesia of urethra, which would seriously interfere with its continued use. As landmarks for treatment the following will be useful: Enlargement Moderate.—Pain little if any ; small quantity of residual urine of normal appearance ; use of catheter has not yet been necessary. Treatment—(i) palliative; (2) prostatectomy; (3) vasectomy; or (4) castration, according to the indications of the case. Considerable Enlargement.—Diameter, 2 inches about; The Prostate Gland. 77 urination frequent; catheterization more or less difficult and pain- ful. About eight ounces of muco-purulent or fetid residual urine. Treatment—(1) vasectomy; (2) castration; (3) prostatectomy (see indications). Serious Enlargement. — Diameter 3 inches, more or less. Catheter introduced with difficulty, and causes considerable pain; may be complete retention of urine ; marked cystitis ; general con- dition poor; kidneys probably diseased (from backward pressure). Treatment—(i) castration; (2) vasectomy, etc., as indicated. Extreme Enlargement. — Bladder atonic and dilated ; com- plete retention of urine; introduction of catheter very difficult; bad cystitis; patient old; general condition very poor (toxaemia). Treatment—castration, etc., (see indications). Tuberculosis of the Prostate. Tuberculosis of the prostate while usually secondary to tuber- cular affections of other organs (kidney and testicle), is occa- sionally seen as a primary condition. The disease usually occurs between the ages of twenty and thirty-five. Primary nodules in the vicinity of the tubules become con- fluent, undergo caseation, forming large soft masses in one or both lateral lobes, the middle lobe being seldom affected. As is the case in other parts of the body, these caseous collections may rupture externally (bladder, urethra, perineum, and rectum). Occasionally, instead of breaking down, there is an overgrowth of connective tissue about the deposits, the contents become imprisoned, and the whole becomes converted into a calcareous mass. Symptoms.—Undue frequency of micturition, attended with a burning, shooting pain ; pain in the perineum; occasionally a slight muco-purulent discharge escapes from the urethra. Haema- turia is often present, and in the later stages, incontinence of urine may be a prominent symptom from infiltration of the vesical sphincter. Tubercle bacilli may occasionally be found in the urine. The constitutional symptoms, anaemia, emaciation, and an even- ing rise of temperature. Treatment.—In the early stages, active antitubercular treat- 78 Genito-Urinary Diseases. ment should be instituted, such as cod liver oil, iodide of iron, good food, fresh air, and sunlight. Injections of emulsion of iodoform in glycerine may be tried (through the perineum). Lannelongue's chloride of zinc solution may also be tried, the prostate being exposed through a median perineal incision. In advanced cases, a median or tranverse perineal incision should be made, the caseous pockets opened, and the contents thoroughly removed with a curette. Prostatic Calculi. Calculi are occasionally seen in the prostate gland. There may be a single large calculus, or they may exist in great numbers, varying in size from a grain of sand to that of a pea. Causes.—These bodies are formed in the prostatic ducts and acini, mucus being the nucleus. Symptoms.—When small they may occasion no symptoms, when large, the symptoms are similar to those occasioned by any prostatic obstruction. Diagnosis.—The diagnosis can usually be made by palpa- tion through the rectum or by the introduction of a vesical sound. Treatment.—When large enough to occasion symptoms a median lithotomy should be done, and the calculus removed with forceps through the perineal incision. I have seen calculi removed from the prostatic sinus by the urethral forceps of Matthieu. Tumors of the Prostate. Exceedingly rare, include cysts, destructive adenoma, and carcinoma. Cysts of the prostate are found in the neighborhood of the utriculus, and are the result of blocking of remnants of the Ducts of Mueller. Carcinoma and destructive adenoma are occasionally seen in the young as well as the old. They form irregular soft tumors, which growing towards the bladder or urethra, finally involve the neighboring tissues. Symptoms.—Similar to prostatic hypertrophy, except more rapid in onset. Haematuria either preceding or following urina- Tbe spongy portion. The membraoooj portion* The prostatic portion. skin. superficial fascia fibrous coal of corpus cavernosum. urethra. corpus. spongiosum Coviper'$ Gland Orifices of du of Cowper's Glands prepuce. neahit deep layer. space between prepate and'glans. corpus cavernosum tiretfira. ( a i u < i (i << i ' << < « < < < < i l< < f i < << 2 (< I i it < t tissue resistance of the individual. The following table of Lanz illustrates the varying lengths of the period of incubation: In 2 cases the period of incubation was one day. " three days. " " four days. " " five days. " seven days. " eight days. " " ten days. " " fourteen days. " twenty days. The vast majority of cases develop between the third and the fifth day, and a period of incubation longer than fourteen days is extremely rare. It is usually shortest after the first infection, and becomes longer with subsequent infections. Symptoms.—The symptoms of the acute inflammatory variety of gonorrhoea attacking the anterior urethra may be considered in three stages: (i) The increasing, (2) the stadium, and (3) the decline. Prodromal Symptoms.—The earliest symptom of a begin- ning gonorrhoea is a slight tickling or pricking sensation about the meatus. During this stage patients will constantly examine the penis, even though the parts seem perfectly normal, the result of a premonition of that which is to come. Increasing Stage.—Within twenty-four or thirty-six hours the inflammatory symptoms become pronounced. (1) The lips of the meatus are reddened, swollen, tender, everted, and often eroded. The course of the entire urethra in the pendulous portion is swollen, tender, and sharp, shooting pains occur spontaneously. (2) The discharge at first scanty appearing as a viscid, slightly grayish fluid, becomes converted into first a milky and then a creamy pus. At the end of the first week, thick green- ish pus appears often streaked with blood. The amount of dis- charge varies with the virulence of the inflammation, increasing until the second or stage of stadium is reached. (3) Ardor Urinae or painful urination becomes well marked 96 Genito-Urinary Diseases. during the first week. The pain varies from a slight burning sensation to that which is most agonizing. This pain results from the contact of the salts of the urine with the inflamed folds of mucous membrane, and also mechanically, from the pressure of the stream of urine distending the engorged membrane. (4) Chordee or painful erections. Erections are very frequent and constant in the very earliest stages of the disease simply from reflex irritation. In the later stages, the inflammation invades the periurethral tissue especially of the spongy body, filling up the erectile spaces with lymph thus interfering with the blood supply, so that when the organ becomes erect, the cavernous bodies can expand while the spongy body does so in a very imperfect manner, causing the penis to curve or bow in the downward direction. If the cavernous bodies become affected, the penis may have an upward curve or to the right or left when one cavernous body is involved. Painful erections occur most frequently at night and may be so persistent as to destroy the patient's rest. Irritation of the lumbar centre from sleeping on the back, and the reflex irrita- tion occasioned by the urine in contact with an irritated and congested vesical neck are, in a measure, responsible for this symptom. General symptoms are seldom or ever present, because even in the most severe varieties of the disease, the inflammatory condition is essentially a local one. In sensitive indviduals there may be slight fever, depression, malaise and anorexia. If untreated, this stage usually lasts from ten days to two weeks. Complications of the Increasing Stage.—(1) Balanitis, (2) posthitis, (3) phimosis, and (4) paraphimosis. Stage of Stadium.—During this stage the discharge becomes very profuse, thick and of a greenish tinge, the ardor urinae is marked, and the chordee severe. At this time the inflammatory process has usually extended to the bulb of the urethra, and a feeling of warmth and fullness of the perineum with pain on pressure are added to the other symptoms. The duration of this stage is about ten days or two weeks. The Urethra. 97 Complications of the Second Stage.—(1) Folliculitis, (2) periurethral abscess, (3) lymphangitis, (4) bubo, (5) cavernitis, and (6) cowperitis. Stage of Decline.—About the end of the fourth or fifth week there is usually a marked change in the symptoms for the better. The inflammatory symptoms diminish, the secretion becomes thinner, then milky, and finally, colorless like glycerine, the disease running its course in from six to eight weeks. Subacute or Catarrhal Gonorrhoea. As one attack of gonorrhoea predisposes the patient to another, repeated infections are far from uncommon. As a result of repeated attacks of inflammation, the anatomical char- acter of the mucous membrane becomes changed, so that succeeding infections assume a subacute or catarrhal course from the start. In this variety of gonorrhoea the period of incubation, while shorter in the earlier infections, may increase with progressive infections. Although the discharge may be a profuse muco-puru- lent one, the subjective symptoms are not marked or may be entirely wanting. The inflammation is usually very superficial, either because the virus is weak, or that the mucous membrane, the result of previous inflammations, becomes changed, and is not suitable for the growth of the gonococcus. Complications.—(1) Gonorrhceal rheumatism (arthritis), and (2) gonorrhceal ophthalmia. Irritative or Abortive Gonorrhoea (Simple Urethritis). Causes.—Contact with foul discharges, leucorrhoea, trauma- tism, irritating conditions of the urine, passage of instruments, and the use of strong irritating injections. Many varieties of cocci may be found in the discharge in these cases, but never the gonococcus. Period of Incubation.—The length of the period of incuba- tion varies a good deal with the cause. It may follow within a few hours after the passage of an instrument or the use of a strong injection, or after infection with a leucorrhceic discharge, in about forty-eight hours. 98 Genito-Urinary Diseases. Symptoms.—The symptoms are identical with the very earliest attendant upon the development of the acute inflammatory variety of gonorrhoea—swelling, redness and itching about the meatus, slight ardor urinae, and a thin milky discharge, which can only be demonstrated by stripping the urethra. If untreated, in the majority of cases, the discharge disap- pears in the course of a week or ten days spontaneously; it may, however, prove as obstinate in its course and treatment as typical gonorrhoea. Acute Posterior Urethritis. In about 90 per cent, of all cases of acute inflammatory gonorrhoea, the disease invades the posterior urethra by continuity of tissue in spite of the fact, that authorities claim the tonic con- tractions of the compressor urethrae muscle closes the urethra at that point and acts as a barrier to deeper infection. Symptoms.—The deep urethra usually becomes infected during- the third week of an acute anterior urethritis. In the early stage of the infection, the patient often thinks that he is getting rapidly well because of the disappearance of the discharge. (1) Increased frequency of micturition.—This symptom is often quite pronounced and is exceedingly distressing. Very often the patient is obliged to assume the recumbent posture with the hips elevated, otherwise, he may be compelled to urinate every few minutes. This symptom is due to the fact, that the neck of the bladder becomes involved in the inflammatory process, so that the smallest quantity of urine which collects in the bas- fond of the organ occasions a desire to urinate. (2) Tenesmus.—Great straining, attended by severe pain, the passage of a few drops of urine, without any sense of relief, is often a prominent symptom. It is due to the spasmodic con- traction of the vesical sphincter. (3) Hematuria.—The last drops of urine are often mixed with a few drops of blood, the result of the violent con- tractions of the vesical sphincter. In some cases the hemorrhage may be severe and flow back into the bladder. (4) Sexual symptoms.—Erections are frequent but painless ; The Urethra. 99 seminal emissions are frequent, and at the moment of ejaculation are attended with a sharp stinging pain in the deep urethra. (5) Perineal pain.—Patients suffering with acute posterior urethritis frequently complain of a deep perineal ache or fulness, increased on defecation and urination. (6) Discharge.—The discharge is analogous to that of anterior urethritis, but never passes forward into the anterior urethra because of the tonic contraction of the compressor urethrae muscle, but flows back into the bladder, there to mingle with the contained urine. (7) General symptoms.—General symptoms are more pro- nounced in posterior than in anterior urethritis. Temperature is usually 990 to ioo°, general malaise, headache, nausea, anorexia, constipation and coated tongue. Complications of Acute Posterior Urethritis.—(1) pros- tatitis ; (2) vesiculitis ; (3) epididymitis, and (4) urethro-cystitis. A pure gonorrhoea inflammation of the bladder is extremely rare. Pathology of Gonorrhoea.—In the vast majority of cases, gonorrhoea is acquired by direct infection during coitus. The number of gonococci, their virulence, and the tissue resistance of the indvidual, influence the rapidity of the onset of the attack. The organisms being deposited in or about the meatus, begin to multiply under favorable conditions, and become distributed over a considerable segment of the urethra. At this stage the discharge, which is thin and sticky, is composed of serum, des- quamated epithelial cells, with here and there perhaps a pus-cell. As the discharge becomes yellow, the epitheliel cells disappear and the pus-cells predominate. In the very earliest stages, the gonoccoci may be found floating free in the serous discharge, but later, are found in the protoplasm of the pus-cell. The microbe is found in the pus- cell, not because of any peculiar movement of its own, but because of the phagocytic activity of the leucocyte. The appearance of pus-cells in the discharge (twenty-four or forty-eight hours) indicates that the gonococcus has penetrated into the sub-epithelial layer of tissue, passing between the epi- thelial cells, and as the epithelial cells are destroyed a deeper ico Genito-Urinary Diseases. infection may occur, the gonococcus penetrating even to the papillary layer. In the declining stage, the discharge changes in character, the pus-cells gradually disappearing, while the number of epi- thelial cells increase. Such a microscopical picture indicates the beginning of the healing process. Gonorrhceal shreds, threads, urethral filaments ; also called tripper faden ; are divided, according to Taylor, into four distinct varieties : (i) The pus thread, which consists of pus-cells held together by mucus. They may exist in the form of threads or irregular masses, and are usually seen at the close of the second stage of gonorrhoea (stadium). Such threads quickly sink to the bottom of the beaker. (2) The gelatinous threads are usually seen towards the close of an acute gonorrhoea (stage of decline), and consist of pus, epithelial cells and mucus. They are often exceedingly fine and long, and slowly float about in the urine. They are, at times, thick and quite short. (3) The Comma thread. These are short, thick, irregular threads of a light brown color, varying from a quarter to a half an inch in length. Often they have a thick well-developed head, and then resemble a comma. They are indicative of chronicity of the inflammation, and that the urethral follicles are involved. (4) Epithelial or scaly threads consist largely of epithelial cells and mucus. They are seen as fine particles, threads, or lumps and flakes of a grayish color. The presence of a large number of epithelial cells indicates a desquamative process, such as is the case with granular patches and erosions. Diagnosis —There are two points to be considered in the diagnosis of a urethral discharge: (1) Is the discharge gonor- rhceal ? and (2) From what part of the urethra does it originate ? A microscopical examination will settle any doubt as to the specific or non-specific nature of any discharge. The following tables of differential diagnosis will prove of great value : [ Acute Anterior Urethritis. Acute Posterior Urethritis. Acute Posterior Urethro-cystitis. Non-specific Cystitis. Phosphaturia Bacteriuria. Secretion at the orifice of 1 the urethra. Abundant. Less abundant and often contrasting with the intensity of turbidity of the urine. Slight and often con-trasting with intensity of turbidity of the urine. None. None. None. Test of the two beakers. First portion cloudy. Second portion always clear. First portion very cloudy. Second portion cloudy, or clear and cloudy alternate-ly ; opacity always less than first portion. First portion cloudy. Second portion always cloudy, difference in the opacity of both parts not marked. First portion cloudy. Second portion always more cloudy than the first. Both portions equally cloudy. Both por-tions equally cloudy. Test of three beakers. First portion cloudy. Second and third por-tions always clear. First portion very cloudy. Second and third portions cloudy, or clear and cloudy alternately; cloudiness al-ways less than that of first portion. First portion cloudy. Second portion always cloudy. Third portion very cloudy, usually more so than the first part. First portion cloudy. Second portion like the first. Third portion more cloudy than the first and second. All three por-tions equally cloudy. All three portions equal-ly cloudy. i Test of two beakers after irrigation of the anterior urethra. Two portions clear. First portion cloudy. Sec-ond portion cloudy, or clear and cloudy alternately; Cloudiness always less than first. First portion cloudy. Second portion more cloudy than the first por-tion. First portion cloudy. Second portion more cloudy than the first portion. Both portions cloudy. Both por-tions cloudy. Strongly acid. Bacteria. Few cells. Reaction of the urine. Acid. Acid. Acid. Acid or alkaline. Acid or alka-line. Crystals of cal-cium phosphate and carbonate. Microscopi-c a 1 examina-tion. Secretion and sediment of first portion: pus-cells containing gono-cocci. Secretion and sediment of both portions: pus-cells con-taining gonococci. Secretion: pus-cells containing gonococci, also abundant bladder epithe-lium in sediment of both portions. Cloudiness unchanged or slightly increased. Sediment of both portions: pus-cells, bladder epithelium, no gonococci, but numer-ous bacteria. Addition of acetic acid to the urine. Other char-acteristic symp-toms. Cloudiness un-changed or in-creased. Cloudiness unchanged or slightly increased. Cloudiness un-changed or slightly in-creased. Cloudiness dis-appears. Very changea-ble. Usually ap-pears only once or twice daily. Cloudiness unchanged. Vesical tenesmus contin-uous or imperative; haema-turia with the last drops of urine. Vesical tenesmus and haematuria from the pros-tatic urethra. Coagula of pus in alkaline urine. 102 Genito-Urinary Diseases. Prognosis.—The prognosis of gonorrhoea is usually good, although it must be remembered that there is no tissue which enters into the formation of the human body that has not been attacked by this organism, and the number of fatalities directly traceable to gonorrhoea are not a few. The prognosis as regards duration is not so good. Ricord says, " Une chaude pisse commence, Dieu le sait quand elle finira," which being translated means A clap commences, but God alone knows when it will end. The prognosis is in a measure influenced by the conduct of the patient. Treatment of Acute Anterior Urethritis.—There are three methods of treating acute anterior urethritis : (i) The abortive method; (2) the hand injection method; (3) the irrigation method. The systematic treatment of gonorrhoea may be considered under the following headings: (1) Hygiene, diet, etc.—During the increasing stage of an acute urethritis, the patient should be confined to bed whenever possible, at all events, all forced movements such as running, dancing, long standing and long walking should be prohibited. Coitus is to be strictly forbidden, and all forms of sexual excite- ment are to be avoided. The diet is to be carefully regulated, avoiding puddings, rice, cheese, peppers, curry, asparagus, and highly salted and acid articles. The patient should confine himself largely to a milk diet whenever possible. Alcoholic drinks of all kinds must be interdicted, especially beer and champagne. In some cases a moderate amount of well- diluted claret may be allowed without doing any serious harm. The drinking of large quantities of pure water is to be recommended, but soda and seltzer are to be avoided. During the night the patient should sleep on a firm, hard mattress, and on the side rather on the back, thus in a measure avoiding the tendency to chordee. He should be lightly covered, and should urinate every time he may awaken. Before going to bed it is well to recommend that patient taking a prolonged warm bath, which in a measure, will relieve the local congestion. The Urethra. 103 The bowels should be opened daily either by the use of small doses of phosphate of soda teaspoonful one hour before breakfast or by the use of hunyadi. The Dressing.—The dressing should be recommended that will collect the discharge, permit the free escape of the same from the urethra, and, at the same time, will be convenient to quickly change, and not be too bulky. When the foreskin entirely covers the glans penis, it should be retracted, a small piece of cotton placed over the glans, then if the prepuce is brought forward, the cotton will be held in place. A piece of lint about four inches square may be used, a hole being cut in the centre so as to freely admit the glans to the corona, then if the four corners are folded over the glans, the discharge will be collected, and soiling of the underwear avoided. The patient may make use of any of the varieties of gonor- rhoea bags or the toe of an old sock, the apex being filled with cotton, and the base attached to a waist band. Under no circumstances should a condom be used for the purpose of collecting the discharge, since it really acts as a poultice. Every time a dressing is changed the patient should be instructed to thoroughly wash the glans and meatus with soap and hot water, thus avoiding such complications as balanitis and posthitis. The patient should be advised to wash the hands thoroughly after each time the organ is handled, and be cautioned as to the dangers and seriousness of conjunctival infection. Internal Treatment.—When the inflammatory symptoms are very marked, and the ardor urince severe, the following mixture will prove of especial value : Jfc. Tincturae aconiti . . gtts. xxiv Tincturae belladonnae . f3ss Sodii bromidi Acidi boracici . . aa 3ij Liq. potassii citratis q. s. ad fgvi M. S. fgss every four hours. io4 Genito-Urinary Diseases. It is a good plan to supplement these remedies by those which when eliminated by the kindeys exert a germicidal effect upon the canal, such a combination as suggested by White will prove of great value in modifying the course of the disease and often preventing complications. Jfc. Salol .... grs. v Oleoresin. cubeb. . . grs. v Balsam, copaibae . . grs. v Pepsin .... grs. i From 4 to 6 to be taken daily. In poorer patients, an emulsion of the balsams known as the Lafayette Mixture may be employed: J&. Balsam copaibae . . . fgss Liq. potassae . . f$i Ext. glycyrrhizae fl. . . fgss Oleii gaultheriae . . . 1T[_ x Aquae . . . q. s. ad. fsiv M. S. f3ii every four hours. The Abortive Treatment.—The abortive treatment consists in the use of strong urethral injections, particularly nitrate of silver, to be used in the very earliest stages of the disease. The objects desired are to convert a specific or microbic inflam- mation into a chemical one, and at the same time, destroy the organisms which lie superficially. It is only in the very earliest stages of the disease that this method of treatment is applicable, that is, when the discharge, examined microscopically, is found to contain gonoccoci and des- quamated epithelial cells. When the discharge contains pus-cells, it indicates that the micro-organisms have penetrated to the sub- epithelial tissue, and, therefore, any injection intended to kill the organism must, of necessity, destroy the urethra. Method of Application.—The patient urinates, the surface of the glans penis is cleansed first with alcohol, then with bichloride of mercury solution i: 2,000. A few drops of a four per cent, solution of cocaine are now injected into the urethra, and the patient requested to compress the urethra at a point two inches behind the meatus. A blunt-pointed urethral syringe The Urethra. 105 holding half an ounce is filled with a solution of nitrate of silver twenty grains to the ounce. The nozzle of the syringe is inserted into the meatus and the piston forced home until the urethra anterior to the point of compression is thoroughly distended. This procedure is to be repeated three times in succession. After this treatment, the patient should be confined to bed for from twenty-four to thirty-six hours, and lead water and laudanum or cold compresses applied to the penis. The discharge becomes profuse within a few hours and often tinged with blood ; at the end of forty-eight hours it again becomes thin and watery, to entirely disappear within a week or ten days if the treatment has been successful. In the event of failure, the acute stage develops with much greater severity. Hand Injection Method. — During the stage of invasion, the use of curative remedies is contraindicated, because the micro- organisms are penetrating into the deeper layers of tissue, and cannot be reached by antiseptic solutions. As most patients demand an injection, one must be selected that will at least not aggravate the trouble, but exert a soothing influence upon the inflammatory condition; it should be antiseptic and sedative. The following is commonly recommended as an injection in the early stages ; {Jr. Acid carbolic ...... f3ss Ext. opii aq. ..... grs. xviii Liq. plumbi subacetatis dil. q. s. ad f^vi M. S. Use after each act of urination, and dilute if painful. In making a hand injection a blunt-pointed syringe of the capacity of half an ounce should be employed. The glans penis should first be cleansed with a little soap and hot water ; the syringe charged with the injecting fluid ; the tip of the syringe gently inserted into the meatus ; the lips of the meatus gently com- pressed about the syringe by the thumb and index finger of the left hand, and then the piston slowly and gently pushed home. The syringe is now removed and the meatus compressed so that the injection may be retained for at least five minutes. The injection should be repeated after each act of micturition. In ordering an injection the patient should be recommended 106 Genito-Urinary Diseases. to dilute the solution at least one-half with plain water, and then to add less water each time until a feeling of warmth is produced. This will always indicate the proper strength; any injection that causes distinct pain is doing harm and not good. Whenever any injection causes pain, no matter how dilute, the use of all injections is contraindicated. About the end of ten days or two weeks when the stage of stadium is reached, when the discharge is profuse and decid- edly muco-purulent, the disease has about run its course and curative injections are indicated: Jfc. Acid carbolic .... f3ss. Zinci sulphocarb. . . grs. xxiv Boroglyceride (25%) . . fgii Aquae . . . q. s. ad fgvi M. S.—Dilute if painful. Jfc. Injection Brou. Zinci sulph. . . grs. vi Plumbi acet. grs. xv Tr. opii Ext. krameria fl. . aa fsiii Aquae q. s. ad fgvi M. S.— #. Ext. hydrast. fl. . f3ii Bismuth subcarb. * J 3ii Glycereni f3ii Aquae fgiv M. S.—Use after urination. If, at the end of a week or ten days the discharge has not entirely disappeared stronger injectic »ns should be ordered: #. Acid carbolic . Acid tannic Acid boracic . Aquae > f3ss 3i f3ii . fSvi M. S.—Dilute if painful. &■ Ultzman's injection. Zinci sulphatis Pulv. alum > aa grs. viii Acid carbolic . , . grs. iii Aquae « fgvi M. S.—Dilute if painful. The Urethra. 107 Jfc. Zinci acetat. Acid tannic . . aa grs. xv Aquae .... fgiii M. S.— When the discharge has entirely disappeared, the patient should be requested to urinate in a urine beaker, and the urine examined for shreds. All shreds that float usually consist of mucus and require no attention, when, however, they sink, it is indicative that they also contain pus-cells, and further treatment is necessary. If the shreds are composed solely of mucus, the injections should be gradually decreased in frequency, so that all treatment is stopped at the end of a week. After the cessation of all treatment a full week should elapse before the patient relaxes the strict regimen under which he has been living. At the end of that time, the first urine passed in the morning should be centrifuged and examined for pus ; if the urine is entirely free, he can safely resume his ordinary mode of life. The ardor urinae is to be relieved by the internal use of aconite, belladonna, and bromides (see page 103). The patient should also be instructed to immerse the penis in a glass of hot water during each act of micturition. This procedure, by equal- izing the circulation, often brings about instantaneous relief from this very distressing symptom. For the relief of chordee, the bowels should be opened daily, the patient should take a hot bath before going to bed, he should sleep on a hard mattress, the room should be cool, and the covers few. Each time the patient awakens during the night he should be recommended to get up and urinate. He should also be instructed to sleep on his side rather than on the back to avoid irritation of the lumbar centre. If these simple measures fail the following formula may be used : {Jr. Pulv. opii . . . grs. v Pulv. camphorae . . grs. xv Ext. belladonnae . . grs. ii Oleii theobrom. q. s. M. F. Ft. Suppos. No. V. S. One at bedtime. In some cases six or eight ounces of blood may be removed from the perineum by leeches. 108 Genito-Urinary Diseases. Irrigation Treatment.—The treatment of gonorrhoea by the method of Janet has attracted considerable attention both in this country and in Europe. It is applicable to any stage of gonorrhoea, and by its use, there is usually a most rapid subsidence of the inflammatory symptoms. The apparatus required is a quart fountain syringe with a tube, so attached that the level of the bag will be about eight feet above the level of the patient's bladder; and a Nelaton catheter of either n or 15 French in caliber. The solutions employed in the irrigator are bichloride of mercury 1 : 25,000; potassium permanganate 1 : 5,000; and nitrate of silver 1 : 10,000. The potassium permanganate solution is the least irritating of the three, and is the one to be employed in the early stage of all acute cases. The technique of application is as follows: The patient is requested to urinate, and the glans penis and the meatus cleansed first with alcohol and then with a solution of bichloride of mercury 1 : 2,000. The sterilized Nelaton catheter is now lubricated with the following: Jfc. Acid, boracic.....gss Acid, carbolic.....f3ss Glycerin. ..... fgiii M. S.— and gently inserted into the urethra as far back as the bulb. The irrigating bag is now filled with one quart of permanga- nate solution 1 : 5,000 at a temperature of 1150 or 1200 (as hot as can be borne by the patient), the snap released, and the air forced out of the tube by the flow of solution. The patient now stands in front of an ordinary wash-stand, the tube of the irrigating bag is connected with the catheter, and the fluid allowed to escape between the catheter and the inflamed urethral walls. The injections are to be repeated twice daily (night and morning), and increased in strength 1 : 500 each day until the eighth day. If the irrigation has been satisfactory, an irrigation of 1 : 5,000 is given for a week and then all treatment stopped. Within a few hours after an irrigation, the discharge is changed into a whitish serum, finally again becoming purulent The Urethra. 109 as the effects of the irrigation wear off (about eight hours) ; hence these irrigations should succeed each other so rapidly that the return of the purulent discharge is entirely prevented. When the irrigation treatment is carefully carried out, usually from 11 to 15 irrigations are necessary to bring about a cure. When nitrate of silver or bichloride solutions are used the increase in strength must be made more gradually because of their excessively irritating qualities. When the discharge recurs after the permanganate treatment, the gonococci have not been entirely destroyed. In such cases, the usual routine must be again instituted and carried out as, above described. If a slight muco-purulent discharge persists after the careful use of the permanganate solution, and a microscopical examina- tion of the same fails to demonstrate the presence of gonococci, the permanganate solution should be stopped and a solution of nitrate of silver used, beginning with 1 : 10,000 and gradually increasing according to the effect produced. The advantages of the irrigation treatment are.—(i) The discharge rapidly becomes changed in character and in quantity; (2) the ardor urianae and chordee are less intense; (3) compli- cations are rare, and (4) the disease usually runs a milder course and the duration of the attack is shortened. When the irrigation treatment is followed by an increase of symptoms, it should be immediately discontinued. During the irrigation treatment the hygienic and the internal medicinal treatment are the same as for the injection treatment. Treatment of Acute Posterior Urethritis. — When salol does not increase the symptoms, it should be administered thrice daily in doses of five grains ; its effects may often be enhanced by the addition of ten grains of boracic acid. The patient should be confined to bed when possible, or at least lounge about the house. The bowels should be opened daily, and the diet limited to milk- The posterior urethra should be irrigated as in a manner described for anterior urethritis, the catheter being passed behind the compressor urethrae muscle, and the solution allowed to flow back into the bladder until the desire to urinate becomes urgent. no Genito-Urinary Diseases. The catheter is then withdrawn and the remainder of the solution allowed to flow through the anterior urethra. Potassium permanganate is to be used, beginning with a strength of i : 8,000 and gradually increased according to the effect produced as in the treatment of anterior inflammations. If the irrigations in any way seem to aggravate the trouble they are to be immediately stopped.. The treatment of the subacute or catarrhal variety of gonor- rhoea is in every way similar to the acute inflammatory, except that curative injections can be used in the very earliest stages. The irritative or abortive variety requires the internal use of salol and the local use of a simple sedative injection : Jfc. Plumbi acetatis . . grs. vii Aquae .... fgiii M. S. To be used after each urination. Chronic Urethral Discharges. Any urethral discharge persisting after three months' treat- ment may be considered chronic. Varieties.—(1) Urethral catarrh or urorrhcea. (2) Chronic gonorrhoea (3) Gleet. Urethral Catarrh or Urorrhcea A catarrhal discharge dependent upon a weak and leaky mucous membrane; it is nothing more than an excess of what is otherwise a normal secretion. Causes.—Such patients are usually very anaemic, and the gen- eral health is below par. They are predisposed to inflammations of mucous membranes. Symptoms.—A sense of moisture about the meatus may be the only symptoms. Sometimes there escapes from the urethra, especially after stripping, a few drops of colorless sticky fluid not unlike glycerine. Such patients are often greatly worried over this, and keep up the trouble by the constant use of injections or by frequent stripping of the urethra. Treatment.—For the relief of this harmless discharge, the general health should be improved by the use of tonics and large doses of iron: The Urethra. m Jfc. Strychniae sulph, . . grs. i Acid phosphoric, Tr. ferri chloridi . . aa fsii Syrup simplex fgi Aquae q. s. ad. . . . fgiii M. S. f3i in water, three times daily through a tube. Such patients may be recommended to use Burgundy and claret with their meals. Chronic Gonorrhoea. In the latter stages of gonorrhoea the inflammatory process shows a great tendency to become localized in some part of the urethra, and there remains in a subacute state. Causes.—Too early cessation of the regimen followed out during the height of the acute attack; sexual and alcoholic indul- gence during the declining stages of the disease ; improper treat- ment ; insufficient treatment and repeated acute attacks. There are certain portions of the urethra predisposed anatomically to the development of chronic inflammations, the fossa navicularis, bulb and prostatic urethra ; first, because of the abundance of follicles, the amount of peri-urethra tissue (bulb), and the great vascu- larity (bulb and prostate). The anatomical investigations of Weichselbaum quoted by Finger, give the following results: Pendulous urethra . . . . . in 15 cases Pendulous urethra and bulb . . . . in 1 case Bulb alone . . . . . . . in 1 case Pendulous urethra and prostatic urethra . . in 1 case Pendulous urethra, bulb, and prostatic urethra in 5 cases Membraneous urethra and prostatic urethra in 1 case Entire urethra . . . . . . . in 1 case Prostatic urethra alone . . . . . in 6 cases 31 cases Pathology.—The cylindrical epithelium is converted into squamous epithelium ; and the subepithelial connected tissue is the seat of a round-celled infiltration, which has a decided ten- dency to transformation into contracting cicatricial tissue. The infiltration may be either superficial or deep. The cicatrix does not result from ulceration, but from chronic connective tissue hyperplasia. n2 Genito-Urinary Diseases. Symptoms.—The symptoms vary according to the seat of the trouble. The most characteristic symptom is a muco-purulent discharge which varies in quantity from that which simply glues the meatus together to several drops during the day. Usually a small drop is seen in the morning upon arising, the scantiness of the discharge and the frequency of micturition during the day prevents its accumulation in sufficient quantities to show. It is increased in quantity by fornication and indulgence in alcohol. Diagnosis.—The diagnosis is usually easy, the urine passed in two portions, the first containing clap threads, while the last is clear. Clap threads are constantly found in the urine and are either of the gelatinous or comma variety. The anterior urethra should always be explored as far as the bulb with bougie a boules and any spots of tenderness or narrowing should be carefully noted. The endescopic tube may be employed to determine accu- rately the position and variety of the localized lesion. Treatment of Chronic Anterior Urethritis.—The caliber of the urethra should be restored by the frequent use of a full- sized steel sound, if the meatus will not admit an instrument of the proper size, a meatotomy should be performed. The use of the sound should be followed by the frequent use of some astrin- gent injection, or by daily irrigations of nitrate of silver i : 10,000 gradually increased according to the effect produced. When an endoscopic examination of the urethra reveals the presence of localized patches of granular urethritis, the erosions may be touched with the following solutions through the endoscopic tube : Nitrate of silver grs. x to the fg.; copper sulphate from a one to a five per cent, solution; pure iodine; Lugol's solution; equal parts of pure carbolic and Lugol's solution. The more superficial the patch the more value the nitrate of silver injections are. In the beginning, weak solutions should be tried, and then gradually increased according to the effect produced. Inflamed follicles may be exposed by the use of the urethral p Leiter's Urethroscope Of Otis's Urethroscope Endoscopic tubes and Urethral Speculum. I 12 Oberliinder's Short Urethral Dilator. Kollmann's Urethral Dilator Kollmann's Prostates Dilators. Oberlander's Long Urethral Dilator. Oberlander's Prostatic Dilator. 113 The Urethra. 113 speculum, the contents may be expressed by pressure, and then a few drops of a two per cent, solution of nitrate of silver may be injected through a fine capillary tube. Many of these cases are benefited by the internal adminis- tration of full doses of the balsams. Chronic Posterior Urethritis.—Like anterior urethritis, the course of chronic posterior urethritis is often a latent one. Pathology.—The pathology is similar to that of chronic anterior. The disease runs its course in the upper layers of the subepithelial connective tissue, and is a chronic inflammatory pro- cess with a first stage of small-cell infiltration and connective tissue proliferation, and a second stage, in which fibrous tissue forms (Finger). The second stage is usually more or less superficial and is not followed by the customary cicatricial contraction. Symptoms.—The inflammation in many cases, may be so superficial as to occasion but few and slight symptoms. When deeper seated, there may be more or less tenesmus, pain in the perineum, frequent nocturnal emissions, impotence, and the general symptoms of sexual neurasthenia. As is the case with acute posterior urethritis, the discharge of the posterior urethra cannot flow forward beyond the compressor urethrae muscle but must flow back into the bladder and there to mix with the urine. These chronic cases may become subacute by over-indulgence in alcohol or coitus, in that case the inflamma- tion by continuity of tissue, extends forward into the bulb, and a discharge appears at the meatus. Diagnosis.—The diagnosis can usually be made by the two glass test. The patient is requested to urinate about half the urine contained in the bladder into one beaker and the remainder into another, when the posterior urethra is involved, the urine con- tained in the second glass will appear cloudy. In mild cases of chronic posterior urethritis the discharge is so slight that it does not flow back into the bladder, in that case the first urine will contain all the shreds of the posterior urethra, and the second urine will appear clear. Under these circum- stances the anterior urethra as far down as the bulb, must be IJ4 Genito-Urinary Diseases. washed free of all secretion by an irrigation through a catheter with boracic acid solution, then when the patient urinates into the beaker, any shreds present will be from the posterior urethra. The table of differential of diagnosis arranged by Finger will prove of value. See Page 115. Treatment.—The same general hygienic and dietetic rules recommended in acute urethritis must be enforced. Internally, salol and boracic acid may be administered, or when they do not dis- agree with the stomach the balsams may be used in full doses. The irrigations should be tried as recommended for the relief of acute posterior urethritis. Failing in these, instillations may be tried. Instillations are made by means of the Ultzmann's syringe introduced as an ordinary catheter until the point reaches the compressor urethrae muscle, then if the handle is slightly depressed through an arc of ten degrees the point of the instrument will be about in the centre of the prostatic urethra. {Figure 20.) For instillation purposes, from ten to twenty drops of the following solutions, depending upon the strength, may be used: Nitrate of silver, from one-half to five per cent. ; copper sulphate, from one-half to five per cent. ; bichloride of mercury, 1 :2,000; Lugol's solution ; equal parts of Lugol's solution and carbolic acid. The effects of an instillation may often be enhanced by the previous introduction of a full-sized steel sound. Ointments have been recommended by Finger because their effects are more lasting ; fifteen to sixty grains of argent, nit. or copper sulph., or creoline thoroughly mixed with three ounces of lanolin and two drachms of olive oil, introduced into the prostatic urethra by means of a Tommasoli's ointment carrier. {Fig. 21.) In inveterate cases, the prostatic urethra must be over-stretched by a prostatic dilator so as to break up the new bands of fibrous connective tissue. This treatment may be repeated every eight or ten days, and may be combined with prostatic massage through the rectum. Gleet. Gleet is a variety of chronic urethral discharge, which always originates from a granular patch behind a stricture. (See stricture.) Ultzmann's Syringe for deep urethral injections. j- < ?:aia 'J£jj[IMjlM'IHIIlijjJaftt%ir)jjy Guyon's Syringe and hollow bougie a boule for deep urethral injections. Valentine's Endoscopic tube for vesical exploration of the Urethra, with bracket for lamp. Klotz's Endoscopic tube for urethral inspection and treatment. 114 Fenwick's Electro-Urethroscope for balooning the Urethra. Oberlander's Endos- copic tube, with light at beveled end for urethral inspection. Antal's Endoscopic tube for exploration of the fossa varicu- Iaris. Goerl's Electrical Endoscopic tubes for Urethral Inspection. H5 Differential Diagnosis Chronic Anterior Urethritis and Chronic Posterior Urethritis. Superficial Variety. Deep Variety. Superficial Variety. Deep Variety. Secretion at the orifice of the ure-thra. In recent cases, muco-purulent secretion, constantly, or a morning drop. In invete-rate cases, gluing of the meatus, constantly or only in the morning, or meatus perfectly dry. No secretion at meatus. Test of the two beakers. First portion slightly cloudy, or clear with clap shreds. Second portion clear, without shreds. In recent cases : First portion slightly tur-bid, with clap shreds. Second portion slightly cloudy. In inveterate cases: First portion clear, with clap shreds. Second portion clear. Test of two beak-ers after irrigation of the anterior ure-thra. Both portions clear. In recent cases: First portion slightly cloudy, with clap shreds. Second portion slightly cloudy. In inveterate cases: First portion clear, with clap shreds. Second por-tion clear. Examination with the urethrometer. No diminution of dilatability. Diminution of dilat-ability in one or more circumscribed spots. Other character-istic symptoms. None. None. Increased or imper-ative vesical tenes-mus. Prostatorrhcea. Increased or impera-tive vesical tenesmus, prostatorrhcea, pollu-tions and impotence. 116 Genito-Urinary Diseases. Gonorrhceal Arthritis. Attacks the knee, ankle, elbow, or wrist. Causes.— Systemic infection with the gonococcus. The disease often appears about the sixth week of a catarrhal ure- thritis, although it may appear as early as the third week. Symptoms.—The symptoms are those of any acute arthritis —heat, swelling, redness, pain, and loss of function. It may be preceded by a chill and is usually attended with moderate fever. Suppuration rarely takes place. Diagnosis.—Gonorrhceal arthritis is to be distinguished from ordinary rheumatism. Gonorrhceal Arthritis. i. Limited to one joint. 2. Remains in one joint. 3. Unattended with sweating. 4. Fever moderate, 102. 5. Presence of a urethral dis- charge. 6. Salicylates of no value. 7. Obstinately resist treatment. Rheumatism. 1. Attacks several joints. 2. Jumps from joint to joint. 3. Profuse sweats. 4. High fever. 5. No urethral history. 6. Usually cured by salicylates. 7. Usually responds quickly to treatment. Treatment.—The course of gonorrhceal arthritis is usually a prolonged one, obstinately resisting all forms of treatment. As soon as the condition can be diagnosed, iodide of potash and bichloride of mercury should be administered internally. Locally absolute fixation in the early stages by splints and the daily application of superheated air constitutes the most suc- cessful plan of treatment. After the acute symptoms have sub- sided, inunctions (locally) of belladonna and mercurial ointment should be used and the joint gently masseyed. Stricture of the Urethra. A stricture is a narrowing of the urethra, caused by changes in the tissues, or by spasm of the muscles. Varieties.—(1) Congenital ; (2) acquired. Congenital strictures are extremely rare except in the neigh- borhood of the meatus. The physiological narrowing of the meatus is not in any sense a stricture, as it favors the projection of Organic strictures of the anterior urethra, showing varieties, seat and situations of the openings. y Urinary fistulae, resulting from ti'Jht deep strictures. 117 The Urethra. 117 the stream of urine and the vigorus ejaculation of the semen. Acquired are classified as (1) inflammatory; (2) spasmodic; (3) organic. Inflammatory Stricture. This variety of stricture may result from an inflammation attacking any narrow canal, and is a result of the inflammatory exudation. It is of but little importance, as it is seldom if ever followed by retention of urine. Spasmodic Stricture. A temporary stricture caused by muscular contraction, usually the compressor urethrae. Causes.—Psychical, as in case of nervous individuals who cannot urinate in the presence of others ; it may result from chronic gonorrhoea (granular patches with hyperaesthesia) ; or it may follow reflexly any disease of the rectum, fissure, piles, worms, etc. Organic Stricture. Organic stricture may be inflammatory or traumatic. Causes.—In the vast majority of instances stricture of the urethra results from some antecedent inflammation of the canal, although it may follow chancre, chancroid, or keloid (Taylor). The longer the duration of gonorrhoea the more liable the patient is to suffer from stricture. Traumatic strictures result from partial or complete rupture of the urethra, or from false passages. Varieties.— /. Large or Small Caliber. — (1) Large when above a 15 French. (2) Small when below a 15 French. 2. Passable or Impassable. — (i) Permeable or passable. (2) Impermeable or impassable. A stricture may be permeable to urine, but impermeable to instruments. j. Simple, Irritable and Resilient.—(1) Simple—Not extreme or complicated, common symptom of strictures. (2) Irritable— Instrumentation followed by severe pain and hemorrhage. (3) Resilient—Recurring in a short time after dilatation. Seats of Stricture.—The majority of gonorrhceal strictures occur at the bulbo membraneous junction ; the next most frequent point is in the fossa navicularis, and the least frequent between n8 Genito-Urinary Diseases. the fossa navicularis and the peno scrotal junction. In other words those parts of the urethra in which gonorrhceal is most likely to become chronic. Strictures are never found in the pros- tatic urethra, and seldom or never in the membraneous urethra. Number of Strictures.—The majority of cases are single. Three or four may occur in the same individual. Time of Occurrence.—Gonorrhceal strictures are usually of slow formation, that is, they do not give rise to symptoms until many months or even years after the attack of gonorrhoea. Pathology.—The pathology of stricture is that of chronic urethritis. As Finger has described, there is at first a prolifer- ation and round celled infiltration of the subepithelial connective tissue, this in time, organizes and like scar tissue in other parts of the body, contraction takes place and a stricture results. After a stricture has existed for some time, the urethra behind the stricture begins to dilate or balloon owing to the increased resistance to the flow of urine. As a result of this, a pouch is formed, the urethral walls are thinned, and a few drops of urine becomes stagnant in the pouch. Ammoniacal fermentation follows, and erosion occurs, a minute rupture results, and the urine escapes into the periurethral connective tissues forming abscesses which finally burrow and appear at some point in the urethral triangle of the perineum. With these changes, the bladder may become thickened or dilated, the ureters involved, and the patient finally dies of advanced kidney degeneration. Symptoms.—(i) Frequency of Micturition—results either from the irritable condition of the bladder caused by the increased effort necessary to expel the urine from the bladder; or it may result from the development of a granular patch behind the stricture, the inflammation extending by continuity of tissue to the posterior urethra. (2) Diminution in the size of the stream.—This is a late symp- tom, as the bladder by compensatory hypertrophy usually coun- teracts until late. (3) Loss of the parabolic curve—is dependent upon the small- ness of the stricture and atony of the bladder. It is usually a late symptom. The Urethra. 119 (4) Dribbling at the end of urination.—This symptom is com- mon to many urethral conditions, but when associated with gleet it becomes one of considerable diagnostic importance. (5) Gleet.—About 60 per cent, of all cases of stricture are associated with a gleety discharge. It is only seen in the morning as a drop, unless there are acute exacerbations result- ing from alcohol or coitus. (6) Vague pains in the back and loins. Diagnosis.—Strictures are to be diagnosed by exploring the urethra with a bougie a boule. In order, however, to be able to say that a given case has stricture, it is necessary to know what the normal caliber should be for each individual case. When circumference of penis is 3 in. urethral caliber 26-28 Fr. " " " 2>/i " " 28-30 Fr. 3^/ << << 3O-32 Fr. " 3ji " " 32-34 Fr- " " " 4 " ' 34-36 Fr. After ascertaining the normal caliber of the urethra, when the meatus is preternaturally small, a meatotomy is to be done, a bougie a boule is selected, about five sizes below the approxi- mate normal caliber, oiled, and passed into the bladder. The instrument is now to be withdrawn slowly, and any point at which the shoulder of the instrument seems to stick, is carefully noted. (See Figure 22.) There are three normal points where the instrument may stick : (1) just behind the fossa navicularis, (2) the anterior layer of the triangular ligament going towards the bladder, and (3) the posterior layer of the triangular ligament coming from the bladder. If the first instrument fails to pass through the strict- ure smaller ones are used, until one will pass to the bladder. A bougie a boule will show the length of a stricture, its distance from the meatus, its caliber, and often its character (hard or soft). Treatment.—The treatment of strictures may be considered under the following headings: (1) Gradual dilatation. 120 Genito-Urinary Diseases. fa. External urethrotomy. (2) Cutting operations -l b. Internal urethrotomy. [ c. Perineal section. (3) Miscellaneous methods (electrolysis and resection). Gradual Dilatation:—All strictures of large caliber should be dilated by the use of graduated steel sounds, except those situated at or near the meatus. This region is not so dilata- ble, and being richly supplied with nerves, dilatation is extremely painful. In general, all strictures that can be dilated should be so treated, as it is attended by distinctly less danger than the cutting operations. However, strictures of small caliber are usually old and cartilaginous, and can, therefore, only be dilated with difficulty. (See Figure 2j.) Technique of Passing a Sound—The patient should be placed in the recumbent posture, with the legs separated and slightly flexed. The glans penis and meatus should be cleaned with alcohol and then bichloride solution, 1 :2/000. A steel sound (sterilized) two sizes larger than the caliber ol the stricture, is thoroughly lubricated and held in the right hand. The surgeon should stand on the left side of the patient when right-handed, grasp the penis between the thumb and fingers of the left hand. The point of the instrument is introduced into the urethra, the shaft being held in the line of the groin (when abdomen prominent). Allow the point of the instrument to enter the urethra as far as it will go, then sweep the handle to the median line of the abdomen. Gradually elevate the shaft, without force, and place the fingers of the left hand behind the scrotum, so as to guide the point of the instrument through the anterior layer of the triangular ligament. Now grasp the handle of the instrument with the left hand, and with the middle and index fingers of the right hand, press down the structures on either side of the penis, so as to straighten out the curve of the urethra, then slowly depress the shaft between the thighs. If the point of the instrument is in the bladder, the shaft should be in the median line, and the handle towards the toes. Two or three instruments may be passed at each sitting, at intervals of three or four days, depending upon the effects pro- Technique of passing a Sound. Organic stricture of the Anterior Urethra. 120 Old No. Fig. 22. Bougie a boule. Old No. Fig. 12. Filliform Bougies. Bangs dilating bougie a boule. Otis's Urethrometer and Cover. ffioj »7| Old No. Fig. 23. Steel Sound. 25 121 Meatus Bougie. The Urethra. 121 duced (inflammatory reaction). In the majority of cases, it is well to follow the introduction of a sound by a urethral irriga- tion of 1 : 5,000 nitrate of silver solution, and during the entire course of treatment, salol and boracic acid are to be administered by the mouth. When full caliber is reached, the patient should be instructed to pass an instrument upon himself, and then recommended to use the instrument at intervals of two or three months for life, otherwise, the stricture will probably return. The cutting operations may be considered under four head- ings : Internal Urethrotomy. The intra-urethral operation for stricture. Indications.—(1) Strictures of either caliber at the meatus and fossa navicularis. (2) All strictures of small caliber in advance of the bulbo membraneous junction that cannot be dilated. Operations.—When the stricture is at the meatus or in the fossa navicularis, a few drops of cocaine are applied and the stricture divided with a blunt-pointed-curved tenotome. Strictures situated deeper than these points require a urethrotome for division. The patient, whenever possible, should be confined to bed for two or three days before the operation, to permit of a bacteriological examination of the urethra, and a thorough chemical and microscopical examination of the urine. The bowels should be opened daily, and the diet limited to milk. Salol grs. v and boracic acid grs. x should be admin- istered thrice daily. The operation may be performed under general or local anaethesia. All instruments should be sterilized by boiling or by im- mersion in 1-20 carbolic acid solution for one hour, and the urethra should be irrigated with 1 : 5,000 nitrate of silver solution. The following instruments (urethrotome) are recommended: (1) White's—cuts from before backwards. {Figure 24.) (2) Gross—cuts from behind forwards. {Figure 25.) (3) Maisonneuve—cuts from before backwards, and also behind forwards. {Figure 26.) 122 Genito-Urinary Diseases. (4) Otis—cuts from behind forwards. {Figure 2/.) (5) Gerster—cuts from behind forwards. {Figure 28.) The stricture is to be divided in the median line and on the roof of the urethra. When the stricture is less than 15 French in caliber the Otis or Gerster instruments cannot be used, as it is first necessary to divide the stricture sufficiently, either with a White or Maisonneuve, then the former instruments can be passed through the stricture and the latter divided from behind for- wards. The Otis and Gerster instruments must be introduced so that the point is one-half inch behind the stricture, then the blades are separated until the stricture is made tense, and finally the knife pulled through, dividing the urethra from a point one- half inch behind to a point one-half inch in front of the strict- ure. The blades are now still further separated until the needle on the dial records the proper caliber desired. A full sized steel sound is now introduced, and then the urethra irrigated with 1 : 5,000 nitrate of silver solution. After Treatment.—The patient should be confined to bed, diet limited to milk. Ten grains of quinine should be adminis- tered immediately after the operation, as well as half a drop of aconite every hour for eight doses ; then salol and boracic acid should be given three times daily. The urethra may be irrigated daily with 1 : 5,000 permanganate of potassium solution. A full- sized steel sound should be passed every fourth day until cica- trization takes place, and then at longer intervals for life. Complications of internal urethrotomy: 1. Hemorrhage.—Usually free, readily controlled by ice or pressure. 2. Periurethral Abscess.—Such a complication is to be avoided by rigid antisepsis of both instruments and urethra. 3. Urinary Extravasations.—To be avoided by not dividing the stricture too deeply. 4. Urethral Fever.—Can usually be avoided by antisepsis. 5, Epididymitis.—Results from the passage of a sound too soon after the operation, from the fourth to the seventh day is sufficiently early. The Urethra. 123 External Urethrotomy. Division of a stricture through a perineal incision, a guide being passed through the stricture. Indications.—Strictures of small caliber at the bulbo-mem- braneous junction that cannot be dilated. Internal urethrotomy is occasionally done in this region, but it is extremely liable to be followed by serious or annoying complications, such as perineal abscesses, epididymitis, etc. The bulb of the urethra being more or less dependent when com- pared with the penile urethra, hence discharge is liable to accumulate here, thus increasing the liability to septic infection. Operation.—Syme's operation. A Syme's staff should be introduced into the urethra until the shoulder of the instrument is in contact with the anterior face of the stricture. (See Figure 29.) The patient is placed in the lithotomy position, the staff held exactly in the median line, with its convexity slightly bulging into the perineum. An incision is made in the median line of the perineum about one and a quarter inches in length, beginning at a point one and a half inches above the anus. This is to be deepened until the knife enters the groove of the staff in front of the stricture, and the latter divided from before backward. A probe-pointed gorget of Teal is intro- duced into the urethra through the perenial incision (see Figure jo), and the staff removed. A full sized steel sound should be passed in order to ascertain whether the stricture has been sufficiently divided or not. The sound is removed and a full-sized Nelaton catheter introduced through the entire urethra until the eye of the instrument is just within the grasp of the vesical neck, and tied in place. The perineal wound should be dressed antiseptically and a T bandage applied. The bladder is to be irrigated daily with boracic acid solution until the third day, when the catheter is to be removed. Nitrate of silver solution 1 :5,000 is substituted for the boracic acid. At the end of a week a full-sized steel sound is passed and then at intervals of four or five days until the wound is entirely healed. 124 Genito-Urinary Diseases. Perineal Section. The operation of dividing an impassable stricture of the deep urethra through perineal incision without a guide. Indication.—Impassable strictures about the bulbo-membran- eous junction. Operations.—(i) Wheelhouse. (2) Cock's. Wheelhouse Operation.—Place the patient in the lithotomy position, and introduce a Wheelhouse staff down to the stricture with its groove looking towards the operator ; then make an incis- ion in the median line of the perineum, opening the urethra at the base of the groove. Now pass two silk threads through the edges of the incised urethra to act as retracters, and at the same time, gently withdraw the staff until the beak appears in the wound (see Figure ji) ; it is then turned round so that the groove looks towards the pelvis, and the hook drawn up into the upper angle of the urethral incision. A strong light is thrown into the interior of the urethra, and a fine probe-pointed director introduced in various directions, and an attempt made to locate the opening of the stricture. If this cannot be found after suffi- cient exploration (fifteen minutes), the tissues should be carefully incised in the median line, and then the probe tried again. Fail- ing in this a suprapubic cystotomy must be done, an instrument passed from the bladder out (retrograde catheterization), and the perineal incision deepened until the point of this instrument is exposed. If in the first instance the director can be made to pass through the stricture, the latter is to be divided along the groove of the instrument with a blunt-pointed straight tenotome, both on the floor and roof. A gorget introduced and the stricture still further dilated. The staff is to be removed and a full-sized sound introduced to ascertain if the stricture has been thor- oughly divided. All further manipulations are similar to those appropriate for external urethrotomy. Cock's Operation.—A perineal operation for opening the urethra at the apex of the prostate gland. Indications.—Impassable strictures of the deep urethra with urgent symptoms, where from the condition of the patient it is The Urethra. 125 not desirable to subject him to the prolonged operation of per- ineal section. Operation.—Place the patient in the lithotomy position, and introduce the index finger of the left hand into the rectum until the apex of the prostate is reached. A double-edged knife is now introduced exactly in the median line of the perineum, and when the point approaches the tip of the finger in the rectum, the handle of the knife is depressed, and the point of the instru- ment made to enter the urethra at the apex of the prostate. The knife is removed, and a permanent Nelaton catheter intro- duced, until patient's general condition will permit of the more prolonged operation (perineal section). Small Deep Strictures.—Strictures of the deep urethra permeable only to filiform bougies. In cases of retention of urine resulting from tight strictures, an attempt should be made to pass a filiform through the stricture. The instrument should be bent at the end because the opening of the stricture is seldom in the centre. (See Figure j2). If one fails to pass, a second or third may be tried. Failing in this, a little trick first sug- gested by White will prove of value: An ordinary blunt-pointed syringe having a capacity of an ounce is filled with carbolized sweet oil. The point of the instrument is inserted in the meatus, and the urethra over-distended with oil. Now if a filiform is introduced while the urethra is still distended, it will often pass easily into the bladder. If such an instrument can be passed into the bladder, there are four procedures that may be carried out: 1. The filiform may be tied in place; with the certainty that the bladder will empty itself alongside of the instrument. 2. A Gouley's tunneled catheter may be passed over the filiform as a guide, and allowed to remain in place. (See Figure jj.) 3. A staff may be introduced over the filiform as a guide and an external urethrotomy done. 4. The filiform may be attached to a Maisonneuve urethro- tome and the stricture divided from before backwards. I26 Genito-Urinary Diseases. Urethral Fistulae. An abnormal opening, either congenital or acquired, through which the urine escapes from the urethra. Varieties.— (i) urethro-rectal, (2) urethro-perineal, and (3) urethro-penile. The urethro-perineal fistulae is the commonest variety met with. Causes.—It usually follows a minute rupture of the urethra behind a very tight or impassable stricture, at or about the bulbo-membraneous junction. Pathology.—As a result of the presence of a tight strict- ure, the increased force of the stream balloons the urethra behind the stricture, forming a pouch in which a few drops of urine collect. This retained urine undergoes ammoniacal fermen- tation, and the resulting inflammation produces a superficial desquamation of the cells lining the urethra, and an erosion results. Through this erosion the urine finds its way into the periurethral connective tissue, abscesses form, and burrow down through the perineum, to open on the cutaneous surface in some part of the urethral triangle of the perineum. Treatment.—If it is possible to dilate the stricture, the fistulous openings often promptly close. Usually, however, it is necessary to do an external urethrotomy, or a perineal section, slit up all the fistulous tracts, pack them with iodoform gauze so that they will heal from the bottom. The after treatment being the same as for the uncomplicated operation for deep stricture. Urethro-rectal fistula.—A communication between the urethra and rectum. Causes.—(1) Prostatic abscess, rupturing into the rectum. (2) Ulceration of a prostatic calculus. Treatment.—The simplest treatment is that of permanent catheterization and repeated cauterization of the fistulous tract. Failing in this the urethra must be opened by a median perin- eal incision, the thickened walls of the fistulous tract cut away, and a permanent catheter introduced into the bladder through the perineal incision. Urethro-penile fistula are commonly congenital, although they The Urethra. 127 may result from the external or internal rupture of a peri- urethral abscess. Treatment.—Freshen the edges of the fistula, close the urethra with fine catgut sutures, and the skin incision with fine silk. A catheter should be retained in the bladder until healing is complete. Urethral Fever. Any fever which follows instrumentation of the urethra. Varieties,—(1) The reflex. (2) The septic or true variety. Causes.—Infection through minute wounds and abrasions made by the introduction of instruments. Symptoms.—The reflex variety is usually indicated by a chill, fever and sweat shortly after the passage of an instru- ment. The chill is pronounced, the fever high, from 1040 to 1060, and the sweat copious. There may also be some head- ache, nausea, pain in the back and vomiting. The septic or true variety usually follows after the first urination, and is ushered in by a similar chill, fever and sweat as in the reflex variety; the fever, however, is a continuous one, with daily remissions almost to the normal. The chills may be repeated several times daily or be limited to one every three or four days. This infection may terminate in the forma- tion of metastatic abscesses as in pyaemia. Treatment.—Urethral infection is to be prevented, or at least, limited to the minimum, by rigid antisepsis of both instru- ments and urethra. If in spite of these precautions, a chill should follow the passage of an instrument give the patient ten grains of quinine, and then a half a drop of aconite every hour for eight doses. When the kidneys fail to act, wet or dry cups may be tried and full doses of tincture of digitalis. In very grave cases where the amount of septic matter absorbed is great, and the symptoms grow progressively worse, a perineal cystotomy should be performed and a drain (catheter) inserted. The general treatment should be that appropriate for septicaemia and pyaemia. 128 Genito-Urinary Diseases. Cowperitis. An inflammation of Cowper's glands. Causes.—Direct infection through the ducts from gonorrhoea of the bulbous urethra. It usually appears about the end of the third week of an acute anterior urethritis. Symptoms.—Intense perineal pain, caused by pressure (because glands are situated between two layers of the triangular ligament) ; increased by pressure, sitting or walking. There is pain on urination and pain on defecation. By deep perineal pressure a tumor can often be palpated. When abscesses form, the symptoms of deep suppuration become manifest. The abscesses :may rupture either into the urethra or, as is usually the case into the perineum. Treatment.—All local urethral treatment should be stopped. The patient should be confined to bed and a gss of sulphate of magnesia administered. Hot fomentations may be applied to the perineum, and morphia may be given in doses sufficient to relieve the pain. Abscess should be opened through the perineum, and the cavity treated as for abscesses in other regions of the body. Periurethral Abscess. The minute glands and follicles scattered along the urethra are particularly predisposed to gonorrhceal infection. Symptoms.—The symptoms of periurethral abscess are similar to those of any acute abscess. Treatment.—In the early stages, by gentle massage, the duct may be freed from its plug and the inflammation often subsides. When signs of suppuration become pronounced the abscess should be opened, curetted and packed with iodoform gauze. Fistulous openings should be closed by plastic operations. Chancroid. A soft chancre is an infectious venereal sore characterized by the absence of constitutional manifestations. Causes.—A chancroid is the result of infection with micro- organisms. The secretion of the sore is very contagious. Chancroid. 129 Ducrey has described a short, thick bacillus, with clubbed ends, found in and between the cells, as the specific organism of chancroid. Recently, Lenglet reports the successful cultivation in pure culture of Ducrey's bacillus. In four experimental inves- tigations the same bacillus was found in pure culture. Inocu- lated into the human subject it yielded positive results, and from the resulting lesions the same bacillus was again successfully cultivated. The organism is a streptobacillus, staining with the ordinary stains, and is decolorized by Gram's method. Period of Incubation.—Chancroids have no period of incuba- tion, the destructive action of the bacillus begins at once, although the resulting lesion is not apparent until the bacillus has pene- trated beneath the epithelial layer. Under some circumstances, the appearance of the ulcer may be delayed for some days. Varieties.—(1) The exulcerating—one which is superficial and saucer-shaped ; (2) the follicular—one in which the lesion begins in a hair or sebaceous follicle, sometimes called acneiform; (3) the echthymatous—one seen on the integument, and is covered with a blackish-green crust; (4) the ulcus elevatum—one asso- ciated with considerable oedema and cell proliferation; (5) the serpiginous—one that has a tendency to spread superficially over a large surface ; and (6) the phagedenic—one associated with exten- sive sloughing. Symptoms.—Chancroid usually begins as a small pustule, which rapidly becomes converted into a ragged, " punched-out" ulcer, with undermined edges. The surface of the ulcer is usually covered by a grayish or brownish slough. In the early stage, the secretion of the chancroid is quite abundant, and consists of a thin, brownish purulent fluid. The ulcers are autoinocuable, that is, they produce similar lesions on surfaces with which they come in contact. The duration of a chancroid is variable, being influenced by the mode of treatment and the habits of the patient. In general, they may be said to persist for from two to four weeks. Complications.—(1) Phimosis, (2) paraphimosis, (3) lymph- angitis, and (4) bubo. Bubo is the most common; in hospital Chancre. Incubation 10 to 42 days. Single. Begins as an erosion, papule, or tubercle. Superficial. Induration. Scanty secretion. Not autoinocuable. Painless. Bubo constant. Herpes. No Incubation. Multiple. Begins as a vesicle, which may ulcerate. Superficial. No induration. Scanty secretion. Not autoinocuable. Extremely painful. Bubo rare. J3o Genito-Urinary Diseases. practice—(as high as 40 per cent.,) while in private practice it is rather uncommon. Diagnosis.—Chancroid may be mistaken for chancre, herpes, balanitis, ulcerating papular syphilides, gummata, tuberculosis and epithelioma. Chancroid. None, appear in less than 7 days. Multiple. Begins as a pustule and then ulcerates. Deep. Slight induration. Profuse secretion. Autoinocuable. Painful. Bubo occasionally Treatment.—The principle involved in the treatment of a chancroid is the conversion of a septic ulcer into a simple one. The glans penis and prepuce should be thoroughly washed with castile soap and warm water twice or three times daily, then peroxide of hydrogen applied, followed by a wash of 1 : 2,500 bichloride solution. After the surface of the ulcer has been thoroughly cleansed and disinfected, powders may be applied, sedative or stimulating, depending upon the variety of chancroid. JJr. Bismuth, subnit. Jfc. Hydrarg. chlorid. mit. Acid, boracic. Pul. opii. Amyl . . . aa 31 Lycopodii . . aa 31 M. S. Dusting powder. M. S. Use freely. When this line of treatment fails to bring about a prompt cure, wet dressings may be applied of 1 to 5,000 bichlor- ide, phenol sodique 1 to 5, or lead water and laudanum to which a 5ss of carbolic acid has been added to every six ounces of solution. After the sore has been cleansed, a small piece of absorbent cotton is saturated with the solution, placed over the ulcer, and maintained in place by drawing the prepuce forward Syphilis. 131 over the glans. When the prepuce is too short, a bandage may be used. Various antiseptic ointments composed of copper, iodoform and zinc have been recommended, but present no advantages. A phagedenic or serpiginous chancroid should be cauterized with pure carbolic acid, acid nitrate of mercury, or pure nitric acid, and then, after the slough separates, treat as a simple ulcer. The objections to the routine cauterization of chancroids are, that it does not remove the infection, and usually converts an open into a concealed sore by excessive inflammatory oedema (phimosis). In subpreputial chancroids or concealed sores the cleansing must be carried out by a syringe with a long, flat nozzle, gently inserted beneath the prepuce and the cleansing solutions allowed to flow out between the prepuce and the glans penis. In the interval the entire penis should be surrounded by lead water and laudanum solution. When concealed sores threaten to destroy the penis, the prepuce must be split up on the dorsum, or a formal circum- cision performed. The danger of performing circumcisions under these circumstances is the likelihood of infecting the entire raw surface incident to the operation with the chancroidal virus. However, in a fair proportion of cases, when every antiseptic precaution has been taken, primary union results. Syphilis. An infectious venereal disease of chronic course, communi- cated from person to person by actual contact with discharges containing the virus, or by heredity. Causes.—Syphilis is almost certainly due to the presence in the system of a specific micro-organism, as clinical evidence will clearly demonstrate. The presence of such an organism, however, is still entirely hypothetical. The alleged bacillus of Lustgarten has never been isolated, cultivated artificially, or sub- jected to inoculation experiments. Van Niessen claims to have cultivated artificially his streptobacillus, but as yet, no inoculating experiments have been made. Methods of Infection.—(1) Direct contact—sexual inter- 132 Genito-Urinary Diseases. course, kissing, etc. ; (2) Mediate infection—instruments, drinking glasses, towels, etc. ; (3) Hereditary transmission. The physiological secretions of syphilitics (saliva, sweat, milk and semen), do not of themselves contain any virulent principle, but they may be contaminated by admixture of the secretions of the secondary lesions (mucous patch). Periods of Syphilis.—There are six periods of syphilis divided in accordance with its clinical course : (1) Primary incubation—the time elapsing between exposure to the contagion and the appearance of the sore. (2) Primary symptoms.—Includes the chancre and adenitis. (3) Secondary incubation.—The time elapsing between the appearance of the chancre and the development of secondary lesions. (4) Secondary symptoms.—Includes fever, alopecia, and the skin eruptions. (5) Intermediate period.—The time which elapses between the disappearance of the secondary lesions and the appearance of the tertiary lesions. (6) Tertiary symptoms.—Includes the gumma and bone diseases. Chancre.—Chancre is the primary lesion of syphilis and always appears at the point of inoculation. Period of Incubation.—The first period of incubation varies in length from ten days to forty-two days, and in exceptional cases from sixty to seventy days. Varieties.—(1) The chancrous erosion appears as a sharply defined, excoriated spot of dull red or coppery color. (2) The "silvery spot" appears on the surface of the glans and the lips of the meatus, suggesting the appearance produced by touching a mucous surface with carbolic acid or nitrate of silver. (3) The dry papule—found on exposed surfaces and appear- ing as a hard, raised, dark colored tubercle. (4) The follicular chancre begins as a small pinkish papule with a minute depression in the centre. (5) The necrotic nodule, beginning first as a papule, often Syphilis. 133 reaching the size of a pea ; it then breaks down with the forma- tion of a purplish colored slough. (6) The echthymatous chancre—one that becomes covered with crusts. Clinical Characteristics.—The clinical characteristics of a typical or Hunterian chancre are as follows: It begins as a superficial papule extending in circumference and depth, followed by redness and desquamation of the epidermis. The induration begins at the end of the first week, and becomes pronounced at the end of the second week. It is cup- shaped on top, occasionally covered with a false membrane, above the level of the surrounding tissue, not autoinocuable, usually single, and generally heals spontaneously. Seats of Chancre.—A chancre may be located in any part of the body, the great majority, however, are situated upon the genitalia. Extra-genital chancres are found on the lips, in the mouth, about the anus, and in the region of the nipple. Pathology.—The organisms are deposited in some minute crack or tear and slowly begin to proliferate. As the infection advances, inflammatory changes follow depending in extent upon the nature of the tissue involved. These inflammatory changes consist in a more or less extensive round-celled infiltration of the connective tissue spaces. The arterioles and venules undergo sclerotic changes, especially in the adventitia, and with the inflamma- tory changes described above, give the sore its characteristic indu- ration. The sclerosed blood vessels being unable to supply the nourishment necessary for the vitality of the tissue, a small super- ficial slough forms, and cause the cup-shaped depression. Induration.—The induration becomes perceptible during the first week or ten days, and reaches its height about the end of the second week. Causes.—Rounded cell—infiltration of the connective tissue spaces with the sclerosis of the arterioles and venules. The induration is in proportion to the amount .of connective tissue and the blood supply. Varieties.—(1) Laminated—sclerosis limited to the papilli; 134 Genito-Urinary Diseases. (2) parchment—somewhat deeper sclerosis than the laminated, and as a consequence, feels thicker; (3) nodular—sclerosis of the cutaneous and subcutaneous vessels ; and (4) annular— sclerosis is limited to the margin of the sore, a hard ring being formed. The induration usually begins to disappear about the end of six weeks ; it may, however, last for years. Diagnosis.—A chancre must be distinguished from chancroid and herpes, and when situated in the urethra, from gonorrhoea. Urethral Chancre. Incubation Ten to Fifty-two Days. Always situated within the first half inch of the urethra. No chordee. Ardor urinae limited to the chan- crous area. Scanty discharge. Induration There may be some obstruction to the flow of urine. Absence of gonococci. Syphilitic bubo. Gonorrhoea. Incubation Three to Five Days. Involves the entire urethra. Chordee marked. Ardor urinae involves the entire urethra. Profuse discharge. No induration. Obstruction rare, except in inflammatory stricture. Gonococci present. Inflammatory bubo. Treatment.—The abortive methods include excision, cauteriza- tion, and the subcutaneous injections of corrosive sublimate solu- tion about the sore. In every authentic case the above methods of treatment have been followed by the appearance of secondary lesions. Excision is to be recommended when the sore is so situated that it would be removed by a formal circumcision. The palliative treatment consists in the thorough cleansing of the sore with soap and hot water, spraying with peroxide of hydrogen, irrigation with 1:3,000 bichloride solution, and the use of the following dusting powder: {Jr. Bismuth, subnit. Acid, boracic. Iodoform. . . . aa 3i Occasionally a chancre may take on an excessive inflammatory reaction, the result of infection with other varieties of microbes, and may then require treatment appropriate for chancroid. *-J Lymphatics of the Genito-Urinary tract. 135 Syphilis. 135 Syphilitic Adenopathy.—Immediately following the appearance of the chancre the lymphatic vessels become involved, and the glands draining the diseased area become enlarged. This enlarge- ment is sometimes appreciable as early as the fifth day, but as a rule, it is not marked until about the tenth or fourteenth day. Clinical Characteristics of Syphilitic Buboes.—Syphilitic buboes possess the following characteristics:—(1) They are polyganglionic, (2) usually painless, (3.) non-adherent to the skin, (4) non-inflam- matory, (5) seldom or never suppurating. When suppuration does take place, it is the result of a mixed infection with pyogenic organisms. Within six weeks after the appearance of the chancre, all the lymphatic glands of the body become enlarged. Route of the infection of the lymphatic glands : (1) Chancre situated about the glans penis. (2) Infection of the dorsal lymphatics of the penis. (3) Enlargement of the superficial inguinal glands. (4) Enlargement of the external iliac glands. (5) Enlargement of the internal iliac glands. (6) Receptaculum chyli. (7) Thoracic duct. (8) Left subclavian vein, and then enters the blood. Secondary Syphilis.—About six weeks after the appear- ance of the chancre the period of secondary syphilis begins. It is usually ushered in by fever of a ioo°-ioi°, vague rheumatic pains, sore throat, general malaise, and alopecia of the entire body. Syphilitic Alopecia.—Syphilitic alopecia is seen best on the sides of the scalp having the general appearance of being moth- eaten, a fact which distinguishes it from ordinary baldness. It is caused by a sclerosis about the hair follicles, which destroying the blood supply causes the hair to die and fall out. The hair, however, will return when appropriate internal treatment is instituted. Immediately following these prodromes, the skin eruptions make their appearance. 136 Genito-Urinary Diseases. Classification of cutaneous syphilides: (1) Erythemas {a) Erythema. (b) Macules. {c) Roseola. > all early eruptions. (2) Papules (3) Pustular {a) Conical or miliary {b) Lenticulo-papular. {c) Small flat papular. {d) Large flat papular. {e) Papulo-squamous. (/) Lichen-like. {a) Acneiform. {b) Variloform. ^ {c) Impetigo. {d) Echthyma. {e) Rupia. (1) Large. (2) Small. (4) Gummata j {a) Gumma. ) {b) Tubercle. Erethymatous Syphilide.—This is usually the earliest syphilitic eruption. It first appears as irregularly distributed round or oval stains, becoming more pronounced by exposure to cold, at first disappearing on pressure (later not), and lasting from ten to fourteen days. At the end of ten or fourteen days the indistinct stains of the erythematous period become more pronounced, slightly ele- vated, and do not disappear on pressure (papules). Papular Syphilide.—The papules may be either large or small, smooth or scaly depending upon the blood supply and the anatomical peculiarities of the tissues. When situated upon the palms of the hand the eruption will be of the papulo-squamous variety. A papule by friction, heat, and moisture, may lose its super- ficial layer of epithelium and become converted into an eroded surface. It then receives the name of mucous patch. Mucous patches are usually found under the arms, in the Syphilis. 137 mouth and pharynx, and around the genitals. When subjected to irritation, an overgrowth of the papillary layer follows, and a condyloma results. Mucous patches are the most contagious of all lesions of syphilis. Pustular Syphilide.—Syphilitic pustules may be either large or small and appear either early or late. The small pustular variety attacks the hair and sebaceous follicles and may be transformed into small ulcers. The large pustular form has a tendency to involve large areas of tissue and is usually found on the hairy parts. Echthyma may be either superficial or deep, the former usually appearing on the lower extremities as very large pustules covered with a thick dark crust. When such lesions heal, they leave a dark brown, copper stain, which gradually becomes whiter as the scar contracts. The deep form is characterized by the formation of more or less deep ulcers which are covered with greenish or brownish imbricated crusts. Rupia appears as a large elevation of the epidermis, filled with blood-stained serum which soon becomes purulent. The bleb bursts and some of the fluid escapes, and as it dries, is covered with a crust, which accumulating new layers becomes imbricated, forming greenish brown cone shaped scabs. Beneath the crust suppuration extends to the papillary layer. The tubercles and gummata belong to the late manifestations of secondaries. Tubercular syphilide consists of diffuse and cir- cumscribed infiltrations involving the entire thickness of the skin. There are two varieties, the ulcerating and the non-ulcerating. They may be isolated or in groups, and healing is attended with the production of a pigmented cicatrix. The gumma is a typical lesion of tertiary syphilis. In the late stage of syphilis the lymph channels become blocked with the broken down products of the secondary stage, as a result of blocking of these spaces, inflammation develops, and a sharply, circumscribed tumor forms. The favorite localities are the face, scalp, shoulders, neck, arms, thighs and legs. After a time owing to the imperfect organization, the gumma softens, breaks down, and discharges its contents (gummy pus). (2) Bone diseases ■< 138 Genito-Urinary Diseases. Clinical Characteristics of the Skin Eruptio?is.—They are (1) polymorphous—tissues involved, blood supply, chronic course of the disease, and the tendency to relapse; (2) crescentic—ana- tomical arrangement of the capillaries ; (3) copper colored—color- ing matter of the blood leaks out owing to the pressure of the sclerosis ; (4) non-itching—so chronic that they do not irritate the skin; (5) symmetrical—because it is a blood disease ; (6) cica- trices are first pigmented, and then grow white with age. Tertiary Syphilis.—When syphilis does not become extinct in the secondary stage, it passes into a chronic state called ter- tiary syphilis. It differs from secondary syphilis in the fact that the lesions are deep and run a long, indolent and a phleg- matic course, with a decided tendency towards the over-growth of connective tissue. Symptoms.—(1) Gummata in various parts of the body. (a) Osteo-periostitis. {b) Rarefying osteitis. {c) Gummatous osteomyelitis. (3) Disease of the ner- ( {a) Meningitis. vous system *j {large on surface of brain; v. {b) Gummata -l small, following the mid- dle cerebral artery. Treatment of Syphilis.—Never begin the use of drugs until the appearance of some characteristic lesion at a distance from the sore, because it is impossible to diagnose syphilis from the sore alone. There are three exceptions to this rule: (1) Confrontation— when it is possible to examine the person from whom the dis- ease was contracted, then the presence of a typical sore with active syphilis in the party from whom the disease was con- tracted, indicates immediate treatment. (2) The presence of a typical sore in a prominent place— as the lip. (3) Typical sores in the mouth—liable to infect other mem- bers of the family. The routine treatment, therefore, consists in waiting for the development of the post-cervical enlargement, and then the admin- Syphilis. 139 istration of the protiodide of mercury in ascending doses. Mercury is indicated in the treatment of syphilis because of its probable germicidal action in constitutional microbic infections, and because of its power to destroy the extensive round-celled infiltration. Jfc. Hydrarg. protiodid. . . .31 Confect. rosae . . q. s. M. ft. pil. No. Lx. S. One t. i. d. p. c. as directed. The patient is directed to begin with one pill three times daily and to increase one pill each day until the premonitory symptoms of ptyalism are produced (fetor of breath, tenderness when the teeth are knocked together, and ropy saliva). Mercury is given in ascending doses in order to ascertain the physiologi- cal limit for each particular case, once knowing this, the dose is so regulated as to just keep within bounds, that is, to get the beneficial effects without the poisonous. The dose is then cut down half when a large number of pills is taken or one- third when a small number is taken. The mercury in some form is to be continued for eighteen months or two years. At the end of this time the biniodide of mercury should be admin- istered in doses of one-twelfth of a grain three times daily, with twenty grains of iodide of potash, and continued for six months. Jfc Potassii iodidi . . . gss Aquae q. s. ad. . . . fgss M. S. Gtts. xx t. i. d. p. c. If at any time during the six months' mixed treatment secondaries reappear, the mixed treatment must still be con- tinued six months from the time of reappearance. Iodide of potash should never be given in the secondary stage of syphilis, unless the disease is of a malignant natiLre, and the deeper or fibrous structures are attacked. Methods of Administering Mercury : (1) By the mouth—the protiodide in doses of one-third of a grain, bichloride in doses of one-twentieth of a grain to be used when the green iodide is not well borne, and mercury with chalk to be used when the other forms of the drug produce gastro- 140 Genito-Urinary Diseases. intestinal symptoms with diarrhoea. The dose is half a grain, to be gradually increased, as in the case of the green iodide. (2) Inunctions—To be recommended when the internal admin- istration of mercury is followed by severe gastro-intestinal irritation. Method.—The patient should take a warm bath, dry the skin and then rub in 3i of the ointment of mercury for twenty min- utes on the non-hairy surfaces. Such treatment to be repeated daily. The body should be divided into six parts, and the dif- ferent parts used in succession so that the same part is only used once in every seven days. By following some such rule you will avoid the cutaneous irritating effects of the mercurial ointment, and by avoiding the hairy surfaces, troublesome eczema and acneiform sores will be prevented. (3) Vaporization is to be used in cases of malignant syphi- lis, where the general health of the patient is seriously affected, so that the internal use of mercury is not to be considered. In these cases the cutaneous surface is usually covered with an extensive eruption so that inunctions cannot be used. Method.—The patient, naked, should sit on a cane seat chair and cover himself (all but the head) with a mackintosh. Under- neath the chair an iron pan should be placed over an alcohol lamp, and 3i of calomel vaporized. In twenty minutes the lamp should be extinguished, but the patient should remain exposed to the fumes for twenty minutes longer. (4) Baths to be recommended where there are wide-spread pustular lesions. The strength should be 1 : 20,000 of bichloride, and at a temperature of 80 to 850. (5) Hypodermics.—Bichloride, calomel, or gray oil. These should be employed when other methods of treatment fail, or when a very rapid effect is desired. It should be remembered that this method of treatment is extremely painful, and that the injections are frequently followed by abscesses and deep sloughing. The dose of mercury should always be temporarily raised when new symptoms make their appearance. During the mercurial treatment, the general health of the patient must be carefully regulated, everything may be recom- , Syphilis. 141 mended which will increase the patient's weight. In general the use of alcohol should be eschewed, unless the patient's weight is increased thereby. The teeth should be kept in order and be kept scrupulously clean by the use of antiseptic washes, the gums should be hardened by the use of astringent and antiseptic mouth-washes. Whenever possible, smoking is to be avoided. The gastro-intestinal tract should be kept free from irritation by the regulation of the diet and the avoidance of constipation. The patient should also be warned as to the contagiousness of his disease and be informed as to the methods of avoiding the inoculations of friends or family. The local treatment of syphilis is subservient to the consti- tutional, but the healing of ulcers may be hastened by local applications. Mucous Patches.—These can often be prevented in the mouth by attention to the general rules of cleanliness. When they appear they should be touched with either a solution of copper sulphate grs. v to 51, or nitrate of silver grs. xv to Si, and the following mixture may be recommended as a mouth wash: (White) $&-. Acid, boracic.... Acid, tannic .... aa3ii Mel. rosae .... fgii Aquae ..... fgvi M. S. Use as a mouth wash. Wrhen situated on the cutaneous surface the following dusting powder may be applied : J£r. Bismuth, subnit. Calomel .... Lycopodii .... aa3i Condylomata when exuberant should be cauterized with pure nitric acid and the above dusting powder freely applied. The pustular eruptions are often greatly benefited by mer- curial baths and vaporization. When the ulcers are indurated and covered with crusts the following may be applied: Jfc. Ung. hydrarg. nit. . . 3i Ung. petroleii . . . %\ M. S. Apply locally. M2 Genito-Urinary Diseases. Gummata, periosteal nodes, and tubercular syphilides non- ulcerating are to be treated by the use of the following: Jfc. Ung. hydrarg. Ung. belladonna. . . aa 3ii Ung. iodi. comp. . . 3i Ung. petroleii . . . 5ii M. S.—Spread on a piece of lint, and keep in place by a bandage. Tertiary Syphilis.—In the treatment of tertiary syphilis it is necessary to administer a remedy that will remove the broken down products of the secondary stages from the lymphatic sys- tem. For this pupose iodine is administered in some form, and is to be pushed until some effect is produced on the lesions. It is customary to combine small doses of mercury or make use of inunctions in the treatment of the tertiary lesions. Jfc. Potassii iodidi . . gss J&. Pil. hydrarg. biniodid. gr. 1/12 Aquae q. s. ad. . . fgss No. XX M. S. Gtts xx t. i. d. p. c. S. One t. i. d. p. c. Hereditary Syphilis.—Syphilis is readily transmissible to the embryo as an active contagious disease, and differs only from acquired syphilis in that it is not preceded by the usual primary sore or chancre. Routes of infection: TT , . . e . .. f (1) By direct contagion. Husband may miect the wife < I (2) Through the child. Child may be infected : , „ _ r . 1 {a) Previous to conception. (1) From father I ; • r . . „ , < (b) At the moment of conception. (2) From mother 1 ; . r v {c) During utero-gestation. (3) By direct infection during birth. Colless Law.—A mother may give birth to a syphilitic child, nurse that child, and remain immune to syphilis. Profetds Law.—A syphilitic mother may give birth to a child, nurse that child, and the child remain immune to syphilis. Syphilitic women frequently abort. This is due to an over- growth of connective tissue in the placenta. The first abortion usually occurs at the third month, each succeeding pregnancy aborting later and later. Hutchinson Teeth. Syphilitic Condylomata. 142 Syphilis. i43 Symptoms.—The primary stage or chancre is never present in hereditary syphilis. Secondaries make their appearance from one to three weeks after the birth of the child. At birth, the child presents a senile, weazened appearance with a characteristic hoarse cry, ulceration of laryngeal mucous membrane, snuffles, and pemphigus of the palms of the hand and the soles of the feet. At the end of the second or third week, the various skin eruptions make their appearance. The first teeth are irregularly developed, opaque, chalky, appear some- what later than usual, and decay early. At the end of eighteen months or two years, an inter- mediate period begins, and extends up to the time of the second dentition or puberty. It is characterized by the absence of special symptoms, although evidences of the existing diathesis still persist. The tertiary symptoms follow this intermediate period, and are especially noticeable about puberty. The characteristic symptoms of the tertiary period are : The Hutchinson Teeth (thick and notched central incisors), stunted growth, sunken nasal bridge, caries of various bones, interstitial keratitis, rhagades (linear scars about the mouth), ulceration of the hard palate, and periosteal nodes. Treatment.—At birth 3ss of the following ointment should be spread daily upon the binder : {Jr. Ung. hydrarg. . . . gss Petrolat.....gss M. S. Apply as directed. If the skin becomes irritable, give the following: {Jr. Hydrarg. cum cretae grs. iii. to vi Sacch. alb. . . grs. xii M. Ft. chart. No. xii. S. One after nursing. At puberty, treatment appropriate for tertiaries in the acquired form is indicated, with the addition of cod liver oil and iron. For the treatment of bone diseases see special operations. Index. Abdominal retention of the testicle, 51 Abortion in syphilis, 142 Abortive gonorrhoea, 97 Abortive treatment of gonorrhoea, 104 Abortive treatment of syphilis, 134 Abscess, gonorrhceal, 128 from hypodermic treatment of syph- ilis, 140 of kidney, 15 seminal vesicles, 62 perinephritic, 16 periurethral, 128 prostatic, 65 Acute anterior urethritis, 94-97 posterior urethritis, 98 Acne syphilitica, 136, 137 Adenitis, chancroidal, 129 gonorrhceal, 97 syphilitic, 135 Adenoma of the kidney, 17 Adherent prepuce, 80 Alopecia, 135 Amputation of penis, 87 Anastomosis of ureters, 22 Angiosarcoma of the kidney, 17 Anomalies of the bladder, 23 of the kidney, 2 Anterior urethritis, 94-97 Ardor urinae, 95, 107 Arthritis, gonorrhceal, 116 Aspiration of bladder, 43 of hydrocele, 56 of kidney, 13 B Balanitis, 82 Balanoposthitis, 82 Baths in the treatment of syphilis, 140 Bigelow's evacuator, 40 lithotrite, 40 Bladder, 22 abscess, 29 adenomata, 33 anatomy, 22, 23 anomalies, 23, 24 aspiration, 43 atony, 27 calculus, 34-41 carcinoma, 33 catheterization, 27-29 cystitis, 29-32 cystocele, 24 cystotomy, 42, 43 dermoids, 33 exstrophy, 23, 24 frequency of micturation, 24, 25 haematuria, 24 hernia, 24 injuries, 41, 42 lateral lithotomy, 37, 38 lithilopaxy, 39-41 median lithotomy, 36, 37 Maydl's operation, 24 mucous polyps, 33 myomata, 33 papillary fibroma, 33 rupture, 41, 42 sarcomata, 33 stone, 34-41 suprapubic lithotomy, 38, 39 Trendelenberg's operation, 23, 24 tuberculosis, 32, 33 tumors, 33, 34 Wood's operation, 23 Bougies a boule, 119 Bubo, chancroidal, 129 gonorrhceal, 97 syphilitic, 135 Calcification of penis, 86 Calculus of bladder, 34 ii Calculus of kidneys, 9-12 of prostate, 78 of ureters, 21 of urethra, 93 Cancer, bladder, 33 kidneys, 17, 18 prostate, 78, 79 scrotum, 45 testicles, 55 Care of urethral instruments, 28 Castration, 63, 75, 76 Catarrhal gonorrhoea, 97 Catheter en chemise, 37 Catheterization, 27, 28 Cauterization of chancroids, 1 31 Chancre, 132 Chancroid, 128 Chimney sweeper's cancer, 45 Chronic urethritis, anterior, 11 i posterior, 113 Circumcision, 81, 84, 85 Clap threads, 100 Cock's operation, 124, 125 Colles's immunity, 142 Colpeurynter, 38 Condylomata, 141 Confrontation in treatment of syphilis, 138 Congenital hydrocele, 49-59 phimosis, 80 stricture, 116, 117 Contagion in syphilis, 131, 132 Contusion of kidney, 4, 5 Cowperitis, 128 Cystitis, 29-32 Cystotomy, 42, 43 D Diarrhoea in the treatment of syphilis, 139, 140 Dilatation for prostatic enlargement, 71 stricture of the urethra, 120, 121 Discharge in gonorrhoea, 95, 99, 110 Drainage, perineal, 32 Index. Dressing, acute gonorrhoea, 103 chancroids, 130, 131 circumcision, 81 Dribbling urination, 70, 119 E Echthyma, 136, 137 Elephantiasis scrotum, 44 Encysted hydrocele of cord, 50 tunica vaginalis, 56 Endoscope, 112 Enlarged prostate, 67 Epididymitis, 60 gonorrhceal, 60, 61 syphilitic, 61 tubercular, 61 Epispadia, 91 Epithelioma of penis, 87 scrotum, 45 Erysipelas of penis, 86 Erythema syphilitica, 136 Evacuating instruments for vesical cal- culi, 40 Excision of chancre, 1 34 of hydrocele, 58 of stricture, 120 Exstrophy of the bladder, 23, 24 Extravasation in rupture of the urethra, 91 kidney, 4—6 bladder, 41 F Fever, urethral, 127 Fibroma of bladder, 33 of kidney, 17 of testicle, 54 Filiform bougies, 125 Fistula, urethral, 126 penile, 126 Floating kidney, 6-9 Folliculitis in gonorrhoea, 97 Foreign bodies in urethra, 93 Frequency of micturition, 24, 25 Index. iii Funicular hydrocele, 49, 50 Funiculitis, 46 Fused kidney, 2 G Gangrene of penis, 86 Gerster's urethrotome, 122 Gleet, 114, 119 Gonococcus, 93, 94 Gonorrhoea, 93 abortive, 97 acute, 94 chronic, III complications, 96, 97, 99 internal medication, 103, 113, 114 pathology, 99, in, 113 prognosis, 102 symptoms, 95, 96, 97, 98, no, 113 treatment, 98, 102, 103, 104, 105, 106, 107, 108, 109, no, 114 Gorgets, 123, 124 Gravel, 34 Gross's urethrotome, 121 Gummata, 136, 137 H Haematuria, 4, 5, 10, 13, 15, 18, 24, 30, 35 Hereditary syphilis, 142 Hernia of the bladder, 24 Herpes progenitalis, 84 Hot baths in treatment of syphilis, 140 Hutchinson teeth, 143 Hydrocele, cord, 49, 50 tunica vaginalis, 55-59 Hydronephrosis, 13 Hypertrophy of prostrate, 67 Hypodermic treatment of syphilis, 140 Hypospadia, 90 I Immunity from syphilis, 142 Colles's law, 142 Profeta's law, 142 Impetigo syphilitica, 136, 137 Implantation of ureters, 22-24 Incontinence of urine, 26, 27 of children, 27 of enlarged prostate, 27, 70 Induration of chancre, 133, 134 Injection treatment of hydrocele, 57 Injections in gonorrhoea, 104, 105, 106, 107, !10 Injuries of bladder, 41, 42 of kidney, 4, 5, 6 Instillations, chronic urethritis, 114 disease of bladder, 32, 33 prostatorrhcea, 67 tubercular prostatitis, 78 Inunctions, 140 Iodides in treatment of syphilis, 142 Irrigating bag in gonorrhoea, 108 J Janet method of treating gonorrhoea, 108 K Kidney, I abscess, 15 absence, 2 adenoma, 17 anatomy, I, 2 angio-sarcoma, 17 anomalies, 2 atrophy, 2 calculi, 9-12 carcinoma, 17 contusions, 4, 5 examinations of, 2, 3 examinations of urine separately, from each kidney, 3, 4 fibromata, 17 floating, 6, 7, 8, 9 fused, 2 haematuria, 4, 5, 10, 13, 15, 18 Harris's apparatus, 3, 4 hydronephrosis, 13 injuries, 4, 5, 6 IV Index. Kidney, Kbnig's incision, 19 lipomata, 17 Langenbuch's incision, 19 malignant disease, 18 movable kidney, 6-9 myxomata, 17 nephralgia, 11 nephrectomy, 5, 6, 8, 11, 13, 14, 16 18, 19, 20, 21 nephritic colic, 6, 10, 18, 21 nephrolithotomy, 11, 12 nephrorrhaphy, 8, 9 nephrotomy, 13, 14, 15, 16, 18, 19 perinephritic abscess, 16 position of kidney, 2 pyelonephritis, 14 pyonephrosis, 15 pyuria, 10, 13, 14, 15, 21, 30, 31, 33, 35 relations of kidney, I, 2 rhabdomyomata, 17 sarcomata, 17 surgical kidney, 15 tuberculosis, 12 tumors, 17 wounds, 5, 6 Lafayette mixture, 104 Laparotomy in wounds of bladder, 42 kidney, 6 ureters, 20 Lichen syphilitica, 136 Light test for diagnosis of hydrocele, 49, 50, 56 Lipoma of kidney, 17 Lithilopaxy, 39-41 Lithotomy, 36-39 lateral, 37, 38 median, 36, 37 suprapubic, 38, 39 Lymphadenitis, balanitic, 83 chancrous, 135 chancroidal, 129 gonorrhceal, 97 syphilitic, 135 M Maisonneuve urethrotome, 121 Massage of prostate, 66, 67 of seminal vesicles, 62 of kidney, 14, 15 Mercuric baths in treatment of syphilis, 140 Mercury in treatment of syphilis, 138- 141 Misplaced testicle, 51, 52 Movable kidney, 6-9 Mucous patch, 136, 141 IN Neisser's gonococcus, 93, 94 Nephralgia, 11 Nephrectomy, 5, 6, 8, 11, 13, 14, 16, 18, 19, 20, 21 Nephritic colic, 6, 10, 18, 21 Nephrolithotomy, n, 12 Nephrorraphy, 8, 9 Nephrotomy, 13, 14, 15, 16, 18, 19 Neurasthenia sexual, 48, 65, 66 Nocturnal pollutions, 65, 98, 99, 113 O (Edema of penis, 91 of scrotum, 43 Orchidopexy, 51, 52 Orchitis, 52-54 Otis's urethrotome, 122 Oxalate calculi in kidney, 9, 10 Oxaluria. 11 Pain in renal calculus, 10 in varicocele, 47 in vesical calculus, 35 Papilloma of bladder, 33 of penis, 87 Papular syphilides, 136, 137 Papulo-squamous syphilides, 136 Index. Paralysis of the bladder, 27 Paraphimosis, 82 Pemphigus, 143 Penis, 79 abscess, 86 anatomy, 79, 80 calcification, 86 cavernitis, 86 condylomata, 85 epithelioma, 87 gangrene, 86 herpes, 84 malignant disease, 87 oedema, 80, 82, 91 phimosis, 80 posthitis, 82 paraphimosis, 82 tuberculosis, 86, 87 tumors, 87 venereal warts, 85 Perineal cystotomy, 42 hypospadia, 90 lithotomy, 36-39 prostatectomy, 73-75 prostatotomy, 72, 73 urethrotomy, 121-123 Periurethral abscess, 128 Perinephritis, 16, 17 Periosteal nodes, 142 Phimosis, 80, 81 Phosphatic calculi, 9, 10, 34 Posterior urethritis, 98, 113 Prepuce, 80 Priapism, 87 Profeta's law, 142 Prostate, 64 abscess, 65 calculi, 78 cancer, 78, 79 enlargement, 67 gonorrhceal, 99 hypertrophy, 67 massage, 66, 67 prostatectomy, 73-75 prostatic dilator, 66, 67, 71 prostatitis, 65, 66 prostatorrhcea, 66, 67 prostatotomy, 72, 73 tuberculosis, 77 tumors, 78, 79 Prostatic hypertrophy, 67 castration, 75-77 catheterization, 72 etiology, 67, 68 exploration, 70 instruments, 70 ligation of vas, 64, 76, 77 massage, 66, 67 operation, 72-79 prostatectomy, 73-75 prostatotomy, 72, 73 retention of urine, 70 Prostatectomy, 73-75 Prostatorrhcea, 66, 67 Prostatotomy, 72, 73 Ptyalism, 139 Puncture, suprapubic, 43 Pustular syphilides, 136, 137 Pyelonephritis, 14 Pyonephrosis, 15 Pyuria, 10, 14, 15, 21, 30, 31, 33, 35 R Renal calcui, 9-12 colic, 6, 10, 18, 21 tuberculosis, 12 tumors, 17 Residual urine, 25, 26, 70 Retention of urine, 26 Rhabdomyoma of kidney, 17 Rheumatism, gonorrhceal, 116 Roseola syphilitica, 136 Routine treatment of syphilis, 138, Rupia, 137 Rupture of bladder, 41, 42 of kidney, 4, 5 of ureter, 20 of urethra, 91, 92 S Sacculation of bladder, 69 Salivation, 139 vi Index. Sarcocele, 53, 54 Sacroma of bladder, 23 of kidney, 17 of testicle, 54 Sclerosis of syphilis, 133 Scrotum, 43 cancer, 45 elephantiasis, 44 gangrene, 44 oedema, 43, 44 tumors, 45 Seminal emissions, 65, 98, 99, 113 vesiculitis, 62, 63 Serpiginous chancroid, 129 Silvery spot, 132 Snuffles, 143 Spasm of urethra, 117 Spermatic cord, 45 anatomy, 45, 46 contusions, 46 funiculitis, 46 hematocele, 46 hydrocele, 49, 50 lipoma, 46 tumors, 46 varicocele, 47, 48 vasectomy, 64 wounds, 46 Spermatocele, 60 Steel sounds, 120, 121 Sterilization of instruments, 28 Stone in the bladder, 34-41 in kidney, 9-12 in ureter, 21 in urethra, 93 Stricture of the urethra, 116 of ureter, 21 Suppression of urine, 26 Suprapubic cystotomy, 42 prostatectomy, 73-75 puncture, 43 Surgical kidney, 15 Syme's operation, 123 Syphilides, 136, 137 Syphilis, 131 chancre, 132 constitutional, 135 contagion, 131, 132 etiology, 131 hereditary, 142, 143 immunity, 142 incubation, 132 infection, 131, 132 lymphatic involvement, 135 periods, 132 treatment, 138-143 T Tampon for hemorrhage in prostatec- tomy, 74 Tapping for hydrocele, 57 Teeth, syphilitic, 143 Tertiary syphilis, 142 Testicles, 50 abscess, 52 cancer, 55 castration, 63, 64 epididymitis, 60-62 hematocele, 60 hydrocele, 55-59 inflammation, 52, 53 malignant disease, 55 misplaced, 51,52 orcidopexy, 51,52 retained, 51, 52 spermatocele, 60 syphilis, 54 tuberculosis, 53, 54 Test of two beakers in chronic urethri- tis, 113 Thiersch's method in epispadia, 91 Tuberculosis, bladder, 32, 33 epididymis, 61 kidney, 12 penis, 86, 87 prostate, 77 testicle, 53, 54 Tumors, bladder, 33, 34 kidney, 17 penis, 87 prostate, 78, 79 scrotum, 45 Index. vii U Ultzmann's injection, 106 Ureteral catheterization, 3, 4, 21 Ureteritis, 20, 21 Ureteroplasty, 21 Ureterotomy, 21 Ureters, 20 anastomosis, 22 anatomy, 20 calculus, 21 catheterization, 3, 4, 21 colic, 21 haematuria, 21, 22 massage of, 14, 15 rupture, 20 transplantation, 22, 24 ureterectomy, 21 ureteritis, 20, 21 uretero-cystostomy, 22 uretero-enterostomy, 22 uretero-lithotomy, 21 ureteroplasty, 21 ureterorrhaphy, 22 uretero-ureterostomy, 22 wounds, 20 Urethra, 89 anatomy, 89 calculi, 93 catarrh, no chancre, 134 epispadia, 91 fever, 127 fistula, 126 foreign bodies, 93 hypospadia, 91 inflammations, 93 instillations, 114 irrigations, 108, 114 meatotomy, 92 rupture, 91, 92 spasm, 117 stricture, 116 urethritis, 93 urethrotomes, 121, 122 urethrotomy, 121-123 Urethritis, 93 Urethro-penile fistula, 126 Urethro-perineal fistula, 126 Urethro-rectal fistulae, 126 Urethrotomy, 121 Cock's operation, 124 external, 123 internal, 121 Urinary fever, 127 Urorrhcea, 11 o V Vaporization of mercury, 140 Varicocele, 47, 48 Vasectomy, 64 Venereal warts, 85 Vesical calculus, 34 haematuria, 30, 31, 33, 35,41 pouches, 69 tumors, 33, 34 Vesiculitis, 62 W Wheelhouse operation, 124 White's capsules, 104 Wood's operation, 23 Wounds of bladder, 41, 42 of kidney, 5, 6 of ureters, 20 of urethra, 91, 92 v> » t f ■ \ ."' . ■*■'■ * * ->-v **.«< ■** .#. £». 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